Pharmacology Bullet Review (2)

8/3/2019 Pharmacology Bullet Review (2)

http://slidepdf.com/reader/full/pharmacology-bullet-review-2 1/342

PharmacologyPharmacology

Bullet ReviewBullet Review



Drug classification

Nursing process

applied to

pharmacology

Pharmacokinetics

Pharmacodynamic

s



Diuretics ComparisonDiuretics ComparisonDiuretic class

Major site of action

Special Sideeffect (s)

1. Carbonicanhydraseinhibitor

Proximal tubule Acidosis

2. Thiazideand thiazidelike

Proximal tubule HyperuricemiaHypokalemia

3. Loop

diuretics

Loop of Henle Hypokalemia

Ototoxicity4. Potassiumsparing

Distal tubule Hyperkalemia

5. Osmoticdiuretic

Glomerulus Hypovolemia &hypotension



Diuretics ComparisonDiuretics Comparison

Diuretic class Special Uses

1. Carbonicanhydrase

inhibitor

Mountain sickness

Meniere’s disease2. Thiazide andthiazide like

Nephrolithiasis due to calciumstones

Hypocalcemia

3. Loopdiuretics

Hypercalcemia

4. Potassiumsparing

CHF taking digoxin

5. Osmotic Increased ICP



ThiazidesThiazides

Prototype: HydrochloroPrototype: Hydrochlorothiazidethiazide

1. Bendroflume1. Bendroflumethiazidethiazide 2. Ben2. Benthiazidethiazide 3. Chloro3. Chlorothiazidethiazide (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 beSodium in the distal tubule to be

excreted into the urineexcreted into the urine

Potassium is alsoPotassium is also

flushed out!!flushed out!!



ThiazideThiazide

Special Pharmacodynamics: SideSpecial Pharmacodynamics: Side

effectseffects HypokalemiaHypokalemia

DECREASED calcium excretionDECREASED calcium excretion hypercalcemiahypercalcemia

DECREASED uric acid secretionDECREASED uric acid secretion

hyperuricemiahyperuricemia HyperglycemiaHyperglycemia



Loop DiureticsLoop Diuretics

Prototype: FurosemidePrototype: Furosemide

1. Bumetanide1. Bumetanide 2. Ethacrynic acid2. Ethacrynic acid

3. Torsemide3. Torsemide





High-ceiling diureticsHigh-ceiling diuretics

BLOCK the chloride pump in theBLOCK the chloride pump in theascending loop of Henleascending loop of Henle

SODIUM and CHLORIDE reabsorptionSODIUM and CHLORIDE reabsorption

is preventedis prevented Potassium is also excreted togetherPotassium 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 electrolyteOtotoxicity- due to the electrolyteimbalancesimbalances



Potassium sparingPotassium sparing

diureticsdiureticsPrototype: SpironolactonePrototype: Spironolactone

1. Amiloride1. Amiloride 2. Triamterene2. Triamterene




diureticsdiureticsPharmacodynamicsPharmacodynamics

Spironolactone is an ALDOSTERONESpironolactone is an ALDOSTERONE

antagonistantagonist

Triamterene and Amiloride BLOCK Triamterene and Amiloride BLOCK

the potassium secretion in the distalthe potassium secretion in the distal

tubuletubule

Diuretic effect is achieved by theDiuretic effect is achieved by thesodium loss to offset potassiumsodium loss to offset potassium

retentionretention




diureticsdiuretics




diureticsdiureticsPharmacokinetics: Side effectsPharmacokinetics: Side effects

HYPERkalemia!HYPERkalemia!

Avoid high potassium foods:Avoid high potassium foods:

BananasBananas PotatoesPotatoes

SpinachSpinach

BroccoliBroccoli

NutsNuts

PrunesPrunes

TomatoesTomatoes

OrangesOranges

PeachesPeaches



Osmotic DiureticsOsmotic Diuretics

Prototype: MannitolPrototype: Mannitol

1. Glycerin1. Glycerin 2. Isosorbide2. Isosorbide

3. Urea3. Urea





Mannitol is a sugar not well absorbedMannitol is a sugar not well absorbedin the nephronin the nephron osmotic pull of osmotic pull of

waterwater diuresisdiuresis




Pharmacokinetics: side effectsPharmacokinetics: side effects Sudden hypovolemiaSudden hypovolemia

Important for the nurse to warm theImportant for the nurse to warm thesolution to allow the crystals tosolution to allow the crystals to

DISSOLVE in the bottle!DISSOLVE in the bottle!



Carbonic AnhydraseCarbonic Anhydrase

InhibitorsInhibitorsPrototype: AcetazolamidePrototype: Acetazolamide

1. Methazolamide1. Methazolamide




InhibitorsInhibitorsPharmacodynamicsPharmacodynamics

Carbonic Anhydrase forms sodiumCarbonic Anhydrase forms sodiumbicarbonatebicarbonate

BLOCK of the enzyme results toBLOCK of the enzyme results to

slow movement of hydrogen andslow movement of hydrogen and

bicarbonate into the tubulesbicarbonate into the tubules

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




InhibitorsInhibitorsPharmacokinetics: side effectsPharmacokinetics: side effects

Metabolic ACIDOSIS happens whenMetabolic ACIDOSIS happens when

bicarbonate is lost bicarbonate is lost

HypokalemiaHypokalemia



The Nursing Process andThe Nursing Process and

the diureticsthe diuretics

ASSESSMENTASSESSMENT

Assess the REASON why the drug isAssess the REASON why the drug isgiven:given:

______ ______

______ ______

______ ______ ______ ______






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






Physical assessmentPhysical assessment

Vital signsVital signs

Special electrolyte and laboratorySpecial electrolyte and laboratoryexaminationexamination

Assess symptom of body weaknessAssess symptom of body weaknesswhich may indicate hypokalemiawhich may indicate hypokalemia





Nursing DiagnosisNursing Diagnosis Fluid volume deficit related to diureticFluid 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 forSafety precaution for

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

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

spironolactonespironolactone Provide skin care, oral care andProvide skin care, oral care and

urinary careurinary care





IMPLEMENTATIONIMPLEMENTATION

Monitor DAILY WEIGHT- to evaluateMonitor DAILY WEIGHT- to evaluatethe effectiveness of the therapythe effectiveness of the therapy

Monitor urine output, cardiac rhythm.Monitor urine output, cardiac rhythm.

Serum electrolytesSerum 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 congestionNormal BPNormal BP



The ANXIOLYTICS AND HYPNOTICSThe ANXIOLYTICS AND HYPNOTICS

These drugs are used to change theThese drugs are used to change the

individual’s responses to theindividual’s responses to the

environment.environment.




The medications that can prevent theThe medications that can prevent the

feelings of tension and fear are calledfeelings of tension and fear are called

ANXIOLYTICS. ANXIOLYTICS.

– Anti-anxiety drugs Anti-anxiety drugs




The drugs that can calm individualsThe drugs that can calm individuals

making them unaware of themaking them unaware of the

environment are called SEDATIVES.environment are called SEDATIVES.




The drugs that can induce sleep areThe drugs that can induce sleep are

called HYPNOTICS.called HYPNOTICS.




The drugs in this class are theThe drugs in this class are the

– BENZODIAZEPINESBENZODIAZEPINES

– BARBITURATESBARBITURATES



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 anxiety2. Formation of sedative state2. Formation of sedative state

3. Induction of sleep3. Induction of sleep



The BENZODIAZEPINESThe BENZODIAZEPINES

The benzodiazepines are the most frequentlyThe benzodiazepines are the most frequentlyused anxiolytic drugs.used anxiolytic drugs.

These agents prevent anxiety states withoutThese agents prevent anxiety states withoutcausing much sedation, with less physicalcausing much sedation, with less physicaldependence than other agents.dependence than other agents.




The following are the benzodiazepinesThe following are the benzodiazepines Alprazolam (Xanax) Alprazolam (Xanax)

Chlordiazepoxide (LibriumChlordiazepoxide (Librium))

clonazepamclonazepam

clorazepateclorazepate

Diazepam (Valium)Diazepam (Valium)

estazolamestazolam

flurazepamflurazepam

lorazepamlorazepam

midazolammidazolamoxazepamoxazepam

quazepamquazepam

temazepamtemazepam

triazolamtriazolam




Special 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 systemThese 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 causingaminobutyric acid) more effective causinginterference with neuron firing.interference with neuron firing.




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

The GABA is an inhibitoryThe GABA is an inhibitory

neurotransmitter.neurotransmitter.This will result to an anxiolyticThis will result to an anxiolyticeffect at lower doses thaneffect at lower doses than

required for sedation/hypnosis.required for sedation/hypnosis.




These agents are indicated for the treatmentThese agents are indicated for the treatmentof of

1.1. anxiety disordersanxiety disorders

2.2.

alcohol withdrawalalcohol withdrawal3.3. hyperexcitability, and agitationhyperexcitability, and agitation

4.4. pre-operative relief of anxiety andpre-operative relief of anxiety andtension and in induction of balancedtension and in induction of balanced

anesthesia.anesthesia.




Pharmacodynamics: The adverse effectsPharmacodynamics: The adverse effects

CNS effects=CNS effects= sedation, drowsiness,sedation, drowsiness,depression, lethargy, blurred visiondepression, lethargy, blurred vision

GIT=GIT= dry mouth, constipationdry mouth, constipation, nausea,, nausea,vomitingvomiting

CVS=CVS= HypotensionHypotension or hypertension,or hypertension,arrhythmias, palpitations, andarrhythmias, palpitations, andrespiratory difficulties.respiratory difficulties.

Hematologic= blood dyscrasias andHematologic= blood dyscrasias andanemiaanemia

GU= 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 hazardousInstruct to avoid hazardousactivities like driving and machineactivities like driving and machineoperation.operation.

Instruct to avoid consuming Instruct to avoid consuming ALCOHOL while taking the drug ALCOHOL while taking the drug ..




Nursing Considerations:Nursing Considerations:

Provide comfort measures to helpProvide comfort measures to helppatients tolerate drug effects-patients tolerate drug effects- – instruct to urinate before takinginstruct to urinate before taking

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

ambulation.ambulation.

Have availableHave available FLUMAZENIL as anFLUMAZENIL as anantidote for benzodiazepineantidote for benzodiazepineoverdose.overdose.



The BARBITURATESThe BARBITURATES

These are also anxiolytics andThese are also anxiolytics andhypnotics with a greater likelihood of hypnotics with a greater likelihood of producing sedation, with increaseproducing sedation, with increase

risk of addiction and dependence.risk of addiction and dependence.




The following are the barbituratesThe following are the barbiturates

amobarbitalamobarbital

aprobarbitalaprobarbital

butabarbitalbutabarbitalmephobarbitalmephobarbital

pentobarbitalpentobarbital

Phenobarbital Phenobarbital

secobarbitalsecobarbital




The Mechanism of Action of the BarbituratesThe Mechanism of Action of the Barbiturates

They depress the motor output from theThey depress the motor output from thebrain.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 manifestations

2.2. For sedationFor sedation

3.3. For patients with insomniaFor patients with insomnia4.4. For pre-anesthesiaFor pre-anesthesia

5.5. seizures/epilepsy seizures/epilepsy

6.6. The rapid acting barbiturates are alsoThe rapid acting barbiturates are alsoused for the treatment of acute manicused for the treatment of acute manicreactions 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, paradoxicalvertigo, lethargy, ataxia, paradoxicalexcitement, anxiety and hallucinations.excitement, anxiety and hallucinations.

GIT=GIT= nausea, vomiting,nausea, vomiting, constipation/diarrhea and epigastric painconstipation/diarrhea and epigastric pain

CVS= bradycardia, Hypotension andCVS= bradycardia, Hypotension andsyncope.syncope.

Respi= serious hypoventilation, respiratoryRespi= serious hypoventilation, respiratorydepression and laryngospasmsdepression and laryngospasms

Others=Others= hypersensitivity and Stevens-hypersensitivity and Stevens-Johnson syndrome.Johnson syndrome.




Nursing ConsiderationsNursing ConsiderationsProvide stand-by life support facilitiesProvide stand-by life support facilitiesin cases of severe respiratoryin cases of severe respiratorydepression or hypersensitivitydepression or hypersensitivity

reaction.reaction.Taper the drug gradually after long-Taper the drug gradually after long-term therapy to avoid withdrawalterm therapy to avoid withdrawalsyndrome.syndrome.

Provide comfort measures includingProvide comfort measures includingsmall frequent meals, access tosmall frequent meals, access tobathroom facilities, high-fiber foods,bathroom facilities, high-fiber foods,environmental control, safetyenvironmental control, safety

precaution and skin care.precaution and skin care.



The CNS stimulantsThe CNS stimulants

These are drugs used to treat certainThese are drugs used to treat certain

disordersdisorders

1.1. exogenous obesityexogenous obesity

2.2. attention-deficit hyperactivityattention-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, whichhyperactive children, whichallows them to focus on oneallows 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 Methyl phenidate (Ritalin)= most

commonly used for ADHDcommonly used for ADHD

2. Dextroamphetamine= a CNS stimulant2. 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 Mechanism of ActionThe Mechanism of Action

These agents act as to stimulate theThese agents act as to stimulate the

cortical and reticular activating systemcortical and reticular activating system(RAS) of the brain.(RAS) of the brain.

This is by releasing neurotransmittersThis is by releasing neurotransmittersfrom the nerve cells leading tofrom 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 tostimulation seen in ADHD is believed to

be related to the increased stimulationbe related to the increased stimulationof an IMMATURE Reticular Activating of an IMMATURE Reticular Activating

System leading to the ability to be moreSystem leading to the ability to be more

selective in response to incoming selective in response to incoming stimuli.stimuli.




Pharmacodynamics: Adverse effects of the CNSPharmacodynamics: Adverse effects of the CNS

stimulantsstimulants

CNS=CNS= nervousness, insomnianervousness, insomnia, dizziness,, dizziness,

headache, and blurred visionheadache, and blurred visionGIT=GIT= anorexiaanorexia, nausea and weight loss, nausea and weight loss

CVS= hypertension, tachycardia arrhythmias, andCVS= hypertension, tachycardia arrhythmias, and

anginaanginaOthers= rashes, physical/psychologicalOthers= rashes, physical/psychological

dependence.dependence.



The CNS stimulantsThe CNS stimulantsImplementationImplementation

The nurse must ensure that the drug is only given toThe 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 insomniaBEST given AFTER meals to prevent the effect BEST g iven AFTER meals to prevent the effect

of anorexiaof anorexia

Consult with school personnel to monitor the patientConsult with school personnel to monitor the patientunder therapyunder therapy

Provide safety measures such as side-rails andProvide safety measures such as side-rails and

assisted ambulationassisted ambulation




EvaluationEvaluationEvaluate 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 narcolepsy Alertness for patients with narcolepsy

The Anti epilepticsThe Anti epileptics



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 manybenzodiazepines, Succinimides and many

others are given to a specific type of others are given to a specific type of

seizure.seizure.



Anti-epileptics Anti-epilepticsAgents for treating TONIC-CLONIC SEIZURESAgents for treating TONIC-CLONIC SEIZURES

1. Hydantoins1. Hydantoins – PhenytoinPhenytoin – EthotoinEthotoin – FosphenytoinFosphenytoin – MephenytoinMephenytoin

2. Benzodiazepines2. Benzodiazepines – DiazepamDiazepam – ClonazepamClonazepam – ClorazepateClorazepate

3. Barbiturates3. Barbiturates – PhenobarbitalPhenobarbital



Anti-epileptics Anti-epileptics

Agents for treating ABSENCE SEIZURES Agents for treating ABSENCE SEIZURES

1. Succinimides1. Succinimides

a. Ethosuximidea. Ethosuximide

b. Methsuximideb. Methsuximidec. Phensuximidec. Phensuximide

2. Valproic Acid2. Valproic Acid

3. Zosinamide3. Zosinamide



Anti-epileptics Anti-epileptics

Agents for treating Partial FOCAL SEIZURES Agents for treating Partial FOCAL SEIZURES

1. Carbamazepine1. Carbamazepine

2. Gabapentin2. Gabapentin

3.Lamotrigine3.Lamotrigine4. Tiagabine4. Tiagabine

5. Topiramate5. Topiramate



The hydantoinsThe hydantoins

These agents are utilized for general seizuresThese agents are utilized for general seizuresbecause they can depress the centralbecause they can depress the central

nervous system.nervous system.

They affect the entire brain and reduce theThey affect the entire brain and reduce thechance of sudden electrical outburst that chance of sudden electrical outburst that

causes seizures.causes seizures.

These agents generally are less sedating thanThese agents generally are less sedating thanother 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 inFor the prevention of seizures in

neurosurgeryneurosurgery

4.4. For muscle relaxation.For muscle relaxation.




Contraindications and PrecautionsContraindications and Precautions

Hydantoins are NOT given to pregnantHydantoins are NOT given to pregnant

patient because it can cause fetalpatient because it can cause fetal

hydantoin syndromehydantoin syndrome..




Pharmacodynamics: Adverse effects of thePharmacodynamics: Adverse effects of theHydantoinsHydantoins

CNS effects- depression, confusion,CNS effects- depression, confusion,drowsiness, lethargy, fatiguedrowsiness, lethargy, fatigue

GIT- GI upset, constipation, dry mouthGIT- GI upset, constipation, dry mouth,,GINGIVAL HYPERPLASIA , severe liver GINGIVAL HYPERPLASIA , severe liver toxicity which are all related to cellular toxicity which are all related to cellular

toxicity.toxicity.SKIN- hirsutism and coarsening of theSKIN- hirsutism and coarsening of thefacial skinfacial skin

Bone Marrow depressionBone Marrow depression




ImplementationImplementation Administer the drug with food to Administer the drug with food toalleviate GI irritationalleviate GI irritation

Discontinue 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 care

Rule out pregnancy and advise womenRule out pregnancy and advise womento use contraceptive measures toto use contraceptive measures toprevent pregnancy.prevent pregnancy.



ff



Drugs affecting GI secretionsDrugs affecting GI secretions

There are five types of drugs that affecthere are five types of drugs that affectgastric acid secretions and are useful forastric acid secretions and are useful for

the treatment of peptic ulcer.he treatment of peptic u lcer.

1.. Histamine (H2) receptoristamine (H2) receptorantagonist/blockersntagonist/blockers

2.. Antacidsntacids

3.. Proton pump inhibitorsroton pump inhibitors

4.. Mucosal protectantsucosal protectants

5.. Prostaglandin analogsrostaglandin analogs

Drugs affecting secretions:Drugs affecting secretions:



Drugs affecting secretions:Drugs affecting secretions:

anti ulceranti 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 drugsGeneral indication of the drugs



General indication of the drugsGeneral 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 theGeneral time of administration of the



General time of administration of theGeneral 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 ONEhour after ANTACID

Antacids AlOH and MgOH Usually after meals

Proton pumpinhibitors

Omeprazole BEFORE MEALS

Mucosal protectants Sucralfate BEFORE MEALS

Prostaglandin analogMisoprostol WITH MEALS



Pharmacology of Anti-ulcerharmacology of Anti-ulcer

drugsrugsDrug Mechanism of Action

Antacids- AlOH, MgOH Neutral ize Gastric ACIDITY

H2-Blockers- “t i d i ne ”

Cimetidine, Ranitidine

Block Histamine receptorcausing decreased secretionand acidity

Proton pump inhibitors-“P r a z o l e s ”

Om ep ra z o l e , p an t op r a z o l e

Inhibit Proton Pump in parietalcel l decreasing secretion andacidity

h l f i l dPh l f A ti l d



Pharmacology of Anti-ulcer drugsPharmacology of Anti-ulcer drugs

Drug Mechanism of Action

Anti-cholinergic- ProphantelineBromide

Blocks VAGUS nerve, decreasessecretion

Sucralfate (Carafate) Coats the mucosal l ining

Misoprostol (Cytotec) Prostaglandin Analogue, causessecretion of MUCUS

Ph d iPh d i




Histamine (H2) receptor blockersistamine (H2) receptor blockers

►These drugs BLOCK the release ofhese drugs BLOCK the release of

hydrochloric acid in the stomachydrochloric acid in the stomachin response to gastrinn response to gastrin

D ff ti GI tiD ff ti GI ti




Antacidsntacids

►These drugs interact with thehese drugs interact with the

gastric acids at the chemicalastric acids at the chemicallevel to neutralize themevel to neutralize them





Proton pump inhibitorsroton pump inhibitors

►These drugs suppress thehese drugs suppress the

secretion of hydrochloric acidecretion of hydrochloric acidinto the lumen of the stomachnto the lumen of the stomach





Mucosal protectantsucosal protectants

►These are agents that coathese are agents that coat

any injured area in theny injured area in thestomach to prevent furthertomach to prevent further

injury from acidnjury from acid





Prostaglandin analogsrostaglandin analogs

►These are agents thathese are agents that i n h i b i tnh i b i t

the secretion of gastrin andhe secretion of gastrin and►i n c r ea sen c r ea s e the secretion ofthe secretion of

mucus lining of the stomach,ucus lining of the stomach,

providing a buffer.roviding a buffer.

Th H2 Bl k “tidi ”Th H2 Bl k “tidi ”



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

Prototype: CimetidinePrototype: Cimetidine

►1. Ranitidine1. Ranitidine

►2. Famotidine2. Famotidine

►3. Nizatidine3. Nizatidine

Th H2 Bl k “tidi ”Th H2 Bl k “tidi ”




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

receptors in the parietal cells of theeceptors in the parietal cells of thestomach.tomach.

► The blockage results to inhibition of thehe blockage results to inhibition of thehormone gastrin.ormone gastrin.

► There will be decreased production ofhere will be decreased production of

gastric acid from the parietal cells.astric acid from the parietal cells.► Also, the chief cells will secrete lesslso, the chief cells will secrete lesspepsinogen.epsinogen.

Th H2 Bl k “tidi ”The H2 Blocke s “tidines”




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

benign gastric ulcerbenign gastric ulcer►

Treatment of hypersecretory conditions like theTreatment of hypersecretory conditions like theZollinger-Ellison syndromeZollinger-Ellison syndrome

► Prevention of stress-induced ulcers and acute GIPrevention of stress-induced ulcers and acute GIbleedingbleeding

► Treatment of erosive GERD (reflux disease)Treatment of erosive GERD (reflux disease)► Relief of Symptoms of heart burn and acidRelief of Symptoms of heart burn and acid

indigestionindigestion

Th H2 Bl k “tidi ”The H2 Blockers “tidines”




Precautions and ContraindicationsPrecautions and Contraindications

► Any known allergy is a clear contraindication Any known allergy is a clear contraindication

to the use of the agents. Conditions such asto the use of the agents. Conditions such as

pregnancy, lactation, renal dysfunction andpregnancy, lactation, renal dysfunction andhepatic dysfunction should warrant cautioushepatic dysfunction should warrant cautious

use.use.

►Nizatidine can be used in hepaticNizatidine can be used in hepaticdysfunction.dysfunction.

Th H2 Bl k “ idi ”Th H2 Bl k “tidi ”




Pharmocodynamics- Side effects and adverse effectsPharmocodynamics- Side effects and adverse effects► GIT= diarrhea or constipationGIT= diarrhea or constipation

► CNS= Dizziness, headache, drowsiness, confusionCNS= Dizziness, headache, drowsiness, confusion

and hallucinationsand hallucinations► Cardio= arrhythmias,Cardio= arrhythmias, H Y P O T E N S I O NY P O T E N S I O N (related to(related to

H2 receptor blockage in the heart)H2 receptor blockage in the heart)

►

Cimetidine=Cimetidine= T R E M O R S ,R E M O R S ,

Gyne com as t ia a ndyne com as t ia a nd

imp o t en ce i n ma l e sm p o t en ce in m a le s

The H2 Blocke s “tidines”The H2 Blockers “tidines”




Drug-drug Interactionsrug-drug Interactions

►Cimetidine, Famotidine, Rani tidineimetidine, Famotidine, Ranitidine

are metabolized in the l iver- theyre metabolized in the l iver- they

can cause slowing of excretion ofan cause slowing of excretion ofother drugs leading to theirther drugs leading to their

increased concentration.ncreased concentration.

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




Drug-drug Interactionsrug-drug Interactions

►These drugs can interact withhese drugs can interact with

CIMETIDINE anticoagulants,IMETIDINE anticoagulants,

phenytoin, alcohol, antidepressants.henytoin, alcohol, antidepressants.




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

Nursing considerations:ursing considerations:►Administer the drugdminister the drug WITH WITH mealseals atat

BEDTIME BEDTIME to ensure therapeutico ensure therapeutic

levelevel►One hour after Antacidsne hour after Antacids

►Stress the importance of thetress the importance of the

continued use for the length ofontinued use for the length oftime prescribedime prescribed





Nursing considerations:ursing considerations:►Monitor the cardiovascular statusonitor the cardiovascular statusespecial ly if the drugs are given IVspecial ly if the drugs are given IV

►

Warn patient of the potentialarn patient of the potentialproblems of increased drugroblems of increased drugconcentration if the H2 blockersoncentration if the H2 blockersare used with other drugs or OTCre used with other drugs or OTC

drugs. Advise consultation first!rugs. Advise consultation first!





Nursing considerations:Nursing considerations:

►Provide comfort measures l ikerovide comfort measures l ike

analgesics for headache, assistancenalgesics for headache, assistance

with ambulation and safety measuresith ambulation and safety measures►Warn the patients taking cimetidinearn the patients taking cimetidine

that drowsiness may pose a hazard i fhat drowsiness may pose a hazard if

driving or operating delicateriving or operating delicatemachines.achines.




The H2 Blockers- tidines The H2 Blockers- tidines

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

frequency, comfort measures to initiatefrequency, comfort measures to initiate

when side-effects are intolerablewhen side-effects are intolerable

Evaluate the effectiveness:Evaluate the effectiveness:

►Relief of symptoms of ulcer, heart burn andRelief of symptoms of ulcer, heart burn and

GERDGERD

The AntacidsThe Antacids




► These are drugs or inorganic chemicals thatThese are drugs or inorganic chemicals thathave been used for years to neutralize acid inhave been used for years to neutralize acid inthe stomach. The following are the commonthe stomach. The following are the commonantacids that can be bought OTC: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 magnesiumMagaldrate (aluminum and magnesiumcombination)combination)





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

in the stomach.in the stomach.

►They do not affect the rate of gastric acidThey do not affect the rate of gastric acid

secretion.secretion.





Pharmacodynamics: drug actionPharmacodynamics: drug action►The administration of antacid may cause anThe administration of antacid may cause an

acid rebound.acid rebound.

►Neutralizing the stomach content to anNeutralizing the stomach content to an

alkaline level stimulates gastrin productionalkaline level stimulates gastrin production

to cause an increase in acid production andto cause an increase in acid production and

return the stomach to its normal acidicreturn the stomach to its normal acidicstate.state.





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

associated with hyperacidityassociated with hyperacidity

►Hyperacidic conditions like peptic ulcer,Hyperacidic conditions like peptic ulcer,

gastritis, esophagitis and hiatal herniagastritis, esophagitis and hiatal hernia

►S pe c i a l u s e o f AM P H O G EL ( a lu m in u mpe c i a l u s e o f AM P H O G EL ( a lu m in u m

hyd ro x id e ) : t o B IND pho sp ha t eyd r o x id e ) : t o B IND pho sp ha t e





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

Caution should be instituted if used inCaution should be instituted if used in

electrolyte imbalances, GI obstruction andelectrolyte imbalances, GI obstruction andrenal dysfunction.renal dysfunction.

►Sodium bicarbonate is rarely used becauseSodium bicarbonate is rarely used because

of potential systemic absorptionof potential systemic absorption





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

locally in the stomachlocally in the stomach





Pharmacodynamics: Effects of drugsPharmacodynamics: Effects of drugs1.1. GIT= rebound acidity; alkalosis may occur.GIT= rebound acidity; alkalosis may occur.► Calcium salts may lead toCalcium salts may lead to hype r ca l c em iaype r ca l c em ia ►

Magnes i um sa l t s c an cause D IARRH EAagnes i um sa l ts c an cause D IARRH EA► A lum inum sa l ts may causel um inum sa l t s may cause

CON STIPAT ION andON STIPAT ION and

hypophospha t em ia by b i nd ing w i thypophospha t em ia by b i nd ing w i th

pho sph a tes i n the G IT.hos pha tes i n the G IT.2.2. F lu i d r e t en t i onlu i d r e t en t i on due to the high sodiumdue to the high sodium

content of the antacids.content of the antacids.




The AntacidsThe AntacidsNursing Considerations:Nursing Considerations:

► Administer the antacids apart from any Administer the antacids apart from anyother medications byother medications by O N E h ou r b e f o reNE h ou r b e f o re oror T W O h ou r s a f t e r-W O h ou r s a f t e r- to ensureto ensure

adequate absorption of the otheradequate absorption of the othermedicationsmedications

►Tell the patient toTell the patient to C H E WH E W the tabletthe tabletthoroughly before swallowing. Follow itthoroughly before swallowing. Follow it

with one glass of waterwith one glass of water►Regularly monitor for manifestations of Regularly monitor for manifestations of

acid-base imbalances as well as electrolyteacid-base imbalances as well as electrolyte

imbalancesimbalances





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

constipation associated with aluminum andonstipation associated with aluminum and

diarrhea associated with magnesium salts.iarrhea associated with magnesium salts.

► Monitor for the side-effects, effectivenessonitor for the side-effects, effectiveness

of the comfort measures, patient’sf the comfort measures, patient’s

response to the medication and theesponse to the medication and theeffectiveness of the health teachingsffectiveness of the health teachings





Nursing Considerations:ursing Considerations:►Evaluate for effectiveness:valuate for effectiveness:

Decreased symptoms of ulcer andecreased symptoms of ulcer and

pyrosisyrosis

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

The PPIThe PPI



The PPIThe PPI

These are the newer agents for ulcerThese are the newer agents for ulcertreatmenttreatment

►The “prazoles” The “prazoles”

Prototype: OmePrototype: Omep ra zo l era zo l e

►LanisoLanisop razo l era zo l e

►EsomeEsomep ra zo l era zo l e

►PantoPantop razo l era zo l e

The PPIThe PPI



The PPIThe PPIPharmacodynamics: drug actionPharmacodynamics: drug action

►They act at specific secretory surfaceThey act at specific secretory surface

receptors to prevent the final step of acidreceptors to prevent the final step of acid

production and thus decrease the level of production and thus decrease the level of

acid in the stomach.acid in the stomach.

►The “pump” in the parietal cell is theThe “pump” in the parietal cell is the H -K-K

ATPase enzyme system on the secretory ATPase enzyme system on the secretory

surface of the gastric parietal cellssurface of the gastric parietal cells

The PPIThe PPI



The PPIThe PPI

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

ulcers, GERD, erosive esophagitis andulcers, GERD, erosive esophagitis and

benign gastric ulcer.benign gastric ulcer.► Long-term- maintenance therapy forLong-term- maintenance therapy for

healing of erosive disorders.healing of erosive disorders.

The PPIThe PPI



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 contraindication.Known allergy is a clear contraindication.

Caution if patient is pregnantCaution if patient is pregnant

The PPIThe PPI



The PPIThe PPI

Pharmacodynamics: Adverse effectsPharmacodynamics: Adverse effects►CNS-CNS- d i z z i n e s si z z i n e s s ,, headache, asthenia (lossheadache, asthenia (loss

of strength),of strength), ve r t i goe r t i g o ,, insomnia, apathyinsomnia, apathy

►GIT- d i a r r h ea , a bdo m ina l p a in ,I T- d i a r r h ea , a b dom ina l p a i n ,

n au sea , vom i t i n g , d r y m ou t hau sea , v om i t i n g , d r y m ou t h andand

tongue atrophytongue atrophy

►Respi- cough, stuffy nose, hoarseness andRespi- cough, stuffy nose, hoarseness andepistaxis.epistaxis.

The PPIThe PPI



The PPIThe PPI

Nursing considerations:Nursing considerations:► Administer the drug Administer the drug B E F O R EE F O R E meals.meals.

Ensure that patient does not open, chew orEnsure that patient does not open, chew or

crush the drug.crush the drug.►Provide safety measures if CNS dysfunctionProvide safety measures if CNS dysfunction

happens.happens.►

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

The PPIThe PPI



The PPIThe PPI

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

dosages and frequency, safety measures todosages and frequency, safety measures to

handle common problems.handle common problems.►Monitor patient response to the drug, theMonitor patient response to the drug, the

effectiveness of the teaching plan and theeffectiveness of the teaching plan and the

measures to employmeasures to employ

The PPIThe PPI



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 ulcerThis is given to protect the eroded ulcer

sites in the GIT from further damage bysites in the GIT from further damage by

acid and digestive enzymesacid and digestive enzymes

SucralfateSucralfate




Pharmacodynamics: Action of drugPharmacodynamics: Action of drug►It forms anIt forms an ulcer-adherent complex ulcer-adherent complex atat

duodenal ulcer sites, protecting the sitesduodenal ulcer sites, protecting the sites

against acid, pepsin and bile.against acid, pepsin and bile.►This action prevents further breakdown of This action prevents further breakdown of

proteins in the area and promotes healing.proteins in the area and 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 gastritisNSAIDs induced gastritis

►Prevention of stress ulcerPrevention of stress ulcer

►Treatment of oral and esophageal ulcersTreatment of oral and esophageal ulcers

due to radiation, chemotherapy ordue to radiation, chemotherapy or

sclerotherapy.sclerotherapy.





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

person with known allergy to the drug,person with known allergy to the drug,

and to those patients with renaland to those patients with renalfailure/dialysis because of build-up of failure/dialysis because of build-up of

aluminum may occur if used withaluminum may occur if used with

aluminum containing products.aluminum containing products.





Pharmacodynamics: Side-effects & adversePharmacodynamics: Side-effects & adversereactionsreactions

►P r im a r i l y G I T = CO NS T I P AT I O N ,r im a r i l y G I T = CO NS T I P AT I O N ,

o c c a s i ona l ly d i a r rh ea , n au sea ,c c a s iona l ly d i a r rh ea , n au sea ,i nd i ge s t i on , ga s t r i c d i s c om fo r t , andnd i ge s t i on , ga s t r i c d is c om fo r t , and

d r y m ou t h m a y a ls o o c cu rr y m ou t h m a y a ls o o c cu r

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





Drug-drug interactionsDrug-drug interactions► I f u s ed w i th a l um i num s a l ts= h i ghf u s ed w i th a l u m i n u m s a l t s= h i g h

r is k o f a c c u m u la t io n o f a l u m i n u m a n dis k o f a c c u m u la t io n o f a l u m in u m a n d

tox i c i t yox i c i t y ..►If used with phenytoin, fluoroquinolonesIf used with phenytoin, fluoroquinolones

and penicillamines- decreased levels of and penicillamines- decreased levels of

these drugs when taken with sucralfatethese drugs when taken with sucralfate





Nursing ConsiderationsNursing Considerations► Administer drug Administer drug O N A N E M P T Y st om a c hN A N E M P T Y s to m a c h , 11

hou r b e f o r e me a l s , o r 2 hou r a f t e r m ea l sou r b e f o r e me a l s , o r 2 hou r a f te r m ea l s

and a t BE DT IMEnd a t BE DT IME

► Monitor for side-effects like constipation and GIMonitor for side-effects like constipation and GIupsetupset

► Encourage intake of high-fiber foods andEncourage intake of high-fiber foods andincreased fluid intakeincreased fluid intake

► Administer antacids Administer antacids B E T W E E NE T W E E N doses of doses of sucralfate,sucralfate, N O T W I T H I N 3 0O T W I T H I N 3 0 minutes of minutes of sucralfate dosesucralfate dose





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

occuroccur

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

►Monitor patient response to the drug, theMonitor patient response to the drug, theeffectiveness of the teaching plan and theeffectiveness of the teaching plan and themeasures employedmeasures 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



Prostaglandin analogueostag a d a a ogue

MisoprostolMisoprostol►This agent is a synthetic prostaglandin E1This agent is a synthetic prostaglandin E1

analog that is employed to protect the lininganalog that is employed to protect the lining

of the mucosa of the stomachof the mucosa of the stomach




Prostaglandin analogueg g

Misoprostol: PharmacodynamicsMisoprostol: Pharmacodynamics►Being a prostaglandin analog, itBeing a prostaglandin analog, it i n h i b i t snh i b i t s

gastric acid secretion to some degreegastric acid secretion to some degree

►ItIt I N C R E A S E S m u c u sN C R E A S E S m u c u s production in theproduction in thestomach lining.stomach lining.




Prostaglandin analogueg g

Misoprostol: Clinical useMisoprostol: Clinical use►NSAIDs-induced gastric ulcersNSAIDs-induced gastric ulcers

►Duodenal ulcers unresponsive to H2Duodenal ulcers unresponsive to H2

antagonists.antagonists.




ostag a d a a ogueg g

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

because it is anbecause it is an abo r t i f a c i en t .bo r t i f a c i en t .

► Women should be advised to have aWomen should be advised to have a nega t i v eega t i v e

p r egnan cy t e s t w i t h in 2 w eek s o fr egnan cy t e s t w i t h in 2 w eek s o fb eg i nn i ng t he r apy and shou l d b eg i n theeg i nn i ng t he rapy an d shou l d b eg i n t he

d rug on t he s e con d o r t h i r d day o f t herug on t he s e cond o r t h ir d day o f t he

nex t m ens t r ua l c y c le .e x t m ens t r ua l c y c le .

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




g gg g

Pharmacodynamic effects: drug reactionsPharmacodynamic effects: drug reactions►GIT= Nausea, diarrhea, abdominal pain,GIT= Nausea, diarrhea, abdominal pain,

flatulence, vomiting, dyspepsiaflatulence, vomiting, dyspepsia

►GU effects= miscarriages,GU effects= miscarriages, ex ce s s i v ex ce s s i v e

u t e r i n e CR AM P I NG a n d b l e e d in gt e r i n e CR AM P I NG a n d b l e e d in g ,,

spotting, hypermenorrhea and menstrualspotting, hypermenorrhea and menstrual

disorders.disorders.




g gg g

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

ulcers during the full course of NSAIDs therapyulcers during the full course of NSAIDs therapy

► Administer four times daily with meals and at Administer four times daily with meals and atbedtimebedtime

► Obtain pregnancy test within 2 weeks of beginningObtain pregnancy test within 2 weeks of beginning

therapy. Begin the therapy on second or third daytherapy. Begin the therapy on second or third day

of menstrual periodof menstrual period to ensure that the woman is to ensure that the woman is not pregnant not pregnant




g gg g

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

information regarding the associated risks of information regarding the associated risks of

pregnancypregnancy

► Provide health teaching as to drug name,Provide health teaching as to drug name,

dosages and frequency, safety measures todosages and frequency, safety measures to

handle common problems.handle common problems.

► Monitor patient response to the drug, theMonitor patient response to the drug, theeffectiveness of the teaching plan and theeffectiveness of the teaching plan and the

measures to employmeasures to employ



LaxativesLaxatives



Type Prototype Action

Chemicalstimulants

Bisacodyl (Dulcolax) Direct stimulation of theGIT nervesIrritant laxatives

Mechanical (bulk)stimulants

Lactulose Increased fluid content of the fecal material causingstimulation of the localreflex

Lubricants Docusate Lubricating the intestinalmaterial to promotepassage through the GIT

LaxativesLaxatives



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

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

1. Chemical stimulants1. Chemical stimulants

2. Mechanical stimulants2. Mechanical stimulants

3. Lubricants3. Lubricants

Therapeutic Indications of theTherapeutic Indications of the

LaxativesLaxatives



LaxativesLaxatives

►SHORT term relief of SHORT term relief of Cons t i p a t i onons t i p a t i on

►P reve n t i on o f s t ra i n i ngreven t ion o f s t ra i n i ng in conditions likein conditions like

CHF, post-MI, post partum, post-opCHF, post-MI, post partum, post-op

►Preparation forPreparation for d i agno s t i c e x am i na t io ni a gno s t ic e x a m i na t io n

►Removal of poison or toxinsRemoval of poison or toxins

► Adjunct in anti-helminthic therapy Adjunct in anti-helminthic therapy

Contraindications in Laxative useContraindications in Laxative use



► ACUTE abdominal disorders ACUTE abdominal disorders Append i c i t i sppend i c i t i s

Dive r t i cu l i t i si ve r t i cu l i t i s

U l ce ra t i ve co l i t isl ce ra t i ve c o l i t is

Chemical Stimulant CatharticsChemical Stimulant Cathartics



Prototype: BisacodylPrototype: BisacodylIrritant laxatives:Irritant laxatives:

►1. Castor oil1. Castor oil

►2. Senna2. Senna

►3. Cascara3. Cascara

►

4. Phenolphthalein4. Phenolphthalein

Chemical Stimulant CatharticsChemical Stimulant Cathartics



PharmacodynamicsPharmacodynamics►These agents DIRECTLY stimulate the nerveThese agents DIRECTLY stimulate the nerve

plexus in the intestinal wallplexus in the intestinal wall

►The result is INCREASED movement orThe result is INCREASED movement ormotility of the colonmotility of the colon

Mechanical Stimulant CatharticsMechanical Stimulant Cathartics



►Prototype: LACTULOSE (Cephulac)Prototype: LACTULOSE (Cephulac)Bulk-forming laxativesBulk-forming laxatives

►1. Magnesium (citrate, hydroxide, sulfate)1. Magnesium (citrate, hydroxide, sulfate)

►2. Psyllium2. Psyllium

►3. Polycarbophil3. Polycarbophil

Mechanical Stimulant CatharticsMechanical Stimulant Cathartics



PharmacodynamicsPharmacodynamics►These agents are rapid-acting laxatives thatThese agents are rapid-acting laxatives that

INCREASE the GI motility byINCREASE the GI motility by

Increasing the fluids in the colonic materialIncreasing the fluids in the colonic material 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 fat andDocusate increases the admixture of fat and

water producing a softer stoolwater producing a softer stool

►GlycerinGlycerin►Mineral oil forms a slippery coat on theMineral oil forms a slippery coat on the

colonic contentscolonic contents

Pharmacokinetics:harmacokinetics:



Common Side-effects of the Laxativesommon Side-effects of the Laxatives

►DiarrheaDiarrhea► Abdominal cramping Abdominal 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 LaxativeThe Nursing Process and Laxative



ASSESSMENT ASSESSMENT►Nursing History- elicit allergy to anyNursing History- elicit allergy to any

laxatives, elicit history of conditions likelaxatives, elicit history of conditions like

diverticulitis and ulcerative colitisdiverticulitis and ulcerative colitis►Physical Examination- abdominalPhysical Examination- abdominal

assessmentassessment

►Laboratory Test: fecalysis, electrolyte levelsLaboratory Test: fecalysis, electrolyte levels




NURSING DIAGNOSISNURSING DIAGNOSIS► Alteration in bowel pattern Alteration in bowel pattern

► Alteration in comfort: pain Alteration in comfort: pain

►Knowledge deficitKnowledge deficit



IMPLEMENTATIONIMPLEMENTATION4.4. Encourage fluid intake, high fiber diet andEncourage fluid intake, high fiber diet and

daily exercisedaily exercise

5 . DO N OT adm i n is t e r i f a c u t e. DO N OT adm i n is t e r i f a c u t e

abd om ina l c ond i t i o n l ik ebdom ina l c ond i t i o n l ik e

app end i c i t i s i s p r e s en tpp end i c i t i s is p r e sen t

6. Advise to change position slowly an avoid6. Advise to change position slowly an avoidhazardous activities because of potentialhazardous activities because of potential

dizzinessdizziness




EVALUATION of drug effectivenessEVALUATION of drug effectiveness1.1. Evaluate relief of GI symptoms, absence of Evaluate relief of GI symptoms, absence of

staining and increased evacuation of GIstaining and increased evacuation of GI

tracttract2.2. For Lactulose: decreased ammoniaFor Lactulose: decreased ammonia

The Anti-diarrhealsThe Anti-diarrheals



►These are agents used to calm the irritationThese are agents used to calm the irritationof the GIT for the symptomatic relief of of the GIT for the symptomatic relief of

diarrheadiarrhea

►General ClassificationsGeneral Classifications1. 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-diarrheals



Type Prototype Action

Local reflex inhibitor Bismuth subsalicylate Locally coats thelining of the GIT tosoothe irritation that

may stimulate thereflex

Local anti-motility Loperamide Directly inhibits theintestinal muscleactivity to SLOW

peristalsisCentral acting agent Opium derivatives

(paregoric)Stops GIT spasm by CNS action

Clinical Indications of drug useClinical Indications of drug use



►Relief of symptoms of acute and chronicRelief of symptoms of acute and chronicdiarrheadiarrhea

►Reduction of fecal volume discharges fromReduction of fecal volume discharges from

ileostomiesileostomies►Prevention and treatment of traveler'sPrevention and treatment of traveler's

diarrheadiarrhea

Contraindications of anti-diarrhealContraindications of anti-diarrheal

UseUse



UseUse

►Po i s on i ngo i s on i ng►Drug a l le r g yrug a l l e r g y

►G I ob s t r u c t ionI ob s t r u c t i on

►Acu t e abdo m ina l c ond i t io n scu t e abdom ina l c ond i t io n s

Pharmacokinetics: Side effectsPharmacokinetics: Side effects



►Cons t i p a t i onons t i p a t i on►Na usea , vom i t i n gau sea , vom i t i n g

►Abd om ina l d i s ten t i o n and d i s c om fo rtbdom i na l d i s ten t i o n and d i s c om fo rt

►T O X IC M E G A C O L O NO X IC M E G A C O L O N

Nursing process and anti-diarrhealsNursing process and anti-diarrheals



ASSESSMENT ASSESSMENT►Nursing History – Elicit history of drugNursing History – Elicit history of drug

allergy, conditions like poisoning, GIallergy, conditions like poisoning, GI

obstruction and acute abdominal conditionsobstruction and acute abdominal conditions►Physical Examination- AbdominalPhysical Examination- Abdominal

examinationexamination

►Laboratory test- electrolyte levelsLaboratory test- electrolyte levels




NURSING DIAGNOSISNURSING DIAGNOSIS► Alteration in bowel pattern Alteration in bowel pattern

► Alteration in comfort: pain Alteration in comfort: pain




IMPLEMENTATIONIMPLEMENTATION1.1. Monitor patient response within 48 hours.Monitor patient response within 48 hours.

Discontinue drug use if no effectDiscontinue drug use if no effect

2.2. Provide comfort measures for painProvide comfort measures for pain

3.3. Provide teachingProvide teaching




EVALUATIONEVALUATION1.1. Monitor effectiveness of drug-Monitor effectiveness of drug- R EL I E F o fE L I E F o f

d i a r r h eai a r r h ea

2.2. Monitor adverse effects, effectiveness of Monitor adverse effects, effectiveness of pain measures and effectiveness of pain measures and effectiveness of

teaching planteaching plan

Emetics and Anti-emeticsEmetics and Anti-emetics



E m e t ic A gen tm e t ic A gen t► Sy rup o f I p e ca cy rup o f I p e ca c

Anti-emetics Anti-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 locally,Ipecac syrup irritates the GI mucosa locally,

resulting to stimulation of the vomitingresulting to stimulation of the vomiting

centercenter►It acts within 20 minutesIt acts within 20 minutes

EMETICEMETIC



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

overdose and certain poisoningsoverdose 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 amountsARDIOTOXICITY if large amounts

are absorbed in the bodyre absorbed in the body

Nursing process and the EMETICNursing process and the EMETIC



ASSESSMENT ASSESSMENT►Nursing History- elicit the exact nature of Nursing History- elicit the exact nature of

poisoningpoisoning

►Physical Examination- CNS status andPhysical Examination- CNS status andabdominal examabdominal exam




IMPLEMENTATIONIMPLEMENTATION1.1. 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 water Administer with a large amount of water

4.4. Vomiting should occur within 20 minutes Vomiting should occur within 20 minutes

of the first dose.of the first dose. Repeat the dose andRepeat the dose and

expect vomiting to occur with 20 minutesexpect vomiting to occur with 20 minutes




IMPLEMENTATIONIMPLEMENTATION5. Provide comfort measures like ready access5. Provide comfort measures like ready access

to bathroom, assistance with ambulationto bathroom, assistance with ambulation

6. Offer support6. Offer support




EVALUATIONEVALUATION1.1. Evaluate patient response within 20Evaluate patient response within 20

minutes of drug ingestionminutes of drug ingestion

2.2. Monitor for adverse effectsMonitor for adverse effects3.3. Evaluate effectiveness of comfortEvaluate effectiveness of comfort

measures and teaching planmeasures and teaching plan

ANTI-EMETICS ANTI-EMETICS



►These are agents used to manage nauseaThese are agents used to manage nauseaand vomitingand vomiting

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

ANTIEMETICS ANTIEMETICS



Anti-emetic types Common examples

Phenothiazines Prochlorperazine, promethazine

Non-phenothiazines Metoclopramide

Anticholinergics and Antihistaminics Meclizine, buclizine

Serotonin Receptor blockers “setron”- dolasetron

Miscellaneous Dronabinol, hydroxyzine

ANTIEMETICS ANTIEMETICSTypes Pharmacodynamics



Types Pharmacodynamics

Phenothiazines Centrally block the vomitingcenter in the medulla

Non-phenothiazine Reduces the responsiveness

of the nerve cell in the medulla

Anticholinergics Block the transmission of theimpulses to the medulla

Serotonin receptor blockers

Centrally and locally inhibitsthe serotonin receptors

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

ANTIEMETICS ANTIEMETICSTypes Clinical Use



Types Clinical Use

Phenothiazines N/V associated withanesthesia, intractable hiccups

Non-phenothiazine N/V associated with chemicalstimulation

Anticholinergics N/V associated with motionsickness

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-effects1.1. P H O T H O S ENS I T I V I T YH O T H O S ENS I T I V I T Y

2.2. Drow s in e s s , d i z z i n e s s , weakn e s sr ows i n e s s , d i zz in e s s , w eakn e s s

a n d t rem o r s a n d DE H YD R AT O Nn d t rem o r s a n d DE H YD R AT O N

3. Phenothiazines= autonomic3. Phenothiazines= autonomic anti-anti-

cholinergic effectscholinergic effects like dry mouth, nasallike dry mouth, nasal

congestion and urinary retentioncongestion and urinary retention

Nursing Process and theNursing Process and the ANTIEMETICS ANTIEMETICS



ASSESSMENT ASSESSMENT► Nursing History- elicit allergy, impairedNursing History- elicit allergy, impaired

hepatic function and CNS depressionhepatic function and CNS depression

► Physical Examination- CNS status andPhysical Examination- CNS status andabdominal examinationabdominal examination

► Laboratory test- Liver function studiesLaboratory test- Liver function studies




NURSING DIAGNOSISNURSING DIAGNOSIS1.1. Alteration in comfort: pain Alteration in comfort: pain

2.2. High risk for injuryHigh risk for injury

3.3. Knowledge deficitKnowledge deficit




IMPLEMENTATIONIMPLEMENTATION1.1. Assess patient’s intake of other drugs that Assess patient’s intake of other drugs that

may cause dangerous drug interactionmay cause dangerous drug interaction

2.2. Emphasize that this is given on a shortEmphasize that this is given on a shortterm basisterm basis




IMPLEMENTATIONIMPLEMENTATION3.3. Provide comfort and safety measuresrovide comfort and safety measures Advise to change position slowlydvise to change position slowly

Avoid hazardous activitiesvoid hazardous activities Provide mouth care and ice chipsrovide mouth care and ice chips

Monitor for dehydration and offer fluidsonitor for dehydration and offer fluids

if it occursf it occurs




IMPLEMENTATIONIMPLEMENTATION4. Protect from sun exposure4. Protect from sun exposure SunscreensSunscreens

Protective coveringProtective covering

5. Provide health teaching5. Provide health teaching




EVALUATIONEVALUATION1.1. Monitor for the drug effectivenessonitor for the drug effectiveness

• Relief of nausea and vomitingelief of nausea and vomiting

2. Monitor for adverse effects2. Monitor for adverse effects3. Evaluate effectiveness of comfort measures3. Evaluate effectiveness of comfort measures

and teaching planand teaching plan

Pharmacology of thePharmacology of the



Pharmacology of thePharmacology of the

Selected EndocrineSelected Endocrine

DrugsDrugs

Nursing ReviewNursing Review

Endocrine MedicationsEndocrine Medications



Anti-diuretic hormonesAnti-diuretic hormonesEnhance re-absorption of water in theEnhance re-absorption of water in the

kidneyskidneys

Used in DIUsed in DI

1. Desmopressin and Lypressin1. Desmopressin and Lypressin

intranasallyintranasally

2. Pitressin IM2. Pitressin IM

Endocrine MedicationsEndocrine Medications



Anti-diuretic hormonesAnti-diuretic hormonesSIDE-effectsSIDE-effects

Flushing and headacheFlushing and headacheWater intoxicationWater intoxication

Thyroid MedicationsThyroid Medications



Thyroid hormonesThyroid hormones

These products are used to treatThese products are used to treat

the manifestations of the manifestations of hypothyroidismhypothyroidism

Replace hormonal deficit in theReplace hormonal deficit in thetreatment of HYPOTHYROIDSMtreatment of HYPOTHYROIDSM




Thyroid hormonesThyroid hormones

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




Thyroid hormonesThyroid hormonesSide-effectsSide-effects

1.1. Nausea and VomitingNausea and Vomiting

2.2. Signs of increased metabolism=Signs of increased metabolism=

tachycardia, hypertension, cardiactachycardia, hypertension, cardiac

arrhythmias, anxiety, headachearrhythmias, anxiety, headache




Thyroid hormones : Nursing responsibilityThyroid hormones : Nursing responsibility

1. Monitor weight, VS1. Monitor weight, VS

2. Instruct client to take daily2. Instruct client to take daily

medication the same timemedication the same time eacheach

morning WITHOUT FOODmorning WITHOUT FOOD

Monitor blood tests to check theMonitor blood tests to check theactivity 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 pain4. Instruct to avoid foods that4. Instruct to avoid foods that

inhibit thyroid secretions likeinhibit thyroid secretions like

cabbage, spinach and radishescabbage, spinach and radishes

ANTI-Thyroid Medications ANTI-Thyroid Medications



ANTI-THYROID medicationsANTI-THYROID medications

The thyroid becomesThe thyroid becomes

oversaturated with iodine andoversaturated with iodine andstop producing thyroidstop producing thyroid

hormonehormone





Drugs used to BLOCK theDrugs used to BLOCK the

thyroid hormones and treatthyroid hormones and treathyperthyroidismhyperthyroidism

Inhibit the synthesis of thyroidInhibit the synthesis of thyroidhormoneshormones




ANTI THYROID medicationsANTI THYROID medications




Side-effects of thionamidesSide-effects of thionamides N/V, drowsiness, lethargy,N/V, drowsiness, lethargy,

bradycardia, skin rashbradycardia, skin rash GI complaintsGI complaints AGRANULOCYTOSIS AGRANULOCYTOSIS

Most important to monitor Most important to monitor


ANTI THYROID medicationsANTI-THYROID medications




Side-effects of Iodine solutionsSide-effects of Iodine solutions Most common adverse effects isMost common adverse effects is

HYPOTHYROIDISMHYPOTHYROIDISM Iodism= metallic taste, burning inIodism= 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,weightweight

2. The medications2. The medications WITH WITH

MEALS MEALS to avoid gastric upsetto avoid gastric upset


ANTI-THYROID medications NursingANTI-THYROID medications Nursing



ANTI THYROID medications Nursingg

responsibilitiesresponsibilities3. Instruct to report SORE3. Instruct to report SORETHROAT or unexplained FEVERTHROAT or unexplained FEVER

4. Monitor for signs of 4. Monitor for signs of hypothyroidism.hypothyroidism.

Instruct not to stop abruptInstruct not to stop abruptmedicationmedication

ANTI-Thyroid Medications ANTI-Thyroid MedicationsANTI-THYROID medicationsANTI-THYROID medications



Lugol’s SolutionLugol’s SolutionUsed to decrease the vascularity of theUsed to decrease the vascularity of thethyroid (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 juice

Use straw to decrease stainingUse straw to decrease staining

Monitor iodism (metallic taste, burning inMonitor iodism (metallic taste, burning inmouth)mouth)

STEROIDSSTEROIDS



Replaces the steroids inReplaces the steroids inthe bodythe body

Interfere with the releaseInterfere with the releaseof inflammatory factorsof inflammatory factors

and immune responsesand immune responses

STEROIDSSTEROIDS



Cortisol, cortisone,Cortisol, cortisone,betamethasone, andbetamethasone, and

hydrocortisonehydrocortisone

Dexamethasone= longDexamethasone= long

actingacting

STEROIDSSTEROIDS



These drugs enter theThese drugs enter thecells and bind tocells and bind to

receptorsreceptors

They inhibit the enzymeThey inhibit the enzyme

phospholipasephospholipase

STEROIDSSTEROIDS

C ti t id d t i ll



Corticosteroids are used topicallyCorticosteroids are used topically

and locally to achieve the desiredand locally to achieve the desired

anti-inflammatory effects at aanti-inflammatory effects at a

particular siteparticular site

STEROIDSSTEROIDS

St id Cli i l



Steroid Clinical use

Dexamethasone Use to induce theformation of lungsurfactant

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

allergic symptoms

STEROIDSSTEROIDS



Side-effectsSide-effects HYPERglycemiaHYPERglycemia Increased susceptibility toIncreased susceptibility to

infectioninfection(immunosuppression)(immunosuppression)

HypokalemiaHypokalemia Edema and HypertensionEdema and Hypertension Peptic ulcerationPepti c ulceration

STEROIDSSTEROIDS



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

growth retardation, pepticgrowth retardation, peptic

ulcer, hypertension,ulcer, hypertension,

cataractcataract, mood changes,, mood changes,

hirsutism, and fragile skinhirsutism, and fragile skin

STEROIDSSTEROIDS



Nursing responsibilitiesNursing responsibilities1. Monitor VS, electrolytes,1. Monitor VS, electrolytes,

glucoseglucose2. Monitor weight edema2. Monitor weight edema

and I/O. Encourageand I/O. EncouragePotassium supplementsPotassium supplements

STEROIDSSTEROIDS



Nursing responsibilitiesNursing responsibilities3. Protect patient from infection3. Protect patient from infection

4. Handle patient gently4. Handle patient gently

5. Instruct to take meds5. Instruct to take meds WITH WITH

MEALS MEALS to prevent gastric ulcer to prevent gastric ulcer

formationformation

STEROIDSSTEROIDS



Nursing responsibilitiesNursing responsibilities6. Caution the patient NOT to6. Caution the patient NOT to

abruptly stop the drugabruptly stop the drug

7.7. Drug is tapered to allow theDrug is tapered to allow the

adrenal gland to secreteadrenal g land to secrete

endogenous hormonesendog enous hormones



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



These are agents extracted from theThese are agents extracted from the

foxglove plant. They are available infoxglove plant. They are available inoral and parenteral preparations. Theoral and parenteral preparations. The

following are the cardiac glycosides:following are the cardiac glycosides:

Digoxin (Lanoxin) Digoxin (Lanoxin)

Digitoxin (Crystodigin) Digitoxin (Crystodigin)

Ouabain Ouabain

The cardiac glycosidesThe cardiac glycosides



Pharmacodynamics: the Mechanism of Pharmacodynamics: the Mechanism of actionaction

TheyThey i n c rease the l eve l o fnc r ease the l e ve l o f

CALC IUMALC IUM inside the cell by inhibitinginside the cell by inhibitingthe Sodium-Potassium pump.the Sodium-Potassium pump.

More calcium will accumulate inside theMore calcium will accumulate inside the

cell during cellular depolarization.cell during cellular depolarization.

The cardiac glycosidesThe cardiac glycosides Pos i t i v e i no t rop i co s i t iv e i n o t r op i c Effect-Effect- thethe



myocardium will contract forcefullymyocardium will contract forcefully – Increased cardiac outputIncreased cardiac output

– Increased blood flow to the body organs likeIncreased blood flow to the body organs likethe kidney and liverthe kidney and liver

Ne ga t i ve c h r ono t r op icega t i v e c h r ono t r op ic effect- the hearteffect- the heartrate is slowed due to decreased rate of rate is slowed due to decreased rate of cellular repolarizationcellular repolarization

– BradycardiaBradycardia De c r ea s ed c on du c t i o n v e l o c i tye c r e a s ed c ondu c t io n v e l o c i ty

through the AV nodethrough the AV node




Clinical Use of the cardiac glycosidesClinical Use of the cardiac glycosides Treatment of Treatment of congestive heart failurecongestive heart failure

Treatment of Treatment of dysrhythmiasdysrhythmias like atriallike atrial

flutter, atrial fibrillation andflutter, atrial fibrillation and

paroxysmal atrial tachycardiaparoxysmal atrial tachycardia

The cardiac glycosidesThe cardiac glycosidesContraindications and PrecautionsContraindications and Precautions



Contraindicated in the presence of allergyContraindicated in the presence of allergyto any cardiac glycoside.to any cardiac glycoside.

They areThey are N OTOT given to patients withgiven to patients with

ventricular dysrhythmias, heart block orventricular dysrhythmias, heart block orsick sinus syndrome, aortic stenosis, acutesick sinus syndrome, aortic stenosis, acuteMI, electrolyte imbalancesMI, electrolyte imbalances((H Y P O K A L E M I A , H Y P O M A G N E S E M I AY P O K A L E M IA , H Y P O M A G N E S E M I A

a n d H Y P E R C A L C E M I An d H Y P E R C A L C E M I A ) and) and renal failurerenal failure (may cause accumulation of drug)(may cause accumulation of drug)


Pharmacodynamics: the Adverse Effects of thePharmacodynamics: the Adverse Effects of the



yy

Cardiac glycosidesCardiac glycosides CNS- Headache, weakness , seizures andCNS- Headache, weakness , seizures and

drowsinessdrowsiness

CVS- arrhythmiasCVS- arrhythmias If digitalis toxicity is developing- the nurse mustIf digitalis toxicity is developing- the nurse must

assess the following adverse effects:assess the following adverse effects: Ano rex i a ,no r ex i a ,

nau sea and vom it ing , v is ua l c hange s -au sea a nd vom i t ing , v i sua l c hange s -

YE L LOW ha l o a round an ob j e c t, a ndE L LOW ha l o a round an ob j e c t, a nd

pa l p i t a t ions o r ve r y s l ow hea r t ra t ea l p i t a t ions o r ve r y s l ow h ea r t ra t e


Remember= NAVDA and hypokalemiaRemember= NAVDA and hypokalemia



Remember NAVDA and hypokalemiaRemember NAVDA and hypokalemia


Drug-Drug InteractionsDrug-Drug Interactions



Drug Drug InteractionsDrug Drug Interactions

I f ta k en w i th po t a s s ium - lo s i n gf t a k en w i th p o t a s s ium - lo s i n g

d i u r e t i c s l i k e fu r o se m ide - c ani u r e t ic s l i k e fu r o se m ide - c an

INCR EAS E t h e r i s k o f t o x ic i ty a n dNC RE ASE t h e r i s k o f t o x ic i ty a n d

a r r h y t hm i a s . P o t a s s i um r ep l a c em en tr r h y t hm i a s . P o t a s s i um r ep l a c em en t

m u s t b e g iv e n .u s t b e g i v en .

The cardiac glycosidesThe cardiac glycosidesImplementationImplementation



Administer the initial rapid digitalization Administer the initial rapid digitalizationand loading dose as ordered intravenouslyand loading dose as ordered intravenously

Monitor theMonitor the AP I CALP I CAL pulse rate for ONEpulse rate for ONE

full minute before administering the drug.full minute before administering the drug.Withhold the drug if Withhold the drug if – Less than 60 in adultsLess 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 remainRetake pulse in one hour, if pulses remainabnormal, refer!abnormal, refer!




Check the spelling of the drug- DIGOXINCheck the spelling of the drug- DIGOXINis different from DIGITOXIN!is different from DIGITOXIN!

Check the dosage preparation and theCheck the dosage preparation and the

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

Administer intravenous drug VERY slow IV Administer intravenous drug VERY slow IV

over 5 minutes to avoid arrhythmias. Doover 5 minutes to avoid arrhythmias. DoNOT administer intramuscularly because itNOT administer intramuscularly because it

can cause severe paincan cause severe pain




Administer the drug Administer the drug w i thou t food i f po s s i b lei thou t f ood i f po s s i b let o a vo i d de l a yed ab so rp t iono a vo i d de l a yed ab so rp t ion . Weight patient. Weight patient

daily to determine fluid retentiondaily to determine fluid retention

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 bradycardia.phenytoin for seizures, atropine for bradycardia.

Provide comfort measures- small, frequentProvide comfort measures- small, frequent

meals, adequate lighting, comfortable position,meals, adequate lighting, comfortable position,rest periods and safety precautionsrest periods and safety precautions




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

dosage and side effects. Advise the patient todosage and side effects. Advise the patient to

report any of the following:report any of the following: V i sua l changes ,i s ua l changes ,rap id w e igh t ga in , unu sua l l y low h ea r tap i d we i gh t ga i n , unusua l ly l ow hea r t

r a t e , pe r s i s t en t nausea , vom i t i ng anda te , pe r s i s ten t nausea , vom i t i ng and

ano rex i ano rex i a

Mon i to r s e rum p o t a s s ium l e ve lon i t o r s e rum po t a s s ium l e vel




Eva lua t i onva lua t i onEva lua te e f f ec t ivene ss o f theva lua te e f fec t i veness o f the

d rug :r ug :

Inc reased u r ine ou tpu tnc reased u r i ne ou tpu t

No rma l hea r t ra t e i n a r r hy thm iao rm a l hea r t r a te i n a r r hy thm ia

The Antianginal drugshe Antianginal drugs



In the treatment of angina, three agentsIn the treatment of angina, three agentsare commonly employed-are commonly employed-

– O rgan i c n i t ra t e srgan i c n i tr a t e s

– Be t a - b l o c ke r s ande t a - b lo c ke r s an d

– Ca l c ium - channe l b lo c ke r s .a l c ium - channe l b l o c ke r s .

The benefits of the drugs lie in theirThe benefits of the drugs lie in their

different mode of action.different mode of action.


The nitrates can cause vasodilatationThe nitrates can cause vasodilatation



of the veins and to some extent,of the veins and to some extent,coronary arterycoronary artery




Beta-blockers will decrease the heartBeta-blockers will decrease the heart

raterate


Calcium-channel blockers will decreaseCalcium-channel blockers will decrease



force of contraction leading to aforce of contraction leading to adecreased myocardial workload anddecreased myocardial workload and

demand.demand.

They can also produce vasodilationThey can also produce vasodilation

The Organic nitratesThe Organic nitrates



These agents are simple nitric and nitrousThese agents are simple nitric and nitrousacid esters of alcohols. Being alcohol, theyacid esters of alcohols. Being alcohol, they

differ in their volatility. The following arediffer in their volatility. The following are

the nitrates commonly used:the nitrates commonly used:

N i t r og l y c e r i n -i t r og l y c e r i n - A moderately volatile A moderately volatile

nitratenitrate

Isosorbide Dinitrate (Isordil) orIsosorbide Dinitrate (Isordil) ormononitratemononitrate

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




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

transdermal and ointment preparations.transdermal and ointment preparations.




Pharmacodynamics: the mechanism of Pharmacodynamics: the mechanism of actionaction

Ni t rog l yce r i n re l axes the sm oothi t rog l yce r in r e l axes the sm ooth

m usc l e s i n t he vascu l a r s y s t emusc l e s i n the vascu l a r sys temby i t s conve r s i on to n i t r i c ox ide ,y i t s conve r s i on to n i t r i c ox ide ,

a chem i ca l m ed i a to r in t he bod ychem i ca l med i a to r in t he bod y

tha t re l a xes sm oo th m usc l e s .ha t r e la xes smo o th m usc l e s .

The Organic nitratesThe Organic nitrates Administered nitrates Administered 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 myosinincreased dephosphorylation of myosin

Vascular smooth muscle relaxation Vascular smooth muscle relaxation

vasod i l a t a t i onasod i l a t a t i on




Pharmacokinetics- absorption to excretionPharmacokinetics- absorption to excretion It can be given orally, parenterally andIt can be given orally, parenterally and

topically.topically.

The onset of action of nitroglycerin isThe onset of action of nitroglycerin ismore than 1 hour.more than 1 hour.

Because significant first-pass hepaticBecause significant first-pass hepatic

effect,effect, Nitroglycerin is givenNitroglycerin is givenSUBLINGUALY.SUBLINGUALY.

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



adverse effectsadverse effects H E A D A C H E i s t h e m o s t c o m m o nE A D A C H E i s th e m o s t c o m m o n

e f fe c t o f n i t rog l y c e r i nf f e c t o f n i t r og l y ce r i n .

CVS- postural Hypotension, facial flushing,CVS- postural Hypotension, facial flushing,tachycardiatachycardia

TOLERANCETOLERANCE- the tolerance to the actions- the tolerance to the actions

of nitrates develop rapidly. This can beof nitrates develop rapidly. This can bemanaged by providing a day of managed by providing a day of

abstinence.abstinence.

The NitratesThe NitratesImplementationImplementation



Monitor vital signs, especially watchful forMonitor vital signs, especially watchful forhypotensive episodeshypotensive episodes

Advise patient to remain supine or sit on a Advise patient to remain supine or sit on a

chair when taking the nitroglycerin for thechair when taking the nitroglycerin for thefirst time. Emphasize that he shouldfirst time. Emphasize that he shouldchange his position slowly or rise from bedchange his position slowly or rise from bedslowly to avoid orthostatic Hypotensionslowly to avoid orthostatic Hypotension

Offer sips of water before givingOffer sips of water before givingsublingual nitroglycerin because drynesssublingual nitroglycerin because drynessmay inhibit drug absorptionmay inhibit drug absorption

The NitratesThe NitratesImplementationImplementation



Apply nitroglycerin ointment to the Apply nitroglycerin ointment to thedesignated mark on paper.designated mark on paper.

The nurse should remove any excessThe nurse should remove any excess

ointment on the skin from the previousointment on the skin from the previousdose.dose.

She shouldShe should N E V E R U S EE V E R U S E her bare fingersher bare fingers

because the drug can be absorbed, utilizebecause the drug can be absorbed, utilizegloves or tongue blades instead.gloves or tongue blades instead.

The NitratesThe Nitrates



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

few hairs. Never touch the medicationfew hairs. Never touch the medication

portion.portion. The patch and the ointment should NOTThe patch and the ointment should NOT

be applied near the area for defibrillationbe applied near the area for defibrillation

because explosion and skin burns maybecause explosion and skin burns may

resultresult




IMPLEMENTATIONIMPLEMENTATION Emphasize that tolerance to theEmphasize that tolerance to the

nitroglycerin can occur.nitroglycerin can occur.

If the medication cannot relieve the pain,If the medication cannot relieve the pain,report to the hospital immediately.report to the hospital immediately.


IMPLEMENTATIONIMPLEMENTATION



Provide client health teaching- the sublingualProvide client health teaching- the sublingualnitroglycerin tablet is USED if chest pain occursnitroglycerin tablet is USED if chest pain occurs

The dose may be repeated if pain ishe dose may be repeated if pain is

unrelieved within 5 minutes.nrelieved within 5 minutes. Repeat the medication administration ifepeat the medication administration if

the pain has not yet subsidedhe pain has not yet subsided .

DO NOT g iv e m o r e t h an 3 t a b le t s !O NOT g iv e m o r e t h an 3 t a b le t s ! !! If! If

chest pain persists for more than 15hest pain persists for more than 15minutes, hospital consult should be doneinutes, hospital consult should be doneimmediately.mmediately.




IMPLEMENTATIONIMPLEMENTATION Instruct the client to avoid alcohol whileInstruct the client to avoid alcohol while

taking nitroglycerin to avoid potentiatingtaking nitroglycerin to avoid potentiating

the hypotensive effect of the medicationthe hypotensive effect of the medication If beta blockers and calcium-channelIf beta blockers and calcium-channel

blockers are given, instruct the patients toblockers are given, instruct the patients to

consult the physician before discontinuingconsult the physician before discontinuing

the medicationthe medication




IMPLEMENTATIONIMPLEMENTATION Other components of health teaching forOther components of health teaching for

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

should be instructed toshould be instructed to p lace the t ab l e tl a ce the t ab l e t

unde r t h e t onguende r t h e t ongue for quick absorption.for quick absorption.

– A burning sensation/biting/stinging sensation A burning sensation/biting/stinging sensation

may indicate that the tablet ismay indicate that the tablet is FRESH !RESH !

– Store the tablet in aStore the tablet in a da rk con ta i ne ra r k con ta i ne r , keep it, keep it

away from heat and direct sunlight to avoidaway from heat and direct sunlight to avoid

lessening the potencylessening the potency

The NitratesThe NitratesIMPLEMENTATIONIMPLEMENTATION



Other components of health teaching for homeOther components of health teaching for homeself-administration:self-administration:

– HEADACHESHEADACHES are common in the initial period of are common in the initial period of

nitroglycerin therapy. Advise patient to takenitroglycerin therapy. Advise patient to take

PARACETAMOL for relief PARACETAMOL for relief – The nitroglycerin patch is applied once a day,The nitroglycerin patch is applied once a day,

usually in the morning. The sites should beusually in the morning. The sites should be

rotated, in the chest, arms and thighs avoidingrotated, in the chest, arms and thighs avoiding

hairy areas.hairy areas.




IMPLEMENTATIONIMPLEMENTATION Other components of health teaching forOther components of health teaching for

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

Hypotension.Hypotension.

– N i t rog l yce r i n t ab l e t can be takeni t rog l yce r i n t ab l e t can be take n

p rophy l ac t i ca l l y in s i t ua t i ons wh ererophy l ac t i ca l l y in s i t ua t i ons wh ere

ches t pa in is an t i c i pa ted- Sex , exe rc i se ,hes t pa in i s an t i c i pa ted- Sex , exe rc i se ,

e t c . .t c . .

– If patient is taking beta blockers, instruct how toIf patient is taking beta blockers, instruct how to

obtain heart rate in a minuteobtain heart rate in a minute

Drugs for Shock Drugs for Shock



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

used to treat Hypotension in shock statesused to treat Hypotension in shock states

that are not caused by Hypovolemia.that are not caused by Hypovolemia. This drug is an immediate precursor of This drug is an immediate precursor of

nor-epinephrine, occurs naturally in thenor-epinephrine, occurs naturally in the

CNS basal ganglia where it functions as aCNS basal ganglia where it functions as a

neurotransmitter.neurotransmitter.




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

alpha and beta adrenergic receptoralpha and beta adrenergic receptor

depending upon the concentration. Itdepending upon the concentration. Itstimulates receptors to causestimulates receptors to cause c a r d i a ca rd i a c

s t im u l a t i on and r en a l v a sod i la t i ont im u l a t i on and r en a l v a sod i la t i on ..

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




DopamineDopamine Pharmacokinetics: Dopamine isPharmacokinetics: Dopamine is

administered IV, excreted in the urine.administered IV, excreted in the urine.

At At l ow d o s eow d o s e ((1-2 micrograms1-2 micrograms),),dopamine DILATES the renal anddopamine DILATES the renal and

mesenteric blood vessels producing anmesenteric blood vessels producing an

increase output (dopaminergic effect)increase output (dopaminergic effect)




DopamineDopamine At At m od e r a te d o s eode r a t e do s e of of 2-10 micrograms,2-10 micrograms,

dopamine enhance cardiac output bydopamine enhance cardiac output by

increasing heart rate (increasing heart rate (beta 1-adrenergicbeta 1-adrenergiceffect)effect) and elevates blood pressureand elevates blood pressure

through peripheral vasoconstrictionthrough peripheral vasoconstriction (alpha(alpha

adrenergic effect)adrenergic effect)




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

micrograms-micrograms- va socon s t r ic t i on o f a l la s o co ns t r i c t ion o f a l l

v e s se l se s se l s

will predominate that can lead towill predominate that can lead todiminished tissue perfusiondiminished tissue perfusion


Dopamine



Dopamine Dopamine is indicated to treat Hypotension, toDopamine is indicated to treat Hypotension, to

increase heart rate and to increase urine outputincrease heart rate and to increase urine output

(given less than 5 mg/kg/min)(given less than 5 mg/kg/min)

The nurse typically prepares the dopamine drip-The nurse typically prepares the dopamine drip-dopamine (at a concentration of 400-800 mg) isdopamine (at a concentration of 400-800 mg) is

mixed in 250 mL D5W and administered as dripmixed in 250 mL D5W and administered as drip

via an infusion pump for precise dosagevia an infusion pump for precise dosage

administration.administration.

Sodium bicarbonate will inactivate the dopamineSodium bicarbonate will inactivate the dopamine




DopamineDopamine Pharmacodynamics: side effects-Pharmacodynamics: side effects-

TachycardiaTachycardia

hypertensionhypertensionectopic beats, angina, dysrhythmias,ectopic beats, angina, dysrhythmias,

myocardial ischemia, nausea andmyocardial ischemia, nausea and

vomiting.vomiting.




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

infiltration of dopamine, which can causeinfiltration of dopamine, which can cause

tissue necrosis.tissue necrosis.

– Phen to l am i nehen to l am i ne should be infiltrated inshould be infiltrated inmultiple areas to reduce tissue damage.multiple areas to reduce tissue damage.

– Drug is effective if Urine output is increasedDrug is effective if Urine output is increased

and BP is increasedand BP is increased

Antihypertensive drugs Antihypertensive drugs

The D rug s em p lo y ed t o c on t ro lh e D r ug s em p lo y ed t o c on t ro l



hype r t en s i on c an be c l a s s i f i e d a s :ype r t en s i on c an be c la s s i f i e d a s :

D iu re t i c si u re t i c s

Be t a - b l o c ke r se t a -b l o cke r s

A l pha a d r ene rg i c b l o c ke r sl pha ad r ene rg i c b l o c ke r s Ca l c i um cha nne l b lo c ke r sa l c ium chan ne l b l o c ke r s

Ang i o ten s i n - conve r t i ng e n zym e inh i b i t o r sng i o t en s in - conve r t ing en zym e inh i b i to r s

Ang i o ten s i n I I r e cep t o r b l o c ke rsng i o t en s in I I r e cep t o r b l o c ke rs

Pe r i phe ra l v a sod i la t o r se r i phe ra l v a sod i la t o r s

Common Drugs in HPNCommon Drugs in HPN

l i h ff i f hl i h ff i f h



IN Evaluating the effectiveness of theseIN Evaluating the effectiveness of thesedrugs is simply to monitor the BP if itdrugs is simply to monitor the BP if it

becomes NORMALbecomes NORMAL

Anti-hypertensive drugs Anti-hypertensive drugsClass Prototype MOA Side effects

Diuretics Furosemide Decreases blood Hypokalemia



volume

Beta-blocker Propranolol Blocks B1 receptorin the heart

Bradycardia,hypoglycemia

ACE Inhibitors Captopril Prevents A1 to AIIconversion

Headache, Cough,flushing

Ca channelblockers

Nifedipine Blocks Ca entry intocell

Headache, flushing,reflex tachycardia

Vasodilator Nitroglycerin Dilates veins andarteries

HEADACHE

Alpha blockers Prazozin Blocks alpha

receptor in BVcausingvasodilatation

Urination

Central alphaagonist

Clonidine Stimulates CNSalpha 2 receptor

Depression

Anticoagulants AnticoagulantsHEPARIN WARFARIN



Parenteral (SQ and IV) OralAction is to enhance natural

anti-thrombin III in the blood

Action is to INHIBIT Vitamin-Kdependent clott ing factors(10,9,7,2)

Acts within minutes Acts within daysMonitor for aPTT Monitor for PT and INR

Large molecule, can be given topregnant

Small molecule CANNOT begiven to pregnant

Antidote: Protaminesulfate

Antidote: Vit. K

SE: bleeding, decreasedplatelets

SE: Bleeding

The antianemics: Ironhe antianemics: Ironpreparations and Epoetinreparations and Epoetin



Iron preparationsron preparations Iron is important for hemoglobin formation.Iron is important for hemoglobin formation.

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


Side-effects:ide-effects:



GIT- constipation (usually), diarrhea,IT- constipation (usually), diarrhea,vomiting,omiting, ep i ga s t r i c pa i n , ga s t r icp i ga s t r i c pa i n , g a s t r i cu l c e r a t ion an dl c e r a t ion a nd da r k en ing o f s t o o ls .a r ke n i ng o f s t oo ls .

Liquid preparation can stain theiquid preparation can stain theteeth, and injectable iron can causeeeth, and injectable iron can causetissue discolorationissue discoloration

Other- dizzinessther- dizziness


Drug-Drug interactionrug-Drug interactionT li bi i h i



Tetracyclines combine with ironTetracyclines combine with ironpreparations and render the ironpreparations and render the ironunabsorbable.unabsorbable.

Antacids and cimetidine- decrease iron Antacids and cimetidine- decrease ironabsorption and effectsabsorption and effects Foods can impair iron absorption but theyFoods can impair iron absorption but they

should be taken with iron to reduce GIshould be taken with iron to reduce GI

discomfort.discomfort. Milk containing foods, coffee, tea and eggsMilk containing foods, coffee, tea and eggs

are NOT given with iron because they delayare NOT given with iron because they delayiron absorption.iron absorption.


ImplementationImplementation

E th ti t t t i i h f d lik li lE th ti t t t i i h f d lik li l



Encourage the patient to eat iron-rich foods like liver, leanEncourage the patient to eat iron-rich foods like liver, leanmeat, egg yolk, dried beans, green leafy vegetables.meat, egg yolk, dried beans, green leafy vegetables. Administer iron preparations orally with foods to decrease GI Administer iron preparations orally with foods to decrease GI

discomfort.discomfort. If increased absorption is necessary, administer IN BETWEENIf increased absorption is necessary, administer IN BETWEEN

meals with full glass of water or juice.meals with full glass of water or juice. I t i s bes t t o o f f e r c it ru s j u i ce s becau se the v i t am in Ct i s bes t t o o f f e r c it ru s j u i ce s becau se the v i t am in C

con t en t c an i n c r ea se i r on abso rp t i on .on t en t c an i n c r ea se ir on abso rp t i on . Instruct the patient to swallow the whole tablet and remainInstruct the patient to swallow the whole tablet and remain

upright for 30 minutes to prevent esophageal corrosion fromupright for 30 minutes to prevent esophageal corrosion fromreflux.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-containingingesting tetracyclines, antacids, milk and milk-containingproducts.products.

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


Implementationmplementation



Emphasize that the therapeutic effect of ironmphasize that the therapeutic effect of irontherapy may not be apparent until severalherapy may not be apparent until severalweeks.eeks.

If injecting a parenteral iron preparation,f injecting a parenteral iron preparation,

inject DEEP IM util izingnject DEEP IM util izing t h e Z - t ra c k m e thod t ohe Z - t ra c k m e thod t oa vo i d le a kage i n t o th e s ub cu t aneou s t i s s u e svo i d le a kage i n t o th e s ub cu t aneou s t i s s u e s

and s k i nnd s k i n . Offer straw if giving liquid iron preparation toffer straw if giving liquid iron preparation to

avoid staining the teeth.void staining the teeth. To p r e ven t und ue a l a rm , i n s t r u c t t h e pa t i e n to p r e ven t und ue a l a rm , in s t r u c t th e pa t i e n t

t h a t t h e s t o o l s may t u r n b l a c k o r d a r k g r e en .h a t t h e s t o o l s may t u r n b l a c k o r d a r k g r e en .

Th i s is a h a rm l e s s o c cu r ren c e .h i s is a h a rm l e s s o c cu r r en c e .


EvaluationEvaluation Th l t th ff ti f thTh l t th ff ti f th



The nurse evaluates the effectiveness of theThe nurse evaluates the effectiveness of thedrug therapy by determining that thedrug therapy by determining that the client isclient isnot fatigued, with absence of pallor, and withnot fatigued, with absence of pallor, and withhemoglobin results within desired rangehemoglobin results within desired range..

ErythropoietinErythropoietin

The mechanism of action of epoetinhe mechanism of action of epoetin



alfalfa(Epogen)(Epogen)

This drug acts like the natural glycoproteinThis drug acts like the natural glycoprotein

erythropoietin to stimulate the productionerythropoietin to stimulate the productionof RBC in the bone marrow.of RBC in the bone marrow.




Clinical indicationslinical indications It is given SUBCUTANEOUSLY orIt is given SUBCUTANEOUSLY or

INTRAVENOUSLY INTRAVENOUSLY for the treatment of for the treatment of

anemia associated with renal failure or foranemia associated with renal failure or for

patients on dialysispatients on dialysis..

It is also used in patients for bloodIt is also used in patients for blood

transfusion to decrease the need for bloodtransfusion to decrease the need for blood

in surgical patients.in surgical patients.




Pharmacodynamics: the adverseharmacodynamics: the adverseeffects of epoetin alfaffects of epoetin alfa

CNS- headache, fatigue, asthenia,CNS- headache, fatigue, asthenia,

dizziness and seizuresthese are due todizziness and seizuresthese are due to

the cellular response to the glycoprotein.the cellular response to the glycoprotein.

GIT- nausea, vomiting and diarrheaGIT- nausea, vomiting and diarrhea

CVS- hypertension, edema andCVS- hypertension, edema and chest painchest paindue to increase RBC numberdue to increase RBC number

ErythropoietinErythropoietinImplementationImplementation

Administer the drug SC or IV usually 3 times per weekAdminister the drug SC or IV usually 3 times per week



Administer the drug SC or IV usually 3 times per week. Administer the drug SC or IV usually 3 times per week. Monitor the IV access line if given IV. Do not mix withMonitor the IV access line if given IV. Do not mix with

other solutionsother solutions Determine periodically the level of hematocrit and ironDetermine periodically the level of hematocrit and iron

stores during therapy. If patient does not respond to thestores during therapy. If patient does not respond to the

drug, reevaluate the cause of anemia.drug, reevaluate the cause of anemia. Maintain seizure precaution on stand by as seizure canMaintain seizure precaution on stand by as seizure can

occur.occur. Provide comfort measures like small frequent feedingsProvide comfort measures like small frequent feedings

and pain medications for headache.and pain medications for headache. Provide thorough health teaching: need for lifetimeProvide thorough health teaching: need for lifetime

injectioninjection




EvaluationEvaluation

Monitor patient response to the drug=Monitor patient response to the drug=

increased hemoglobinincreased hemoglobin



Psychotrophic drugsPsychotrophic drugs

•Drugs that can:Drugs that can:



Drugs that can:Drugs that can:1.1. Stimulate the release of Stimulate the release of

neurotransmittersneurotransmitters

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

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

4.4. Prevents the breakdown of thePrevents the breakdown of theneurotransmitters or the re-uptakeneurotransmitters or the re-uptake

mechanismmechanism

Anti-Anti-Psychotics/NeurolepticsPsychotics/Neuroleptics

•Drugs used to treat PSYCHOSESDrugs used to treat PSYCHOSES



Drugs used to treat PSYCHOSESDrugs used to treat PSYCHOSES

• MAIN ACTION: Blockage of theMAIN ACTION: Blockage of the

DOPAMINE receptor in the CNSDOPAMINE receptor in the CNS


Class Prototype Others

Phenothiazines Chlorpromazine Thioridazine



Phenothiazines Chlorpromazine Thioridazine,Fluphenazine,Perphenazine

Butyrophenones Haloperidol droperidol

Thioxanthines Chlorprothixene thirothixene

Dibenzoxapine Molindone

Diphenylbutlypiperi

dine

Pimozide

Atypical drugs Clozapine Olanzapine

Risperidone quetiapine

Anti-Anti-Psychotics/NeurolepticsPsychotics/NeurolepticsDesired Effects

1 Reduced hallucination and illusions



1 Reduced hallucination and illusions

2 CNS sedation and emotional slowing

3 Decreased ambivalence, reduced

delusion4 Reduced agitation resulting to

calmness

5 Relief of emotional turmoil6 Reduced flattening of affect


Common SE Nursing Interventions



Common SE Nursing InterventionsAnticholinergiceffects

Sugarless gum, bed rest

Photosensitivity Sunglasses, sunscreen,

avoid sun

Posturalhypotension

Change position slowly,lie prone for 1 hour afterdrug intake, monitor BP

Agranulocytosis Instruct to report sorethroat and fever, monitorWBC


Extra-Pyramidal

Syndrome

Nursing Intervention



Syndrome

Parkinsonism-Tremor,rigidity, bradikinesia

Avoid abrupt withdrawal,give anti-EPS drugs likeCogentin

Dystonia- torticollis,contraction of face andtongue

Remain with client,administer anti-EPS

Akathisia= motorrestlessness

Verbalize understanding of the condition, administeranti-EPS

Tardive Dyskinesia=irreversible drooling,tongue movement and

No treatment exceptdiscontinue drug

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 Cranio-Sacral spinal



CNS origin Thoraco lumbar spinalcord

Cranio Sacral spinalcord

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



Pharmacologic use depends on theirEFFECTS 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



They can STIMULATE= agonists OR mimetics

DIRECT STIMULATION by binding with

receptors

INDIRECT STIMULATION by blocking

the enzymes that degrade theneurotransmitters or increasing the release

of neurotransmitters

The autonomic drugs

They can DECREASE THE RESPONSE=



They can DECREASE THE RESPONSE=antagonists OR blockers

DIRECT blockage by removing theneurotransmitter or competing with the

neurotransmitter

Binding with the receptor and NORESPONSE will happen

The autonomic drugsThey can be

NON SELECTIVE h th ti l t



NON-SELECTIVE when they stimulate orblock many receptors

SELECTIVE when they stimulate or block specific receptors

SPECIFIC when only ONE type of receptor isstimulated or blocked

The autonomic drugs: Pharmacologic use

depends on their EFFECTS on the body

Effect on the body Therapeutic use



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



Also called SYMPATHOMIMETIC agents

These drugs MIMIC the effects of the

sympathetic nervous system


They usually stimulate DIRECTLY the



They usually stimulate DIRECTLY thereceptors of the adrenergic system


Alpha and Beta agonists (non-selective)



Alpha and Beta agonists (non selective) Prototype: Epinephrine

Alpha Agonists (Selective) Prototype: Phenylephrine

Beta Agonists (Selective) Prototype: Isoproterenol


Alpha and Beta agonists (non-selective)



Alpha and Beta agonists (non selective)Pharmacodynamics:

These agents stimulate ALL types of

adrenergic receptors in the body by directinteraction or by releasing

neurotransmitters from the nerve cells


Alpha and Beta agonists



Alpha and Beta agonists Prototype: Epinephrine

1. Ephedrine

2. Epinephrine

3. Metaraminol

4. Norepinephrine

5. Dobutamine (sometimes a B1 specific)

6. Dopamine


Alpha and Beta agonists: Clinical Use



Alpha 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

I d di l t tilit



Increased myocardial contractility

Bronchial DILATATION

Vasoconstriction

Increased blood pressure

Decreased intraocular pressure

Pupillary dilatation



The Adrenergic AGONISTS Alpha and Beta agonists: Adverse effects

Sympathetic stimulation effects



Sympathetic stimulation effects

CVS- hypertension, tachycardia, palpitations

Respi- tachypneaGI- nausea, vomiting

Others- sweating, headache, piloerection


Alpha and Beta agonists: Nursing



Alpha and Beta agonists: Nursingconsiderations

1. Monitor patient response to the drug

2. Emphasize to avoid the use with MAOIsand TCA

3. Maintain phentolamine (alpha blocker) to

manage extravasation of IV drug4. Usually given IV


Alpha and Beta agonists: Nursing



Alpha and Beta agonists: Nursingconsiderations

Determine effectiveness of the drug:

Increased BP in shock

Relief of anaphylaxis and asthma attack

Relief of nasal congestion


Alpha Agonists (selective)



Alpha Agonists (selective)

Prototype: phenylephrine

clonidine (alpha-2 specific)


Alpha Agonists Pharmacodynamics:



p go s s cody cs:

These agents bind primarily to the alpha

receptors in the body

Clonidine

Stimulating the ALPHA-2 receptor causes

decreased sympathetic outflow from theCNS/ decreased release of NE


Alpha Agonists: Clinical use



p g

1. Phenylephrine- vasoconstricting drug,

used topically to decrease the symptoms of rhinitis

2. Clonidine- for hypertension


Alpha Agonists: Contraindication



p g1. Allergy to drug

2. Caution in the following conditions:

• Hyperthyroidism-aggravation of symptoms

• Diabetes- increased glucose levels

• Tachyarrhythmias- possible additive effect


Alpha Agonists: Adverse effects



p gCNS- anxiety, depression, fatigue

CVS- palpitations

GI- nausea, vomiting and anorexia

GU- oliguria, dysuria


Alpha Agonists: Nursing considerations



p g g1. DO NOT discontinue drug abruptly to

prevent rebound effect

2. Maintain phentolamine if giving IV drug

3. Provide comfort measures- rest, quiet

environment, analgesics


Alpha Agonists: Nursing considerations



p g gEvaluate effectiveness:

Decreased BP

Decreased Nasal congestion


Beta Agonists (Selective): ANTI-ASTHMADRUGS



g ( )DRUGS

Prototype: isoproterenol (B1 and B2)

salbutamol (Ventolin)= B2 specific

1. Ritodrine (B2 specific)

2. “terol”- albuterol, salmeterol, bitolterol

3. Terbutaline (B2)


Beta Agonists Pharmacodynamics



g y

These agents bind to the BETA receptors

causing the sympathetic manifestationsand effects


Beta Agonists Clinical use



g1. Asthma- due to the bronchodilation!

2. Preterm labor- ritodrine is given to relax

the uterine muscles

3. Shock= To increase BP


Beta Agonists Adverse effects



gCNS- restlessness, headache, anxiety , tremors

CVS- tachycardia, angina, palpitations

GI- nausea, vomiting and anorexia

Others- pupilary dilation, rash, sweating,

pulmonary edema


Beta Agonists Nursing considerationsM it VS h i i th d



g g1. Monitor VS when giving the drug

2. Remind mothers to lie on the left side

during ritodrine administration3. Maintain a beta blocker on stand by

4. Provide comfort- quiet environment, rest,analgesics.

5. Prevent over-hydration to avoidpulmonary edema


Beta Agonists Nursing considerations



g g These are given usually inhalational for

asthma attack

Instruct on how to use inhalers andnebulizers

Evaluate effectiveness:

Normal RR

Clear breath sounds

The Adrenergic ANTAGONISTS

These are called adrenergic blockers



g

They can be Alpha Blockers (selective)

Beta Blockers (selective)

Both Alpha & Beta Blockers

(non-selective)


The alpha blockers (selective)



Prototype: Phentolamine

Phenoxybenzamine

“zosin”- prazosin, doxazosin,

terazosin- these are

alpha 1blockers


The alpha blockers: Pharmacodynamics



These agents have affinity for the ALPHA

receptors

Blocking the alpha receptors will cause:

Vasodilation

Sphincter relaxation in the bladder


The alpha blockers: Clinical use



1. Phenoxybenzamine- used in

pheochromocytoma

2. Phentolamine- also used inpheochomocytoma

3. “zosin” drugs- are used to decrease blood

pressure and to relax the urinarysphincter in BPH!


The alpha blockers: Contraindications



1. Myocardial infarction

2. Allergy


The alpha blockers: Adverse EffectsCVS h i fl h di



CVS- hypotension, reflex tachycardia,

flushing

CNS- dizziness, weakness, fatigue, drowsinessOthers- nasal congestion, reddened eyes,

priapism


The alpha blockers: nursing consideration1 Monitor heart rate and BP



1. Monitor heart rate and BP

2. Caution to change position slowly

3. Advise to avoid hazardous activities4. Provide supportive measures like quiet

environment, rest and analgesics

5. Monitor response to the drug-improvement of blood pressure readingsand urination


The Beta blockersTh t d t t t



These are agents used to treat

cardiovascular problems- Hypertension,

CHF, angina Blocking beta receptor will cause

decreased heart rate

decreased BP


The Beta blocker or The “olol”sThey can be beta 1 blockers beta 2



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

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

carteOLOL

nadOLOL

penbutOLOL

sotaLOL


The Beta blocker or The “olol”sTh b b t 1 bl k b t 2



They can be beta 1 blockers, beta 2

blockers or Both

Prototype of B1 selective: atenOLOLacebutOLOL

betaxOLOL

esmOLOL

metoprOLOL


The Beta blockers: pharmacodynamicsTh t bl k th b t t f



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 Beta blockers: Clinical useH t i



1. Hypertension

2. Angina and MI

3. Cardiac arrhythmias

4. Migraine headache

5. HYPERTHYROIDISM

The Adrenergic ANTAGONISTSThe Beta blockers: Clinical use

H t i t d BP



Hypertension to decrease BP

Angina and MI to decrease cardiac workload

Cardiac tachyarrhythmias to terminate arrhythmias

Migraine headache to cause vasoconstriction in thecranial vessels

HYPERTHYROIDISMto decrease the tachycardia


The Beta blockers: contraindicationsAll



1. Allergy

2. Heart blocks

3. Bradycardia

4. COPD

5. Precaution in DM


The Beta blockers: Adverse effectsCVS b d di h potension h t bl k



CVS- bradycardia, hypotension, heart block

CNS- fatigue, dizziness, depression

Respi- bronchospasm, pulmonary edema

GI- nausea, vomiting, diarrhea, hypoglycemia

GU- decreased libido, impotence, dysuria


The Beta blockers: nursing considerations1 Emphasize NOT to stop abruptly the drug



1. Emphasize NOT to stop abruptly the drug

intake

2. Give with FOODS to improve absorption3. Provide comfort measures

Adequate rest periods

Avoidance of hazardous activities Change position slowly


The Beta blockers: nursing considerationsEvaluate effectiveness:



Evaluate effectiveness:

Decreased BP in hypertension

Decreased HR in hyperthyroidism

Decreased PAIN angina



The Cholinergic Agonists

These are also calledparasympathomimetic agents



parasympathomimetic agents

Their action mimics the parasympatheticnervous system

The Cholinergic Agonists

These agents INCREASE the activity of acetylcholine in the acetylcholine receptors



acetylcholine in the acetylcholine receptors

DIRECTLY by occupying the receptor

INDIRECTLY by blocking the enzyme thatdegrades the acetylcholine, preventing it

from breakdown - the enzyme:

acetylcholin ESTERASE

The Cholinergic Agonists Direct acting cholinergic agonists

Prototype: BetaneCHOL



CarbaCHOL

Pilocarpine Indirect acting cholinergics

Prototype: Pyridostigmine

NeostigmineEndrophonium (Tensilon)


Pharmacodynamics



They are similar to acetylcholine and

directly act on the acetylcholine

receptors


Parasympathetic stimulation will cause:



DUMBELS

urinationmiosis (pupil constriction)

The Cholinergic Agonists Direct 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 Agonists Direct 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 Agonists Direct acting cholinergic agonists:

Contraindications



1. Bradycardia

2. Hypotension

3. Asthma

The Cholinergic Agonists Direct 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 Agonists Direct 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: evaluateeffectiveness

Drug effectiveness



Pilocarpine Decreased IOP in glaucoma

Betanechol/Carbachol Urination/ relief of bladder

distention

The Cholinergic Agonists Indirect 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 excessivesalivation, diarrhea, vomiting become

problematic


Nursing considerations



Evaluate effectiveness

Decreased muscle weaknessDecreased 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!!!


Anticholinergics:Prototype: Atropine



o o ype t opi e

dicyclomine

glycopyrrolate

propantheline

scopolamine


Anticholinergics: pharmacodynamicsThese agents work by BLOCKING or



g y

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 bronchialsecretions

Used as pre-op med



Mydriasis Used in cataract surgery

Cyclopledia Used in cataract surgeryInhibits vagal response inthe heart

Used in BRADYCARDIAand heart block

Constipation Used in partly to control diarrhea (in

Lomotil)

Reverses cholinergictoxicity

Used in Cholinergic andOrganophosphate poisoning

Scopolamine

Decreases nausea and vomiting associatedwith motion sickness



Anticholinergic

Contraindications of anticholinergic



1. Known allergy

2. Glaucoma

3. Bladder obstruction (like PBH)

Anticholinergic

Adverse effects: anticholinergic effectsCNS- blurred vision, pupil DILATION,



, p p ,

photophobia, cycloplegia and increased

Intraocular pressureGI- dry mouth, constipation, bloatedness

CVS- tachycardia, palpitations

GU- urinary retentionOthers- decreased sweating, flushing

Anticholinergic

Nursing considerations1. 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

Anticholinergic

Nursing considerations2. Monitor for toxicity:



y

3. Ensure adequate hydration to prevent

Pharmacology Bullet Review (2)

Documents

Transcript of Pharmacology Bullet Review (2)