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A1. ACETAMINOPHEN (Tylenol)

EFFECTS: Analgesic (mild to moderate pain) Antipyretic

NO anti-inflammatory action NO platelet action THERAPEUTIC LEVEL: 10 – 30 mg/dL ANTIDOTE: Acetlycysteine (Mucomyst) ADVERSE EFFECTS: hepatotoxic

2. AMINOGLYCOSIDES STREPTOMYCIN/ GENTAMYCIN Obtain Peak and trough level

o Peak level – 30 minutes after taking the drugo Trough level – 30 minutes before the next dose

Adverse effects: Neurotoxic Ototoxic therapeutic to Meniere’s disease to relieve from vertigo (but this is the last resort because it will lead to permanent deafness) Nephrotoxic Monitor BUN

3. ANESTHESIA Epidural anesthesia Spinal headache Spinal anesthesia Hypotension

4. ANTICOAGULANTS AND THROMBOLYTICS WARFARIN SODIUM

(Coumadin)HEPARIN

(Hepalean)Action Blocks prothrombin synthesis Blocks conversionof prothrombin to thrombinOnset 2 to 5 days 30 seconds to 1 minuteUse Thrombosis and embolism

Atrial fibrillation with embolization Adjunct in treatment of coronary occlusion

Thrombosis and embolism Prevention of clotting in heparin lock sets, blood samples and during dialysis Treatment of disseminated intravascular coagulation

Route Oral SQ, IV(DO NOT give IM, may lead to hematoma and pain)

Expressed in Milligrams UnitsAntidote Vitamin K/ Phytonadione (AquaMEPHYTON) Protamine sulfate

Laboratory Test

Prothrombin time (PT) Normal value:11 to 13 seconds

Partial Thromboplastin Time (PTT) Normal value: 60 to 70 seconds; 2 to 2.5 times the controlActivated Partial thromboplastin time (APTT) Normal value: 30 to 45 seconds; 1.5 to 2 times the control

Usage Long term therapy Short term therapyEffect Slow Quick

Coumadin and Heparin CAN BE GIVEN together

WHAT ARE THE DRUGS THAT ENHANCE THE EFFECTS OF ANTICOAGULANTS?4A – Aspirin, Antihistamines, Alcohol, Antibiotics5G – Ginseng, Garlic, Ginger, Ginko biloba, Guiafenesin

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ANTICOGULANT – prevents clot formation THROMBOLYTICS – dissolves clot

USE: pulmonary embolism, coronary artery thrombosis, deep vein thrombosis, MI SIDE EFFECT: bleeding Start therapy as soon as possible after thrombus appears as thrombi older than 7 days react poorly to streptokinase Heparin is discontinued before streptokinase is started IM injections are contraindicated ANTIDIOTE: aminocaproic acid (Amicar) Examples: streptokinase (Streptase) – PROTOTYPE; alteplase (Activase), urokinase (Abbokinase), reteplase (Retavase), tenecteplase (TNKase), anistreplase (Eminase)

5. ANTIDEPRESSANTS 2 weeks interval in shifting from one type of anti-depressant to another Antidepressant effect: 2 – 4 weeks Tricyclic Antidepressants (TCA) – increases norepinephrine and/or serotonin in CNS by blocking the reuptake of norepinephrine by presynaptic neurons1. Imipramine (Tofranil)2. Amitriptyline (Elavil)

SIDE EFFECTS: hypotension, arrhythmias, blurred vision, constipation, urinary retention, dry mouth NURSING CONSIDERATIONS:

Check BP and PR Give drug at BEDTIME Changing from TCA to MAOI, patient must discontinue TCA for 14 days 2 to 4 weeks needed before the full therapeutic effect happens TCA OVERDOSE (anticholinergic toxicity):

o Coma, convulsiono Ataxia, agitationo Stupor, sedation

Selective Serotonin Reuptake Inhibitor (SSRI) inhibits CNS neuron uptake of serotonin, but not of norepinephrine1. Fluoxetine (Prozac)2. Sertraline (Zoloft) SIDE EFFECTS: hypotension, headaches, arrhythmias, insomnia, dry mouth, weight loss, sexual dysfunction NURSING CONSIDERATIONS:

o Give drug in the MORNINGo Takes 4 weeks for full effecto Changing from MAOI to SSRI, patient must discontinue MAOI for 2 weeks

Changing from SSRI to MAOI, patient must discontinue SSRI for 5 weekso Monitor for weighto Provide oral hygiene

Monoamine Oxidase Inhibitor (MAOI) – acts as a psychomotor stimulator or psychic energizers; blocks oxidative deamination of naturally occurring monoamines (epinephrine, norepinephrine, serotonin) causing CNS stimulation1. tranylcypromine (Parnate)2. isocarboxazid (Marplan)3. phenelzine (Nardil)

SIDE EFFECTS: Hypertensive crisis – happens if the drug is taken with tyramine-containing foodso Sweating Constipationo Headache, HPN Orthostatic hypotensiono Urinary retention Photophobia, dilated pupilso Nausea, Neck stiffness Agranulocytosiso Tachycardia

AVOID tyramine or tryptophan containing foods:o Aged meat, avocadoo Banana, beans

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o Chocolates, coffee, cheese (cheddar, aged, swiss), chicken and beef livero Drinks that are fermented (wine, beer)o Smoked fish, soy sauce, sour cream, sausageo Pickled foods (herring)o Overripe foodso Raisinso Teao Yogurt, yeast

ALLOW: cottage and cream cheese Monitor BP Therapeutic effect are achieved within 10 days to 4 weeks

6. ANTI-GOUT COLCHICINE (Novocolchine) anti-inflammatory

o SIDE EFFECTS; diarrhea, abdominal crampso NURSING CONSIDERATIONS:

DO NOT give IM or SQ, this may lead to irritation Administer drug after meals No more than 12 tablets should be given in a 24 hour period

ALLOPURINOL (Zyloprim) prevent production of uric acid by inhibiting the enzyme xanthine oxidoseo USE: prophylactic for attacks of gout; clients with calcium oxalate calculio SIDE EFFECTS: hepatotoxic

PROBENECID (Benemid)/ SULFINPYRAZONE (Anturane) – uricosuric agents: reduces uric acid in the blood by increasing its renal excretion

7. ANTI-PARKINSONS Dopaminergic Drugs (increase dopamine)

1. Amantadine (Symmetrel)2. Levodopa (L-dopa)3. Levodopa-Carbidopa (Sinemet)

Anticholinergic Drugs (decrease Acetylcholine)1. Akineton2. Cogentin3. Artane4. Benadryl

8. ANTI-PSYCHOTIC (MAJOR TRANQUILIZERS) USE: Schizophrenia1. Haloperidol (Haldol)2. Chlorpromazine (Thorazine) SIDE EFFECTS:

HYPOtension leukopenia (sore throat) NEUROLEPTIC MALIGNANT SYNDROME (HYPERthermia/ diaphoresis, HYPERtension) pink-red urine (normal: thorazine)

9. ASPIRIN/ SALICYLATES/ ACETYLSALICYLIC ACID EFFECTS:

Antiplatelets reduce risk of myocardial infarction and transient ischemic attack Anti-inflammatory rheumatic fever, Kawasaki disease, rheumatoid arthritis Antipyretic fever Analgesic mild to moderate pain

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Aspirin toxicity Tinnitus – early sign of salicylism Metabolic acidosis – late sign of salicylism Epistaxis, nephrotoxic

ANTIDOTE: activated charcoal (can also give Ipecac syrup to induce vomiting of aspirin) Give the drug with full stomach after meals Aspirin is ulcerogenic Monitor CBC, Prothrombin time, renal and liver functions DO NOT give with any anticoagulant (Coumadin, Heparin). It may cause additive effect, high risk for bleeding AVOID Aspirin in patients with viral infection to prevent Reye’s Syndrome AVOID Aspirin with OHA causes hypoglycemia

10. ATROPINE SULFATE (Atropair, AtroPen) block neurotransmitter acetylcholine and inhibits parasympathetic actions USE: pre-op medication to reduce secretions and bradycardia; produces mydriasis CONTRAINDICATED in acute glaucoma, prostatic hypertrophy

B11. BETABLOCKERS

Example: propanolol (Inderal), timolol (Blocadren), pinolol (Visken), nadolol (Corgard), metoprolol (Lopressor), timolol maleate (Timoptic) MODE OF ACTION: inhibit sympathetic stimulation of beta receptors in the –

HEART – decreasing myocardial oxygen consumption and demand by: decreases heart rate and *** decreases force of myocardial contraction

EYES – decreases intraocular pressure (IOP) by decreasing aqueous humor formation and increases aqueous humor outflow

Change of position gradually Take pulse before taking drug***

12. BRONCHODILATOR USE: bronchospasms, asthma EXAMPLES:

BETA-ADRENERGIC: abuterol (Proventil, Ventolin), metaproterenol (Alupent) XANTHINES: theophylline (Theo-Dur) – PROTOTYPE, aminophylline (Truphylline)

THERAPEUTIC LEVEL OF THEOPHYLLINE: 10 – 20 mcg/ml (mg/dl) SIGN OF THEOPHYLLINE TOXICITY:

Tachycardia nausea and vomiting

FOODS TO BE AVOID ICE TEA – caffeine and caffeine containing foods because Theophylline is a xanthine derivative which has same effect with caffeine

D13. DIAZEPAM (Valium)

USE: Drug of choice for status epilepticus EFFECTS:

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Anxiolytic Anti-convulsant Muscle relaxant

DO NOT MIX with other drugs DO NOT withdraw abruptly AVOID alcohol, smoking, activities that requires alertness May cause physical dependence Oral form should be given BEFORE MEALS Examples: alprazolam (Xanax), clorazepate (Tranxene), flurazepam (Dalmane), midazolam (Versed), triazolam (Halcion), chlordiazepoxide (Librium), clonazepam (Klonopin), lorazepam (Ativan)

14. DIGOXIN (Lanoxin) Effects:

o (+) inotropic – increases FORCE OF CONTRATION increase cardiac outputo (-) chronotropic – decreases HEART RATE decrease oxygen demand of the heart muscles

Digoxin toxicity – nausea, yellow color vision, arrhythmia, sign of hypokalemia (weakness, muscle cramps) Antidote: Digibind

15. DIURETICS CLASSIFICATIONS SITE OF

ACTIONEXAMPLES INDICATIONS SPECIAL NURSING

INTERVENTIONSCarbonic Anhydrase Inhibitors

Proximal tubule

Acetazolamide (Diamox) Meniere’s disease, OPEN glaucoma

Loop Diuretics Loop of Henle

Furosemide (Lasix)Bumetanide (Bumex)

Potent diuretic

Osmotic Diuretics Glomerulus MannitolOsmitrolGlycerinUrea

Increased ICP Warm solution to avoid crystallization

Potassium Sparing Distal tubule

Spironolactone (Aldactone)Amiloride (Modiuretic, Midamor)Triamterene (Dyrenium)

Mild diuretic, CHF, HPN Avoid potassium-rich foods (banana, potatoes, spinach, broccoli, nuts, prunes, tomatoes. Oranges, peaches)

Thiazide and Thiazide-like

Proximal tubule

HydrochlorothiazideChlorothiazide (Diuril)Metolazone

HPN (Not effective for immediate dieresis)

K-sparing: Spironolactone, Amiloride, Triamterene K-wasting: CAI, Loop, Osmotic Thiazides

NURSING INTERVENTION1. Monitor blood pressure (first/ before) and weight (second/ after)2. Administer in the MORNING3. Administer with FOOD

EVALUATION: for effectiveness of therapy Weight loss Increased urine output Resolution of edema Decreased congestion Normal BP

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16. HERBAL DRUGS that causs BLEEDING GINKO BILOBA GINGER GARLIC GINSENG

I17. IMCI DRUGS: IRON

1 dose daily x 14 daysAGE or WEIGHT TABLET

Ferrous sulphate 200mg + 250 mcg Folate(60 mg elemental iron)

SYRUPFerrous sulphate 150 mg per 5 ml

(6 mg elemental iron per ml)

DROPSFerrous sulphate 25

(25 mg elemental iron per ml)2 to 4 months(4 to <6 kg)

THY 2.5 ml (1/2 tsp) 0.6 ml

4 to 12 months(6 to <10 kg)

4 ml (3/4 tsp) 1 ml

1 to 3 years(10 to <14 kg)

½ tablet 5 ml (1 tsp) 1.5 ml

3 to 5 years(14 to <19 kg)

1 tab 7.5 ml (1.5tsp) 2 ml

18. IMCI DRUG: VITAMIN A

AGEVITAMIN A CAPSULES

100,000 IU 200,000 IU6 months to 12 months 1 ½ capsule12 months to 5 years 2 capsules 1 capsules

19. IMCI DRUG: MEBENDAZOLE/ ALBENDAZOLE AGE or WEIGHT Albendazole 400 mg tablet Mebendazole 500 mg tablet

12 months to 24 months ½ or 200 mg tablet 124 months to 59 months 1 1

20. INSULIN MODE OF ACTION: decreases blood sugar by –

Increasing glucose transport across cell membranes Enhancing conversion of glucose to glycogen

TYPE DESCRIPTION ONSET PEAK DURATIONRAPID-ACTING:Regular, Humulin R

Color: ClearRoute: IV, SQ

30 min – 1 hr

2 – 4 hrs 6 – 8 hrs

INTERMEDIATE-ACTING:NPH/ Neutral Protamine Hagedorn(Insulin Isophane Suspension),Humulin N

Color: CloudyRoute: SQ

1 – 2 hrs 6 – 8 hrs 18 – 24 hrs

LONG-ACTING:Ultralente (extended insulin zinc suspension)Humulin U

Color: CloudyRoute: SQ

3 – 4 hrs 16 – 20 hrs

30 to 36 hrs

PEAK TIME – time of hypoglycemic episodes 1ml of tuberculin = 100 units of insulin U100 insulin syringe is – 100 units Administer insulin in room temperature

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ROUTE: SQ Administer insulin at either 45 degree (for skinny patient) or 90 degrees (for fat patients)

Area: Abdomen – fastest absorption Deltoid thigh buttocks

AVOID: massage and apply compression (increase absorption) aspirate after injection shake. Gently roll vial in between palms Cold insulin lipodystrophy

STORAGE: In room temperature – last for 1 month Refrigerated once opened – last for 3 months

ADJUSMENT OF DOSE: increase insulin requirement Infection, Stress, Illness decrease insulin requirement Breast feeding (Antidiabetic effect)

Mixing of insulin: (Aspirate 1st – clear, Inject air 1st – cloudy)(1) Inject air to NPH(2) Inject air to Regular(3) Aspirate Regular(4) Aspirate NPH

Most common used: U100 (1)U40 (2)

21. IRON SUPPLEMENTS SIDE EFFECTS: dark stools (tarry stool), constipation, abdominal cramps Tablet: give with citrus juice (orange, tomato)Liquid: give with citrus juice (orange, tomato) and strawIM: Z-track method; DO NOT massage BEST given with empty stomach Citrus juice is AVOIDED with iron elixir preparation

L22. LACTULOSE (DUPHALAC, CEPHULAC)

Laxative SIDE EFFECT: ammonia binder (therapeutic to patient with hepatic encephalopathy)

23. LITHIUM Anti-mania Therapeutic Level: 0.5 – 1.5 mEq/L Lithium toxicity (n/c, anorexia, abdominal cramps, diarrhea) PREPARATIONS:

o Tablets: 300, and 450mg. o Capsules: 150, 300, and 600 mg. o Syrup: 300 mg/5 ml

Maintain:o increase fluid (3L/day)o Increase Na (3 gm/day)

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M24. MAGNESIUM SULFATE

tocolytic agent USE: premature labor, anticonvulsants in pregnancy induced hypertension (PIH) Check:

o deep tendon reflex (DTR) – FIRST reflex lost with CNS toxicityo Check RR (at least >12 breaths/ mino Check urine output (at least 30 mL/ hr)

ANTIDOTE: calcium gluconate

25. METRONIDAZOLE (FLAGYL) Anti-amoeba AVOID alcohol (Metronidazole + Alcohol = Disulfiram-like effect)

26. MORPHINE SULFATE (Duramorph) EFFECT: induce sedation, analgesia and euphoria INDICATION: moderate to severe pain, pain relief in myocardial infarction DECREASES preload and afterload DECREASES workload SIDE EFFECTS of Morphine SO4

Miosis Orthostatic hypotension Respiratory depression Produces tolerance and dependence Hyperglycemia Increase urinary retention/ constipation, Nausea and vomiting Euphoria Sedation/ dizziness

Assess client’s pain before giving medication Check before and after the respiration May lead to tolerance

FIRST SIGN of tolerance is decrease duration of effect of the analgesic AVOID activities that require alertness, alcoholic beverages, smoking, CNS depressants, sedatives, muscle relaxants Change position gradually

N27. NITRATES AND NITROGLYCERINE (Nitro-bid, Nitrodur, Nitrostat IV)

MODE OF ACTION: vasodilator USE: angina pectoris and hypertension SIDE EFFECTS OF NITRATES: headache, flushing, orthostatic hypotension, dizziness Other Related drugs: isosorbide dinitrate (Isordil), isosorbide mononitrate (Imdur) SUBLINGUAL form: 0.15 – 0.6 mg

No more than 3 tablets should be taken in a 15 minute period (one tablet every 5 minutes); if pain not relieved after 15 minutes and 3 tablets, notify physician immediately SIGN OF POTENCY: burning sensation under tongue Drink water first BEFORE taking drug

OINTMENT

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applied to a hairless or clipped/ shaved area new site should be used with each new dose use ruled applicator paper that comes with ointment to measure dose wear gloves during application leave applicator on site and cover it with plastic wrap and secure it with tape

TRANSDERMAL PATCH Apply a patch once a day only Rotate site Place patch in non-hairy area Determine a base region and remove the old patch Wear gloves during application IV form: 5 mcg/ min

dilute IV nitroglycerine in 5% dextrose or 0.9% sodium chloride and titrate every 3 to 5 minutes STORAGE: store in original dark glass container in a cool, dry place. date bottle when opening discard after 6 months NURSING CONSIDERATIONS: Change position gradually to prevent dizziness HEADACHE is a sign that the drug is taking effect. It will discontinue with long term use. AVOID alcohol, hot baths Carry drug at all times DO NOT administer nitrates with sildenafil (Viagra), both drugs are vosadilator which may lead to HYPOTENSON

28. NONI JUICE Morinda citrifolia High in fibers

O29. OCTREOTIDE (SANDOSTATIN)

Inhibits GROWTH HORMONE, GLUCAGON, INSULIN 2 formulations

Sandostatin®is a short acting version Sandostatin LAR®is a long acting version.

Sandostatin® is given by subcutaneous injection It may be necessary to take the shot several times a day. The injection sites should be rotated regularly. This medication may also be given intravenously. Sandostatin LAR® is given by intramuscular injection. This medication is generally given once every 4 weeks. The preferred site for injection is the hip, because it is painful given into the arm. Sandostatin LAR® should NOT be given by S.C. or IV routes. COMMON SIDE EFFECT: constipation

30. OXYTOCIN (Pitocin) stimulate uterine contraction USE: postpartum bleeding, labor induction ADVERSE EFFECTS: uterine hyperstimulation, arrhythmias, tachycardia, hypertension Given IM or IV; IV via piggyback and delivered with an infusion pump Observe fetal hypoxia or distress

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31. PANCREATIC ENZYMES USE: aid in digestion; cystic fibrosis Give WITH MEALS*** Expected outcome of the drug is absence of steatorrhea EXAMPLES: pancreatin (Dizymes), pancrelipase (Cotazym)

32. PHENYTOIN (Dilantin) USE: seizure SIDE EFFECT: gingival hyperplasia, may turn urine pink, red, or red-brown ADVERSE EFFECTS: hepatotoxic, Steven-Johnson’s syndrome DO NOT administer IM Give drug with NSS BEFORE AND AFTER (flushing) drug administration Provide oral hygiene, Use soft, bristled toothbrush Takes 7 to 10 days to achieve therapeutic serum level Therapeutic level: 10 – 20 mg/ dl

S33. STEROIDS

EFFECTS: Anti-inflammatory Hormonal replacement

USE: USE: bronchial asthma, Addison’s disease, allergies Examples: hydrocortisone (Cortisol), prednisone (Strap red), dexamethasone (Decadron), methylprednisone (Solu- medrol), betamethasone (Celestone) SIDE EFFECTS:

Cushing’s syndrome Immunosuppression therapeutic to AUTOIMMUNE DISEASES 9 like nephrotic syndrome, SLE, multiple sclerosis, Rheumatoid arthritis, for organ transplant, hyperthyroidism, allergies) causes GI irritation and ulceration Long term: Adrenal insufficiency***, osteoporosis Short term: Immunosuppresant, hypokalemia, hypocalcemia, edema

Give with food Watch out for infection Taper the dose (abrupt withdrawal may lead to acute adrenal crisis) Parenteral form: Give IM avoid SQOral form: Give it WITH food or milk, may cause gastric irritationTopical creams: DO NOT apply in broken skin and near eyes Administer in the morning (before 9 am); Take medication with breakfast (corresponds to biorhythms and reduces gastric irritation) Wear medic alert bracelet Isolation precaution AVOID sunlight, people with infections or crowded placeAVOID immobility to prevent osteoporosisAVOID crowd DIET: Restrict sodium, alcohol and caffeine; high potassium foods Carry extra medication during travel. Adjust medications during periods of acute or chronic stress such as pregnancy or infections; contact health care provider.

34. SYMPATHETIC AND PARSYMPATHETIC

SYMPATHETIC PARASYMPATHETIC

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SNS (Adrenergic) PNS (Cholinergic)Dumping Syndrome, MGAtropineCholinesterase

Glaucoma, GERDProstigmineAnticholinesterase

“fight or flight” response “Sleep and digest” response(BIOAMINE THEORY)Epinephrine (Adrenaline) – faster release but short actingNorepinephrineDopamineSerotonin

Acetylcholine – slowly release but long acting

(Increase) HR, RR, BP(Decrease) peristalsis, UO, secretionsPupil dilation (mydriasis)BronchodilationHyperglycemia

(Decrease) HR, RR, BP(Increase) peristalsis, UO, secretionsPupil constriction (miosis)Bronchoconstriction

DiarrheaUrinary frequencyMiosis (constriction)BradycardiaBronchoconstrictionErection/ emesisLSalivation

T35. THYROID AND ANTI-THYROID DRUGS

THYROID AGONISTS – used to increase blood thyroid hormones LEVOTHYROXINE (Synthroid) USE: hypothyroidism (myxedema), cretinism (congenital hypothyroidism) SIDE EFFECTS: insomnia, tachycardia, diarrhea Taper the dose Monitor vital signs (temperature, BP, PR) Give the drug in the morning (due to insomnia side effect) CONTRAINDICATIONS:

Cabbage, Cauliflower Peaches, Peas, Pears Raddish, turnips Spinach

THYROID ANTAGONISTS – used to decrease blood thyroid hormonesA. ANTITHYROID DRUGS – inhibit synthesis of thyroid hormones

Examples: propylthiouracil (PTU, Propacil, Propyl-Thyracil), methimazole (Tapazole)B. IODIDES – inhibit secretion/ release of thyroid hormone; decrease vascularity of the thyroid gland (for

thyroidectomy preparation)Examples: Potassium Iodide Saturated Solution (Lugol’s solution)

Give at least 10 day before surgery

SIDE EFFECTS: o agranulocytosis (sore throat)o paresthesiaso bleeding (inhibits vitamin K)

Taper the dose Monitor vital signs (temperature, BP, PR) AVOID iodine, iodine containing foods and sea foods ORAL form: dilute with water or juice (to improve taste) and use straw (to prevent discoloration)

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