pharmacology bullet review

Pharmacology Pharmacology Bullet ReviewBullet Review

Nursing Board 2005Nursing Board 2005

Drug classification

Nursing process applied to pharmacology

Pharmacokinetics

Pharmacodynamics

Diuretics ComparisonDiuretics ComparisonDiuretic class Major site of

actionSpecial Side

effect (s)

1. Carbonic anhydrase inhibitor

Proximal tubule

Acidosis

2. Thiazide and thiazide like

Proximal tubule

HyperuricemiaHypokalemia

3. Loop diuretics

Loop of Henle HypokalemiaOtotoxicity

4. Potassium sparing

Distal tubule Hyperkalemia

5. Osmotic diuretic

Glomerulus Hypovolemia & hypotension

Diuretics ComparisonDiuretics ComparisonDiuretic class

Special Uses

1. Carbonic anhydrase inhibitor

Mountain sicknessMeniere’s disease

2. Thiazide and thiazide like

Nephrolithiasis due to calcium stonesHypocalcemia

3. Loop diuretics

Hypercalcemia

4. Potassium sparing

CHF taking digoxin

5. Osmotic diuretic

Increased ICPLITHIUM TOXICITY

ThiazidesThiazides

Prototype: HydrochloroPrototype: Hydrochlorothiazide thiazide

1. Bendroflume1. Bendroflumethiazidethiazide 2. Ben2. Benthiazidethiazide 3. Chloro3. Chlorothiazide thiazide (Diuril)(Diuril) 4. Hydroflume4. Hydroflumethiazidethiazide 5. Methylclo5. Methylclothiazidethiazide 6. Trichlorme6. Trichlormethiazidethiazide

Thiazide-likeThiazide-like

1. Indapamide1. Indapamide 2. Quinethazone2. Quinethazone 3. Metolazone3. Metolazone 4. Chlorthalidone4. Chlorthalidone

ThiazidesThiazides

PharmacodynamicsPharmacodynamics These drugs BLOCK the chloride These drugs BLOCK the chloride

pumppump This will keep the Chloride and This will keep the Chloride and

Sodium in the distal tubule to be Sodium in the distal tubule to be excreted into the urine excreted into the urine

Potassium is alsoPotassium is also

flushed out!! flushed out!!

ThiazideThiazide

Special Pharmacodynamics: Side Special Pharmacodynamics: Side effectseffects HypokalemiaHypokalemia DECREASED calcium excretionDECREASED calcium excretion

hypercalcemiahypercalcemia DECREASED uric acid secretionDECREASED uric acid secretion

hyperuricemiahyperuricemia Hyperglycemia Hyperglycemia

Loop DiureticsLoop Diuretics

Prototype: FurosemidePrototype: Furosemide

1. Bumetanide1. Bumetanide 2. Ethacrynic acid2. Ethacrynic acid 3. Torsemide3. Torsemide


PharmacodynamicsPharmacodynamics High-ceiling diureticsHigh-ceiling diuretics BLOCK the chloride pump in the BLOCK the chloride pump in the

ascending loop of Henleascending loop of Henle SODIUM and CHLORIDE SODIUM and CHLORIDE

reabsorption is preventedreabsorption is prevented Potassium is also excreted together Potassium is also excreted together

with Na and Clwith Na and Cl


Special Pharmacodynamics: side-Special Pharmacodynamics: side-effectseffects HypokalemiaHypokalemia Bicarbonate is lost in the urineBicarbonate is lost in the urine INCREASED calcium excretionINCREASED calcium excretion

HypocalcemiaHypocalcemia Ototoxicity- due to the electrolyte Ototoxicity- due to the electrolyte

imbalancesimbalances

Potassium sparing Potassium sparing diureticsdiuretics

Prototype: SpironolactonePrototype: Spironolactone

1. Amiloride1. Amiloride 2. Triamterene2. Triamterene


PharmacodynamicsPharmacodynamics Spironolactone is an ALDOSTERONE Spironolactone is an ALDOSTERONE

antagonistantagonist Triamterene and Amiloride BLOCK Triamterene and Amiloride BLOCK

the potassium secretion in the distal the potassium secretion in the distal tubuletubule

Diuretic effect is achieved by the Diuretic effect is achieved by the sodium loss to offset potassium sodium loss to offset potassium retentionretention


Pharmacokinetics: Side effectsPharmacokinetics: Side effects HYPERkalemia!HYPERkalemia! Avoid high potassium foods:Avoid high potassium foods:

BananasBananas PotatoesPotatoes SpinachSpinach BroccoliBroccoli NutsNuts PrunesPrunes TomatoesTomatoes OrangesOranges Peaches Peaches

Osmotic DiureticsOsmotic Diuretics

Prototype: MannitolPrototype: Mannitol

1. Glycerin1. Glycerin 2. Isosorbide2. Isosorbide 3. Urea3. Urea


PharmacodynamicsPharmacodynamics Mannitol is a sugar not well Mannitol is a sugar not well

absorbed in the nephronabsorbed in the nephron osmotic osmotic pull of waterpull of water diuresis diuresis


Pharmacokinetics: side effectsPharmacokinetics: side effects Sudden hypovolemiaSudden hypovolemia

Important for the nurse to warm the Important for the nurse to warm the solution to allow the crystals to solution to allow the crystals to DISSOLVE in the bottle!DISSOLVE in the bottle!

Carbonic Anhydrase Carbonic Anhydrase InhibitorsInhibitors

Prototype: AcetazolamidePrototype: Acetazolamide

1. Methazolamide1. Methazolamide


PharmacodynamicsPharmacodynamics Carbonic Anhydrase forms sodium Carbonic Anhydrase forms sodium

bicarbonatebicarbonate BLOCK of the enzyme results to BLOCK of the enzyme results to

slow movement of hydrogen and slow movement of hydrogen and bicarbonate into the tubulesbicarbonate into the tubules

plus sodium is lost in the urineplus sodium is lost in the urine


Pharmacokinetics: side effectsPharmacokinetics: side effects Metabolic ACIDOSIS happens when Metabolic ACIDOSIS happens when

bicarbonate is lostbicarbonate is lost HypokalemiaHypokalemia

The Nursing Process and The Nursing Process and the diureticsthe diuretics

ASSESSMENTASSESSMENT Assess the REASON why the drug is Assess the REASON why the drug is

given:given:

____________

____________

____________

____________


ASSESSMENTASSESSMENT The nurse must elicit history of The nurse must elicit history of

allergy to the drugsallergy to the drugs Allergy to sulfonamides may Allergy to sulfonamides may

contraindicate the use of thiazidescontraindicate the use of thiazides Assess fluid and electrolyte balanceAssess fluid and electrolyte balance Assess other conditions like gout, Assess other conditions like gout,

diabetes, pregnancy and lactationdiabetes, pregnancy and lactation


ASSESSMENTASSESSMENT Physical assessmentPhysical assessment

Vital signsVital signs Special electrolyte and laboratory Special electrolyte and laboratory

examinationexamination Assess symptom of body weakness Assess symptom of body weakness

which may indicate hypokalemiawhich may indicate hypokalemia


Nursing DiagnosisNursing Diagnosis Fluid volume deficit related to diuretic Fluid volume deficit related to diuretic

effecteffect Alteration in urinary patternAlteration in urinary pattern Potential for injury (ototoxocity, Potential for injury (ototoxocity,

hypotension)hypotension) Knowledge deficitKnowledge deficit


IMPLEMENTATIONIMPLEMENTATION Administer IV drug slowlyAdminister IV drug slowly Safety precaution for Safety precaution for

dizziness/hypotensiondizziness/hypotension Provide potassium RICH foods for Provide potassium RICH foods for

most diuretics, with the exception of most diuretics, with the exception of spironolactonespironolactone

Provide skin care, oral care and Provide skin care, oral care and urinary careurinary care


IMPLEMENTATIONIMPLEMENTATION Monitor DAILY WEIGHT- to evaluate Monitor DAILY WEIGHT- to evaluate

the effectiveness of the therapy the effectiveness of the therapy Monitor urine output, cardiac Monitor urine output, cardiac

rhythm. Serum electrolytesrhythm. Serum electrolytes ADMINISTER in the MORNING!ADMINISTER in the MORNING! Administer with FOOD!Administer with FOOD!


EVALUATION: for effectiveness of EVALUATION: for effectiveness of therapytherapy

Weight lossWeight loss

Increased urine outputIncreased urine output

Resolution of edemaResolution of edema

Decreased congestionDecreased congestion

Normal BPNormal BP

The ANXIOLYTICS AND HYPNOTICSThe ANXIOLYTICS AND HYPNOTICS

These drugs are used to change the These drugs are used to change the individual’s responses to the individual’s responses to the environment. environment.


The medications that can prevent the The medications that can prevent the feelings of tension and fear are called feelings of tension and fear are called ANXIOLYTICS. ANXIOLYTICS. – Anti-anxiety drugsAnti-anxiety drugs


The drugs that can calm individuals The drugs that can calm individuals making them unaware of the making them unaware of the environment are called SEDATIVES. environment are called SEDATIVES.


The drugs that can induce sleep are The drugs that can induce sleep are called HYPNOTICS. called HYPNOTICS.


The drugs in this class are theThe drugs in this class are the– BENZODIAZEPINESBENZODIAZEPINES– BARBITURATES BARBITURATES

Use of The DrugsUse of The Drugs

Clinical indications for the use of theClinical indications for the use of the

anxiolytics, sedatives and hypnoticsanxiolytics, sedatives and hypnotics

1. Prevention of anxiety1. Prevention of anxiety

2. Formation of sedative state2. Formation of sedative state

3. Induction of sleep3. Induction of sleep

The BENZODIAZEPINESThe BENZODIAZEPINES

The benzodiazepines are the most frequently The benzodiazepines are the most frequently used anxiolytic drugs. used anxiolytic drugs.

These agents prevent anxiety states without These agents prevent anxiety states without causing much sedation, with less physical causing much sedation, with less physical dependence than other agents.dependence than other agents.


The following are the benzodiazepinesThe following are the benzodiazepinesAlprazolam (Xanax)Alprazolam (Xanax)Chlordiazepoxide (LibriumChlordiazepoxide (Librium))clonazepamclonazepamclorazepateclorazepateDiazepam (Valium)Diazepam (Valium)estazolamestazolamflurazepamflurazepamlorazepamlorazepammidazolammidazolamoxazepamoxazepamquazepamquazepamtemazepamtemazepamtriazolamtriazolam

The BENZODIAZEPINESThe BENZODIAZEPINESSpecial usesSpecial uses

Diazepam(Valium)

Status epilepticus

Chlordiazepoxide (Librium)

Alcohol withdrawal

Alprazolam (Xanax)

Panic attack


The Mechanism of Action of the BenzodiazepinesThe Mechanism of Action of the Benzodiazepines

These agents act on the Limbic system These agents act on the Limbic system and the RAS (reticular activating system) and the RAS (reticular activating system) to make the GABA ( Gamma-to make the GABA ( Gamma-aminobutyric acid) more effective aminobutyric acid) more effective causing interference with neuron firing. causing interference with neuron firing.


The Mechanism of Action of the BenzodiazepinesThe Mechanism of Action of the Benzodiazepines

The GABA is an inhibitory The GABA is an inhibitory neurotransmitter. neurotransmitter. This will result to an anxiolytic This will result to an anxiolytic effect at lower doses than effect at lower doses than required for sedation/hypnosis.required for sedation/hypnosis.


These agents are indicated for the treatment These agents are indicated for the treatment of of

1.1. anxiety disordersanxiety disorders2.2. alcohol withdrawalalcohol withdrawal3.3. hyperexcitability, and agitationhyperexcitability, and agitation4.4. pre-operative relief of anxiety and pre-operative relief of anxiety and

tension and in induction of balanced tension and in induction of balanced anesthesia. anesthesia.

The BENZODIAZEPINESThe BENZODIAZEPINESPharmacodynamics: The adverse effectsPharmacodynamics: The adverse effects

CNS effects= CNS effects= sedation, drowsiness, sedation, drowsiness, depression, lethargy, blurred visiondepression, lethargy, blurred visionGIT= GIT= dry mouth, constipationdry mouth, constipation, nausea, , nausea, vomitingvomitingCVS= CVS= HypotensionHypotension or hypertension, or hypertension, arrhythmias, palpitations, and arrhythmias, palpitations, and respiratory difficulties. respiratory difficulties. Hematologic= blood dyscrasias and Hematologic= blood dyscrasias and anemiaanemiaGU= urinary retention, hesitancy, loss of GU= urinary retention, hesitancy, loss of libido and sexual functions changes.libido and sexual functions changes.


Nursing Considerations:Nursing Considerations:Maintain patients on bed for at Maintain patients on bed for at least 3 hours after drug least 3 hours after drug administration.administration. Instruct to avoid hazardous Instruct to avoid hazardous activities like driving and machine activities like driving and machine operation. operation. Instruct to avoid consuming Instruct to avoid consuming ALCOHOL while taking the drugALCOHOL while taking the drug..


Nursing Considerations:Nursing Considerations:Provide comfort measures to help Provide comfort measures to help patients tolerate drug effects-patients tolerate drug effects-– instruct to urinate before taking instruct to urinate before taking

drugdrug– give high fiber foodsgive high fiber foods– use side-rails and assistance with use side-rails and assistance with

ambulation.ambulation.Have available Have available FLUMAZENIL as an FLUMAZENIL as an antidote for benzodiazepine antidote for benzodiazepine overdose.overdose.

The BARBITURATESThe BARBITURATES

These are also anxiolytics and These are also anxiolytics and hypnotics with a greater likelihood of hypnotics with a greater likelihood of producing sedation, with increase producing sedation, with increase risk of addiction and dependence. risk of addiction and dependence.


The following are the barbituratesThe following are the barbiturates

amobarbitalamobarbitalaprobarbitalaprobarbitalbutabarbitalbutabarbitalmephobarbitalmephobarbitalpentobarbitalpentobarbitalPhenobarbitalPhenobarbitalsecobarbitalsecobarbital


The Mechanism of Action of the The Mechanism of Action of the BarbituratesBarbituratesThey depress the motor output from the They depress the motor output from the brain.brain.The results of their MOA are sedation, The results of their MOA are sedation, hypnosis and anesthesia, and if extreme, hypnosis and anesthesia, and if extreme, coma.coma.


Clinical indications of the BarbituratesClinical indications of the Barbiturates1.1. Relief of anxiety manifestationsRelief of anxiety manifestations2.2. For sedationFor sedation3.3. For patients with insomniaFor patients with insomnia4.4. For pre-anesthesiaFor pre-anesthesia5.5. seizures/epilepsyseizures/epilepsy6.6. The rapid acting barbiturates are also The rapid acting barbiturates are also

used for the treatment of acute manic used for the treatment of acute manic reactions and status epilepticusreactions and status epilepticus

The BARBITURATESThe BARBITURATESPharmacodynamics: The Adverse effectsPharmacodynamics: The Adverse effects

CNS= CNS= CNS depressionCNS depression, somnolence, somnolence, , vertigo, lethargy, ataxia, paradoxical vertigo, lethargy, ataxia, paradoxical excitement, anxiety and hallucinations.excitement, anxiety and hallucinations.GIT= GIT= nausea, vomiting,nausea, vomiting, constipation/diarrhea and epigastric painconstipation/diarrhea and epigastric painCVS= bradycardia, Hypotension and CVS= bradycardia, Hypotension and syncope. syncope. Respi= serious hypoventilation, respiratory Respi= serious hypoventilation, respiratory depression and laryngospasmsdepression and laryngospasmsOthers= Others= hypersensitivity and Stevens-hypersensitivity and Stevens-Johnson syndrome.Johnson syndrome.

The BARBITURATESThe BARBITURATESNursing ConsiderationsNursing Considerations

Provide stand-by life support facilities Provide stand-by life support facilities in cases of severe respiratory in cases of severe respiratory depression or hypersensitivity reaction.depression or hypersensitivity reaction.Taper the drug gradually after long-term Taper the drug gradually after long-term therapy to avoid withdrawal syndrome.therapy to avoid withdrawal syndrome.Provide comfort measures including Provide comfort measures including small frequent meals, access to small frequent meals, access to bathroom facilities, high-fiber foods, bathroom facilities, high-fiber foods, environmental control, safety environmental control, safety precaution and skin care.precaution and skin care.

The CNS stimulantsThe CNS stimulants

These are drugs used to treat certain These are drugs used to treat certain disordersdisorders

1.1. exogenous obesityexogenous obesity

2.2. attention-deficit hyperactivity attention-deficit hyperactivity disorders (ADHD)disorders (ADHD)

3.3. narcolepsynarcolepsy


What is unusual is the ability of What is unusual is the ability of the CNS stimulants to CALM the CNS stimulants to CALM hyperactive children, which hyperactive children, which allows them to focus on one allows them to focus on one activity for a longer period.activity for a longer period.


The following are the CNS stimulants:The following are the CNS stimulants:

1. 1. Methylphenidate (Ritalin)= most Methylphenidate (Ritalin)= most commonly used for ADHDcommonly used for ADHD

2. Dextroamphetamine= a CNS stimulant 2. Dextroamphetamine= a CNS stimulant that is used for short tem therapy for that is used for short tem therapy for obesity.obesity.

3. Modafinil= used for narcolepsy3. Modafinil= used for narcolepsy

4. Pemoline= used for ADHD4. Pemoline= used for ADHD

The CNS stimulantsThe CNS stimulantsThe Mechanism of Action The Mechanism of Action

These agents act as to stimulate the These agents act as to stimulate the cortical and reticular activating system cortical and reticular activating system (RAS) of the brain. (RAS) of the brain.

This is by releasing neurotransmitters This is by releasing neurotransmitters from the nerve cells leading to from the nerve cells leading to increased increased stimulation of the post-synaptic stimulation of the post-synaptic neurons.neurons.


The paradoxical effect of calming The paradoxical effect of calming hyperexcitability through CNS hyperexcitability through CNS stimulation seen in ADHD is believed to stimulation seen in ADHD is believed to be related to the increased stimulation of be related to the increased stimulation of an IMMATURE Reticular Activating an IMMATURE Reticular Activating System leading to the ability to be more System leading to the ability to be more selective in response to incoming selective in response to incoming stimuli.stimuli.


Pharmacodynamics: Adverse effects of the CNS Pharmacodynamics: Adverse effects of the CNS stimulantsstimulants

CNS= CNS= nervousness, insomnianervousness, insomnia, dizziness, , dizziness, headache, and blurred visionheadache, and blurred vision

GIT=GIT= anorexiaanorexia, nausea and weight loss, nausea and weight loss

CVS= hypertension, tachycardia arrhythmias, and CVS= hypertension, tachycardia arrhythmias, and anginaangina

Others= rashes, physical/psychological Others= rashes, physical/psychological dependence.dependence.

The CNS stimulantsThe CNS stimulantsImplementationImplementation

The nurse must ensure that the drug is only given to The nurse must ensure that the drug is only given to the indicated conditionsthe indicated conditions

Administer the drug before 6 pm to reduce the Administer the drug before 6 pm to reduce the effect of insomniaeffect of insomnia

BEST given AFTER meals to prevent the effect BEST given AFTER meals to prevent the effect of anorexiaof anorexia

Consult with school personnel to monitor the patient Consult with school personnel to monitor the patient under therapyunder therapy

Provide safety measures such as side-rails and Provide safety measures such as side-rails and assisted ambulationassisted ambulation

The CNS stimulantsThe CNS stimulantsEvaluationEvaluation

Evaluate the effectiveness of the drug:Evaluate the effectiveness of the drug:

1.1. Calming effect in the patient with ADHDCalming effect in the patient with ADHD

2.2. Alertness for patients with narcolepsyAlertness for patients with narcolepsy

The Anti-epilepticsThe Anti-epileptics

These agents, also called anticonvulsants, These agents, also called anticonvulsants, are used to treat epileptic conditions.are used to treat epileptic conditions.

Hydantoins, Barbiturates, Hydantoins, Barbiturates, benzodiazepines, Succinimides and many benzodiazepines, Succinimides and many others are given to a specific type of others are given to a specific type of seizure. seizure.

Anti-epilepticsAnti-epilepticsAgents for treating TONIC-CLONIC SEIZURESAgents for treating TONIC-CLONIC SEIZURES1. Hydantoins1. Hydantoins

– PhenytoinPhenytoin– EthotoinEthotoin– FosphenytoinFosphenytoin– MephenytoinMephenytoin

2. Benzodiazepines2. Benzodiazepines– DiazepamDiazepam– ClonazepamClonazepam– Clorazepate Clorazepate

3. Barbiturates3. Barbiturates– PhenobarbitalPhenobarbital

Anti-epilepticsAnti-epileptics

Agents for treating ABSENCE SEIZURESAgents for treating ABSENCE SEIZURES1. Succinimides1. Succinimides

a. Ethosuximidea. Ethosuximide b. Methsuximideb. Methsuximide c. Phensuximidec. Phensuximide

2. Valproic Acid2. Valproic Acid3. Zosinamide3. Zosinamide

Anti-epilepticsAnti-epileptics

Agents for treating Partial FOCAL SEIZURESAgents for treating Partial FOCAL SEIZURES1. Carbamazepine1. Carbamazepine2. Gabapentin2. Gabapentin3.Lamotrigine3.Lamotrigine4. Tiagabine4. Tiagabine5. Topiramate5. Topiramate

The hydantoinsThe hydantoins

These agents are utilized for general seizures These agents are utilized for general seizures because they can depress the central because they can depress the central nervous system. nervous system.

They affect the entire brain and reduce the They affect the entire brain and reduce the chance of sudden electrical outburst that chance of sudden electrical outburst that causes seizures. causes seizures.

These agents generally are less sedating than These agents generally are less sedating than other anti-epilepticsother anti-epileptics..


Mechanism of Action of the HydantoinsMechanism of Action of the Hydantoins

These agents STABILIZE the nerve cell These agents STABILIZE the nerve cell membrane throughout the brain reducing membrane throughout the brain reducing and limiting the excitability and and limiting the excitability and conduction through nerve pathways.conduction through nerve pathways.


Clinical Indications of the hydantoinsClinical Indications of the hydantoins

1.1. Tonic-clonic seizuresTonic-clonic seizures

2.2. Status epilepticusStatus epilepticus

3.3. For the prevention of seizures in For the prevention of seizures in neurosurgeryneurosurgery

4.4. For muscle relaxation. For muscle relaxation.


Contraindications and PrecautionsContraindications and Precautions

Hydantoins are NOT given to pregnant Hydantoins are NOT given to pregnant patient because it can cause fetal patient because it can cause fetal hydantoin syndromehydantoin syndrome. .

The hydantoinsThe hydantoinsPharmacodynamics: Adverse effects of the Pharmacodynamics: Adverse effects of the

HydantoinsHydantoinsCNS effects- depression, confusion, CNS effects- depression, confusion, drowsiness, lethargy, fatiguedrowsiness, lethargy, fatigueGIT- GI upset, constipation, dry mouthGIT- GI upset, constipation, dry mouth, , GINGIVAL HYPERPLASIA , severe liver toxicity GINGIVAL HYPERPLASIA , severe liver toxicity which are all related to cellular toxicity.which are all related to cellular toxicity.SKIN- hirsutism and coarsening of the facial SKIN- hirsutism and coarsening of the facial skinskinBone Marrow depressionBone Marrow depression

The hydantoinsThe hydantoinsImplementationImplementation

Administer the drug with food to alleviate Administer the drug with food to alleviate GI irritationGI irritationDiscontinue the drug at any sign of Discontinue the drug at any sign of hypersensitivity reaction, severe liver hypersensitivity reaction, severe liver dysfunction and severe skin rashes.dysfunction and severe skin rashes.Provide meticulous mouth oral careProvide meticulous mouth oral careRule out pregnancy and advise women to Rule out pregnancy and advise women to use contraceptive measures to prevent use contraceptive measures to prevent pregnancy.pregnancy.

Drugs affecting GI secretionsDrugs affecting GI secretions

There are five types of drugs that affect There are five types of drugs that affect gastric acid secretions and are useful gastric acid secretions and are useful for the treatment of peptic ulcer.for the treatment of peptic ulcer.

1.1. Histamine (H2) receptor Histamine (H2) receptor antagonist/blockersantagonist/blockers

2.2. AntacidsAntacids

3.3. Proton pump inhibitorsProton pump inhibitors

4.4. Mucosal protectantsMucosal protectants

5.5. Prostaglandin analogsProstaglandin analogs

Drugs affecting secretions:Drugs affecting secretions: anti ulcer anti ulcer

Anti-ulcer drugs Prototype

Histamine (H2) receptor antagonist/blockers

Cimetidine

Antacids AlOH and MgOH

Proton pump inhibitors Omeprazole

Mucosal protectants Sucralfate

Prostaglandin analog Misoprostol

General indication of the drugs General indication of the drugs affecting gastric acid secretionaffecting gastric acid secretion

►Peptic ulcerPeptic ulcer►GastritisGastritis►Patient on NPO to prevent stress ulcerPatient on NPO to prevent stress ulcer

General time of administration of the General time of administration of the drugs affecting gastric acid secretiondrugs affecting gastric acid secretion

Anti-ulcer drugs Prototype Best time to give

Histamine (H2) receptor antagonist/blockers

Cimetidine With FOOD or ONE hour after ANTACID

Antacids AlOH and MgOH Usually after meals

Proton pump inhibitors

Omeprazole BEFORE MEALS

Mucosal protectants

Sucralfate BEFORE MEALS

Prostaglandin analog

Misoprostol WITH MEALS

Pharmacology of Anti-Pharmacology of Anti-ulcer drugsulcer drugs

Drug Drug Mechanism of Action

Antacids- AlOH, MgOHAntacids- AlOH, MgOH Neutralize Gastric ACIDITY

H2-Blockers- “H2-Blockers- “tidinetidine””

CimetidineCimetidine, Ranitidine, RanitidineBlock Histamine receptor causing decreased secretion and acidity

Proton pump inhibitors- Proton pump inhibitors- ““Prazoles”Prazoles”

Omeprazole, pantoprazoleOmeprazole, pantoprazole

Inhibit Proton Pump in parietal cell decreasing secretion and acidity

Pharmacology of Anti-ulcer Pharmacology of Anti-ulcer drugsdrugs

Drug Drug Mechanism of Action

Anti-cholinergic- Anti-cholinergic- Prophanteline BromideProphanteline Bromide

Blocks VAGUS nerve, decreases secretion

Sucralfate (Carafate)Sucralfate (Carafate) Coats the mucosal lining

Misoprostol (Cytotec)Misoprostol (Cytotec) Prostaglandin Analogue, causes secretion of MUCUS

PharmacodynamicsPharmacodynamics

Histamine (H2) receptor Histamine (H2) receptor blockersblockers

►These drugs BLOCK the These drugs BLOCK the release of hydrochloric acid in release of hydrochloric acid in the stomach in response to the stomach in response to gastringastrin


AntacidsAntacids►These drugs interact with These drugs interact with

the gastric acids at the the gastric acids at the chemical level to neutralize chemical level to neutralize themthem


Proton pump inhibitorsProton pump inhibitors►These drugs suppress the These drugs suppress the

secretion of hydrochloric secretion of hydrochloric acid into the lumen of the acid into the lumen of the stomachstomach


Mucosal protectantsMucosal protectants►These are agents that coat These are agents that coat

any injured area in the any injured area in the stomach to prevent further stomach to prevent further injury from acidinjury from acid


Prostaglandin analogsProstaglandin analogs►These are agents that These are agents that inhibitinhibit

the secretion of gastrin and the secretion of gastrin and ►increaseincrease the secretion of the secretion of

mucus lining of the stomach, mucus lining of the stomach, providing a buffer.providing a buffer.

The H2 Blockers- “tidines”The H2 Blockers- “tidines”

Prototype: CimetidinePrototype: Cimetidine

►1. Ranitidine1. Ranitidine►2. Famotidine2. Famotidine►3. Nizatidine3. Nizatidine


Pharmacodynamics: Drug ActionPharmacodynamics: Drug Action► The H2 blockers are antagonists at the The H2 blockers are antagonists at the

receptors in the parietal cells of the receptors in the parietal cells of the stomach. stomach.

► The blockage results to inhibition of The blockage results to inhibition of the hormone gastrin. the hormone gastrin.

► There will be decreased production of There will be decreased production of gastric acid from the parietal cells.gastric acid from the parietal cells.

► Also, the chief cells will secrete less Also, the chief cells will secrete less pepsinogen.pepsinogen.


Therapeutic use of the H2 blockersTherapeutic use of the H2 blockers► Short-term treatment of active duodenal Short-term treatment of active duodenal

ulcer or benign gastric ulcerulcer or benign gastric ulcer► Treatment of hypersecretory conditions like Treatment of hypersecretory conditions like

the Zollinger-Ellison syndromethe Zollinger-Ellison syndrome► Prevention of stress-induced ulcers and Prevention of stress-induced ulcers and

acute GI bleedingacute GI bleeding► Treatment of erosive GERD (reflux disease)Treatment of erosive GERD (reflux disease)► Relief of Symptoms of heart burn and acid Relief of Symptoms of heart burn and acid

indigestion indigestion


Precautions and ContraindicationsPrecautions and Contraindications►Any known allergy is a clear Any known allergy is a clear

contraindication to the use of the contraindication to the use of the agents. Conditions such as pregnancy, agents. Conditions such as pregnancy, lactation, renal dysfunction and hepatic lactation, renal dysfunction and hepatic dysfunction should warrant cautious dysfunction should warrant cautious use. use.

►Nizatidine can be used in hepatic Nizatidine can be used in hepatic dysfunction. dysfunction.


Pharmocodynamics- Side effects and adverse Pharmocodynamics- Side effects and adverse effectseffects

► GIT= diarrhea or constipationGIT= diarrhea or constipation► CNS= Dizziness, headache, drowsiness, CNS= Dizziness, headache, drowsiness,

confusion and hallucinationsconfusion and hallucinations► Cardio= arrhythmias, Cardio= arrhythmias, HYPOTENSIONHYPOTENSION

(related to H2 receptor blockage in the heart)(related to H2 receptor blockage in the heart)► Cimetidine= Cimetidine= TREMORS,TREMORS, Gynecomastia Gynecomastia

and impotence in malesand impotence in males


Drug-drug InteractionsDrug-drug Interactions►Cimetidine, Famotidine, Cimetidine, Famotidine,

Ranitidine are metabolized in the Ranitidine are metabolized in the liver- they can cause slowing of liver- they can cause slowing of excretion of other drugs leading excretion of other drugs leading to their increased concentration.to their increased concentration.


Drug-drug InteractionsDrug-drug Interactions►These drugs can interact with These drugs can interact with

CIMETIDINE anticoagulants, CIMETIDINE anticoagulants, phenytoin, alcohol, phenytoin, alcohol, antidepressants.antidepressants.

The H2 Blockers- “tidines”The H2 Blockers- “tidines”Nursing considerations:Nursing considerations:►Administer the drug Administer the drug WITH WITH mealsmeals

at at BEDTIME BEDTIME to ensure to ensure therapeutic leveltherapeutic level

►One hour after AntacidsOne hour after Antacids►Stress the importance of the Stress the importance of the

continued use for the length of continued use for the length of time prescribed time prescribed

The H2 Blockers- “tidines”The H2 Blockers- “tidines”Nursing considerations:Nursing considerations:►Monitor the cardiovascular Monitor the cardiovascular

status especially if the drugs are status especially if the drugs are given IVgiven IV

►Warn patient of the potential Warn patient of the potential problems of increased drug problems of increased drug concentration if the H2 blockers concentration if the H2 blockers are used with other drugs or OTC are used with other drugs or OTC drugs. Advise consultation first!drugs. Advise consultation first!


Nursing considerations:Nursing considerations:►Provide comfort measures like Provide comfort measures like

analgesics for headache, analgesics for headache, assistance with ambulation and assistance with ambulation and safety measuressafety measures

►Warn the patients taking Warn the patients taking cimetidine that drowsiness may cimetidine that drowsiness may pose a hazard if driving or pose a hazard if driving or operating delicate machines.operating delicate machines.


Nursing considerations:Nursing considerations:►Provide health teaching as to the dose, Provide health teaching as to the dose,

frequency, comfort measures to frequency, comfort measures to initiate when side-effects are initiate when side-effects are intolerableintolerable

Evaluate the effectiveness:Evaluate the effectiveness:►Relief of symptoms of ulcer, heart burn Relief of symptoms of ulcer, heart burn

and GERDand GERD

The AntacidsThe Antacids

► These are drugs or inorganic chemicals These are drugs or inorganic chemicals that have been used for years to neutralize that have been used for years to neutralize acid in the stomach. The following are the acid in the stomach. The following are the common antacids that can be bought OTC:common antacids that can be bought OTC:

► Aluminum salts (hydroxide)Aluminum salts (hydroxide)► Calcium salts (carbonate)Calcium salts (carbonate)► MagnesiumMagnesium salts (milk of magnesia) salts (milk of magnesia)► Sodium bicarbonateSodium bicarbonate► Magaldrate (aluminum and magnesium Magaldrate (aluminum and magnesium

combination)combination)


Pharmacodynamics: drug actionPharmacodynamics: drug action►These agents act to neutralize the These agents act to neutralize the

acidic pH in the stomach. acidic pH in the stomach. ►They do not affect the rate of gastric They do not affect the rate of gastric

acid secretion. acid secretion.


Pharmacodynamics: drug actionPharmacodynamics: drug action►The administration of antacid may The administration of antacid may

cause an acid rebound. cause an acid rebound. ►Neutralizing the stomach content to an Neutralizing the stomach content to an

alkaline level stimulates gastrin alkaline level stimulates gastrin production to cause an increase in acid production to cause an increase in acid production and return the stomach to production and return the stomach to its normal acidic state. its normal acidic state.


Therapeutic IndicationsTherapeutic Indications►Symptomatic relief of upset stomach Symptomatic relief of upset stomach

associated with hyperacidity associated with hyperacidity ►Hyperacidic conditions like peptic ulcer, Hyperacidic conditions like peptic ulcer,

gastritis, esophagitis and hiatal herniagastritis, esophagitis and hiatal hernia►Special use of AMPHOGEL Special use of AMPHOGEL

(aluminum hydroxide): to BIND (aluminum hydroxide): to BIND phosphatephosphate


Precautions of Antacid UsePrecautions of Antacid Use►Known allergy is a clear Known allergy is a clear

contraindication. Caution should be contraindication. Caution should be instituted if used in electrolyte instituted if used in electrolyte imbalances, GI obstruction and renal imbalances, GI obstruction and renal dysfunction. dysfunction.

►Sodium bicarbonate is rarely used Sodium bicarbonate is rarely used because of potential systemic because of potential systemic absorptionabsorption


PharmacokineticsPharmacokinetics► These agents are taken orally and act These agents are taken orally and act

locally in the stomachlocally in the stomach

The AntacidsThe AntacidsPharmacodynamics: Effects of drugsPharmacodynamics: Effects of drugs1.1. GIT= rebound acidity; alkalosis may occur.GIT= rebound acidity; alkalosis may occur.► Calcium salts may lead to Calcium salts may lead to hypercalcemiahypercalcemia ► Magnesium salts can cause DIARRHEAMagnesium salts can cause DIARRHEA► Aluminum salts may cause Aluminum salts may cause

CONSTIPATION and hypophosphatemia CONSTIPATION and hypophosphatemia by binding with phosphates in the GIT.by binding with phosphates in the GIT.

2. 2. Fluid retentionFluid retention due to the high sodium due to the high sodium content of the antacids.content of the antacids.

The AntacidsThe AntacidsNursing Considerations:Nursing Considerations:►Administer the antacids apart from Administer the antacids apart from

any other medications by any other medications by ONE hour ONE hour beforebefore or or TWO hours after-TWO hours after- to to ensure adequate absorption of the ensure adequate absorption of the other medicationsother medications

►Tell the patient to Tell the patient to CHEWCHEW the tablet the tablet thoroughly before swallowing. Follow thoroughly before swallowing. Follow it with one glass of waterit with one glass of water

►Regularly monitor for manifestations Regularly monitor for manifestations of acid-base imbalances as well as of acid-base imbalances as well as electrolyte imbalanceselectrolyte imbalances


Nursing Considerations:Nursing Considerations:► Provide comfort measures to alleviate Provide comfort measures to alleviate

constipation associated with aluminum constipation associated with aluminum and diarrhea associated with magnesium and diarrhea associated with magnesium salts. salts.

► Monitor for the side-effects, Monitor for the side-effects, effectiveness of the comfort measures, effectiveness of the comfort measures, patient’s response to the medication and patient’s response to the medication and the effectiveness of the health teachingsthe effectiveness of the health teachings


Nursing Considerations:Nursing Considerations:►Evaluate for effectiveness:Evaluate for effectiveness:

Decreased symptoms of ulcer and Decreased symptoms of ulcer and pyrosispyrosis

Decreased Phosphate level Decreased Phosphate level (amphogel)(amphogel)

The PPIThe PPI

These are the newer agents for ulcer These are the newer agents for ulcer treatment treatment

►The “prazoles”The “prazoles”

Prototype: OmePrototype: Omeprazoleprazole►LanisoLanisoprazoleprazole►EsomeEsomeprazoleprazole►PantoPantoprazoleprazole

The PPIThe PPIPharmacodynamics: drug actionPharmacodynamics: drug action►They act at specific secretory surface They act at specific secretory surface

receptors to prevent the final step of receptors to prevent the final step of acid production and thus decrease acid production and thus decrease the level of acid in the stomach.the level of acid in the stomach.

►The “pump” in the parietal cell is the The “pump” in the parietal cell is the H-K H-K ATPase enzyme system on the ATPase enzyme system on the secretory surface of the gastric secretory surface of the gastric parietal cellsparietal cells

The PPIThe PPI

Clinical use of the PPIsClinical use of the PPIs►Short-term treatment of active Short-term treatment of active

duodenal ulcers, GERD, erosive duodenal ulcers, GERD, erosive esophagitis and benign gastric ulcer.esophagitis and benign gastric ulcer.

► Long-term- maintenance therapy for Long-term- maintenance therapy for healing of erosive disorders.healing of erosive disorders.

The PPIThe PPI

Clinical use of the PPIs.Clinical use of the PPIs.

Precautions with the use of the PPIsPrecautions with the use of the PPIs►Known allergy is a clear Known allergy is a clear

contraindication. Caution if patient is contraindication. Caution if patient is pregnantpregnant

The PPIThe PPI

Pharmacodynamics: Adverse effectsPharmacodynamics: Adverse effects►CNS- CNS- dizzinessdizziness,, headache, asthenia headache, asthenia

(loss of strength), (loss of strength), vertigovertigo,, insomnia, insomnia, apathyapathy

►GIT- diarrhea, abdominal pain, GIT- diarrhea, abdominal pain, nausea, vomiting, dry mouthnausea, vomiting, dry mouth and and tongue atrophytongue atrophy

►Respi- cough, stuffy nose, hoarseness Respi- cough, stuffy nose, hoarseness and epistaxis.and epistaxis.

The PPIThe PPI

Nursing considerations:Nursing considerations:►Administer the drug Administer the drug BEFORE BEFORE meals. meals.

Ensure that patient does not open, Ensure that patient does not open, chew or crush the drug. chew or crush the drug.

►Provide safety measures if CNS Provide safety measures if CNS dysfunction happens. dysfunction happens.

►Arrange for a medical follow-up if Arrange for a medical follow-up if symptoms are NOT resolved after 4-8 symptoms are NOT resolved after 4-8 weeks of therapy. weeks of therapy.

The PPIThe PPI

Nursing considerations: Nursing considerations: ►Provide health teaching as to drug Provide health teaching as to drug

name, dosages and frequency, safety name, dosages and frequency, safety measures to handle common measures to handle common problems. problems.

►Monitor patient response to the drug, Monitor patient response to the drug, the effectiveness of the teaching plan the effectiveness of the teaching plan and the measures to employand the measures to employ

The PPIThe PPI

Nursing considerations: Nursing considerations:

Evaluate for effectiveness of the drugEvaluate for effectiveness of the drug►Healing of peptic ulcerHealing of peptic ulcer►Decreased symptoms of ulcerDecreased symptoms of ulcer

The Mucosal ProtectantThe Mucosal Protectant

SucralfateSucralfate►This is given to protect the eroded This is given to protect the eroded

ulcer sites in the GIT from further ulcer sites in the GIT from further damage by acid and digestive damage by acid and digestive enzymesenzymes

SucralfateSucralfate

Pharmacodynamics: Action of drugPharmacodynamics: Action of drug► It forms an It forms an ulcer-adherent complexulcer-adherent complex at at

duodenal ulcer sites, protecting the duodenal ulcer sites, protecting the sites against acid, pepsin and bile. sites against acid, pepsin and bile.

►This action prevents further This action prevents further breakdown of proteins in the area and breakdown of proteins in the area and promotes healing. promotes healing.


Clinical use of sucralfateClinical use of sucralfate►Short and long term management of Short and long term management of

duodenal ulcer.duodenal ulcer.►NSAIDs induced gastritis NSAIDs induced gastritis ►Prevention of stress ulcerPrevention of stress ulcer►Treatment of oral and esophageal Treatment of oral and esophageal

ulcers due to radiation, chemotherapy ulcers due to radiation, chemotherapy or sclerotherapy.or sclerotherapy.


Precautions on the use of SucralfatePrecautions on the use of Sucralfate►This agent should NOT be given to This agent should NOT be given to

any person with known allergy to the any person with known allergy to the drug, and to those patients with renal drug, and to those patients with renal failure/dialysis because of build-up of failure/dialysis because of build-up of aluminum may occur if used with aluminum may occur if used with aluminum containing products.aluminum containing products.


Pharmacodynamics: Side-effects & Pharmacodynamics: Side-effects & adverse reactionsadverse reactions

►Primarily GIT= CONSTIPATION, Primarily GIT= CONSTIPATION, occasionally diarrhea, nausea, occasionally diarrhea, nausea, indigestion, gastric discomfort, indigestion, gastric discomfort, and dry mouth may also occurand dry mouth may also occur

►CNS= dizziness, drowsiness, vertigoCNS= dizziness, drowsiness, vertigo►Others= rash and back painOthers= rash and back pain


Drug-drug interactionsDrug-drug interactions►If used with aluminum salts= high If used with aluminum salts= high

risk of accumulation of aluminum risk of accumulation of aluminum and toxicityand toxicity..

► If used with phenytoin, If used with phenytoin, fluoroquinolones and penicillamines- fluoroquinolones and penicillamines- decreased levels of these drugs when decreased levels of these drugs when taken with sucralfatetaken with sucralfate


Nursing ConsiderationsNursing Considerations► Administer drug Administer drug ON AN EMPTY stomachON AN EMPTY stomach, ,

1 hour before meals , or 2 hour after 1 hour before meals , or 2 hour after meals and at BEDTIMEmeals and at BEDTIME

► Monitor for side-effects like constipation Monitor for side-effects like constipation and GI upsetand GI upset

► Encourage intake of high-fiber foods and Encourage intake of high-fiber foods and increased fluid intakeincreased fluid intake

► Administer antacids Administer antacids BETWEENBETWEEN doses of doses of sucralfate, sucralfate, NOT WITHIN 30NOT WITHIN 30 minutes of minutes of sucralfate dosesucralfate dose


Nursing ConsiderationsNursing Considerations►Provide comfort measures if CNS effects Provide comfort measures if CNS effects

occuroccur►Provide health teaching as to drug Provide health teaching as to drug

name, dosages and frequency, safety name, dosages and frequency, safety measures to handle common problems. measures to handle common problems.

►Monitor patient response to the drug, Monitor patient response to the drug, the effectiveness of the teaching plan the effectiveness of the teaching plan and the measures employedand the measures employed


Nursing ConsiderationsNursing Considerations►Evaluate effectiveness of therapyEvaluate effectiveness of therapy

Healing of ulcerHealing of ulcer

No formation of ulcerNo formation of ulcer

Prostaglandin analogueProstaglandin analogue

MisoprostolMisoprostol►This agent is a synthetic prostaglandin This agent is a synthetic prostaglandin

E1 analog that is employed to protect E1 analog that is employed to protect the lining of the mucosa of the the lining of the mucosa of the stomach stomach


Misoprostol: PharmacodynamicsMisoprostol: Pharmacodynamics►Being a prostaglandin analog, it Being a prostaglandin analog, it

inhibitsinhibits gastric acid secretion to some gastric acid secretion to some degreedegree

► It It INCREASES mucusINCREASES mucus production in production in the stomach lining. the stomach lining.


Misoprostol: Clinical useMisoprostol: Clinical use►NSAIDs-induced gastric ulcers NSAIDs-induced gastric ulcers ►Duodenal ulcers unresponsive to H2 Duodenal ulcers unresponsive to H2

antagonists.antagonists.


Precautions of Misoprostol UsePrecautions of Misoprostol Use► This drug is CONTRAINDICATED during This drug is CONTRAINDICATED during

pregnancy because it is an pregnancy because it is an abortifacient.abortifacient.► Women should be advised to have a Women should be advised to have a

negative pregnancy test within 2 negative pregnancy test within 2 weeks of beginning therapy and should weeks of beginning therapy and should begin the drug on the second or third begin the drug on the second or third day of the next menstrual cycle.day of the next menstrual cycle.

► They should be instructed in the use of They should be instructed in the use of contraceptives during therapy. contraceptives during therapy.


Pharmacodynamic effects: drug Pharmacodynamic effects: drug reactionsreactions

►GIT= Nausea, diarrhea, abdominal GIT= Nausea, diarrhea, abdominal pain, flatulence, vomiting, dyspepsia pain, flatulence, vomiting, dyspepsia

►GU effects= miscarriages, GU effects= miscarriages, excessive excessive uterine CRAMPING and bleedinguterine CRAMPING and bleeding, , spotting, hypermenorrhea and spotting, hypermenorrhea and menstrual disorders.menstrual disorders.


Nursing ConsiderationsNursing Considerations► Administer to patients at risk for NSAIDs-Administer to patients at risk for NSAIDs-

induced ulcers during the full course of induced ulcers during the full course of NSAIDs therapyNSAIDs therapy

► Administer four times daily with meals and Administer four times daily with meals and at bedtimeat bedtime

► Obtain pregnancy test within 2 weeks of Obtain pregnancy test within 2 weeks of beginning therapy. Begin the therapy on beginning therapy. Begin the therapy on second or third day of menstrual period second or third day of menstrual period to to ensure that the woman is not pregnantensure that the woman is not pregnant


Nursing ConsiderationsNursing Considerations► Provide patient with both written and oral Provide patient with both written and oral

information regarding the associated risks information regarding the associated risks of pregnancyof pregnancy

► Provide health teaching as to drug name, Provide health teaching as to drug name, dosages and frequency, safety measures dosages and frequency, safety measures to handle common problems. to handle common problems.

► Monitor patient response to the drug, the Monitor patient response to the drug, the effectiveness of the teaching plan and the effectiveness of the teaching plan and the measures to employmeasures to employ

LaxativesLaxativesType Prototype Action

Chemical stimulants

Bisacodyl (Dulcolax) Direct stimulation of the GIT nerves Irritant laxatives

Mechanical (bulk) stimulants

Lactulose Increased fluid content of the fecal material causing stimulation of the local reflex

Lubricants Docusate Lubricating the intestinal material to promote passage through the GIT

LaxativesLaxatives

►Generally used to INCREASE the Generally used to INCREASE the passage of the colonic contentspassage of the colonic contents

►The general classifications is as The general classifications is as follows:follows:

1. Chemical stimulants1. Chemical stimulants

2. Mechanical stimulants2. Mechanical stimulants

3. Lubricants3. Lubricants

Therapeutic Indications of the Therapeutic Indications of the LaxativesLaxatives

►SHORT term relief of SHORT term relief of ConstipationConstipation►Prevention of strainingPrevention of straining in in

conditions like CHF, post-MI, post conditions like CHF, post-MI, post partum, post-oppartum, post-op

►Preparation for Preparation for diagnostic diagnostic examinationexamination

►Removal of poison or toxinsRemoval of poison or toxins►Adjunct in anti-helminthic therapyAdjunct in anti-helminthic therapy

Contraindications in Laxative Contraindications in Laxative useuse

►ACUTE abdominal disordersACUTE abdominal disorders AppendicitisAppendicitis DiverticulitisDiverticulitis Ulcerative colitisUlcerative colitis

Chemical Stimulant Chemical Stimulant CatharticsCathartics

Prototype: BisacodylPrototype: Bisacodyl

Irritant laxatives:Irritant laxatives:►1. Castor oil1. Castor oil►2. Senna2. Senna►3. Cascara3. Cascara►4. Phenolphthalein4. Phenolphthalein

Chemical Stimulant Chemical Stimulant CatharticsCathartics

PharmacodynamicsPharmacodynamics►These agents DIRECTLY stimulate the These agents DIRECTLY stimulate the

nerve plexus in the intestinal wallnerve plexus in the intestinal wall►The result is INCREASED movement or The result is INCREASED movement or

motility of the colonmotility of the colon

Mechanical Stimulant Mechanical Stimulant CatharticsCathartics

►Prototype: LACTULOSE (Cephulac)Prototype: LACTULOSE (Cephulac)

Bulk-forming laxativesBulk-forming laxatives►1. Magnesium (citrate, hydroxide, 1. Magnesium (citrate, hydroxide,

sulfate)sulfate)►2. Psyllium2. Psyllium►3. Polycarbophil3. Polycarbophil

Mechanical Stimulant Mechanical Stimulant CatharticsCathartics

PharmacodynamicsPharmacodynamics►These agents are rapid-acting These agents are rapid-acting

laxatives that INCREASE the GI motility laxatives that INCREASE the GI motility byby Increasing the fluids in the colonic Increasing the fluids in the colonic

materialmaterial Stimulating the local stretch receptorsStimulating the local stretch receptors Activating Activating local defection reflexlocal defection reflex

LubricantsLubricants

►Prototype: DocusatePrototype: Docusate

►1. Glycerin1. Glycerin►2. Mineral oil2. Mineral oil

LubricantsLubricants

PharmacodynamicsPharmacodynamics►Docusate increases the admixture of Docusate increases the admixture of

fat and water producing a softer stoolfat and water producing a softer stool►Glycerin Glycerin ►Mineral oil forms a slippery coat on the Mineral oil forms a slippery coat on the

colonic contents colonic contents

Pharmacokinetics: Pharmacokinetics: Common Side-effects of the Common Side-effects of the

LaxativesLaxatives►DiarrheaDiarrhea►Abdominal crampingAbdominal cramping►NauseaNausea►Fluid and electrolyte imbalanceFluid and electrolyte imbalance►Sympathetic reactions- sweating, Sympathetic reactions- sweating,

palpitations, flushing and faintingpalpitations, flushing and fainting►CATHARTIC dependenceCATHARTIC dependence

The Nursing Process and The Nursing Process and LaxativeLaxative

ASSESSMENTASSESSMENT►Nursing History- elicit allergy to any Nursing History- elicit allergy to any

laxatives, elicit history of conditions laxatives, elicit history of conditions like diverticulitis and ulcerative colitislike diverticulitis and ulcerative colitis

►Physical Examination- abdominal Physical Examination- abdominal assessmentassessment

►Laboratory Test: fecalysis, electrolyte Laboratory Test: fecalysis, electrolyte levelslevels


NURSING DIAGNOSISNURSING DIAGNOSIS►Alteration in bowel patternAlteration in bowel pattern►Alteration in comfort: painAlteration in comfort: pain►Knowledge deficitKnowledge deficit


IMPLEMENTATIONIMPLEMENTATION

1.1. Emphasize that it is use on a Emphasize that it is use on a SHORT SHORT term basisterm basis

2.2. Provide comfort and safety measures Provide comfort and safety measures like ready access to the bathroom, like ready access to the bathroom, side-rails side-rails

3.3. Administer with a Administer with a full glass of waterfull glass of water



4. 4. Encourage fluid intake, high fiber diet Encourage fluid intake, high fiber diet and daily exerciseand daily exercise

5. DO NOT administer if acute 5. DO NOT administer if acute abdominal condition like abdominal condition like appendicitis is presentappendicitis is present

6. Advise to change position slowly an 6. Advise to change position slowly an avoid hazardous activities because of avoid hazardous activities because of potential dizzinesspotential dizziness


EVALUATION of drug effectivenessEVALUATION of drug effectiveness

1.1. Evaluate relief of GI symptoms, Evaluate relief of GI symptoms, absence of staining and increased absence of staining and increased evacuation of GI tractevacuation of GI tract

2.2. For Lactulose: decreased ammoniaFor Lactulose: decreased ammonia

The Anti-diarrhealsThe Anti-diarrheals

►These are agents used to calm the These are agents used to calm the irritation of the GIT for the irritation of the GIT for the symptomatic relief of diarrheasymptomatic relief of diarrhea

►General ClassificationsGeneral Classifications

1. Local anti-motility1. Local anti-motility

2. Local reflex inhibition2. Local reflex inhibition

3. Central action on the CNS3. Central action on the CNS

The Anti-diarrhealsThe Anti-diarrhealsType Prototype Action

Local reflex inhibitor Bismuth subsalicylate Locally coats the lining of the GIT to soothe irritation that may stimulate the reflex

Local anti-motility Loperamide Directly inhibits the intestinal muscle activity to SLOW peristalsis

Central acting agent Opium derivatives (paregoric)

Stops GIT spasm by CNS action

Clinical Indications of drug Clinical Indications of drug useuse

►Relief of symptoms of acute and Relief of symptoms of acute and chronic diarrheachronic diarrhea

►Reduction of fecal volume discharges Reduction of fecal volume discharges from ileostomies from ileostomies

►Prevention and treatment of traveler's Prevention and treatment of traveler's diarrheadiarrhea

Contraindications of anti-Contraindications of anti-diarrheal Usediarrheal Use

►PoisoningPoisoning►Drug allergyDrug allergy►GI obstructionGI obstruction►Acute abdominal conditionsAcute abdominal conditions

Pharmacokinetics: Side Pharmacokinetics: Side effectseffects

►ConstipationConstipation►Nausea, vomitingNausea, vomiting►Abdominal distention and Abdominal distention and

discomfort discomfort ►TOXIC MEGACOLONTOXIC MEGACOLON

Nursing process and anti-Nursing process and anti-diarrhealsdiarrheals

ASSESSMENTASSESSMENT►Nursing History – Elicit history of drug Nursing History – Elicit history of drug

allergy, conditions like poisoning, GI allergy, conditions like poisoning, GI obstruction and acute abdominal obstruction and acute abdominal conditionsconditions

►Physical Examination- Abdominal Physical Examination- Abdominal examinationexamination

►Laboratory test- electrolyte levelsLaboratory test- electrolyte levels


NURSING DIAGNOSISNURSING DIAGNOSIS►Alteration in bowel patternAlteration in bowel pattern►Alteration in comfort: painAlteration in comfort: pain



1.1. Monitor patient response within 48 Monitor patient response within 48 hours. Discontinue drug use if no hours. Discontinue drug use if no effecteffect

2.2. Provide comfort measures for painProvide comfort measures for pain

3.3. Provide teaching Provide teaching


EVALUATIONEVALUATION

1.1. Monitor effectiveness of drug- Monitor effectiveness of drug- RELIEF of diarrheaRELIEF of diarrhea

2.2. Monitor adverse effects, Monitor adverse effects, effectiveness of pain measures and effectiveness of pain measures and effectiveness of teaching planeffectiveness of teaching plan

Emetics and Anti-emeticsEmetics and Anti-emetics

Emetic AgentEmetic Agent► Syrup of IpecacSyrup of Ipecac

Anti-emeticsAnti-emetics► 1. Phenothiazines1. Phenothiazines► 2. Non-phenothiazines2. Non-phenothiazines► 3. Anticholinergics/Antihistamines3. Anticholinergics/Antihistamines► 4. Serotonin receptor Blockers4. Serotonin receptor Blockers► 5. Miscellaneous5. Miscellaneous

EMETICEMETIC

►Prototype: Ipecac SyrupPrototype: Ipecac Syrup

EMETICEMETIC

PharmacodynamicsPharmacodynamics► Ipecac syrup irritates the GI mucosa Ipecac syrup irritates the GI mucosa

locally, resulting to stimulation of the locally, resulting to stimulation of the vomiting centervomiting center

► It acts within 20 minutes It acts within 20 minutes

EMETICEMETIC

Clinical Use of ipecacClinical Use of ipecac►To induce vomiting as a treatment for To induce vomiting as a treatment for

drug overdose and certain poisoningsdrug overdose and certain poisonings

EMETICEMETIC

Contraindications of Ipecac useContraindications of Ipecac use► Ingestion of CORROSIVE chemicalsIngestion of CORROSIVE chemicals► Ingestion of petroleum productsIngestion of petroleum products►Unconscious and convulsing patientUnconscious and convulsing patient

EMETICEMETIC

Pharmacokinetics: side effects of IpecacPharmacokinetics: side effects of Ipecac►NauseaNausea►DiarrheaDiarrhea►GI upsetGI upset►Mild CNS depressionMild CNS depression►CARDIOTOXICITY if large amounts CARDIOTOXICITY if large amounts

are absorbed in the bodyare absorbed in the body

Nursing process and the Nursing process and the EMETICEMETIC

ASSESSMENTASSESSMENT►Nursing History- elicit the exact nature Nursing History- elicit the exact nature

of poisoning of poisoning ►Physical Examination- CNS status and Physical Examination- CNS status and

abdominal examabdominal exam



1.1. Administer to Administer to conscious patient onlyconscious patient only

2.2. Administer ipecac Administer ipecac as soon as possibleas soon as possible

3.3. Administer with a large amount of Administer with a large amount of waterwater

4.4. Vomiting should occur within 20 Vomiting should occur within 20 minutes of the first dose. minutes of the first dose. Repeat the Repeat the dose and expect vomiting to occur with dose and expect vomiting to occur with 20 minutes20 minutes



5. Provide comfort measures like ready 5. Provide comfort measures like ready access to bathroom, assistance with access to bathroom, assistance with ambulationambulation

6. Offer support6. Offer support



1.1. Evaluate patient response within 20 Evaluate patient response within 20 minutes of drug ingestionminutes of drug ingestion

2.2. Monitor for adverse effectsMonitor for adverse effects

3.3. Evaluate effectiveness of comfort Evaluate effectiveness of comfort measures and teaching planmeasures and teaching plan

ANTI-EMETICSANTI-EMETICS

►These are agents used to manage These are agents used to manage nausea and vomitingnausea and vomiting

►They act either locally or centrallyThey act either locally or centrally

ANTIEMETICSANTIEMETICS

Anti-emetic types Common examples

Phenothiazines Prochlorperazine, promethazine

Non-phenothiazines Metoclopramide (Reglan)

Anticholinergics and Antihistaminics Meclizine, buclizine

Serotonin Receptor blockers “setron”- dolasetron

Miscellaneous Dronabinol, hydroxyzine

ANTIEMETICSANTIEMETICSTypes Pharmacodynamics

Phenothiazines Centrally block the vomiting center in the medulla

Non-phenothiazine Reduces the responsiveness of the nerve cell in the medulla

Anticholinergics Block the transmission of the impulses to the medulla

Serotonin receptor blockers Centrally and locally inhibits the serotonin receptors

Miscellaneous Act in the CNS , either in the medulla or in the cortex

ANTIEMETICSANTIEMETICSTypes Clinical Use

Phenothiazines N/V associated with anesthesia, intractable hiccups

Non-phenothiazine N/V associated with chemical stimulation

Anticholinergics N/V associated with motion sickness

Serotonin-receptor Blockers N/V associated with chemotherapy

Miscellaneous N/V associated with chemotherapy


ContraindicationsContraindications►1. Severe CNS depression1. Severe CNS depression►2. Severe liver dysfunction2. Severe liver dysfunction


Pharmacokinetics: Side-effectsPharmacokinetics: Side-effects

1. 1. PHOTHOSENSITIVITYPHOTHOSENSITIVITY

2. 2. Drowsiness, dizziness, Drowsiness, dizziness, weakness and tremors and weakness and tremors and DEHYDRATONDEHYDRATON

3. Phenothiazines= autonomic 3. Phenothiazines= autonomic anti-anti-cholinergic effectscholinergic effects like dry mouth, like dry mouth, nasal congestion and urinary nasal congestion and urinary retentionretention

Nursing Process and the Nursing Process and the ANTIEMETICSANTIEMETICS

ASSESSMENTASSESSMENT► Nursing History- elicit allergy, Nursing History- elicit allergy,

impaired hepatic function and CNS impaired hepatic function and CNS depressiondepression

► Physical Examination- CNS status and Physical Examination- CNS status and abdominal examinationabdominal examination

► Laboratory test- Liver function Laboratory test- Liver function studiesstudies


NURSING DIAGNOSISNURSING DIAGNOSIS

1.1. Alteration in comfort: painAlteration in comfort: pain

2.2. High risk for injuryHigh risk for injury

3.3. Knowledge deficitKnowledge deficit



1.1. Assess patient’s intake of other drugs Assess patient’s intake of other drugs that may cause dangerous drug that may cause dangerous drug interactioninteraction

2.2. Emphasize that this is given on a Emphasize that this is given on a short term basisshort term basis



3. 3. Provide comfort and safety Provide comfort and safety measuresmeasures

Advise to change position slowlyAdvise to change position slowly Avoid hazardous activitiesAvoid hazardous activities Provide mouth care and ice chipsProvide mouth care and ice chips Monitor for dehydration and offer Monitor for dehydration and offer

fluids if it occursfluids if it occurs



4. Protect from sun exposure4. Protect from sun exposure Sunscreens Sunscreens Protective coveringProtective covering

5. Provide health teaching5. Provide health teaching



1. 1. Monitor for the drug Monitor for the drug effectivenesseffectiveness

• Relief of nausea and vomitingRelief of nausea and vomiting

2. Monitor for adverse effects2. Monitor for adverse effects

3. Evaluate effectiveness of comfort 3. Evaluate effectiveness of comfort measures and teaching planmeasures and teaching plan

Pharmacology of the Pharmacology of the Selected Endocrine Selected Endocrine

DrugsDrugs

Nursing ReviewNursing Review

Endocrine MedicationsEndocrine Medications

Anti-diuretic hormonesAnti-diuretic hormones

Enhance re-absorption of water in the Enhance re-absorption of water in the kidneyskidneys

Used in DIUsed in DI

1. Desmopressin and Lypressin 1. Desmopressin and Lypressin intranasallyintranasally

2. Pitressin IM2. Pitressin IM

Endocrine MedicationsEndocrine Medications

Anti-diuretic hormonesAnti-diuretic hormones

SIDE-effectsSIDE-effects

Flushing and headacheFlushing and headache

Water intoxicationWater intoxication

Thyroid MedicationsThyroid Medications

Thyroid hormonesThyroid hormones

These products are used to treat These products are used to treat the manifestations of the manifestations of hypothyroidismhypothyroidism

Replace hormonal deficit in the Replace hormonal deficit in the treatment of HYPOTHYROIDSMtreatment of HYPOTHYROIDSM



Levothyroxine (Synthroid)Levothyroxine (Synthroid)

Liothyroxine (Cytomel)Liothyroxine (Cytomel)

Thyroid dessicatedThyroid dessicated

Liotrix (Thyrolar)Liotrix (Thyrolar)


Thyroid hormones: ActionsThyroid hormones: Actions

Increase the metabolic rateIncrease the metabolic rate

Increase O2 consumptionIncrease O2 consumption

Increase HR, RR, BPIncrease HR, RR, BP



Side-effectsSide-effects

1.1. Nausea and VomitingNausea and Vomiting

2.2. Signs of increased metabolism= Signs of increased metabolism= tachycardia, hypertension, tachycardia, hypertension, cardiac arrhythmias, anxiety, cardiac arrhythmias, anxiety, headacheheadache


Thyroid hormones : Nursing responsibilityThyroid hormones : Nursing responsibility

1. Monitor weight, VS1. Monitor weight, VS

2. Instruct client to take daily 2. Instruct client to take daily medication the same time medication the same time each each morning WITHOUT FOODmorning WITHOUT FOOD

Monitor blood tests to check the Monitor blood tests to check the activity of thyroidactivity of thyroid


Thyroid hormones: Nursing responsibilityThyroid hormones: Nursing responsibility

3. Advise to report palpitation, 3. Advise to report palpitation, tachycardia, and chest paintachycardia, and chest pain

4. Instruct to avoid foods that 4. Instruct to avoid foods that inhibit thyroid secretions like inhibit thyroid secretions like cabbage, spinach and radishescabbage, spinach and radishes

ANTI-Thyroid MedicationsANTI-Thyroid Medications

ANTI-THYROID medicationsANTI-THYROID medications

The thyroid becomes The thyroid becomes oversaturated with iodine and oversaturated with iodine and stop producing thyroid stop producing thyroid hormonehormone



Drugs used to BLOCK the Drugs used to BLOCK the thyroid hormones and treat thyroid hormones and treat hyperthyroidismhyperthyroidism

Inhibit the synthesis of thyroid Inhibit the synthesis of thyroid hormoneshormones



1. Methimazole (Tapazole)1. Methimazole (Tapazole)

2. PTU (prophylthiouracil)2. PTU (prophylthiouracil)

3. Iodine solution- SSKI and 3. Iodine solution- SSKI and Lugol’s solutionLugol’s solution

ANTI-Thyroid MedicationsANTI-Thyroid MedicationsANTI-THYROID medicationsANTI-THYROID medicationsSide-effects of thionamidesSide-effects of thionamides

N/V, drowsiness, lethargy, N/V, drowsiness, lethargy, bradycardia, skin rashbradycardia, skin rash

GI complaintsGI complaints AGRANULOCYTOSISAGRANULOCYTOSIS

Most important to monitorMost important to monitor

ANTI-Thyroid MedicationsANTI-Thyroid MedicationsANTI-THYROID medicationsANTI-THYROID medicationsSide-effects of Iodine solutionsSide-effects of Iodine solutions

Most common adverse effects is Most common adverse effects is HYPOTHYROIDISMHYPOTHYROIDISM

Iodism= metallic taste, burning in Iodism= metallic taste, burning in the mouth, sore teeth and gums, the mouth, sore teeth and gums, diarrhea, stomach upsetdiarrhea, stomach upset


ANTI-THYROID medicationsANTI-THYROID medicationsNursing responsibilitiesNursing responsibilities

1. Monitor VS, T3 and T4, 1. Monitor VS, T3 and T4, weightweight2. The medications 2. The medications WITH WITH MEALSMEALS to avoid gastric upset to avoid gastric upset


ANTI-THYROID medications Nursing ANTI-THYROID medications Nursing responsibilitiesresponsibilities

3. Instruct to report SORE 3. Instruct to report SORE THROAT or unexplained FEVERTHROAT or unexplained FEVER4. Monitor for signs of 4. Monitor for signs of hypothyroidism. hypothyroidism. Instruct not to stop abrupt Instruct not to stop abrupt

medicationmedication

ANTI-Thyroid MedicationsANTI-Thyroid MedicationsANTI-THYROID medicationsANTI-THYROID medicationsLugol’s SolutionLugol’s Solution

Used to decrease the vascularity of the Used to decrease the vascularity of the thyroid (in preparation for thyroid surgery)thyroid (in preparation for thyroid surgery)T3 and T4 production diminishesT3 and T4 production diminishesGiven per orem, can be diluted with juiceGiven per orem, can be diluted with juiceUse straw to decrease stainingUse straw to decrease stainingMonitor iodism (metallic taste, burning in Monitor iodism (metallic taste, burning in mouth)mouth)

STEROIDSSTEROIDS

Replaces the steroids in Replaces the steroids in the bodythe body

Interfere with the release Interfere with the release of inflammatory factors of inflammatory factors and immune responses and immune responses

STEROIDSSTEROIDS

Cortisol, cortisone, Cortisol, cortisone, betamethasone, and betamethasone, and hydrocortisonehydrocortisone

Dexamethasone= long Dexamethasone= long actingacting

STEROIDSSTEROIDS

These drugs enter the These drugs enter the cells and bind to cells and bind to receptorsreceptors

They inhibit the enzyme They inhibit the enzyme phospholipasephospholipase

STEROIDSSTEROIDSCorticosteroids are used topically Corticosteroids are used topically and locally to achieve the desired and locally to achieve the desired anti-inflammatory effects at a anti-inflammatory effects at a particular siteparticular site

STEROIDSSTEROIDS

SteroidSteroid Clinical useClinical use

DexamethasoneDexamethasone Use to induce the Use to induce the formation of lung formation of lung surfactantsurfactant

Other steroidsOther steroids Use for the treatment of Use for the treatment of immune-related immune-related diseases, control of diseases, control of asthma and allergic asthma and allergic symptoms symptoms

STEROIDSSTEROIDSSide-effectsSide-effects

HYPERglycemiaHYPERglycemia Increased susceptibility to Increased susceptibility to

infection infection (immunosuppression)(immunosuppression)

HypokalemiaHypokalemia Edema and HypertensionEdema and Hypertension Peptic ulcerationPeptic ulceration

STEROIDSSTEROIDS

Side-effectsSide-effects If high doses- osteoporosis, If high doses- osteoporosis,

growth retardation, peptic growth retardation, peptic ulcer, hypertension, ulcer, hypertension, cataractcataract, mood changes, , mood changes, hirsutism, and fragile skinhirsutism, and fragile skin

STEROIDSSTEROIDS

Nursing responsibilitiesNursing responsibilities

1. Monitor VS, electrolytes, 1. Monitor VS, electrolytes, glucoseglucose

2. Monitor weight edema 2. Monitor weight edema and I/O. Encourage and I/O. Encourage Potassium supplementsPotassium supplements

STEROIDSSTEROIDS


3. Protect patient from infection3. Protect patient from infection

4. Handle patient gently4. Handle patient gently

5. Instruct to take meds 5. Instruct to take meds WITH WITH MEALSMEALS to prevent gastric ulcer to prevent gastric ulcer formationformation

STEROIDSSTEROIDS


6. Caution the patient NOT to 6. Caution the patient NOT to abruptly stop the drugabruptly stop the drug

7. 7. Drug is tapered to allow the Drug is tapered to allow the adrenal gland to secrete adrenal gland to secrete endogenous hormonesendogenous hormones

STEROIDSSTEROIDS

Evaluation:Evaluation:

The drugs are effective if there The drugs are effective if there is: is:

1.1. Relief of signs and Relief of signs and symptoms of inflammationsymptoms of inflammation

2.2. Return of adrenal function to Return of adrenal function to normalnormal

The cardiac glycosidesThe cardiac glycosides These are agents extracted from These are agents extracted from

the foxglove plant. They are the foxglove plant. They are available in oral and parenteral available in oral and parenteral preparations. The following are preparations. The following are the cardiac glycosides:the cardiac glycosides:

Digoxin (Lanoxin)Digoxin (Lanoxin) Digitoxin (Crystodigin)Digitoxin (Crystodigin) OuabainOuabain

The cardiac glycosidesThe cardiac glycosides

Pharmacodynamics: the Pharmacodynamics: the Mechanism of action Mechanism of action

They They increase the level of increase the level of CALCIUMCALCIUM inside the cell by inside the cell by inhibiting the Sodium-Potassium inhibiting the Sodium-Potassium pump. pump.

More calcium will accumulate More calcium will accumulate inside the cell during cellular inside the cell during cellular depolarization. depolarization.

The cardiac glycosidesThe cardiac glycosides Positive inotropicPositive inotropic Effect- Effect- the the

myocardium will contract forcefullymyocardium will contract forcefully– Increased cardiac outputIncreased cardiac output– Increased blood flow to the body organs Increased blood flow to the body organs

like the kidney and liverlike the kidney and liver Negative chronotropicNegative chronotropic effect- the effect- the

heart rate is slowed due to decreased heart rate is slowed due to decreased rate of cellular repolarizationrate of cellular repolarization– BradycardiaBradycardia

Decreased conduction velocityDecreased conduction velocity through the AV nodethrough the AV node


Clinical Use of the cardiac Clinical Use of the cardiac glycosidesglycosides

Treatment of Treatment of congestive heart congestive heart failurefailure

Treatment of Treatment of dysrhythmiasdysrhythmias like like atrial flutter, atrial fibrillation and atrial flutter, atrial fibrillation and paroxysmal atrial tachycardiaparoxysmal atrial tachycardia

The cardiac glycosidesThe cardiac glycosidesContraindications and PrecautionsContraindications and Precautions Contraindicated in the presence of Contraindicated in the presence of

allergy to any cardiac glycoside. allergy to any cardiac glycoside. They are They are NOTNOT given to patients with given to patients with

ventricular dysrhythmias, heart block ventricular dysrhythmias, heart block or sick sinus syndrome, aortic or sick sinus syndrome, aortic stenosis, acute MI, electrolyte stenosis, acute MI, electrolyte imbalances (imbalances (HYPOKALEMIA, HYPOKALEMIA, HYPOMAGNESEMIA and HYPOMAGNESEMIA and HYPERCALCEMIAHYPERCALCEMIA) and ) and renal failurerenal failure (may cause accumulation of drug)(may cause accumulation of drug)

The cardiac glycosidesThe cardiac glycosidesPharmacodynamics: the Adverse Effects of Pharmacodynamics: the Adverse Effects of

the Cardiac glycosidesthe Cardiac glycosides CNS- Headache, weakness , seizures and CNS- Headache, weakness , seizures and

drowsinessdrowsiness CVS- arrhythmiasCVS- arrhythmias If digitalis toxicity is developing- the nurse If digitalis toxicity is developing- the nurse

must assess the following adverse effects: must assess the following adverse effects: Anorexia, nausea and vomiting, visual Anorexia, nausea and vomiting, visual changes- YELLOW halo around an changes- YELLOW halo around an object, and palpitations or very slow object, and palpitations or very slow heart rateheart rate

The cardiac glycosidesThe cardiac glycosidesRemember= NAVDA and hypokalemiaRemember= NAVDA and hypokalemia

The cardiac glycosidesThe cardiac glycosidesDrug-Drug InteractionsDrug-Drug Interactions If taken with potassium-losing If taken with potassium-losing

diuretics like furosemide- can diuretics like furosemide- can INCREASE the risk of toxicity and INCREASE the risk of toxicity and arrhythmias. Potassium arrhythmias. Potassium replacement must be given.replacement must be given.

The cardiac glycosidesThe cardiac glycosidesImplementationImplementation Administer the initial rapid Administer the initial rapid

digitalization and loading dose as digitalization and loading dose as ordered intravenouslyordered intravenously

Monitor the Monitor the APICALAPICAL pulse rate for ONE pulse rate for ONE full minute before administering the full minute before administering the drug. Withhold the drug ifdrug. Withhold the drug if– Less than 60 in adults Less than 60 in adults – Less than 90 in infantsLess than 90 in infants– More than 110 in adultsMore than 110 in adults

Retake pulse in one hour, if pulses Retake pulse in one hour, if pulses remain abnormal, refer!remain abnormal, refer!

The cardiac glycosidesThe cardiac glycosidesImplementationImplementation Check the spelling of the drug- DIGOXIN Check the spelling of the drug- DIGOXIN

is different from DIGITOXIN!is different from DIGITOXIN! Check the dosage preparation and the Check the dosage preparation and the

level of digitalis in the blood. level of digitalis in the blood. ((Therapeutic level is 0.5 to 2.0 Therapeutic level is 0.5 to 2.0 nanograms/mLnanograms/mL))

Administer intravenous drug VERY slow Administer intravenous drug VERY slow IV over 5 minutes to avoid arrhythmias. IV over 5 minutes to avoid arrhythmias. Do NOT administer intramuscularly Do NOT administer intramuscularly because it can cause severe painbecause it can cause severe pain

The cardiac glycosidesThe cardiac glycosidesImplementationImplementation Administer the drug Administer the drug without food if without food if

possible to avoid delayed absorptionpossible to avoid delayed absorption. . Weight patient daily to determine fluid Weight patient daily to determine fluid retentionretention

Maintain emergency equipment and drugs= Maintain emergency equipment and drugs= Potassium salts, Lidocaine for arrhythmias, Potassium salts, Lidocaine for arrhythmias, phenytoin for seizures, atropine for phenytoin for seizures, atropine for bradycardia.bradycardia.

Provide comfort measures- small, frequent Provide comfort measures- small, frequent meals, adequate lighting, comfortable meals, adequate lighting, comfortable position, rest periods and safety position, rest periods and safety precautionsprecautions


ImplementationImplementation Provide health teaching- drug name, Provide health teaching- drug name,

action, dosage and side effects. Advise action, dosage and side effects. Advise the patient to report any of the the patient to report any of the following: following: Visual changes, rapid Visual changes, rapid weight gain, unusually low heart weight gain, unusually low heart rate, persistent nausea, vomiting rate, persistent nausea, vomiting and anorexiaand anorexia

Monitor serum potassium level Monitor serum potassium level


EvaluationEvaluation

Evaluate effectiveness of the Evaluate effectiveness of the drug:drug:

Increased urine outputIncreased urine output

Normal heart rate in Normal heart rate in arrhythmiaarrhythmia

The Antianginal drugsThe Antianginal drugs

In the treatment of angina, three In the treatment of angina, three agents are commonly employed-agents are commonly employed-– Organic nitratesOrganic nitrates– Beta-blockers and Beta-blockers and – Calcium-channel blockers.Calcium-channel blockers.

The benefits of the drugs lie in their The benefits of the drugs lie in their different mode of action. different mode of action.


The nitrates can cause The nitrates can cause vasodilatation of the veins and to vasodilatation of the veins and to some extent, coronary artery some extent, coronary artery


Beta-blockers will decrease the Beta-blockers will decrease the heart rateheart rate


Calcium-channel blockers will Calcium-channel blockers will decrease force of contraction decrease force of contraction leading to a decreased leading to a decreased myocardial workload and myocardial workload and demand. demand.

They can also produce They can also produce vasodilationvasodilation

The Organic nitratesThe Organic nitrates

These agents are simple nitric and These agents are simple nitric and nitrous acid esters of alcohols. Being nitrous acid esters of alcohols. Being alcohol, they differ in their volatility. The alcohol, they differ in their volatility. The following are the nitrates commonly following are the nitrates commonly used:used:

Nitroglycerin-Nitroglycerin- A moderately volatile A moderately volatile nitratenitrate

Isosorbide Dinitrate (Isordil) or Isosorbide Dinitrate (Isordil) or mononitratemononitrate

Amyl nitrate- an extremely volatile Amyl nitrate- an extremely volatile nitratenitrate


NitroglycerinNitroglycerin This agent is supplied in oral, spray, This agent is supplied in oral, spray,

transdermal and ointment transdermal and ointment preparations.preparations.


Pharmacodynamics: the Pharmacodynamics: the mechanism of actionmechanism of action

Nitroglycerin relaxes the Nitroglycerin relaxes the smooth muscles in the smooth muscles in the vascular system by its vascular system by its conversion to nitric oxide, a conversion to nitric oxide, a chemical mediator in the body chemical mediator in the body that relaxes smooth muscles. that relaxes smooth muscles.

The Organic nitratesThe Organic nitratesAdministered nitratesAdministered nitrates

Increased nitrates in the bloodIncreased nitrates in the blood

increased formation of nitric oxideincreased formation of nitric oxide

increased cGMP formationincreased cGMP formation

increased dephosphorylation of myosin increased dephosphorylation of myosin

Vascular smooth muscle relaxationVascular smooth muscle relaxation

vasodilatation vasodilatation


Pharmacokinetics- absorption to Pharmacokinetics- absorption to excretionexcretion

It can be given orally, parenterally It can be given orally, parenterally and topically. and topically.

The onset of action of nitroglycerin The onset of action of nitroglycerin is more than 1 hour.is more than 1 hour.

Because significant first-pass Because significant first-pass hepatic effect, hepatic effect, Nitroglycerin is Nitroglycerin is given SUBLINGUALY. given SUBLINGUALY.

The Organic nitratesThe Organic nitratesPharmacodynamics: Side effects and Pharmacodynamics: Side effects and

adverse effectsadverse effects HEADACHE is the most common HEADACHE is the most common

effect of nitroglycerineffect of nitroglycerin.. CVS- postural Hypotension, facial CVS- postural Hypotension, facial

flushing, tachycardiaflushing, tachycardia TOLERANCETOLERANCE- the tolerance to the - the tolerance to the

actions of nitrates develop rapidly. actions of nitrates develop rapidly. This can be managed by providing a This can be managed by providing a day of abstinence. day of abstinence.

The NitratesThe NitratesImplementationImplementation Monitor vital signs, especially watchful Monitor vital signs, especially watchful

for hypotensive episodesfor hypotensive episodes Advise patient to remain supine or sit on Advise patient to remain supine or sit on

a chair when taking the nitroglycerin for a chair when taking the nitroglycerin for the first time. Emphasize that he should the first time. Emphasize that he should change his position slowly or rise from change his position slowly or rise from bed slowly to avoid orthostatic bed slowly to avoid orthostatic HypotensionHypotension

Offer sips of water before giving Offer sips of water before giving sublingual nitroglycerin because sublingual nitroglycerin because dryness may inhibit drug absorptiondryness may inhibit drug absorption

The NitratesThe NitratesImplementationImplementation Apply nitroglycerin ointment to the Apply nitroglycerin ointment to the

designated mark on paper. designated mark on paper. The nurse should remove any excess The nurse should remove any excess

ointment on the skin from the ointment on the skin from the previous dose. previous dose.

She should She should NEVER USENEVER USE her bare her bare fingers because the drug can be fingers because the drug can be absorbed, utilize gloves or tongue absorbed, utilize gloves or tongue blades instead.blades instead.

The NitratesThe Nitrates

ImplementationImplementation Apply nitroglycerin patch to an area Apply nitroglycerin patch to an area

with few hairs. Never touch the with few hairs. Never touch the medication portion. medication portion.

The patch and the ointment should The patch and the ointment should NOT be applied near the area for NOT be applied near the area for defibrillation because explosion and defibrillation because explosion and skin burns may resultskin burns may result


IMPLEMENTATIONIMPLEMENTATION Emphasize that tolerance to the Emphasize that tolerance to the

nitroglycerin can occur. nitroglycerin can occur. If the medication cannot relieve the If the medication cannot relieve the

pain, report to the hospital pain, report to the hospital immediately.immediately.


IMPLEMENTATIONIMPLEMENTATION Provide client health teaching- the Provide client health teaching- the

sublingual nitroglycerin tablet is USED if sublingual nitroglycerin tablet is USED if chest pain occurschest pain occurs

The dose may be repeated if pain is The dose may be repeated if pain is unrelieved within 5 minutes. unrelieved within 5 minutes.

Repeat the medication administration Repeat the medication administration if the pain has not yet subsidedif the pain has not yet subsided. .

DO NOT give more than 3 tablets!DO NOT give more than 3 tablets!!! If !! If chest pain persists for more than 15 chest pain persists for more than 15 minutes, hospital consult should be minutes, hospital consult should be done immediately.done immediately.


IMPLEMENTATIONIMPLEMENTATION Instruct the client to avoid alcohol Instruct the client to avoid alcohol

while taking nitroglycerin to avoid while taking nitroglycerin to avoid potentiating the hypotensive effect of potentiating the hypotensive effect of the medicationthe medication

If beta blockers and calcium-channel If beta blockers and calcium-channel blockers are given, instruct the blockers are given, instruct the patients to consult the physician patients to consult the physician before discontinuing the medicationbefore discontinuing the medication


IMPLEMENTATIONIMPLEMENTATION Other components of health teaching Other components of health teaching

for home self-administration:for home self-administration:– If taking Sublingual Nitroglycerin, the patient If taking Sublingual Nitroglycerin, the patient

should be instructed to should be instructed to place the tablet place the tablet under the tongueunder the tongue for quick absorption. for quick absorption.

– A burning sensation/biting/stinging sensation A burning sensation/biting/stinging sensation may indicate that the tablet is may indicate that the tablet is FRESH!FRESH!

– Store the tablet in a Store the tablet in a dark containerdark container, keep it , keep it away from heat and direct sunlight to avoid away from heat and direct sunlight to avoid lessening the potencylessening the potency

The NitratesThe NitratesIMPLEMENTATIONIMPLEMENTATION Other components of health teaching for Other components of health teaching for

home self-administration:home self-administration:– HEADACHESHEADACHES are common in the initial are common in the initial

period of nitroglycerin therapy. Advise period of nitroglycerin therapy. Advise patient to take PARACETAMOL for reliefpatient to take PARACETAMOL for relief

– The nitroglycerin patch is applied once a The nitroglycerin patch is applied once a day, usually in the morning. The sites day, usually in the morning. The sites should be rotated, in the chest, arms and should be rotated, in the chest, arms and thighs avoiding hairy areas. thighs avoiding hairy areas.


IMPLEMENTATIONIMPLEMENTATION Other components of health teaching Other components of health teaching

for home self-administration:for home self-administration:– Position supine with elevated legs to Position supine with elevated legs to

manage Hypotension. manage Hypotension. – Nitroglycerin tablet can be taken Nitroglycerin tablet can be taken

prophylactically in situations where prophylactically in situations where chest pain is anticipated- Sex, chest pain is anticipated- Sex, exercise, etc..exercise, etc..

– If patient is taking beta blockers, instruct If patient is taking beta blockers, instruct how to obtain heart rate in a minutehow to obtain heart rate in a minute

Drugs for ShockDrugs for Shock

DopamineDopamine This is a sympathomimetic drug often This is a sympathomimetic drug often

used to treat Hypotension in shock used to treat Hypotension in shock states that are not caused by states that are not caused by Hypovolemia. Hypovolemia.

This drug is an immediate precursor This drug is an immediate precursor of nor-epinephrine, occurs naturally in of nor-epinephrine, occurs naturally in the CNS basal ganglia where it the CNS basal ganglia where it functions as a neurotransmitter.functions as a neurotransmitter.


DopamineDopamine Pharmacodynamics: It can activate the Pharmacodynamics: It can activate the

alpha and beta adrenergic receptor alpha and beta adrenergic receptor depending upon the concentration. It depending upon the concentration. It stimulates receptors to cause stimulates receptors to cause cardiac cardiac stimulation and renal stimulation and renal vasodilationvasodilation. .

The dose range is 1-20 The dose range is 1-20 micrograms/kg/minmicrograms/kg/min


DopamineDopamine Pharmacokinetics: Dopamine is Pharmacokinetics: Dopamine is

administered IV, excreted in the urine. administered IV, excreted in the urine. At At low doselow dose ( (1-2 micrograms1-2 micrograms), ),

dopamine DILATES the renal and dopamine DILATES the renal and mesenteric blood vessels producing mesenteric blood vessels producing an increase output (dopaminergic an increase output (dopaminergic effect)effect)


DopamineDopamine At At moderate dosemoderate dose of of 2-10 2-10

micrograms,micrograms, dopamine enhance dopamine enhance cardiac output by increasing heart cardiac output by increasing heart rate (rate (beta 1-adrenergic effect)beta 1-adrenergic effect) and and elevates blood pressure through elevates blood pressure through peripheral vasoconstriction peripheral vasoconstriction (alpha (alpha adrenergic effect)adrenergic effect)


DopamineDopamine At higher doses of At higher doses of more than 10 more than 10

micrograms-micrograms- vasoconstriction of vasoconstriction of all vesselsall vessels will predominate that will predominate that can lead to diminished tissue can lead to diminished tissue perfusionperfusion


DopamineDopamine Dopamine is indicated to treat Hypotension, Dopamine is indicated to treat Hypotension,

to increase heart rate and to increase urine to increase heart rate and to increase urine output (given less than 5 mg/kg/min)output (given less than 5 mg/kg/min)

The nurse typically prepares the dopamine The nurse typically prepares the dopamine drip- dopamine (at a concentration of 400-drip- dopamine (at a concentration of 400-800 mg) is mixed in 250 mL D5W and 800 mg) is mixed in 250 mL D5W and administered as drip via an infusion pump administered as drip via an infusion pump for precise dosage administration. for precise dosage administration.

Sodium bicarbonate will inactivate the Sodium bicarbonate will inactivate the dopaminedopamine


DopamineDopamine Pharmacodynamics: side effects- Pharmacodynamics: side effects-

TachycardiaTachycardia

hypertensionhypertension

ectopic beats, angina, dysrhythmias, ectopic beats, angina, dysrhythmias, myocardial ischemia, nausea and myocardial ischemia, nausea and vomiting.vomiting.


Dopamine: Nursing considerationDopamine: Nursing consideration– Check the IV site hourly for signs of drug Check the IV site hourly for signs of drug

infiltration of dopamine, which can infiltration of dopamine, which can cause tissue necrosis. cause tissue necrosis.

– PhentolaminePhentolamine should be infiltrated in should be infiltrated in multiple areas to reduce tissue damage.multiple areas to reduce tissue damage.

– Drug is effective if Urine output is Drug is effective if Urine output is increased and BP is increasedincreased and BP is increased

Antihypertensive drugsAntihypertensive drugs

The Drugs employed to control The Drugs employed to control hypertension can be classified as:hypertension can be classified as:

DiureticsDiuretics Beta-blockersBeta-blockers Alpha adrenergic blockersAlpha adrenergic blockers Calcium channel blockersCalcium channel blockers Angiotensin-converting enzyme Angiotensin-converting enzyme

inhibitorsinhibitors Angiotensin II receptor blockersAngiotensin II receptor blockers Peripheral vasodilatorsPeripheral vasodilators

Common Drugs in HPNCommon Drugs in HPN

IN Evaluating the effectiveness of IN Evaluating the effectiveness of these drugs is simply to monitor the these drugs is simply to monitor the BP if it becomes NORMALBP if it becomes NORMAL

Anti-hypertensive drugsAnti-hypertensive drugsClassClass PrototypePrototype MOAMOA Side effectsSide effects

DiureticsDiuretics FurosemideFurosemide Decreases blood Decreases blood volumevolume

HypokalemiaHypokalemia

Beta-Beta-blockerblocker

PropranololPropranolol Blocks B1 Blocks B1 receptor in the receptor in the heartheart

Bradycardia, Bradycardia, hypoglycemiahypoglycemia

ACE ACE InhibitorsInhibitors

CaptoprilCaptopril Prevents A1 to Prevents A1 to AII conversionAII conversion

Headache, Cough, Headache, Cough, flushingflushing

Ca channel Ca channel blockersblockers

NifedipineNifedipine Blocks Ca entry Blocks Ca entry into cellinto cell

Headache, Headache, flushing, reflex flushing, reflex tachycardiatachycardia

VasodilatorVasodilator NitroglyceriNitroglycerinn

Dilates veins and Dilates veins and arteriesarteries

HEADACHEHEADACHE

Alpha Alpha blockersblockers

PrazozinPrazozin Blocks alpha Blocks alpha receptor in BV receptor in BV causing causing vasodilatationvasodilatation

UrinationUrination

Central Central alpha alpha agonistagonist

ClonidineClonidine Stimulates CNS Stimulates CNS alpha 2 receptoralpha 2 receptor

DepressionDepression

AnticoagulantsAnticoagulantsHEPARINHEPARIN WARFARINWARFARIN

Parenteral (SQ and IV)Parenteral (SQ and IV) OralOralAction is to enhance natural Action is to enhance natural

anti-thrombin III in the anti-thrombin III in the bloodblood

Action is to INHIBIT Vitamin-Action is to INHIBIT Vitamin-K dependent clotting factors K dependent clotting factors (10,9,7,2)(10,9,7,2)

Acts within minutesActs within minutes Acts within daysActs within days

Monitor for aPTTMonitor for aPTT Monitor for PT and INRMonitor for PT and INRLarge molecule, can be Large molecule, can be given to pregnantgiven to pregnant

Small molecule CANNOT be Small molecule CANNOT be given to pregnantgiven to pregnant

Antidote: Protamine Antidote: Protamine sulfatesulfate

Antidote: Vit. KAntidote: Vit. K

SE: bleeding, SE: bleeding, decreased plateletsdecreased platelets

SE: BleedingSE: Bleeding

The antianemics: Iron The antianemics: Iron preparations and Epoetinpreparations and Epoetin

Iron preparationsIron preparations Iron is important for hemoglobin Iron is important for hemoglobin

formation.formation.

The iron preparations are:The iron preparations are: Ferrous sulfateFerrous sulfate Ferrous fumarateFerrous fumarate Ferrous gluconateFerrous gluconate


Side-effects: Side-effects: GIT- constipation (usually), GIT- constipation (usually),

diarrhea, vomiting, diarrhea, vomiting, epigastric epigastric pain, gastric ulceration and pain, gastric ulceration and darkening of stools.darkening of stools.

Liquid preparation can stain the Liquid preparation can stain the teeth, and injectable iron can teeth, and injectable iron can cause tissue discolorationcause tissue discoloration

Other- dizzinessOther- dizziness


Drug-Drug interactionDrug-Drug interaction Tetracyclines combine with iron Tetracyclines combine with iron

preparations and render the iron preparations and render the iron unabsorbable. unabsorbable.

Antacids and cimetidine- decrease iron Antacids and cimetidine- decrease iron absorption and effectsabsorption and effects

Foods can impair iron absorption but they Foods can impair iron absorption but they should be taken with iron to reduce GI should be taken with iron to reduce GI discomfort. discomfort.

Milk containing foods, coffee, tea and Milk containing foods, coffee, tea and eggs are NOT given with iron because eggs are NOT given with iron because they delay iron absorption.they delay iron absorption.


ImplementationImplementation Encourage the patient to eat iron-rich foods like liver, Encourage the patient to eat iron-rich foods like liver,

lean meat, egg yolk, dried beans, green leafy vegetables.lean meat, egg yolk, dried beans, green leafy vegetables. Administer iron preparations orally with foods to decrease Administer iron preparations orally with foods to decrease

GI discomfort. GI discomfort. If increased absorption is necessary, administer IN If increased absorption is necessary, administer IN

BETWEEN meals with full glass of water or juice. BETWEEN meals with full glass of water or juice. It is best to offer citrus juices because the vitamin It is best to offer citrus juices because the vitamin

C content can increase iron absorption. C content can increase iron absorption. Instruct the patient to swallow the whole tablet and Instruct the patient to swallow the whole tablet and

remain upright for 30 minutes to prevent esophageal remain upright for 30 minutes to prevent esophageal corrosion from reflux. corrosion from reflux.

DO NOT administer iron together with or within 1 hour of DO NOT administer iron together with or within 1 hour of ingesting tetracyclines, antacids, milk and milk-ingesting tetracyclines, antacids, milk and milk-containing products. containing products.

Advise clients to increase fluid intake and consume fiber Advise clients to increase fluid intake and consume fiber rich foods if constipation becomes a problem. rich foods if constipation becomes a problem.


ImplementationImplementation Emphasize that the therapeutic effect of Emphasize that the therapeutic effect of

iron therapy may not be apparent until iron therapy may not be apparent until several weeks. several weeks.

If injecting a parenteral iron preparation, If injecting a parenteral iron preparation, inject DEEP IM utilizing inject DEEP IM utilizing the Z-track method the Z-track method to avoid leakage into the subcutaneous to avoid leakage into the subcutaneous tissues and skintissues and skin. .

Offer straw if giving liquid iron preparation Offer straw if giving liquid iron preparation to avoid staining the teeth. to avoid staining the teeth.

To prevent undue alarm, instruct the To prevent undue alarm, instruct the patient that the stools may turn black or patient that the stools may turn black or dark green. This is a harmless occurrence.dark green. This is a harmless occurrence.


EvaluationEvaluation The nurse evaluates the effectiveness The nurse evaluates the effectiveness

of the drug therapy by determining that of the drug therapy by determining that the the client is not fatigued, with absence client is not fatigued, with absence of pallor, and with hemoglobin results of pallor, and with hemoglobin results within desired rangewithin desired range. .

ErythropoietinErythropoietinThe mechanism of action of The mechanism of action of

epoetin alfaepoetin alfa

(Epogen)(Epogen) This drug acts like the natural This drug acts like the natural

glycoprotein erythropoietin to glycoprotein erythropoietin to stimulate the production of RBC in stimulate the production of RBC in the bone marrow.the bone marrow.

ErythropoietinErythropoietin

Clinical indicationsClinical indications It is given SUBCUTANEOUSLY or It is given SUBCUTANEOUSLY or

INTRAVENOUSLY INTRAVENOUSLY for the treatment of for the treatment of anemia associated with renal failure anemia associated with renal failure or for patients on dialysisor for patients on dialysis. .

It is also used in patients for blood It is also used in patients for blood transfusion to decrease the need for transfusion to decrease the need for blood in surgical patients. blood in surgical patients.


Pharmacodynamics: the adverse Pharmacodynamics: the adverse effects of epoetin alfaeffects of epoetin alfa

CNS- headache, fatigue, asthenia, CNS- headache, fatigue, asthenia, dizziness and seizures- these are due dizziness and seizures- these are due to the cellular response to the to the cellular response to the glycoprotein. glycoprotein.

GIT- nausea, vomiting and diarrheaGIT- nausea, vomiting and diarrhea CVS- hypertension, edema and CVS- hypertension, edema and chest chest

pain due to increase RBC numberpain due to increase RBC number

ErythropoietinErythropoietinImplementationImplementation Administer the drug SC or IV usually 3 times per Administer the drug SC or IV usually 3 times per

week.week. Monitor the IV access line if given IV. Do not mix Monitor the IV access line if given IV. Do not mix

with other solutionswith other solutions Determine periodically the level of hematocrit and Determine periodically the level of hematocrit and

iron stores during therapy. If patient does not iron stores during therapy. If patient does not respond to the drug, reevaluate the cause of respond to the drug, reevaluate the cause of anemia.anemia.

Maintain seizure precaution on stand by as seizure Maintain seizure precaution on stand by as seizure can occur.can occur.

Provide comfort measures like small frequent Provide comfort measures like small frequent feedings and pain medications for headache.feedings and pain medications for headache.

Provide thorough health teaching: need for lifetime Provide thorough health teaching: need for lifetime injectioninjection


EvaluationEvaluation Monitor patient response to the Monitor patient response to the

drug= increased hemoglobindrug= increased hemoglobin

Psychotrophic drugsPsychotrophic drugs

• Drugs that can:Drugs that can:

1.1. Stimulate the release of Stimulate the release of neurotransmittersneurotransmitters

2.2. Block the receptor/activity of the Block the receptor/activity of the neurotransmitter= like dopamineneurotransmitter= like dopamine

3.3. Stimulate the receptors in the CNSStimulate the receptors in the CNS

4.4. Prevents the breakdown of the Prevents the breakdown of the neurotransmitters or the re-uptake neurotransmitters or the re-uptake mechanismmechanism

Anti-Anti-Psychotics/Psychotics/

NeurolepticsNeuroleptics• Drugs used to treat PSYCHOSESDrugs used to treat PSYCHOSES

• MAIN ACTION: Blockage of the MAIN ACTION: Blockage of the DOPAMINE receptor in the CNSDOPAMINE receptor in the CNS


NeurolepticsNeurolepticsClassClass PrototypePrototype OthersOthers

PhenothiazinesPhenothiazines ChlorpromazineChlorpromazine Thioridazine, Thioridazine, Fluphenazine, Fluphenazine, PerphenazinePerphenazine

ButyrophenonesButyrophenones HaloperidolHaloperidol droperidoldroperidol

ThioxanthinesThioxanthines ChlorprothixeneChlorprothixene thirothixenethirothixene

DibenzoxapineDibenzoxapine MolindoneMolindone

DiphenylbutlypipeDiphenylbutlypiperidineridine

PimozidePimozide

Atypical drugsAtypical drugs ClozapineClozapine OlanzapineOlanzapine

RisperidoneRisperidone quetiapinequetiapine


NeurolepticsNeurolepticsDesired EffectsDesired Effects

11 Reduced hallucination and illusionsReduced hallucination and illusions

22 CNS sedation and emotional slowingCNS sedation and emotional slowing

33 Decreased ambivalence, reduced Decreased ambivalence, reduced delusiondelusion

44 Reduced agitation resulting to Reduced agitation resulting to calmnesscalmness

55 Relief of emotional turmoilRelief of emotional turmoil

66 Reduced flattening of affectReduced flattening of affect


NeurolepticsNeurolepticsCommon SECommon SE Nursing InterventionsNursing Interventions

Anticholinergic Anticholinergic effectseffects

Sugarless gum, bed restSugarless gum, bed rest

Photosensitivity Photosensitivity Sunglasses, sunscreen, Sunglasses, sunscreen, avoid sunavoid sun

Postural Postural hypotensionhypotension

Change position slowly, Change position slowly, lie prone for 1 hour lie prone for 1 hour after drug intake, after drug intake, monitor BPmonitor BP

AgranulocytosisAgranulocytosis Instruct to report sore Instruct to report sore throat and fever, throat and fever, monitor WBC monitor WBC

SeizureSeizure Monitor EEGMonitor EEG

SedationSedation Safety, no machine Safety, no machine operationoperation


NeurolepticsNeurolepticsExtra-Pyramidal Extra-Pyramidal SyndromeSyndrome

Nursing InterventionNursing Intervention

Parkinsonism-Tremor, Parkinsonism-Tremor, rigidity, bradikinesiarigidity, bradikinesia

Avoid abrupt withdrawal, Avoid abrupt withdrawal, give anti-EPS drugs like give anti-EPS drugs like CogentinCogentin

Dystonia- torticollis, Dystonia- torticollis, contraction of face and contraction of face and tonguetongue

Remain with client, Remain with client, administer anti-EPSadminister anti-EPS

Akathisia= motor Akathisia= motor restlessnessrestlessness

Verbalize understanding of Verbalize understanding of the condition, administer the condition, administer anti-EPSanti-EPS

Tardive Dyskinesia= Tardive Dyskinesia= irreversible drooling, irreversible drooling, tongue movement and tongue movement and shuffling gaitshuffling gait

No treatment except No treatment except discontinue drugdiscontinue drug

Neuroleptic Malignant Neuroleptic Malignant syndrome= elevated syndrome= elevated temp, treme muscle temp, treme muscle rigidityrigidity

Notify physician, prepare to Notify physician, prepare to administer dantroleneadminister dantrolene

Review Outline Adrenergic Agonists Adrenergic Antagonists Cholinergic Agonists Cholinergic Antagonists

Comparison of the Sympathetic and Parasympathetic Nervous systemCharacteristics Sympathetic Parasympathetic

CNS origin Thoraco-lumbar spinal cord

Cranio-Sacral spinal cord

Pre-ganglionic neuron Short axon Long axon

Pre-ganglionic NTA Acetylcholine Acetylcholine

Ganglia location Next to spinal cord Near target organ

Post-ganglionic neuron

Long axon Short axon

Post-ganglionic NTA Epi and NE Acetylcholine

Enzyme for NTA MAO, COMT Acetylcholine-ESTERASE

General response Fight or flight Rest and Digest

The autonomic drugs Pharmacologic use depends on their

EFFECTS on the body

They can STIMULATE= agonists OR mimetics

They can DECREASE THE RESPONSE= antagonists OR blockers

The autonomic drugs They can STIMULATE= agonists OR mimetics DIRECT STIMULATION by binding with

receptors

INDIRECT STIMULATION by blocking the enzymes that degrade the neurotransmitters or increasing the release of neurotransmitters

The autonomic drugs They can DECREASE THE RESPONSE=

antagonists OR blockers

DIRECT blockage by removing the neurotransmitter or competing with the neurotransmitter

Binding with the receptor and NO RESPONSE will happen

The autonomic drugs They can be

NON-SELECTIVE when they stimulate or block many receptors

SELECTIVE when they stimulate or block specific receptors

SPECIFIC when only ONE type of receptor is stimulated or blocked

The autonomic drugs: Pharmacologic use depends on their EFFECTS on the body

Effect on the body Therapeutic use

Increases BP Used for SHOCK where there is LOW BP

Decreases BP and heart rate

Used for HYPERTENSION and Tachycardia

The Adrenergic AGONISTS Also called SYMPATHOMIMETIC agents

These drugs MIMIC the effects of the sympathetic nervous system

The Adrenergic AGONISTS They usually stimulate DIRECTLY the

receptors of the adrenergic system

The Adrenergic AGONISTS Alpha and Beta agonists (non-selective)

Prototype: Epinephrine

Alpha Agonists (Selective) Prototype: Phenylephrine

Beta Agonists (Selective) Prototype: Isoproterenol

The Adrenergic AGONISTS Alpha and Beta agonists (non-selective)

Pharmacodynamics:

These agents stimulate ALL types of adrenergic receptors in the body by direct interaction or by releasing neurotransmitters from the nerve cells

The Adrenergic AGONISTS Alpha and Beta agonists

Prototype: Epinephrine

1. Ephedrine

2. Epinephrine

3. Metaraminol

4. Norepinephrine

5. Dobutamine (sometimes a B1 specific)

6. Dopamine

The Adrenergic AGONISTSAlpha and Beta agonists: Clinical Use 1. Dopamine- used in shock 2. Epinephrine- drug of choice of

anaphylaxis, Status asthmaticus 3. Norepinephrine- used in shock 4. Dobutamine- used in CHF 5. Ephedrine- used in shock, asthma and

rhinitis

The Adrenergic AGONISTS Alpha and Beta agonists: Desirable effects

Increased myocardial contractility Bronchial DILATATION Vasoconstriction Increased blood pressure Decreased intraocular pressure Pupillary dilatation

The Adrenergic AGONISTS Alpha and Beta agonists:

Contraindications Pheochromocytoma Tachyarrhythmias With halogenated anesthesia- increased

sensitivity to adrenergic drugs

The Adrenergic AGONISTS Alpha and Beta agonists: Adverse effects

Sympathetic stimulation effects

CVS- hypertension, tachycardia, palpitations

Respi- tachypnea

GI- nausea, vomiting

Others- sweating, headache, piloerection

The Adrenergic AGONISTSAlpha and Beta agonists: Nursing

considerations

1. Monitor patient response to the drug

2. Emphasize to avoid the use with MAOIs and TCA

3. Maintain phentolamine (alpha blocker) to manage extravasation of IV drug

4. Usually given IV

The Adrenergic AGONISTSAlpha and Beta agonists: Nursing

considerations

Determine effectiveness of the drug:

Increased BP in shock

Relief of anaphylaxis and asthma attack

Relief of nasal congestion

The Adrenergic AGONISTSAlpha Agonists (selective)

Prototype: phenylephrine

clonidine (alpha-2 specific)

The Adrenergic AGONISTSAlpha Agonists Pharmacodynamics:

These agents bind primarily to the alpha receptors in the body

Clonidine

Stimulating the ALPHA-2 receptor causes decreased sympathetic outflow from the CNS/ decreased release of NE

The Adrenergic AGONISTSAlpha Agonists: Clinical use

1. Phenylephrine- vasoconstricting drug, used topically to decrease the symptoms of rhinitis

2. Clonidine- for hypertension

The Adrenergic AGONISTSAlpha Agonists: Contraindication

1. Allergy to drug

2. Caution in the following conditions:• Hyperthyroidism-aggravation of symptoms• Diabetes- increased glucose levels• Tachyarrhythmias- possible additive effect

The Adrenergic AGONISTSAlpha Agonists: Adverse effects

CNS- anxiety, depression, fatigue

CVS- palpitations

GI- nausea, vomiting and anorexia

GU- oliguria, dysuria

The Adrenergic AGONISTSAlpha Agonists: Nursing considerations

1. DO NOT discontinue drug abruptly to prevent rebound effect

2. Maintain phentolamine if giving IV drug

3. Provide comfort measures- rest, quiet environment, analgesics

The Adrenergic AGONISTSAlpha Agonists: Nursing considerations

Evaluate effectiveness:

Decreased BP

Decreased Nasal congestion

The Adrenergic AGONISTSBeta Agonists (Selective): ANTI-ASTHMA

DRUGS

Prototype: isoproterenol (B1 and B2)

salbutamol (Ventolin)= B2 specific

1. Ritodrine (B2 specific)

2. “terol”- albuterol, salmeterol, bitolterol

3. Terbutaline (B2)

The Adrenergic AGONISTSBeta Agonists Pharmacodynamics

These agents bind to the BETA receptors causing the sympathetic manifestations and effects

The Adrenergic AGONISTSBeta Agonists Clinical use

1. Asthma- due to the bronchodilation!

2. Preterm labor- ritodrine is given to relax the uterine muscles

3. Shock= To increase BP

The Adrenergic AGONISTSBeta Agonists Adverse effects

CNS- restlessness, headache, anxiety , tremors

CVS- tachycardia, angina, palpitations

GI- nausea, vomiting and anorexia

Others- pupilary dilation, rash, sweating, pulmonary edema

The Adrenergic AGONISTSBeta Agonists Nursing considerations1. Monitor VS when giving the drug2. Remind mothers to lie on the left side

during ritodrine administration3. Maintain a beta blocker on stand by4. Provide comfort- quiet environment, rest,

analgesics.5. Prevent over-hydration to avoid pulmonary

edema

The Adrenergic AGONISTSBeta Agonists Nursing considerations These are given usually inhalational for

asthma attack Instruct on how to use inhalers and

nebulizers


Normal RR

Clear breath sounds

The Adrenergic ANTAGONISTS These are called adrenergic blockers

They can be Alpha Blockers (selective)

Beta Blockers (selective)

Both Alpha & Beta Blockers

(non-selective)

The Adrenergic ANTAGONISTSThe alpha blockers (selective)

Prototype: Phentolamine

Phenoxybenzamine

“zosin”- prazosin, doxazosin, terazosin- these are

alpha 1 blockers

The Adrenergic ANTAGONISTSThe alpha blockers: Pharmacodynamics

These agents have affinity for the ALPHA receptors

Blocking the alpha receptors will cause:

Vasodilation

Sphincter relaxation in the bladder

The Adrenergic ANTAGONISTSThe alpha blockers: Clinical use

1. Phenoxybenzamine- used in pheochromocytoma

2. Phentolamine- also used in pheochomocytoma

3. “zosin” drugs- are used to decrease blood pressure and to relax the urinary sphincter in BPH!

The Adrenergic ANTAGONISTSThe alpha blockers: Contraindications

1. Myocardial infarction

2. Allergy

The Adrenergic ANTAGONISTSThe alpha blockers: Adverse Effects

CVS- hypotension, reflex tachycardia, flushing

CNS- dizziness, weakness, fatigue, drowsiness

Others- nasal congestion, reddened eyes, priapism

The Adrenergic ANTAGONISTSThe alpha blockers: nursing consideration1. Monitor heart rate and BP2. Caution to change position slowly3. Advise to avoid hazardous activities4. Provide supportive measures like quiet

environment, rest and analgesics5. Monitor response to the drug- improvement

of blood pressure readings and urination

The Adrenergic ANTAGONISTSThe Beta blockers

These are agents used to treat cardiovascular problems- Hypertension, CHF, angina

Blocking beta receptor will cause

decreased heart rate

decreased BP

The Adrenergic ANTAGONISTSThe Beta blocker or The “olol”s

They can be beta 1 blockers, beta 2 blockers or Both

Prototype of non-selective: propranOLOL (beta 1 and 2)carteOLOLnadOLOL

penbutOLOLsotaLOL

The Adrenergic ANTAGONISTSThe Beta blocker or The “olol”s

They can be beta 1 blockers, beta 2 blockers or Both

Prototype of B1 selective: atenOLOL

acebutOLOL

betaxOLOL

esmOLOL

metoprOLOL

The Adrenergic ANTAGONISTSThe Beta blockers: pharmacodynamics

These agents block the beta receptors of the sympathetic system. The selective B1 antagonists block the B1 receptors, especially in the heart and the kidney

The Adrenergic ANTAGONISTSThe Beta blockers: Clinical use

1. Hypertension

2. Angina and MI

3. Cardiac arrhythmias

4. Migraine headache

5. HYPERTHYROIDISM

The Adrenergic ANTAGONISTSThe Beta blockers: Clinical use

Hypertension to decrease BP

Angina and MI to decrease cardiac workload

Cardiac tachyarrhythmias to terminate arrhythmias

Migraine headache to cause vasoconstriction in the cranial vessels

HYPERTHYROIDISM to decrease the tachycardia

The Adrenergic ANTAGONISTSThe Beta blockers: contraindications

1. Allergy

2. Heart blocks

3. Bradycardia

4. COPD

5. Precaution in DM

The Adrenergic ANTAGONISTSThe Beta blockers: Adverse effects

CVS- bradycardia, hypotension, heart block

CNS- fatigue, dizziness, depression

Respi- bronchospasm, pulmonary edema

GI- nausea, vomiting, diarrhea, hypoglycemia

GU- decreased libido, impotence, dysuria

The Adrenergic ANTAGONISTSThe Beta blockers: nursing considerations

1. Emphasize NOT to stop abruptly the drug intake

2. Give with FOODS to improve absorption

3. Provide comfort measures Adequate rest periods Avoidance of hazardous activities Change position slowly

The Adrenergic ANTAGONISTSThe Beta blockers: nursing considerations


Decreased BP in hypertension

Decreased HR in hyperthyroidism

Decreased PAIN angina

The Cholinergic Agonists These are also called

parasympathomimetic agents

Their action mimics the parasympathetic nervous system

The Cholinergic Agonists These agents INCREASE the activity of

acetylcholine in the acetylcholine receptors DIRECTLY by occupying the receptor INDIRECTLY by blocking the enzyme that

degrades the acetylcholine, preventing it from breakdown - the enzyme: acetylcholinESTERASE

The Cholinergic Agonists Direct acting cholinergic agonists

Prototype: BetaneCHOL

CarbaCHOL

Pilocarpine Indirect acting cholinergics

Prototype: Pyridostigmine

Neostigmine

Endrophonium (Tensilon)

The Cholinergic AgonistsDirect acting cholinergic agonists

Pharmacodynamics They are similar to acetylcholine and

directly act on the acetylcholine receptors

The Cholinergic AgonistsDirect acting cholinergic agonists

Parasympathetic stimulation will cause:

DUMBELS

urination

miosis (pupil constriction)

The Cholinergic AgonistsDirect acting cholinergic agonists: Clinical use

1. Post operative and post partum urinary retention and to treat neurogenic bladder

2. Relief of increased intraocular pressure of glaucoma by inducing miosis

The Cholinergic AgonistsDirect acting cholinergic agonists: Clinical use

1. The drugs INCREASE the bladder tone, RELAX the GI and urinary sphincters

2. The topical agent (pilocarpine) topically causes pupilary constriction to reduce IOP

The Cholinergic AgonistsDirect acting cholinergic agonists:

Contraindications

1. Bradycardia

2. Hypotension

3. Asthma

The Cholinergic AgonistsDirect acting cholinergic agonists: Adverse

effects (DUMBELS)

CVS- bradycardia, heart block, hypotension

GIT- nausea, vomiting, diarrhea, increased salivation, lacrimation

GUT- sense of urgency, sphincter relaxation

Others- increased sweating, headache, miosis

The Cholinergic AgonistsDirect acting cholinergic agonists: nursing

considerations

1. Assure proper administration of ophthalmic preparations

2. Administer on EMPTY stomach

3. Provide safety precautions- because of poor visual acuity

4. Promote cool environment, maintain access to the bathroom (urination)

The Cholinergic Agonists: evaluate effectivenessDrug effectiveness

Pilocarpine Decreased IOP in glaucoma

Betanechol/Carbachol Urination/ relief of bladder distention

The Cholinergic AgonistsIndirect acting cholinergic agonists

Pharmacodynamics

These agents DO NOT react directly with the receptors but REACT chemically with the enzyme= acetylcholinesterase


Pharmacodynamics

The acetylcholine breakdown is prevented so that the effect of acetylcholine is prolonged!= increased muscle contraction

They are used IN myasthenia gravis


Clinical use

1. Myasthenia gravis Physostigmine, pyridostigmine, Neostigmine,

and endrophonium

2. Alzheimer's disease Tacrine and Donepezil


Adverse effects

GI- nausea, vomiting, cramps, diarrhea, increased salivation, involuntary defection

CVS- bradycardia, heart block, hypotension

GU- urinary urgency

Others- blurred vision, miosis, headache, dizziness


Nursing considerations

1. Administer IV drug slowly

2. Administer with foods BUT better BEFORE meals

3. Maintain atropine sulfate as antidote

4. Discontinue the drug if excessive salivation, diarrhea, vomiting become problematic


Nursing considerations

Evaluate effectiveness

Decreased muscle weakness

Decreased dysphagia, ptosis

Increased muscular activity

The ANTI-cholinergics These are drugs that BLOCK the effect of

acetylcholine They are also called parasympatholytic

agents In effect, the sympathetic system becomes

unopposed!!!

The ANTI-cholinergics Anticholinergics:

Prototype: Atropine

dicyclomine

glycopyrrolate

propantheline

scopolamine

The ANTI-cholinergicsAnticholinergics: pharmacodynamics

These agents work by BLOCKING or COMPETING with acetylcholine for the acetylcholine receptors

BEST taken BEFORE MEALS

Atropine Depresses salivation Decreases bronchial secretions Mydriasis Cyclopedia Inhibits vagal response in the heart Reverses cholinergic toxicity

Atropineeffects Clinical use

Depresses salivation Used as pre-op med

Decreases bronchial secretions

Used as pre-op med

Mydriasis Used in cataract surgery

Cyclopledia Used in cataract surgery

Inhibits vagal response in the heart

Used in BRADYCARDIA and heart block

Constipation Used in partly to control diarrhea (in Lomotil)

Reverses cholinergic toxicity

Used in Cholinergic and Organophosphate poisoning

Scopolamine Decreases nausea and vomiting associated

with motion sickness

Anticholinergic Contraindications of anticholinergic

1. Known allergy

2. Glaucoma

3. Bladder obstruction (like PBH)

AnticholinergicAdverse effects: anticholinergic effects

CNS- blurred vision, pupil DILATION, photophobia, cycloplegia and increased Intraocular pressure

GI- dry mouth, constipation, bloatedness

CVS- tachycardia, palpitations

GU- urinary retention

Others- decreased sweating, flushing

AnticholinergicNursing considerations

1. Provide comfort measures Frequent mouth care Provide increased fluids Protect eyes form lights Advise to avoid hazardous activities Provide high-fiber diet and laxative Avoid extremes of temperature Instruct to void before administering the drug

AnticholinergicNursing considerations

2. Monitor for toxicity:

3. Ensure adequate hydration to prevent hyperpyrexia

Evaluate effectiveness of drug:

Increased HR in heart block

Decreased secretions in pre-op patients

Relief of motion sickness (scopolamine)

pharmacology bullet review

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