pharmacology bullet review
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Pharmacology Pharmacology Bullet ReviewBullet Review
Nursing Board 2005Nursing Board 2005
Drug classification
Nursing process applied to pharmacology
Pharmacokinetics
Pharmacodynamics
Diuretics ComparisonDiuretics ComparisonDiuretic class Major site of
actionSpecial Side
effect (s)
1. Carbonic anhydrase inhibitor
Proximal tubule
Acidosis
2. Thiazide and thiazide like
Proximal tubule
HyperuricemiaHypokalemia
3. Loop diuretics
Loop of Henle HypokalemiaOtotoxicity
4. Potassium sparing
Distal tubule Hyperkalemia
5. Osmotic diuretic
Glomerulus Hypovolemia & hypotension
Diuretics ComparisonDiuretics ComparisonDiuretic class
Special Uses
1. Carbonic anhydrase inhibitor
Mountain sicknessMeniere’s disease
2. Thiazide and thiazide like
Nephrolithiasis due to calcium stonesHypocalcemia
3. Loop diuretics
Hypercalcemia
4. Potassium sparing
CHF taking digoxin
5. Osmotic diuretic
Increased ICPLITHIUM TOXICITY
ThiazidesThiazides
Prototype: HydrochloroPrototype: Hydrochlorothiazide thiazide
1. Bendroflume1. Bendroflumethiazidethiazide 2. Ben2. Benthiazidethiazide 3. Chloro3. Chlorothiazide thiazide (Diuril)(Diuril) 4. Hydroflume4. Hydroflumethiazidethiazide 5. Methylclo5. Methylclothiazidethiazide 6. Trichlorme6. Trichlormethiazidethiazide
Thiazide-likeThiazide-like
1. Indapamide1. Indapamide 2. Quinethazone2. Quinethazone 3. Metolazone3. Metolazone 4. Chlorthalidone4. Chlorthalidone
ThiazidesThiazides
PharmacodynamicsPharmacodynamics These drugs BLOCK the chloride These drugs BLOCK the chloride
pumppump This will keep the Chloride and This will keep the Chloride and
Sodium in the distal tubule to be Sodium in the distal tubule to be excreted into the urine excreted into the urine
Potassium is alsoPotassium is also
flushed out!! flushed out!!
ThiazideThiazide
Special Pharmacodynamics: Side Special Pharmacodynamics: Side effectseffects HypokalemiaHypokalemia DECREASED calcium excretionDECREASED calcium excretion
hypercalcemiahypercalcemia DECREASED uric acid secretionDECREASED uric acid secretion
hyperuricemiahyperuricemia Hyperglycemia Hyperglycemia
Loop DiureticsLoop Diuretics
Prototype: FurosemidePrototype: Furosemide
1. Bumetanide1. Bumetanide 2. Ethacrynic acid2. Ethacrynic acid 3. Torsemide3. Torsemide
Loop DiureticsLoop Diuretics
PharmacodynamicsPharmacodynamics High-ceiling diureticsHigh-ceiling diuretics BLOCK the chloride pump in the BLOCK the chloride pump in the
ascending loop of Henleascending loop of Henle SODIUM and CHLORIDE SODIUM and CHLORIDE
reabsorption is preventedreabsorption is prevented Potassium is also excreted together Potassium is also excreted together
with Na and Clwith Na and Cl
Loop DiureticsLoop Diuretics
Loop DiureticsLoop Diuretics
Special Pharmacodynamics: side-Special Pharmacodynamics: side-effectseffects HypokalemiaHypokalemia Bicarbonate is lost in the urineBicarbonate is lost in the urine INCREASED calcium excretionINCREASED calcium excretion
HypocalcemiaHypocalcemia Ototoxicity- due to the electrolyte Ototoxicity- due to the electrolyte
imbalancesimbalances
Potassium sparing Potassium sparing diureticsdiuretics
Prototype: SpironolactonePrototype: Spironolactone
1. Amiloride1. Amiloride 2. Triamterene2. Triamterene
Potassium sparing Potassium sparing diureticsdiuretics
PharmacodynamicsPharmacodynamics Spironolactone is an ALDOSTERONE Spironolactone is an ALDOSTERONE
antagonistantagonist Triamterene and Amiloride BLOCK Triamterene and Amiloride BLOCK
the potassium secretion in the distal the potassium secretion in the distal tubuletubule
Diuretic effect is achieved by the Diuretic effect is achieved by the sodium loss to offset potassium sodium loss to offset potassium retentionretention
Potassium sparing Potassium sparing diureticsdiuretics
Potassium sparing Potassium sparing diureticsdiuretics
Pharmacokinetics: Side effectsPharmacokinetics: Side effects HYPERkalemia!HYPERkalemia! Avoid high potassium foods:Avoid high potassium foods:
BananasBananas PotatoesPotatoes SpinachSpinach BroccoliBroccoli NutsNuts PrunesPrunes TomatoesTomatoes OrangesOranges Peaches Peaches
Osmotic DiureticsOsmotic Diuretics
Prototype: MannitolPrototype: Mannitol
1. Glycerin1. Glycerin 2. Isosorbide2. Isosorbide 3. Urea3. Urea
Osmotic DiureticsOsmotic Diuretics
PharmacodynamicsPharmacodynamics Mannitol is a sugar not well Mannitol is a sugar not well
absorbed in the nephronabsorbed in the nephron osmotic osmotic pull of waterpull of water diuresis diuresis
Osmotic DiureticsOsmotic Diuretics
Pharmacokinetics: side effectsPharmacokinetics: side effects Sudden hypovolemiaSudden hypovolemia
Important for the nurse to warm the Important for the nurse to warm the solution to allow the crystals to solution to allow the crystals to DISSOLVE in the bottle!DISSOLVE in the bottle!
Carbonic Anhydrase Carbonic Anhydrase InhibitorsInhibitors
Prototype: AcetazolamidePrototype: Acetazolamide
1. Methazolamide1. Methazolamide
Carbonic Anhydrase Carbonic Anhydrase InhibitorsInhibitors
PharmacodynamicsPharmacodynamics Carbonic Anhydrase forms sodium Carbonic Anhydrase forms sodium
bicarbonatebicarbonate BLOCK of the enzyme results to BLOCK of the enzyme results to
slow movement of hydrogen and slow movement of hydrogen and bicarbonate into the tubulesbicarbonate into the tubules
plus sodium is lost in the urineplus sodium is lost in the urine
Carbonic Anhydrase Carbonic Anhydrase InhibitorsInhibitors
Pharmacokinetics: side effectsPharmacokinetics: side effects Metabolic ACIDOSIS happens when Metabolic ACIDOSIS happens when
bicarbonate is lostbicarbonate is lost HypokalemiaHypokalemia
The Nursing Process and The Nursing Process and the diureticsthe diuretics
ASSESSMENTASSESSMENT Assess the REASON why the drug is Assess the REASON why the drug is
given:given:
____________
____________
____________
____________
The Nursing Process and The Nursing Process and the diureticsthe diuretics
ASSESSMENTASSESSMENT The nurse must elicit history of The nurse must elicit history of
allergy to the drugsallergy to the drugs Allergy to sulfonamides may Allergy to sulfonamides may
contraindicate the use of thiazidescontraindicate the use of thiazides Assess fluid and electrolyte balanceAssess fluid and electrolyte balance Assess other conditions like gout, Assess other conditions like gout,
diabetes, pregnancy and lactationdiabetes, pregnancy and lactation
The Nursing Process and The Nursing Process and the diureticsthe diuretics
ASSESSMENTASSESSMENT Physical assessmentPhysical assessment
Vital signsVital signs Special electrolyte and laboratory Special electrolyte and laboratory
examinationexamination Assess symptom of body weakness Assess symptom of body weakness
which may indicate hypokalemiawhich may indicate hypokalemia
The Nursing Process and The Nursing Process and the diureticsthe diuretics
Nursing DiagnosisNursing Diagnosis Fluid volume deficit related to diuretic Fluid volume deficit related to diuretic
effecteffect Alteration in urinary patternAlteration in urinary pattern Potential for injury (ototoxocity, Potential for injury (ototoxocity,
hypotension)hypotension) Knowledge deficitKnowledge deficit
The Nursing Process and The Nursing Process and the diureticsthe diuretics
IMPLEMENTATIONIMPLEMENTATION Administer IV drug slowlyAdminister IV drug slowly Safety precaution for Safety precaution for
dizziness/hypotensiondizziness/hypotension Provide potassium RICH foods for Provide potassium RICH foods for
most diuretics, with the exception of most diuretics, with the exception of spironolactonespironolactone
Provide skin care, oral care and Provide skin care, oral care and urinary careurinary care
The Nursing Process and The Nursing Process and the diureticsthe diuretics
IMPLEMENTATIONIMPLEMENTATION Monitor DAILY WEIGHT- to evaluate Monitor DAILY WEIGHT- to evaluate
the effectiveness of the therapy the effectiveness of the therapy Monitor urine output, cardiac Monitor urine output, cardiac
rhythm. Serum electrolytesrhythm. Serum electrolytes ADMINISTER in the MORNING!ADMINISTER in the MORNING! Administer with FOOD!Administer with FOOD!
The Nursing Process and The Nursing Process and the diureticsthe diuretics
EVALUATION: for effectiveness of EVALUATION: for effectiveness of therapytherapy
Weight lossWeight loss
Increased urine outputIncreased urine output
Resolution of edemaResolution of edema
Decreased congestionDecreased congestion
Normal BPNormal BP
The ANXIOLYTICS AND HYPNOTICSThe ANXIOLYTICS AND HYPNOTICS
These drugs are used to change the These drugs are used to change the individual’s responses to the individual’s responses to the environment. environment.
The ANXIOLYTICS AND HYPNOTICSThe ANXIOLYTICS AND HYPNOTICS
The medications that can prevent the The medications that can prevent the feelings of tension and fear are called feelings of tension and fear are called ANXIOLYTICS. ANXIOLYTICS. – Anti-anxiety drugsAnti-anxiety drugs
The ANXIOLYTICS AND HYPNOTICSThe ANXIOLYTICS AND HYPNOTICS
The drugs that can calm individuals The drugs that can calm individuals making them unaware of the making them unaware of the environment are called SEDATIVES. environment are called SEDATIVES.
The ANXIOLYTICS AND HYPNOTICSThe ANXIOLYTICS AND HYPNOTICS
The drugs that can induce sleep are The drugs that can induce sleep are called HYPNOTICS. called HYPNOTICS.
The ANXIOLYTICS AND HYPNOTICSThe ANXIOLYTICS AND HYPNOTICS
The drugs in this class are theThe drugs in this class are the– BENZODIAZEPINESBENZODIAZEPINES– BARBITURATES BARBITURATES
Use of The DrugsUse of The Drugs
Clinical indications for the use of theClinical indications for the use of the
anxiolytics, sedatives and hypnoticsanxiolytics, sedatives and hypnotics
1. Prevention of anxiety1. Prevention of anxiety
2. Formation of sedative state2. Formation of sedative state
3. Induction of sleep3. Induction of sleep
The BENZODIAZEPINESThe BENZODIAZEPINES
The benzodiazepines are the most frequently The benzodiazepines are the most frequently used anxiolytic drugs. used anxiolytic drugs.
These agents prevent anxiety states without These agents prevent anxiety states without causing much sedation, with less physical causing much sedation, with less physical dependence than other agents.dependence than other agents.
The BENZODIAZEPINESThe BENZODIAZEPINES
The following are the benzodiazepinesThe following are the benzodiazepinesAlprazolam (Xanax)Alprazolam (Xanax)Chlordiazepoxide (LibriumChlordiazepoxide (Librium))clonazepamclonazepamclorazepateclorazepateDiazepam (Valium)Diazepam (Valium)estazolamestazolamflurazepamflurazepamlorazepamlorazepammidazolammidazolamoxazepamoxazepamquazepamquazepamtemazepamtemazepamtriazolamtriazolam
The BENZODIAZEPINESThe BENZODIAZEPINESSpecial usesSpecial uses
Diazepam(Valium)
Status epilepticus
Chlordiazepoxide (Librium)
Alcohol withdrawal
Alprazolam (Xanax)
Panic attack
The BENZODIAZEPINESThe BENZODIAZEPINES
The Mechanism of Action of the BenzodiazepinesThe Mechanism of Action of the Benzodiazepines
These agents act on the Limbic system These agents act on the Limbic system and the RAS (reticular activating system) and the RAS (reticular activating system) to make the GABA ( Gamma-to make the GABA ( Gamma-aminobutyric acid) more effective aminobutyric acid) more effective causing interference with neuron firing. causing interference with neuron firing.
The BENZODIAZEPINESThe BENZODIAZEPINES
The Mechanism of Action of the BenzodiazepinesThe Mechanism of Action of the Benzodiazepines
The GABA is an inhibitory The GABA is an inhibitory neurotransmitter. neurotransmitter. This will result to an anxiolytic This will result to an anxiolytic effect at lower doses than effect at lower doses than required for sedation/hypnosis.required for sedation/hypnosis.
The BENZODIAZEPINESThe BENZODIAZEPINES
These agents are indicated for the treatment These agents are indicated for the treatment of of
1.1. anxiety disordersanxiety disorders2.2. alcohol withdrawalalcohol withdrawal3.3. hyperexcitability, and agitationhyperexcitability, and agitation4.4. pre-operative relief of anxiety and pre-operative relief of anxiety and
tension and in induction of balanced tension and in induction of balanced anesthesia. anesthesia.
The BENZODIAZEPINESThe BENZODIAZEPINESPharmacodynamics: The adverse effectsPharmacodynamics: The adverse effects
CNS effects= CNS effects= sedation, drowsiness, sedation, drowsiness, depression, lethargy, blurred visiondepression, lethargy, blurred visionGIT= GIT= dry mouth, constipationdry mouth, constipation, nausea, , nausea, vomitingvomitingCVS= CVS= HypotensionHypotension or hypertension, or hypertension, arrhythmias, palpitations, and arrhythmias, palpitations, and respiratory difficulties. respiratory difficulties. Hematologic= blood dyscrasias and Hematologic= blood dyscrasias and anemiaanemiaGU= urinary retention, hesitancy, loss of GU= urinary retention, hesitancy, loss of libido and sexual functions changes.libido and sexual functions changes.
The BENZODIAZEPINESThe BENZODIAZEPINES
Nursing Considerations:Nursing Considerations:Maintain patients on bed for at Maintain patients on bed for at least 3 hours after drug least 3 hours after drug administration.administration. Instruct to avoid hazardous Instruct to avoid hazardous activities like driving and machine activities like driving and machine operation. operation. Instruct to avoid consuming Instruct to avoid consuming ALCOHOL while taking the drugALCOHOL while taking the drug..
The BENZODIAZEPINESThe BENZODIAZEPINES
Nursing Considerations:Nursing Considerations:Provide comfort measures to help Provide comfort measures to help patients tolerate drug effects-patients tolerate drug effects-– instruct to urinate before taking instruct to urinate before taking
drugdrug– give high fiber foodsgive high fiber foods– use side-rails and assistance with use side-rails and assistance with
ambulation.ambulation.Have available Have available FLUMAZENIL as an FLUMAZENIL as an antidote for benzodiazepine antidote for benzodiazepine overdose.overdose.
The BARBITURATESThe BARBITURATES
These are also anxiolytics and These are also anxiolytics and hypnotics with a greater likelihood of hypnotics with a greater likelihood of producing sedation, with increase producing sedation, with increase risk of addiction and dependence. risk of addiction and dependence.
The BARBITURATESThe BARBITURATES
The following are the barbituratesThe following are the barbiturates
amobarbitalamobarbitalaprobarbitalaprobarbitalbutabarbitalbutabarbitalmephobarbitalmephobarbitalpentobarbitalpentobarbitalPhenobarbitalPhenobarbitalsecobarbitalsecobarbital
The BARBITURATESThe BARBITURATES
The Mechanism of Action of the The Mechanism of Action of the BarbituratesBarbituratesThey depress the motor output from the They depress the motor output from the brain.brain.The results of their MOA are sedation, The results of their MOA are sedation, hypnosis and anesthesia, and if extreme, hypnosis and anesthesia, and if extreme, coma.coma.
The BARBITURATESThe BARBITURATES
Clinical indications of the BarbituratesClinical indications of the Barbiturates1.1. Relief of anxiety manifestationsRelief of anxiety manifestations2.2. For sedationFor sedation3.3. For patients with insomniaFor patients with insomnia4.4. For pre-anesthesiaFor pre-anesthesia5.5. seizures/epilepsyseizures/epilepsy6.6. The rapid acting barbiturates are also The rapid acting barbiturates are also
used for the treatment of acute manic used for the treatment of acute manic reactions and status epilepticusreactions and status epilepticus
The BARBITURATESThe BARBITURATESPharmacodynamics: The Adverse effectsPharmacodynamics: The Adverse effects
CNS= CNS= CNS depressionCNS depression, somnolence, somnolence, , vertigo, lethargy, ataxia, paradoxical vertigo, lethargy, ataxia, paradoxical excitement, anxiety and hallucinations.excitement, anxiety and hallucinations.GIT= GIT= nausea, vomiting,nausea, vomiting, constipation/diarrhea and epigastric painconstipation/diarrhea and epigastric painCVS= bradycardia, Hypotension and CVS= bradycardia, Hypotension and syncope. syncope. Respi= serious hypoventilation, respiratory Respi= serious hypoventilation, respiratory depression and laryngospasmsdepression and laryngospasmsOthers= Others= hypersensitivity and Stevens-hypersensitivity and Stevens-Johnson syndrome.Johnson syndrome.
The BARBITURATESThe BARBITURATESNursing ConsiderationsNursing Considerations
Provide stand-by life support facilities Provide stand-by life support facilities in cases of severe respiratory in cases of severe respiratory depression or hypersensitivity reaction.depression or hypersensitivity reaction.Taper the drug gradually after long-term Taper the drug gradually after long-term therapy to avoid withdrawal syndrome.therapy to avoid withdrawal syndrome.Provide comfort measures including Provide comfort measures including small frequent meals, access to small frequent meals, access to bathroom facilities, high-fiber foods, bathroom facilities, high-fiber foods, environmental control, safety environmental control, safety precaution and skin care.precaution and skin care.
The CNS stimulantsThe CNS stimulants
These are drugs used to treat certain These are drugs used to treat certain disordersdisorders
1.1. exogenous obesityexogenous obesity
2.2. attention-deficit hyperactivity attention-deficit hyperactivity disorders (ADHD)disorders (ADHD)
3.3. narcolepsynarcolepsy
The CNS stimulantsThe CNS stimulants
What is unusual is the ability of What is unusual is the ability of the CNS stimulants to CALM the CNS stimulants to CALM hyperactive children, which hyperactive children, which allows them to focus on one allows them to focus on one activity for a longer period.activity for a longer period.
The CNS stimulantsThe CNS stimulants
The following are the CNS stimulants:The following are the CNS stimulants:
1. 1. Methylphenidate (Ritalin)= most Methylphenidate (Ritalin)= most commonly used for ADHDcommonly used for ADHD
2. Dextroamphetamine= a CNS stimulant 2. Dextroamphetamine= a CNS stimulant that is used for short tem therapy for that is used for short tem therapy for obesity.obesity.
3. Modafinil= used for narcolepsy3. Modafinil= used for narcolepsy
4. Pemoline= used for ADHD4. Pemoline= used for ADHD
The CNS stimulantsThe CNS stimulantsThe Mechanism of Action The Mechanism of Action
These agents act as to stimulate the These agents act as to stimulate the cortical and reticular activating system cortical and reticular activating system (RAS) of the brain. (RAS) of the brain.
This is by releasing neurotransmitters This is by releasing neurotransmitters from the nerve cells leading to from the nerve cells leading to increased increased stimulation of the post-synaptic stimulation of the post-synaptic neurons.neurons.
The CNS stimulantsThe CNS stimulants
The paradoxical effect of calming The paradoxical effect of calming hyperexcitability through CNS hyperexcitability through CNS stimulation seen in ADHD is believed to stimulation seen in ADHD is believed to be related to the increased stimulation of be related to the increased stimulation of an IMMATURE Reticular Activating an IMMATURE Reticular Activating System leading to the ability to be more System leading to the ability to be more selective in response to incoming selective in response to incoming stimuli.stimuli.
The CNS stimulantsThe CNS stimulants
Pharmacodynamics: Adverse effects of the CNS Pharmacodynamics: Adverse effects of the CNS stimulantsstimulants
CNS= CNS= nervousness, insomnianervousness, insomnia, dizziness, , dizziness, headache, and blurred visionheadache, and blurred vision
GIT=GIT= anorexiaanorexia, nausea and weight loss, nausea and weight loss
CVS= hypertension, tachycardia arrhythmias, and CVS= hypertension, tachycardia arrhythmias, and anginaangina
Others= rashes, physical/psychological Others= rashes, physical/psychological dependence.dependence.
The CNS stimulantsThe CNS stimulantsImplementationImplementation
The nurse must ensure that the drug is only given to The nurse must ensure that the drug is only given to the indicated conditionsthe indicated conditions
Administer the drug before 6 pm to reduce the Administer the drug before 6 pm to reduce the effect of insomniaeffect of insomnia
BEST given AFTER meals to prevent the effect BEST given AFTER meals to prevent the effect of anorexiaof anorexia
Consult with school personnel to monitor the patient Consult with school personnel to monitor the patient under therapyunder therapy
Provide safety measures such as side-rails and Provide safety measures such as side-rails and assisted ambulationassisted ambulation
The CNS stimulantsThe CNS stimulantsEvaluationEvaluation
Evaluate the effectiveness of the drug:Evaluate the effectiveness of the drug:
1.1. Calming effect in the patient with ADHDCalming effect in the patient with ADHD
2.2. Alertness for patients with narcolepsyAlertness for patients with narcolepsy
The Anti-epilepticsThe Anti-epileptics
These agents, also called anticonvulsants, These agents, also called anticonvulsants, are used to treat epileptic conditions.are used to treat epileptic conditions.
Hydantoins, Barbiturates, Hydantoins, Barbiturates, benzodiazepines, Succinimides and many benzodiazepines, Succinimides and many others are given to a specific type of others are given to a specific type of seizure. seizure.
Anti-epilepticsAnti-epilepticsAgents for treating TONIC-CLONIC SEIZURESAgents for treating TONIC-CLONIC SEIZURES1. Hydantoins1. Hydantoins
– PhenytoinPhenytoin– EthotoinEthotoin– FosphenytoinFosphenytoin– MephenytoinMephenytoin
2. Benzodiazepines2. Benzodiazepines– DiazepamDiazepam– ClonazepamClonazepam– Clorazepate Clorazepate
3. Barbiturates3. Barbiturates– PhenobarbitalPhenobarbital
Anti-epilepticsAnti-epileptics
Agents for treating ABSENCE SEIZURESAgents for treating ABSENCE SEIZURES1. Succinimides1. Succinimides
a. Ethosuximidea. Ethosuximide b. Methsuximideb. Methsuximide c. Phensuximidec. Phensuximide
2. Valproic Acid2. Valproic Acid3. Zosinamide3. Zosinamide
Anti-epilepticsAnti-epileptics
Agents for treating Partial FOCAL SEIZURESAgents for treating Partial FOCAL SEIZURES1. Carbamazepine1. Carbamazepine2. Gabapentin2. Gabapentin3.Lamotrigine3.Lamotrigine4. Tiagabine4. Tiagabine5. Topiramate5. Topiramate
The hydantoinsThe hydantoins
These agents are utilized for general seizures These agents are utilized for general seizures because they can depress the central because they can depress the central nervous system. nervous system.
They affect the entire brain and reduce the They affect the entire brain and reduce the chance of sudden electrical outburst that chance of sudden electrical outburst that causes seizures. causes seizures.
These agents generally are less sedating than These agents generally are less sedating than other anti-epilepticsother anti-epileptics..
The hydantoinsThe hydantoins
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.
The hydantoinsThe hydantoins
Clinical Indications of the hydantoinsClinical Indications of the hydantoins
1.1. Tonic-clonic seizuresTonic-clonic seizures
2.2. Status epilepticusStatus epilepticus
3.3. For the prevention of seizures in For the prevention of seizures in neurosurgeryneurosurgery
4.4. For muscle relaxation. For muscle relaxation.
The hydantoinsThe hydantoins
Contraindications and PrecautionsContraindications and Precautions
Hydantoins are NOT given to pregnant Hydantoins are NOT given to pregnant patient because it can cause fetal patient because it can cause fetal hydantoin syndromehydantoin syndrome. .
The hydantoinsThe hydantoinsPharmacodynamics: Adverse effects of the Pharmacodynamics: Adverse effects of the
HydantoinsHydantoinsCNS effects- depression, confusion, CNS effects- depression, confusion, drowsiness, lethargy, fatiguedrowsiness, lethargy, fatigueGIT- GI upset, constipation, dry mouthGIT- GI upset, constipation, dry mouth, , GINGIVAL HYPERPLASIA , severe liver toxicity GINGIVAL HYPERPLASIA , severe liver toxicity which are all related to cellular toxicity.which are all related to cellular toxicity.SKIN- hirsutism and coarsening of the facial SKIN- hirsutism and coarsening of the facial skinskinBone Marrow depressionBone Marrow depression
The hydantoinsThe hydantoinsImplementationImplementation
Administer the drug with food to alleviate Administer the drug with food to alleviate GI irritationGI irritationDiscontinue the drug at any sign of Discontinue the drug at any sign of hypersensitivity reaction, severe liver hypersensitivity reaction, severe liver dysfunction and severe skin rashes.dysfunction and severe skin rashes.Provide meticulous mouth oral careProvide meticulous mouth oral careRule out pregnancy and advise women to Rule out pregnancy and advise women to use contraceptive measures to prevent use contraceptive measures to prevent pregnancy.pregnancy.
Drugs affecting GI secretionsDrugs affecting GI secretions
There are five types of drugs that affect There are five types of drugs that affect gastric acid secretions and are useful gastric acid secretions and are useful for the treatment of peptic ulcer.for the treatment of peptic ulcer.
1.1. Histamine (H2) receptor Histamine (H2) receptor antagonist/blockersantagonist/blockers
2.2. AntacidsAntacids
3.3. Proton pump inhibitorsProton pump inhibitors
4.4. Mucosal protectantsMucosal protectants
5.5. Prostaglandin analogsProstaglandin analogs
Drugs affecting secretions:Drugs affecting secretions: anti ulcer anti ulcer
Anti-ulcer drugs Prototype
Histamine (H2) receptor antagonist/blockers
Cimetidine
Antacids AlOH and MgOH
Proton pump inhibitors Omeprazole
Mucosal protectants Sucralfate
Prostaglandin analog Misoprostol
General indication of the drugs General indication of the drugs affecting gastric acid secretionaffecting gastric acid secretion
►Peptic ulcerPeptic ulcer►GastritisGastritis►Patient on NPO to prevent stress ulcerPatient on NPO to prevent stress ulcer
General time of administration of the General time of administration of the drugs affecting gastric acid secretiondrugs affecting gastric acid secretion
Anti-ulcer drugs Prototype Best time to give
Histamine (H2) receptor antagonist/blockers
Cimetidine With FOOD or ONE hour after ANTACID
Antacids AlOH and MgOH Usually after meals
Proton pump inhibitors
Omeprazole BEFORE MEALS
Mucosal protectants
Sucralfate BEFORE MEALS
Prostaglandin analog
Misoprostol WITH MEALS
Pharmacology of Anti-Pharmacology of Anti-ulcer drugsulcer drugs
Drug Drug Mechanism of Action
Antacids- AlOH, MgOHAntacids- AlOH, MgOH Neutralize Gastric ACIDITY
H2-Blockers- “H2-Blockers- “tidinetidine””
CimetidineCimetidine, Ranitidine, RanitidineBlock Histamine receptor causing decreased secretion and acidity
Proton pump inhibitors- Proton pump inhibitors- ““Prazoles”Prazoles”
Omeprazole, pantoprazoleOmeprazole, pantoprazole
Inhibit Proton Pump in parietal cell decreasing secretion and acidity
Pharmacology of Anti-ulcer Pharmacology of Anti-ulcer drugsdrugs
Drug Drug Mechanism of Action
Anti-cholinergic- Anti-cholinergic- Prophanteline BromideProphanteline Bromide
Blocks VAGUS nerve, decreases secretion
Sucralfate (Carafate)Sucralfate (Carafate) Coats the mucosal lining
Misoprostol (Cytotec)Misoprostol (Cytotec) Prostaglandin Analogue, causes secretion of MUCUS
PharmacodynamicsPharmacodynamics
Histamine (H2) receptor Histamine (H2) receptor blockersblockers
►These drugs BLOCK the These drugs BLOCK the release of hydrochloric acid in release of hydrochloric acid in the stomach in response to the stomach in response to gastringastrin
Drugs affecting GI secretionsDrugs affecting GI secretions
AntacidsAntacids►These drugs interact with These drugs interact with
the gastric acids at the the gastric acids at the chemical level to neutralize chemical level to neutralize themthem
Drugs affecting GI secretionsDrugs affecting GI secretions
Proton pump inhibitorsProton pump inhibitors►These drugs suppress the These drugs suppress the
secretion of hydrochloric secretion of hydrochloric acid into the lumen of the acid into the lumen of the stomachstomach
Drugs affecting GI secretionsDrugs affecting GI secretions
Mucosal protectantsMucosal protectants►These are agents that coat These are agents that coat
any injured area in the any injured area in the stomach to prevent further stomach to prevent further injury from acidinjury from acid
Drugs affecting GI secretionsDrugs affecting GI secretions
Prostaglandin analogsProstaglandin analogs►These are agents that These are agents that inhibitinhibit
the secretion of gastrin and the secretion of gastrin and ►increaseincrease the secretion of the secretion of
mucus lining of the stomach, mucus lining of the stomach, providing a buffer.providing a buffer.
The H2 Blockers- “tidines”The H2 Blockers- “tidines”
Prototype: CimetidinePrototype: Cimetidine
►1. Ranitidine1. Ranitidine►2. Famotidine2. Famotidine►3. Nizatidine3. Nizatidine
The H2 Blockers- “tidines”The H2 Blockers- “tidines”
Pharmacodynamics: Drug ActionPharmacodynamics: Drug Action► The H2 blockers are antagonists at the The H2 blockers are antagonists at the
receptors in the parietal cells of the receptors in the parietal cells of the stomach. stomach.
► The blockage results to inhibition of The blockage results to inhibition of the hormone gastrin. the hormone gastrin.
► There will be decreased production of There will be decreased production of gastric acid from the parietal cells.gastric acid from the parietal cells.
► Also, the chief cells will secrete less Also, the chief cells will secrete less pepsinogen.pepsinogen.
The H2 Blockers- “tidines”The H2 Blockers- “tidines”
Therapeutic use of the H2 blockersTherapeutic use of the H2 blockers► Short-term treatment of active duodenal Short-term treatment of active duodenal
ulcer or benign gastric ulcerulcer or benign gastric ulcer► Treatment of hypersecretory conditions like Treatment of hypersecretory conditions like
the Zollinger-Ellison syndromethe Zollinger-Ellison syndrome► Prevention of stress-induced ulcers and Prevention of stress-induced ulcers and
acute GI bleedingacute GI bleeding► Treatment of erosive GERD (reflux disease)Treatment of erosive GERD (reflux disease)► Relief of Symptoms of heart burn and acid Relief of Symptoms of heart burn and acid
indigestion indigestion
The H2 Blockers- “tidines”The H2 Blockers- “tidines”
Precautions and ContraindicationsPrecautions and Contraindications►Any known allergy is a clear Any known allergy is a clear
contraindication to the use of the contraindication to the use of the agents. Conditions such as pregnancy, agents. Conditions such as pregnancy, lactation, renal dysfunction and hepatic lactation, renal dysfunction and hepatic dysfunction should warrant cautious dysfunction should warrant cautious use. use.
►Nizatidine can be used in hepatic Nizatidine can be used in hepatic dysfunction. dysfunction.
The H2 Blockers- “tidines”The H2 Blockers- “tidines”
Pharmocodynamics- Side effects and adverse Pharmocodynamics- Side effects and adverse effectseffects
► GIT= diarrhea or constipationGIT= diarrhea or constipation► CNS= Dizziness, headache, drowsiness, CNS= Dizziness, headache, drowsiness,
confusion and hallucinationsconfusion and hallucinations► Cardio= arrhythmias, Cardio= arrhythmias, HYPOTENSIONHYPOTENSION
(related to H2 receptor blockage in the heart)(related to H2 receptor blockage in the heart)► Cimetidine= Cimetidine= TREMORS,TREMORS, Gynecomastia Gynecomastia
and impotence in malesand impotence in males
The H2 Blockers- “tidines”The H2 Blockers- “tidines”
Drug-drug InteractionsDrug-drug Interactions►Cimetidine, Famotidine, Cimetidine, Famotidine,
Ranitidine are metabolized in the Ranitidine are metabolized in the liver- they can cause slowing of liver- they can cause slowing of excretion of other drugs leading excretion of other drugs leading to their increased concentration.to their increased concentration.
The H2 Blockers- “tidines”The H2 Blockers- “tidines”
Drug-drug InteractionsDrug-drug Interactions►These drugs can interact with These drugs can interact with
CIMETIDINE anticoagulants, CIMETIDINE anticoagulants, phenytoin, alcohol, phenytoin, alcohol, antidepressants.antidepressants.
The H2 Blockers- “tidines”The H2 Blockers- “tidines”Nursing considerations:Nursing considerations:►Administer the drug Administer the drug WITH WITH mealsmeals
at at BEDTIME BEDTIME to ensure to ensure therapeutic leveltherapeutic level
►One hour after AntacidsOne hour after Antacids►Stress the importance of the Stress the importance of the
continued use for the length of continued use for the length of time prescribed time prescribed
The H2 Blockers- “tidines”The H2 Blockers- “tidines”Nursing considerations:Nursing considerations:►Monitor the cardiovascular Monitor the cardiovascular
status especially if the drugs are status especially if the drugs are given IVgiven IV
►Warn patient of the potential Warn patient of the potential problems of increased drug problems of increased drug concentration if the H2 blockers concentration if the H2 blockers are used with other drugs or OTC are used with other drugs or OTC drugs. Advise consultation first!drugs. Advise consultation first!
The H2 Blockers- “tidines”The H2 Blockers- “tidines”
Nursing considerations:Nursing considerations:►Provide comfort measures like Provide comfort measures like
analgesics for headache, analgesics for headache, assistance with ambulation and assistance with ambulation and safety measuressafety measures
►Warn the patients taking Warn the patients taking cimetidine that drowsiness may cimetidine that drowsiness may pose a hazard if driving or pose a hazard if driving or operating delicate machines.operating delicate machines.
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 frequency, comfort measures to initiate when side-effects are initiate when side-effects are intolerableintolerable
Evaluate the effectiveness:Evaluate the effectiveness:►Relief of symptoms of ulcer, heart burn Relief of symptoms of ulcer, heart burn
and GERDand GERD
The AntacidsThe Antacids
► These are drugs or inorganic chemicals These are drugs or inorganic chemicals that have been used for years to neutralize that have been used for years to neutralize acid in the stomach. The following are the acid in the stomach. The following are the common antacids that can be bought OTC:common antacids that can be bought OTC:
► Aluminum salts (hydroxide)Aluminum salts (hydroxide)► Calcium salts (carbonate)Calcium salts (carbonate)► MagnesiumMagnesium salts (milk of magnesia) salts (milk of magnesia)► Sodium bicarbonateSodium bicarbonate► Magaldrate (aluminum and magnesium Magaldrate (aluminum and magnesium
combination)combination)
The AntacidsThe Antacids
Pharmacodynamics: drug actionPharmacodynamics: drug action►These agents act to neutralize the These agents act to neutralize the
acidic pH in the stomach. acidic pH in the stomach. ►They do not affect the rate of gastric They do not affect the rate of gastric
acid secretion. acid secretion.
The AntacidsThe Antacids
Pharmacodynamics: drug actionPharmacodynamics: drug action►The administration of antacid may The administration of antacid may
cause an acid rebound. cause an acid rebound. ►Neutralizing the stomach content to an Neutralizing the stomach content to an
alkaline level stimulates gastrin alkaline level stimulates gastrin production to cause an increase in acid production to cause an increase in acid production and return the stomach to production and return the stomach to its normal acidic state. its normal acidic state.
The AntacidsThe Antacids
Therapeutic IndicationsTherapeutic Indications►Symptomatic relief of upset stomach Symptomatic relief of upset stomach
associated with hyperacidity associated with hyperacidity ►Hyperacidic conditions like peptic ulcer, Hyperacidic conditions like peptic ulcer,
gastritis, esophagitis and hiatal herniagastritis, esophagitis and hiatal hernia►Special use of AMPHOGEL Special use of AMPHOGEL
(aluminum hydroxide): to BIND (aluminum hydroxide): to BIND phosphatephosphate
The AntacidsThe Antacids
Precautions of Antacid UsePrecautions of Antacid Use►Known allergy is a clear Known allergy is a clear
contraindication. Caution should be contraindication. Caution should be instituted if used in electrolyte instituted if used in electrolyte imbalances, GI obstruction and renal imbalances, GI obstruction and renal dysfunction. dysfunction.
►Sodium bicarbonate is rarely used Sodium bicarbonate is rarely used because of potential systemic because of potential systemic absorptionabsorption
The AntacidsThe Antacids
PharmacokineticsPharmacokinetics► These agents are taken orally and act These agents are taken orally and act
locally in the stomachlocally in the stomach
The AntacidsThe AntacidsPharmacodynamics: Effects of drugsPharmacodynamics: Effects of drugs1.1. GIT= rebound acidity; alkalosis may occur.GIT= rebound acidity; alkalosis may occur.► Calcium salts may lead to Calcium salts may lead to hypercalcemiahypercalcemia ► Magnesium salts can cause DIARRHEAMagnesium salts can cause DIARRHEA► Aluminum salts may cause Aluminum salts may cause
CONSTIPATION and hypophosphatemia CONSTIPATION and hypophosphatemia by binding with phosphates in the GIT.by binding with phosphates in the GIT.
2. 2. Fluid retentionFluid retention due to the high sodium due to the high sodium content of the antacids.content of the antacids.
The AntacidsThe AntacidsNursing Considerations:Nursing Considerations:►Administer the antacids apart from Administer the antacids apart from
any other medications by any other medications by ONE hour ONE hour beforebefore or or TWO hours after-TWO hours after- to to ensure adequate absorption of the ensure adequate absorption of the other medicationsother medications
►Tell the patient to Tell the patient to CHEWCHEW the tablet the tablet thoroughly before swallowing. Follow thoroughly before swallowing. Follow it with one glass of waterit with one glass of water
►Regularly monitor for manifestations Regularly monitor for manifestations of acid-base imbalances as well as of acid-base imbalances as well as electrolyte imbalanceselectrolyte imbalances
The AntacidsThe Antacids
Nursing Considerations:Nursing Considerations:► Provide comfort measures to alleviate Provide comfort measures to alleviate
constipation associated with aluminum constipation associated with aluminum and diarrhea associated with magnesium and diarrhea associated with magnesium salts. salts.
► Monitor for the side-effects, Monitor for the side-effects, effectiveness of the comfort measures, effectiveness of the comfort measures, patient’s response to the medication and patient’s response to the medication and the effectiveness of the health teachingsthe effectiveness of the health teachings
The AntacidsThe Antacids
Nursing Considerations:Nursing Considerations:►Evaluate for effectiveness:Evaluate for effectiveness:
Decreased symptoms of ulcer and Decreased symptoms of ulcer and pyrosispyrosis
Decreased Phosphate level Decreased Phosphate level (amphogel)(amphogel)
The PPIThe PPI
These are the newer agents for ulcer These are the newer agents for ulcer treatment treatment
►The “prazoles”The “prazoles”
Prototype: OmePrototype: Omeprazoleprazole►LanisoLanisoprazoleprazole►EsomeEsomeprazoleprazole►PantoPantoprazoleprazole
The PPIThe PPIPharmacodynamics: drug actionPharmacodynamics: drug action►They act at specific secretory surface They act at specific secretory surface
receptors to prevent the final step of receptors to prevent the final step of acid production and thus decrease acid production and thus decrease the level of acid in the stomach.the level of acid in the stomach.
►The “pump” in the parietal cell is the The “pump” in the parietal cell is the H-K H-K ATPase enzyme system on the ATPase enzyme system on the secretory surface of the gastric secretory surface of the gastric parietal cellsparietal cells
The PPIThe PPI
Clinical use of the PPIsClinical use of the PPIs►Short-term treatment of active Short-term treatment of active
duodenal ulcers, GERD, erosive duodenal ulcers, GERD, erosive esophagitis and benign gastric ulcer.esophagitis and benign gastric ulcer.
► Long-term- maintenance therapy for Long-term- maintenance therapy for healing of erosive disorders.healing of erosive disorders.
The PPIThe PPI
Clinical use of the PPIs.Clinical use of the PPIs.
Precautions with the use of the PPIsPrecautions with the use of the PPIs►Known allergy is a clear Known allergy is a clear
contraindication. Caution if patient is contraindication. Caution if patient is pregnantpregnant
The PPIThe PPI
Pharmacodynamics: Adverse effectsPharmacodynamics: Adverse effects►CNS- CNS- dizzinessdizziness,, headache, asthenia headache, asthenia
(loss of strength), (loss of strength), vertigovertigo,, insomnia, insomnia, apathyapathy
►GIT- diarrhea, abdominal pain, GIT- diarrhea, abdominal pain, nausea, vomiting, dry mouthnausea, vomiting, dry mouth and and tongue atrophytongue atrophy
►Respi- cough, stuffy nose, hoarseness Respi- cough, stuffy nose, hoarseness and epistaxis.and epistaxis.
The PPIThe PPI
Nursing considerations:Nursing considerations:►Administer the drug Administer the drug BEFORE BEFORE meals. meals.
Ensure that patient does not open, Ensure that patient does not open, chew or crush the drug. chew or crush the drug.
►Provide safety measures if CNS Provide safety measures if CNS dysfunction happens. dysfunction happens.
►Arrange for a medical follow-up if Arrange for a medical follow-up if symptoms are NOT resolved after 4-8 symptoms are NOT resolved after 4-8 weeks of therapy. weeks of therapy.
The PPIThe PPI
Nursing considerations: Nursing considerations: ►Provide health teaching as to drug Provide health teaching as to drug
name, dosages and frequency, safety name, dosages and frequency, safety measures to handle common measures to handle common problems. problems.
►Monitor patient response to the drug, Monitor patient response to the drug, the effectiveness of the teaching plan the effectiveness of the teaching plan and the measures to employand the measures to employ
The PPIThe PPI
Nursing considerations: Nursing considerations:
Evaluate for effectiveness of the drugEvaluate for effectiveness of the drug►Healing of peptic ulcerHealing of peptic ulcer►Decreased symptoms of ulcerDecreased symptoms of ulcer
The Mucosal ProtectantThe Mucosal Protectant
SucralfateSucralfate►This is given to protect the eroded This is given to protect the eroded
ulcer sites in the GIT from further ulcer sites in the GIT from further damage by acid and digestive damage by acid and digestive enzymesenzymes
SucralfateSucralfate
Pharmacodynamics: Action of drugPharmacodynamics: Action of drug► It forms an It forms an ulcer-adherent complexulcer-adherent complex at at
duodenal ulcer sites, protecting the duodenal ulcer sites, protecting the sites against acid, pepsin and bile. sites against acid, pepsin and bile.
►This action prevents further This action prevents further breakdown of proteins in the area and breakdown of proteins in the area and promotes healing. promotes healing.
SucralfateSucralfate
Clinical use of sucralfateClinical use of sucralfate►Short and long term management of Short and long term management of
duodenal ulcer.duodenal ulcer.►NSAIDs induced gastritis NSAIDs induced gastritis ►Prevention of stress ulcerPrevention of stress ulcer►Treatment of oral and esophageal Treatment of oral and esophageal
ulcers due to radiation, chemotherapy ulcers due to radiation, chemotherapy or sclerotherapy.or sclerotherapy.
SucralfateSucralfate
Precautions on the use of SucralfatePrecautions on the use of Sucralfate►This agent should NOT be given to This agent should NOT be given to
any person with known allergy to the any person with known allergy to the drug, and to those patients with renal drug, and to those patients with renal failure/dialysis because of build-up of failure/dialysis because of build-up of aluminum may occur if used with aluminum may occur if used with aluminum containing products.aluminum containing products.
The Mucosal ProtectantThe Mucosal Protectant
Pharmacodynamics: Side-effects & Pharmacodynamics: Side-effects & adverse reactionsadverse reactions
►Primarily GIT= CONSTIPATION, Primarily GIT= CONSTIPATION, occasionally diarrhea, nausea, occasionally diarrhea, nausea, indigestion, gastric discomfort, indigestion, gastric discomfort, and dry mouth may also occurand dry mouth may also occur
►CNS= dizziness, drowsiness, vertigoCNS= dizziness, drowsiness, vertigo►Others= rash and back painOthers= rash and back pain
The Mucosal ProtectantThe Mucosal Protectant
Drug-drug interactionsDrug-drug interactions►If used with aluminum salts= high If used with aluminum salts= high
risk of accumulation of aluminum risk of accumulation of aluminum and toxicityand toxicity..
► If used with phenytoin, If used with phenytoin, fluoroquinolones and penicillamines- fluoroquinolones and penicillamines- decreased levels of these drugs when decreased levels of these drugs when taken with sucralfatetaken with sucralfate
The Mucosal ProtectantThe Mucosal Protectant
Nursing ConsiderationsNursing Considerations► Administer drug Administer drug ON AN EMPTY stomachON AN EMPTY stomach, ,
1 hour before meals , or 2 hour after 1 hour before meals , or 2 hour after meals and at BEDTIMEmeals and at BEDTIME
► Monitor for side-effects like constipation Monitor for side-effects like constipation and GI upsetand GI upset
► Encourage intake of high-fiber foods and Encourage intake of high-fiber foods and increased fluid intakeincreased fluid intake
► Administer antacids Administer antacids BETWEENBETWEEN doses of doses of sucralfate, sucralfate, NOT WITHIN 30NOT WITHIN 30 minutes of minutes of sucralfate dosesucralfate dose
The Mucosal ProtectantThe Mucosal Protectant
Nursing ConsiderationsNursing Considerations►Provide comfort measures if CNS effects Provide comfort measures if CNS effects
occuroccur►Provide health teaching as to drug Provide health teaching as to drug
name, dosages and frequency, safety name, dosages and frequency, safety measures to handle common problems. measures to handle common problems.
►Monitor patient response to the drug, Monitor patient response to the drug, the effectiveness of the teaching plan the effectiveness of the teaching plan and the measures employedand the measures employed
The Mucosal ProtectantThe Mucosal Protectant
Nursing ConsiderationsNursing Considerations►Evaluate effectiveness of therapyEvaluate effectiveness of therapy
Healing of ulcerHealing of ulcer
No formation of ulcerNo formation of ulcer
Prostaglandin analogueProstaglandin analogue
MisoprostolMisoprostol►This agent is a synthetic prostaglandin This agent is a synthetic prostaglandin
E1 analog that is employed to protect E1 analog that is employed to protect the lining of the mucosa of the the lining of the mucosa of the stomach stomach
Prostaglandin analogueProstaglandin analogue
Misoprostol: PharmacodynamicsMisoprostol: Pharmacodynamics►Being a prostaglandin analog, it Being a prostaglandin analog, it
inhibitsinhibits gastric acid secretion to some gastric acid secretion to some degreedegree
► It It INCREASES mucusINCREASES mucus production in production in the stomach lining. the stomach lining.
Prostaglandin analogueProstaglandin analogue
Misoprostol: Clinical useMisoprostol: Clinical use►NSAIDs-induced gastric ulcers NSAIDs-induced gastric ulcers ►Duodenal ulcers unresponsive to H2 Duodenal ulcers unresponsive to H2
antagonists.antagonists.
Prostaglandin analogueProstaglandin analogue
Precautions of Misoprostol UsePrecautions of Misoprostol Use► This drug is CONTRAINDICATED during This drug is CONTRAINDICATED during
pregnancy because it is an pregnancy because it is an abortifacient.abortifacient.► Women should be advised to have a Women should be advised to have a
negative pregnancy test within 2 negative pregnancy test within 2 weeks of beginning therapy and should weeks of beginning therapy and should begin the drug on the second or third begin the drug on the second or third day of the next menstrual cycle.day of the next menstrual cycle.
► They should be instructed in the use of They should be instructed in the use of contraceptives during therapy. contraceptives during therapy.
Prostaglandin analogueProstaglandin analogue
Pharmacodynamic effects: drug Pharmacodynamic effects: drug reactionsreactions
►GIT= Nausea, diarrhea, abdominal GIT= Nausea, diarrhea, abdominal pain, flatulence, vomiting, dyspepsia pain, flatulence, vomiting, dyspepsia
►GU effects= miscarriages, GU effects= miscarriages, excessive excessive uterine CRAMPING and bleedinguterine CRAMPING and bleeding, , spotting, hypermenorrhea and spotting, hypermenorrhea and menstrual disorders.menstrual disorders.
Prostaglandin analogueProstaglandin analogue
Nursing ConsiderationsNursing Considerations► Administer to patients at risk for NSAIDs-Administer to patients at risk for NSAIDs-
induced ulcers during the full course of induced ulcers during the full course of NSAIDs therapyNSAIDs therapy
► Administer four times daily with meals and Administer four times daily with meals and at bedtimeat bedtime
► Obtain pregnancy test within 2 weeks of Obtain pregnancy test within 2 weeks of beginning therapy. Begin the therapy on beginning therapy. Begin the therapy on second or third day of menstrual period second or third day of menstrual period to to ensure that the woman is not pregnantensure that the woman is not pregnant
Prostaglandin analogueProstaglandin analogue
Nursing ConsiderationsNursing Considerations► Provide patient with both written and oral Provide patient with both written and oral
information regarding the associated risks information regarding the associated risks of pregnancyof pregnancy
► Provide health teaching as to drug name, Provide health teaching as to drug name, dosages and frequency, safety measures dosages and frequency, safety measures to handle common problems. to handle common problems.
► Monitor patient response to the drug, the Monitor patient response to the drug, the effectiveness of the teaching plan and the effectiveness of the teaching plan and the measures to employmeasures to employ
LaxativesLaxativesType Prototype Action
Chemical stimulants
Bisacodyl (Dulcolax) Direct stimulation of the GIT nerves Irritant laxatives
Mechanical (bulk) stimulants
Lactulose Increased fluid content of the fecal material causing stimulation of the local reflex
Lubricants Docusate Lubricating the intestinal material to promote passage through the GIT
LaxativesLaxatives
►Generally used to INCREASE the Generally used to INCREASE the passage of the colonic contentspassage of the colonic contents
►The general classifications is as The general classifications is as follows:follows:
1. Chemical stimulants1. Chemical stimulants
2. Mechanical stimulants2. Mechanical stimulants
3. Lubricants3. Lubricants
Therapeutic Indications of the Therapeutic Indications of the LaxativesLaxatives
►SHORT term relief of SHORT term relief of ConstipationConstipation►Prevention of strainingPrevention of straining in in
conditions like CHF, post-MI, post conditions like CHF, post-MI, post partum, post-oppartum, post-op
►Preparation for Preparation for diagnostic diagnostic examinationexamination
►Removal of poison or toxinsRemoval of poison or toxins►Adjunct in anti-helminthic therapyAdjunct in anti-helminthic therapy
Contraindications in Laxative Contraindications in Laxative useuse
►ACUTE abdominal disordersACUTE abdominal disorders AppendicitisAppendicitis DiverticulitisDiverticulitis Ulcerative colitisUlcerative colitis
Chemical Stimulant Chemical Stimulant CatharticsCathartics
Prototype: BisacodylPrototype: Bisacodyl
Irritant laxatives:Irritant laxatives:►1. Castor oil1. Castor oil►2. Senna2. Senna►3. Cascara3. Cascara►4. Phenolphthalein4. Phenolphthalein
Chemical Stimulant Chemical Stimulant CatharticsCathartics
PharmacodynamicsPharmacodynamics►These agents DIRECTLY stimulate the These agents DIRECTLY stimulate the
nerve plexus in the intestinal wallnerve plexus in the intestinal wall►The result is INCREASED movement or The result is INCREASED movement or
motility of the colonmotility of the colon
Mechanical Stimulant Mechanical Stimulant CatharticsCathartics
►Prototype: LACTULOSE (Cephulac)Prototype: LACTULOSE (Cephulac)
Bulk-forming laxativesBulk-forming laxatives►1. Magnesium (citrate, hydroxide, 1. Magnesium (citrate, hydroxide,
sulfate)sulfate)►2. Psyllium2. Psyllium►3. Polycarbophil3. Polycarbophil
Mechanical Stimulant Mechanical Stimulant CatharticsCathartics
PharmacodynamicsPharmacodynamics►These agents are rapid-acting These agents are rapid-acting
laxatives that INCREASE the GI motility laxatives that INCREASE the GI motility byby Increasing the fluids in the colonic Increasing the fluids in the colonic
materialmaterial Stimulating the local stretch receptorsStimulating the local stretch receptors Activating Activating local defection reflexlocal defection reflex
LubricantsLubricants
►Prototype: DocusatePrototype: Docusate
►1. Glycerin1. Glycerin►2. Mineral oil2. Mineral oil
LubricantsLubricants
PharmacodynamicsPharmacodynamics►Docusate increases the admixture of Docusate increases the admixture of
fat and water producing a softer stoolfat and water producing a softer stool►Glycerin Glycerin ►Mineral oil forms a slippery coat on the Mineral oil forms a slippery coat on the
colonic contents colonic contents
Pharmacokinetics: Pharmacokinetics: Common Side-effects of the Common Side-effects of the
LaxativesLaxatives►DiarrheaDiarrhea►Abdominal crampingAbdominal cramping►NauseaNausea►Fluid and electrolyte imbalanceFluid and electrolyte imbalance►Sympathetic reactions- sweating, Sympathetic reactions- sweating,
palpitations, flushing and faintingpalpitations, flushing and fainting►CATHARTIC dependenceCATHARTIC dependence
The Nursing Process and The Nursing Process and LaxativeLaxative
ASSESSMENTASSESSMENT►Nursing History- elicit allergy to any Nursing History- elicit allergy to any
laxatives, elicit history of conditions laxatives, elicit history of conditions like diverticulitis and ulcerative colitislike diverticulitis and ulcerative colitis
►Physical Examination- abdominal Physical Examination- abdominal assessmentassessment
►Laboratory Test: fecalysis, electrolyte Laboratory Test: fecalysis, electrolyte levelslevels
The Nursing Process and The Nursing Process and LaxativeLaxative
NURSING DIAGNOSISNURSING DIAGNOSIS►Alteration in bowel patternAlteration in bowel pattern►Alteration in comfort: painAlteration in comfort: pain►Knowledge deficitKnowledge deficit
The Nursing Process and The Nursing Process and LaxativeLaxative
IMPLEMENTATIONIMPLEMENTATION
1.1. Emphasize that it is use on a Emphasize that it is use on a SHORT SHORT term basisterm basis
2.2. Provide comfort and safety measures Provide comfort and safety measures like ready access to the bathroom, like ready access to the bathroom, side-rails side-rails
3.3. Administer with a Administer with a full glass of waterfull glass of water
The Nursing Process and The Nursing Process and LaxativeLaxative
IMPLEMENTATIONIMPLEMENTATION
4. 4. Encourage fluid intake, high fiber diet Encourage fluid intake, high fiber diet and daily exerciseand daily exercise
5. DO NOT administer if acute 5. DO NOT administer if acute abdominal condition like abdominal condition like appendicitis is presentappendicitis is present
6. Advise to change position slowly an 6. Advise to change position slowly an avoid hazardous activities because of avoid hazardous activities because of potential dizzinesspotential dizziness
The Nursing Process and The Nursing Process and LaxativeLaxative
EVALUATION of drug effectivenessEVALUATION of drug effectiveness
1.1. Evaluate relief of GI symptoms, Evaluate relief of GI symptoms, absence of staining and increased absence of staining and increased evacuation of GI tractevacuation of GI tract
2.2. For Lactulose: decreased ammoniaFor Lactulose: decreased ammonia
The Anti-diarrhealsThe Anti-diarrheals
►These are agents used to calm the These are agents used to calm the irritation of the GIT for the irritation of the GIT for the symptomatic relief of diarrheasymptomatic relief of diarrhea
►General ClassificationsGeneral Classifications
1. Local anti-motility1. Local anti-motility
2. Local reflex inhibition2. Local reflex inhibition
3. Central action on the CNS3. Central action on the CNS
The Anti-diarrhealsThe Anti-diarrhealsType Prototype Action
Local reflex inhibitor Bismuth subsalicylate Locally coats the lining of the GIT to soothe irritation that may stimulate the reflex
Local anti-motility Loperamide Directly inhibits the intestinal muscle activity to SLOW peristalsis
Central acting agent Opium derivatives (paregoric)
Stops GIT spasm by CNS action
Clinical Indications of drug Clinical Indications of drug useuse
►Relief of symptoms of acute and Relief of symptoms of acute and chronic diarrheachronic diarrhea
►Reduction of fecal volume discharges Reduction of fecal volume discharges from ileostomies from ileostomies
►Prevention and treatment of traveler's Prevention and treatment of traveler's diarrheadiarrhea
Contraindications of anti-Contraindications of anti-diarrheal Usediarrheal Use
►PoisoningPoisoning►Drug allergyDrug allergy►GI obstructionGI obstruction►Acute abdominal conditionsAcute abdominal conditions
Pharmacokinetics: Side Pharmacokinetics: Side effectseffects
►ConstipationConstipation►Nausea, vomitingNausea, vomiting►Abdominal distention and Abdominal distention and
discomfort discomfort ►TOXIC MEGACOLONTOXIC MEGACOLON
Nursing process and anti-Nursing process and anti-diarrhealsdiarrheals
ASSESSMENTASSESSMENT►Nursing History – Elicit history of drug Nursing History – Elicit history of drug
allergy, conditions like poisoning, GI allergy, conditions like poisoning, GI obstruction and acute abdominal obstruction and acute abdominal conditionsconditions
►Physical Examination- Abdominal Physical Examination- Abdominal examinationexamination
►Laboratory test- electrolyte levelsLaboratory test- electrolyte levels
Nursing process and anti-Nursing process and anti-diarrhealsdiarrheals
NURSING DIAGNOSISNURSING DIAGNOSIS►Alteration in bowel patternAlteration in bowel pattern►Alteration in comfort: painAlteration in comfort: pain
Nursing process and anti-Nursing process and anti-diarrhealsdiarrheals
IMPLEMENTATIONIMPLEMENTATION
1.1. Monitor patient response within 48 Monitor patient response within 48 hours. Discontinue drug use if no hours. Discontinue drug use if no effecteffect
2.2. Provide comfort measures for painProvide comfort measures for pain
3.3. Provide teaching Provide teaching
Nursing process and anti-Nursing process and anti-diarrhealsdiarrheals
EVALUATIONEVALUATION
1.1. Monitor effectiveness of drug- Monitor effectiveness of drug- RELIEF of diarrheaRELIEF of diarrhea
2.2. Monitor adverse effects, Monitor adverse effects, effectiveness of pain measures and effectiveness of pain measures and effectiveness of teaching planeffectiveness of teaching plan
Emetics and Anti-emeticsEmetics and Anti-emetics
Emetic AgentEmetic Agent► Syrup of IpecacSyrup of Ipecac
Anti-emeticsAnti-emetics► 1. Phenothiazines1. Phenothiazines► 2. Non-phenothiazines2. Non-phenothiazines► 3. Anticholinergics/Antihistamines3. Anticholinergics/Antihistamines► 4. Serotonin receptor Blockers4. Serotonin receptor Blockers► 5. Miscellaneous5. Miscellaneous
EMETICEMETIC
►Prototype: Ipecac SyrupPrototype: Ipecac Syrup
EMETICEMETIC
PharmacodynamicsPharmacodynamics► Ipecac syrup irritates the GI mucosa Ipecac syrup irritates the GI mucosa
locally, resulting to stimulation of the locally, resulting to stimulation of the vomiting centervomiting center
► It acts within 20 minutes It acts within 20 minutes
EMETICEMETIC
Clinical Use of ipecacClinical Use of ipecac►To induce vomiting as a treatment for To induce vomiting as a treatment for
drug overdose and certain poisoningsdrug overdose and certain poisonings
EMETICEMETIC
Contraindications of Ipecac useContraindications of Ipecac use► Ingestion of CORROSIVE chemicalsIngestion of CORROSIVE chemicals► Ingestion of petroleum productsIngestion of petroleum products►Unconscious and convulsing patientUnconscious and convulsing patient
EMETICEMETIC
Pharmacokinetics: side effects of IpecacPharmacokinetics: side effects of Ipecac►NauseaNausea►DiarrheaDiarrhea►GI upsetGI upset►Mild CNS depressionMild CNS depression►CARDIOTOXICITY if large amounts CARDIOTOXICITY if large amounts
are absorbed in the bodyare absorbed in the body
Nursing process and the Nursing process and the EMETICEMETIC
ASSESSMENTASSESSMENT►Nursing History- elicit the exact nature Nursing History- elicit the exact nature
of poisoning of poisoning ►Physical Examination- CNS status and Physical Examination- CNS status and
abdominal examabdominal exam
Nursing process and the Nursing process and the EMETICEMETIC
IMPLEMENTATIONIMPLEMENTATION
1.1. Administer to Administer to conscious patient onlyconscious patient only
2.2. Administer ipecac Administer ipecac as soon as possibleas soon as possible
3.3. Administer with a large amount of Administer with a large amount of waterwater
4.4. Vomiting should occur within 20 Vomiting should occur within 20 minutes of the first dose. minutes of the first dose. Repeat the Repeat the dose and expect vomiting to occur with dose and expect vomiting to occur with 20 minutes20 minutes
Nursing process and the Nursing process and the EMETICEMETIC
IMPLEMENTATIONIMPLEMENTATION
5. Provide comfort measures like ready 5. Provide comfort measures like ready access to bathroom, assistance with access to bathroom, assistance with ambulationambulation
6. Offer support6. Offer support
Nursing process and the Nursing process and the EMETICEMETIC
EVALUATIONEVALUATION
1.1. Evaluate patient response within 20 Evaluate patient response within 20 minutes of drug ingestionminutes of drug ingestion
2.2. Monitor for adverse effectsMonitor for adverse effects
3.3. Evaluate effectiveness of comfort Evaluate effectiveness of comfort measures and teaching planmeasures and teaching plan
ANTI-EMETICSANTI-EMETICS
►These are agents used to manage These are agents used to manage nausea and vomitingnausea and vomiting
►They act either locally or centrallyThey act either locally or centrally
ANTIEMETICSANTIEMETICS
Anti-emetic types Common examples
Phenothiazines Prochlorperazine, promethazine
Non-phenothiazines Metoclopramide
Anticholinergics and Antihistaminics Meclizine, buclizine
Serotonin Receptor blockers “setron”- dolasetron
Miscellaneous Dronabinol, hydroxyzine
ANTIEMETICSANTIEMETICSTypes Pharmacodynamics
Phenothiazines Centrally block the vomiting center in the medulla
Non-phenothiazine Reduces the responsiveness of the nerve cell in the medulla
Anticholinergics Block the transmission of the impulses to the medulla
Serotonin receptor blockers Centrally and locally inhibits the serotonin receptors
Miscellaneous Act in the CNS , either in the medulla or in the cortex
ANTIEMETICSANTIEMETICSTypes Clinical Use
Phenothiazines N/V associated with anesthesia, intractable hiccups
Non-phenothiazine N/V associated with chemical stimulation
Anticholinergics N/V associated with motion sickness
Serotonin-receptor Blockers N/V associated with chemotherapy
Miscellaneous N/V associated with chemotherapy
ANTIEMETICSANTIEMETICS
ContraindicationsContraindications►1. Severe CNS depression1. Severe CNS depression►2. Severe liver dysfunction2. Severe liver dysfunction
ANTIEMETICSANTIEMETICS
Pharmacokinetics: Side-effectsPharmacokinetics: Side-effects
1. 1. PHOTHOSENSITIVITYPHOTHOSENSITIVITY
2. 2. Drowsiness, dizziness, Drowsiness, dizziness, weakness and tremors and weakness and tremors and DEHYDRATONDEHYDRATON
3. Phenothiazines= autonomic 3. Phenothiazines= autonomic anti-anti-cholinergic effectscholinergic effects like dry mouth, like dry mouth, nasal congestion and urinary nasal congestion and urinary retentionretention
Nursing Process and the Nursing Process and the ANTIEMETICSANTIEMETICS
ASSESSMENTASSESSMENT► Nursing History- elicit allergy, Nursing History- elicit allergy,
impaired hepatic function and CNS impaired hepatic function and CNS depressiondepression
► Physical Examination- CNS status and Physical Examination- CNS status and abdominal examinationabdominal examination
► Laboratory test- Liver function Laboratory test- Liver function studiesstudies
Nursing Process and the Nursing Process and the ANTIEMETICSANTIEMETICS
NURSING DIAGNOSISNURSING DIAGNOSIS
1.1. Alteration in comfort: painAlteration in comfort: pain
2.2. High risk for injuryHigh risk for injury
3.3. Knowledge deficitKnowledge deficit
Nursing Process and the Nursing Process and the ANTIEMETICSANTIEMETICS
IMPLEMENTATIONIMPLEMENTATION
1.1. Assess patient’s intake of other drugs Assess patient’s intake of other drugs that may cause dangerous drug that may cause dangerous drug interactioninteraction
2.2. Emphasize that this is given on a Emphasize that this is given on a short term basisshort term basis
Nursing Process and the Nursing Process and the ANTIEMETICSANTIEMETICS
IMPLEMENTATIONIMPLEMENTATION
3. 3. Provide comfort and safety Provide comfort and safety measuresmeasures
Advise to change position slowlyAdvise to change position slowly Avoid hazardous activitiesAvoid hazardous activities Provide mouth care and ice chipsProvide mouth care and ice chips Monitor for dehydration and offer Monitor for dehydration and offer
fluids if it occursfluids if it occurs
Nursing Process and the Nursing Process and the ANTIEMETICSANTIEMETICS
IMPLEMENTATIONIMPLEMENTATION
4. Protect from sun exposure4. Protect from sun exposure Sunscreens Sunscreens Protective coveringProtective covering
5. Provide health teaching5. Provide health teaching
Nursing Process and the Nursing Process and the ANTIEMETICSANTIEMETICS
EVALUATIONEVALUATION
1. 1. Monitor for the drug Monitor for the drug effectivenesseffectiveness
• Relief of nausea and vomitingRelief of nausea and vomiting
2. Monitor for adverse effects2. Monitor for adverse effects
3. Evaluate effectiveness of comfort 3. Evaluate effectiveness of comfort measures and teaching planmeasures and teaching plan
Pharmacology of the Pharmacology of the Selected Endocrine Selected Endocrine
DrugsDrugs
Nursing ReviewNursing Review
Endocrine MedicationsEndocrine Medications
Anti-diuretic hormonesAnti-diuretic hormones
Enhance re-absorption of water in the Enhance re-absorption of water in the kidneyskidneys
Used in DIUsed in DI
1. Desmopressin and Lypressin 1. Desmopressin and Lypressin intranasallyintranasally
2. Pitressin IM2. Pitressin IM
Endocrine MedicationsEndocrine Medications
Anti-diuretic hormonesAnti-diuretic hormones
SIDE-effectsSIDE-effects
Flushing and headacheFlushing and headache
Water intoxicationWater intoxication
Thyroid MedicationsThyroid Medications
Thyroid hormonesThyroid hormones
These products are used to treat These products are used to treat the manifestations of the manifestations of hypothyroidismhypothyroidism
Replace hormonal deficit in the Replace hormonal deficit in the treatment of HYPOTHYROIDSMtreatment of HYPOTHYROIDSM
Thyroid MedicationsThyroid Medications
Thyroid hormonesThyroid hormones
Levothyroxine (Synthroid)Levothyroxine (Synthroid)
Liothyroxine (Cytomel)Liothyroxine (Cytomel)
Thyroid dessicatedThyroid dessicated
Liotrix (Thyrolar)Liotrix (Thyrolar)
Thyroid MedicationsThyroid Medications
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 MedicationsThyroid Medications
Thyroid hormonesThyroid hormones
Side-effectsSide-effects
1.1. Nausea and VomitingNausea and Vomiting
2.2. Signs of increased metabolism= Signs of increased metabolism= tachycardia, hypertension, tachycardia, hypertension, cardiac arrhythmias, anxiety, cardiac arrhythmias, anxiety, headacheheadache
Thyroid MedicationsThyroid Medications
Thyroid hormones : Nursing responsibilityThyroid hormones : Nursing responsibility
1. Monitor weight, VS1. Monitor weight, VS
2. Instruct client to take daily 2. Instruct client to take daily medication the same time medication the same time each each morning WITHOUT FOODmorning WITHOUT FOOD
Monitor blood tests to check the Monitor blood tests to check the activity of thyroidactivity of thyroid
Thyroid MedicationsThyroid Medications
Thyroid hormones: Nursing responsibilityThyroid hormones: Nursing responsibility
3. Advise to report palpitation, 3. Advise to report palpitation, tachycardia, and chest paintachycardia, and chest pain
4. Instruct to avoid foods that 4. Instruct to avoid foods that inhibit thyroid secretions like inhibit thyroid secretions like cabbage, spinach and radishescabbage, spinach and radishes
ANTI-Thyroid MedicationsANTI-Thyroid Medications
ANTI-THYROID medicationsANTI-THYROID medications
The thyroid becomes The thyroid becomes oversaturated with iodine and oversaturated with iodine and stop producing thyroid stop producing thyroid hormonehormone
ANTI-Thyroid MedicationsANTI-Thyroid Medications
ANTI-THYROID medicationsANTI-THYROID medications
Drugs used to BLOCK the Drugs used to BLOCK the thyroid hormones and treat thyroid hormones and treat hyperthyroidismhyperthyroidism
Inhibit the synthesis of thyroid Inhibit the synthesis of thyroid hormoneshormones
ANTI-Thyroid MedicationsANTI-Thyroid Medications
ANTI-THYROID medicationsANTI-THYROID medications
1. Methimazole (Tapazole)1. Methimazole (Tapazole)
2. PTU (prophylthiouracil)2. PTU (prophylthiouracil)
3. Iodine solution- SSKI and 3. Iodine solution- SSKI and Lugol’s solutionLugol’s solution
ANTI-Thyroid MedicationsANTI-Thyroid MedicationsANTI-THYROID medicationsANTI-THYROID medicationsSide-effects of thionamidesSide-effects of thionamides
N/V, drowsiness, lethargy, N/V, drowsiness, lethargy, bradycardia, skin rashbradycardia, skin rash
GI complaintsGI complaints AGRANULOCYTOSISAGRANULOCYTOSIS
Most important to monitorMost important to monitor
ANTI-Thyroid MedicationsANTI-Thyroid MedicationsANTI-THYROID medicationsANTI-THYROID medicationsSide-effects of Iodine solutionsSide-effects of Iodine solutions
Most common adverse effects is Most common adverse effects is HYPOTHYROIDISMHYPOTHYROIDISM
Iodism= metallic taste, burning in Iodism= metallic taste, burning in the mouth, sore teeth and gums, the mouth, sore teeth and gums, diarrhea, stomach upsetdiarrhea, stomach upset
ANTI-Thyroid MedicationsANTI-Thyroid Medications
ANTI-THYROID medicationsANTI-THYROID medicationsNursing responsibilitiesNursing responsibilities
1. Monitor VS, T3 and T4, 1. Monitor VS, T3 and T4, weightweight2. The medications 2. The medications WITH WITH MEALSMEALS to avoid gastric upset to avoid gastric upset
ANTI-Thyroid MedicationsANTI-Thyroid Medications
ANTI-THYROID medications Nursing ANTI-THYROID medications Nursing responsibilitiesresponsibilities
3. Instruct to report SORE 3. Instruct to report SORE THROAT or unexplained FEVERTHROAT or unexplained FEVER4. Monitor for signs of 4. Monitor for signs of hypothyroidism. hypothyroidism. Instruct not to stop abrupt Instruct not to stop abrupt
medicationmedication
ANTI-Thyroid MedicationsANTI-Thyroid MedicationsANTI-THYROID medicationsANTI-THYROID medicationsLugol’s SolutionLugol’s Solution
Used to decrease the vascularity of the Used to decrease the vascularity of the thyroid (in preparation for thyroid surgery)thyroid (in preparation for thyroid surgery)T3 and T4 production diminishesT3 and T4 production diminishesGiven per orem, can be diluted with juiceGiven per orem, can be diluted with juiceUse straw to decrease stainingUse straw to decrease stainingMonitor iodism (metallic taste, burning in Monitor iodism (metallic taste, burning in mouth)mouth)
STEROIDSSTEROIDS
Replaces the steroids in Replaces the steroids in the bodythe body
Interfere with the release Interfere with the release of inflammatory factors of inflammatory factors and immune responses and immune responses
STEROIDSSTEROIDS
Cortisol, cortisone, Cortisol, cortisone, betamethasone, and betamethasone, and hydrocortisonehydrocortisone
Dexamethasone= long Dexamethasone= long actingacting
STEROIDSSTEROIDS
These drugs enter the These drugs enter the cells and bind to cells and bind to receptorsreceptors
They inhibit the enzyme They inhibit the enzyme phospholipasephospholipase
STEROIDSSTEROIDSCorticosteroids are used topically Corticosteroids are used topically and locally to achieve the desired and locally to achieve the desired anti-inflammatory effects at a anti-inflammatory effects at a particular siteparticular site
STEROIDSSTEROIDS
SteroidSteroid Clinical useClinical use
DexamethasoneDexamethasone Use to induce the Use to induce the formation of lung formation of lung surfactantsurfactant
Other steroidsOther steroids Use for the treatment of Use for the treatment of immune-related immune-related diseases, control of diseases, control of asthma and allergic asthma and allergic symptoms symptoms
STEROIDSSTEROIDS
Side-effectsSide-effects HYPERglycemiaHYPERglycemia Increased susceptibility to Increased susceptibility to
infection infection (immunosuppression)(immunosuppression)
HypokalemiaHypokalemia Edema and HypertensionEdema and Hypertension Peptic ulcerationPeptic ulceration
STEROIDSSTEROIDS
Side-effectsSide-effects If high doses- osteoporosis, If high doses- osteoporosis,
growth retardation, peptic growth retardation, peptic ulcer, hypertension, ulcer, hypertension, cataractcataract, mood changes, , mood changes, hirsutism, and fragile skinhirsutism, and fragile skin
STEROIDSSTEROIDS
Nursing responsibilitiesNursing responsibilities
1. Monitor VS, electrolytes, 1. Monitor VS, electrolytes, glucoseglucose
2. Monitor weight edema 2. Monitor weight edema and I/O. Encourage and I/O. Encourage Potassium supplementsPotassium supplements
STEROIDSSTEROIDS
Nursing responsibilitiesNursing responsibilities
3. Protect patient from infection3. Protect patient from infection
4. Handle patient gently4. Handle patient gently
5. Instruct to take meds 5. Instruct to take meds WITH WITH MEALSMEALS to prevent gastric ulcer to prevent gastric ulcer formationformation
STEROIDSSTEROIDS
Nursing responsibilitiesNursing responsibilities
6. Caution the patient NOT to 6. Caution the patient NOT to abruptly stop the drugabruptly stop the drug
7. 7. Drug is tapered to allow the Drug is tapered to allow the adrenal gland to secrete adrenal gland to secrete endogenous hormonesendogenous hormones
STEROIDSSTEROIDS
Evaluation:Evaluation:
The drugs are effective if there The drugs are effective if there is: is:
1.1. Relief of signs and symptoms Relief of signs and symptoms of inflammationof inflammation
2.2. Return of adrenal function to Return of adrenal function to normalnormal
The cardiac glycosidesThe cardiac glycosides These are agents extracted from These are agents extracted from
the foxglove plant. They are the foxglove plant. They are available in oral and parenteral available in oral and parenteral preparations. The following are preparations. The following are the cardiac glycosides:the cardiac glycosides:
Digoxin (Lanoxin)Digoxin (Lanoxin) Digitoxin (Crystodigin)Digitoxin (Crystodigin) OuabainOuabain
The cardiac glycosidesThe cardiac glycosides
Pharmacodynamics: the Pharmacodynamics: the Mechanism of action Mechanism of action
They They increase the level of increase the level of CALCIUMCALCIUM inside the cell by inside the cell by inhibiting the Sodium-Potassium inhibiting the Sodium-Potassium pump. pump.
More calcium will accumulate More calcium will accumulate inside the cell during cellular inside the cell during cellular depolarization. depolarization.
The cardiac glycosidesThe cardiac glycosides Positive inotropicPositive inotropic Effect- Effect- the the
myocardium will contract forcefullymyocardium will contract forcefully– Increased cardiac outputIncreased cardiac output– Increased blood flow to the body organs Increased blood flow to the body organs
like the kidney and liverlike the kidney and liver Negative chronotropicNegative chronotropic effect- the effect- the
heart rate is slowed due to decreased heart rate is slowed due to decreased rate of cellular repolarizationrate of cellular repolarization– BradycardiaBradycardia
Decreased conduction velocityDecreased conduction velocity through the AV nodethrough the AV node
The cardiac glycosidesThe cardiac glycosides
Clinical Use of the cardiac Clinical Use of the cardiac glycosidesglycosides
Treatment of Treatment of congestive heart congestive heart failurefailure
Treatment of Treatment of dysrhythmiasdysrhythmias like like atrial flutter, atrial fibrillation and atrial flutter, atrial fibrillation and paroxysmal atrial tachycardiaparoxysmal atrial tachycardia
The cardiac glycosidesThe cardiac glycosidesContraindications and PrecautionsContraindications and Precautions Contraindicated in the presence of Contraindicated in the presence of
allergy to any cardiac glycoside. allergy to any cardiac glycoside. They are They are NOTNOT given to patients with given to patients with
ventricular dysrhythmias, heart block ventricular dysrhythmias, heart block or sick sinus syndrome, aortic or sick sinus syndrome, aortic stenosis, acute MI, electrolyte stenosis, acute MI, electrolyte imbalances (imbalances (HYPOKALEMIA, HYPOKALEMIA, HYPOMAGNESEMIA and HYPOMAGNESEMIA and HYPERCALCEMIAHYPERCALCEMIA) and ) and renal failurerenal failure (may cause accumulation of drug)(may cause accumulation of drug)
The cardiac glycosidesThe cardiac glycosidesPharmacodynamics: the Adverse Effects of Pharmacodynamics: the Adverse Effects of
the Cardiac glycosidesthe Cardiac glycosides CNS- Headache, weakness , seizures and CNS- Headache, weakness , seizures and
drowsinessdrowsiness CVS- arrhythmiasCVS- arrhythmias If digitalis toxicity is developing- the nurse If digitalis toxicity is developing- the nurse
must assess the following adverse effects: must assess the following adverse effects: Anorexia, nausea and vomiting, visual Anorexia, nausea and vomiting, visual changes- YELLOW halo around an changes- YELLOW halo around an object, and palpitations or very slow object, and palpitations or very slow heart rateheart rate
The cardiac glycosidesThe cardiac glycosidesRemember= NAVDA and hypokalemiaRemember= NAVDA and hypokalemia
The cardiac glycosidesThe cardiac glycosidesDrug-Drug InteractionsDrug-Drug Interactions If taken with potassium-losing If taken with potassium-losing
diuretics like furosemide- can diuretics like furosemide- can INCREASE the risk of toxicity and INCREASE the risk of toxicity and arrhythmias. Potassium arrhythmias. Potassium replacement must be given.replacement must be given.
The cardiac glycosidesThe cardiac glycosidesImplementationImplementation Administer the initial rapid Administer the initial rapid
digitalization and loading dose as digitalization and loading dose as ordered intravenouslyordered intravenously
Monitor the Monitor the APICALAPICAL pulse rate for ONE pulse rate for ONE full minute before administering the full minute before administering the drug. Withhold the drug ifdrug. Withhold the drug if– Less than 60 in adults Less than 60 in adults – Less than 90 in infantsLess than 90 in infants– More than 110 in adultsMore than 110 in adults
Retake pulse in one hour, if pulses Retake pulse in one hour, if pulses remain abnormal, refer!remain abnormal, refer!
The cardiac glycosidesThe cardiac glycosidesImplementationImplementation Check the spelling of the drug- DIGOXIN Check the spelling of the drug- DIGOXIN
is different from DIGITOXIN!is different from DIGITOXIN! Check the dosage preparation and the Check the dosage preparation and the
level of digitalis in the blood. level of digitalis in the blood. ((Therapeutic level is 0.5 to 2.0 Therapeutic level is 0.5 to 2.0 nanograms/mLnanograms/mL))
Administer intravenous drug VERY slow Administer intravenous drug VERY slow IV over 5 minutes to avoid arrhythmias. IV over 5 minutes to avoid arrhythmias. Do NOT administer intramuscularly Do NOT administer intramuscularly because it can cause severe painbecause it can cause severe pain
The cardiac glycosidesThe cardiac glycosidesImplementationImplementation Administer the drug Administer the drug without food if without food if
possible to avoid delayed absorptionpossible to avoid delayed absorption. . Weight patient daily to determine fluid Weight patient daily to determine fluid retentionretention
Maintain emergency equipment and drugs= Maintain emergency equipment and drugs= Potassium salts, Lidocaine for arrhythmias, Potassium salts, Lidocaine for arrhythmias, phenytoin for seizures, atropine for phenytoin for seizures, atropine for bradycardia.bradycardia.
Provide comfort measures- small, frequent Provide comfort measures- small, frequent meals, adequate lighting, comfortable meals, adequate lighting, comfortable position, rest periods and safety position, rest periods and safety precautionsprecautions
The cardiac glycosidesThe cardiac glycosides
ImplementationImplementation Provide health teaching- drug name, Provide health teaching- drug name,
action, dosage and side effects. Advise action, dosage and side effects. Advise the patient to report any of the the patient to report any of the following: following: Visual changes, rapid Visual changes, rapid weight gain, unusually low heart weight gain, unusually low heart rate, persistent nausea, vomiting rate, persistent nausea, vomiting and anorexiaand anorexia
Monitor serum potassium level Monitor serum potassium level
The cardiac glycosidesThe cardiac glycosides
EvaluationEvaluation
Evaluate effectiveness of the Evaluate effectiveness of the drug:drug:
Increased urine outputIncreased urine output
Normal heart rate in Normal heart rate in arrhythmiaarrhythmia
The Antianginal drugsThe Antianginal drugs
In the treatment of angina, three In the treatment of angina, three agents are commonly employed-agents are commonly employed-– Organic nitratesOrganic nitrates– Beta-blockers and Beta-blockers and – Calcium-channel blockers.Calcium-channel blockers.
The benefits of the drugs lie in their The benefits of the drugs lie in their different mode of action. different mode of action.
The Antianginal drugsThe Antianginal drugs
The nitrates can cause The nitrates can cause vasodilatation of the veins and to vasodilatation of the veins and to some extent, coronary artery some extent, coronary artery
The Antianginal drugsThe Antianginal drugs
Beta-blockers will decrease the Beta-blockers will decrease the heart rateheart rate
The Antianginal drugsThe Antianginal drugs
Calcium-channel blockers will Calcium-channel blockers will decrease force of contraction decrease force of contraction leading to a decreased leading to a decreased myocardial workload and myocardial workload and demand. demand.
They can also produce They can also produce vasodilationvasodilation
The Organic nitratesThe Organic nitrates
These agents are simple nitric and These agents are simple nitric and nitrous acid esters of alcohols. Being nitrous acid esters of alcohols. Being alcohol, they differ in their volatility. The alcohol, they differ in their volatility. The following are the nitrates commonly following are the nitrates commonly used:used:
Nitroglycerin-Nitroglycerin- A moderately volatile A moderately volatile nitratenitrate
Isosorbide Dinitrate (Isordil) or Isosorbide Dinitrate (Isordil) or mononitratemononitrate
Amyl nitrate- an extremely volatile Amyl nitrate- an extremely volatile nitratenitrate
The Organic nitratesThe Organic nitrates
NitroglycerinNitroglycerin This agent is supplied in oral, spray, This agent is supplied in oral, spray,
transdermal and ointment transdermal and ointment preparations.preparations.
The Organic nitratesThe Organic nitrates
Pharmacodynamics: the Pharmacodynamics: the mechanism of actionmechanism of action
Nitroglycerin relaxes the Nitroglycerin relaxes the smooth muscles in the smooth muscles in the vascular system by its vascular system by its conversion to nitric oxide, a conversion to nitric oxide, a chemical mediator in the body chemical mediator in the body that relaxes smooth muscles. that relaxes smooth muscles.
The Organic nitratesThe Organic nitratesAdministered nitratesAdministered nitrates
Increased nitrates in the bloodIncreased nitrates in the blood
increased formation of nitric oxideincreased formation of nitric oxide
increased cGMP formationincreased cGMP formation
increased dephosphorylation of myosin increased dephosphorylation of myosin
Vascular smooth muscle relaxationVascular smooth muscle relaxation
vasodilatation vasodilatation
The Organic nitratesThe Organic nitrates
Pharmacokinetics- absorption to Pharmacokinetics- absorption to excretionexcretion
It can be given orally, parenterally It can be given orally, parenterally and topically. and topically.
The onset of action of nitroglycerin The onset of action of nitroglycerin is more than 1 hour.is more than 1 hour.
Because significant first-pass Because significant first-pass hepatic effect, hepatic effect, Nitroglycerin is Nitroglycerin is given SUBLINGUALY. given SUBLINGUALY.
The Organic nitratesThe Organic nitratesPharmacodynamics: Side effects and Pharmacodynamics: Side effects and
adverse effectsadverse effects HEADACHE is the most common HEADACHE is the most common
effect of nitroglycerineffect of nitroglycerin.. CVS- postural Hypotension, facial CVS- postural Hypotension, facial
flushing, tachycardiaflushing, tachycardia TOLERANCETOLERANCE- the tolerance to the - the tolerance to the
actions of nitrates develop rapidly. actions of nitrates develop rapidly. This can be managed by providing a This can be managed by providing a day of abstinence. day of abstinence.
The NitratesThe NitratesImplementationImplementation Monitor vital signs, especially watchful Monitor vital signs, especially watchful
for hypotensive episodesfor hypotensive episodes Advise patient to remain supine or sit on Advise patient to remain supine or sit on
a chair when taking the nitroglycerin for a chair when taking the nitroglycerin for the first time. Emphasize that he should the first time. Emphasize that he should change his position slowly or rise from change his position slowly or rise from bed slowly to avoid orthostatic bed slowly to avoid orthostatic HypotensionHypotension
Offer sips of water before giving Offer sips of water before giving sublingual nitroglycerin because dryness sublingual nitroglycerin because dryness may inhibit drug absorptionmay inhibit drug absorption
The NitratesThe NitratesImplementationImplementation Apply nitroglycerin ointment to the Apply nitroglycerin ointment to the
designated mark on paper. designated mark on paper. The nurse should remove any excess The nurse should remove any excess
ointment on the skin from the ointment on the skin from the previous dose. previous dose.
She should She should NEVER USENEVER USE her bare her bare fingers because the drug can be fingers because the drug can be absorbed, utilize gloves or tongue absorbed, utilize gloves or tongue blades instead.blades instead.
The NitratesThe Nitrates
ImplementationImplementation Apply nitroglycerin patch to an area Apply nitroglycerin patch to an area
with few hairs. Never touch the with few hairs. Never touch the medication portion. medication portion.
The patch and the ointment should The patch and the ointment should NOT be applied near the area for NOT be applied near the area for defibrillation because explosion and defibrillation because explosion and skin burns may resultskin burns may result
The NitratesThe Nitrates
IMPLEMENTATIONIMPLEMENTATION Emphasize that tolerance to the Emphasize that tolerance to the
nitroglycerin can occur. nitroglycerin can occur. If the medication cannot relieve the If the medication cannot relieve the
pain, report to the hospital pain, report to the hospital immediately.immediately.
The NitratesThe Nitrates
IMPLEMENTATIONIMPLEMENTATION Provide client health teaching- the Provide client health teaching- the
sublingual nitroglycerin tablet is USED if sublingual nitroglycerin tablet is USED if chest pain occurschest pain occurs
The dose may be repeated if pain is The dose may be repeated if pain is unrelieved within 5 minutes. unrelieved within 5 minutes.
Repeat the medication administration Repeat the medication administration if the pain has not yet subsidedif the pain has not yet subsided. .
DO NOT give more than 3 tablets!DO NOT give more than 3 tablets!!! If !! If chest pain persists for more than 15 chest pain persists for more than 15 minutes, hospital consult should be minutes, hospital consult should be done immediately.done immediately.
The NitratesThe Nitrates
IMPLEMENTATIONIMPLEMENTATION Instruct the client to avoid alcohol Instruct the client to avoid alcohol
while taking nitroglycerin to avoid while taking nitroglycerin to avoid potentiating the hypotensive effect of potentiating the hypotensive effect of the medicationthe medication
If beta blockers and calcium-channel If beta blockers and calcium-channel blockers are given, instruct the blockers are given, instruct the patients to consult the physician patients to consult the physician before discontinuing the medicationbefore discontinuing the medication
The NitratesThe Nitrates
IMPLEMENTATIONIMPLEMENTATION Other components of health teaching Other components of health teaching
for home self-administration:for home self-administration:– If taking Sublingual Nitroglycerin, the patient If taking Sublingual Nitroglycerin, the patient
should be instructed to should be instructed to place the tablet place the tablet under the tongueunder the tongue for quick absorption. for quick absorption.
– A burning sensation/biting/stinging sensation A burning sensation/biting/stinging sensation may indicate that the tablet is may indicate that the tablet is FRESH!FRESH!
– Store the tablet in a Store the tablet in a dark containerdark container, keep it , keep it away from heat and direct sunlight to avoid away from heat and direct sunlight to avoid lessening the potencylessening the potency
The NitratesThe NitratesIMPLEMENTATIONIMPLEMENTATION Other components of health teaching for Other components of health teaching for
home self-administration:home self-administration:– HEADACHESHEADACHES are common in the initial are common in the initial
period of nitroglycerin therapy. Advise period of nitroglycerin therapy. Advise patient to take PARACETAMOL for reliefpatient to take PARACETAMOL for relief
– The nitroglycerin patch is applied once a The nitroglycerin patch is applied once a day, usually in the morning. The sites day, usually in the morning. The sites should be rotated, in the chest, arms and should be rotated, in the chest, arms and thighs avoiding hairy areas. thighs avoiding hairy areas.
The NitratesThe Nitrates
IMPLEMENTATIONIMPLEMENTATION Other components of health teaching Other components of health teaching
for home self-administration:for home self-administration:– Position supine with elevated legs to Position supine with elevated legs to
manage Hypotension. manage Hypotension. – Nitroglycerin tablet can be taken Nitroglycerin tablet can be taken
prophylactically in situations where prophylactically in situations where chest pain is anticipated- Sex, chest pain is anticipated- Sex, exercise, etc..exercise, etc..
– If patient is taking beta blockers, instruct If patient is taking beta blockers, instruct how to obtain heart rate in a minutehow to obtain heart rate in a minute
Drugs for ShockDrugs for Shock
DopamineDopamine This is a sympathomimetic drug often This is a sympathomimetic drug often
used to treat Hypotension in shock used to treat Hypotension in shock states that are not caused by states that are not caused by Hypovolemia. Hypovolemia.
This drug is an immediate precursor This drug is an immediate precursor of nor-epinephrine, occurs naturally in of nor-epinephrine, occurs naturally in the CNS basal ganglia where it the CNS basal ganglia where it functions as a neurotransmitter.functions as a neurotransmitter.
Drugs for ShockDrugs for Shock
DopamineDopamine Pharmacodynamics: It can activate the Pharmacodynamics: It can activate the
alpha and beta adrenergic receptor alpha and beta adrenergic receptor depending upon the concentration. It depending upon the concentration. It stimulates receptors to cause stimulates receptors to cause cardiac cardiac stimulation and renal vasodilationstimulation and renal vasodilation. .
The dose range is 1-20 The dose range is 1-20 micrograms/kg/minmicrograms/kg/min
Drugs for ShockDrugs for Shock
DopamineDopamine Pharmacokinetics: Dopamine is Pharmacokinetics: Dopamine is
administered IV, excreted in the urine. administered IV, excreted in the urine. At At low doselow dose ( (1-2 micrograms1-2 micrograms), ),
dopamine DILATES the renal and dopamine DILATES the renal and mesenteric blood vessels producing mesenteric blood vessels producing an increase output (dopaminergic an increase output (dopaminergic effect)effect)
Drugs for ShockDrugs for Shock
DopamineDopamine At At moderate dosemoderate dose of of 2-10 2-10
micrograms,micrograms, dopamine enhance dopamine enhance cardiac output by increasing heart cardiac output by increasing heart rate (rate (beta 1-adrenergic effect)beta 1-adrenergic effect) and and elevates blood pressure through elevates blood pressure through peripheral vasoconstriction peripheral vasoconstriction (alpha (alpha adrenergic effect)adrenergic effect)
Drugs for ShockDrugs for Shock
DopamineDopamine At higher doses of At higher doses of more than 10 more than 10
micrograms-micrograms- vasoconstriction of vasoconstriction of all vesselsall vessels will predominate that will predominate that can lead to diminished tissue can lead to diminished tissue perfusionperfusion
Drugs for ShockDrugs for Shock
DopamineDopamine Dopamine is indicated to treat Hypotension, Dopamine is indicated to treat Hypotension,
to increase heart rate and to increase urine to increase heart rate and to increase urine output (given less than 5 mg/kg/min)output (given less than 5 mg/kg/min)
The nurse typically prepares the dopamine The nurse typically prepares the dopamine drip- dopamine (at a concentration of 400-drip- dopamine (at a concentration of 400-800 mg) is mixed in 250 mL D5W and 800 mg) is mixed in 250 mL D5W and administered as drip via an infusion pump administered as drip via an infusion pump for precise dosage administration. for precise dosage administration.
Sodium bicarbonate will inactivate the Sodium bicarbonate will inactivate the dopaminedopamine
Drugs for ShockDrugs for Shock
DopamineDopamine Pharmacodynamics: side effects- Pharmacodynamics: side effects-
TachycardiaTachycardia
hypertensionhypertension
ectopic beats, angina, dysrhythmias, ectopic beats, angina, dysrhythmias, myocardial ischemia, nausea and myocardial ischemia, nausea and vomiting.vomiting.
Drugs for ShockDrugs for Shock
Dopamine: Nursing considerationDopamine: Nursing consideration– Check the IV site hourly for signs of drug Check the IV site hourly for signs of drug
infiltration of dopamine, which can infiltration of dopamine, which can cause tissue necrosis. cause tissue necrosis.
– PhentolaminePhentolamine should be infiltrated in should be infiltrated in multiple areas to reduce tissue damage.multiple areas to reduce tissue damage.
– Drug is effective if Urine output is Drug is effective if Urine output is increased and BP is increasedincreased and BP is increased
Antihypertensive drugsAntihypertensive drugs
The Drugs employed to control The Drugs employed to control hypertension can be classified as:hypertension can be classified as:
DiureticsDiuretics Beta-blockersBeta-blockers Alpha adrenergic blockersAlpha adrenergic blockers Calcium channel blockersCalcium channel blockers Angiotensin-converting enzyme Angiotensin-converting enzyme
inhibitorsinhibitors Angiotensin II receptor blockersAngiotensin II receptor blockers Peripheral vasodilatorsPeripheral vasodilators
Common Drugs in HPNCommon Drugs in HPN
IN Evaluating the effectiveness of IN Evaluating the effectiveness of these drugs is simply to monitor the these drugs is simply to monitor the BP if it becomes NORMALBP if it becomes NORMAL
Anti-hypertensive drugsAnti-hypertensive drugsClassClass PrototypePrototype MOAMOA Side effectsSide effects
DiureticsDiuretics FurosemideFurosemide Decreases blood Decreases blood volumevolume
HypokalemiaHypokalemia
Beta-Beta-blockerblocker
PropranololPropranolol Blocks B1 Blocks B1 receptor in the receptor in the heartheart
Bradycardia, Bradycardia, hypoglycemiahypoglycemia
ACE ACE InhibitorsInhibitors
CaptoprilCaptopril Prevents A1 to Prevents A1 to AII conversionAII conversion
Headache, Cough, Headache, Cough, flushingflushing
Ca channel Ca channel blockersblockers
NifedipineNifedipine Blocks Ca entry Blocks Ca entry into cellinto cell
Headache, Headache, flushing, reflex flushing, reflex tachycardiatachycardia
VasodilatorVasodilator NitroglyceriNitroglycerinn
Dilates veins and Dilates veins and arteriesarteries
HEADACHEHEADACHE
Alpha Alpha blockersblockers
PrazozinPrazozin Blocks alpha Blocks alpha receptor in BV receptor in BV causing causing vasodilatationvasodilatation
UrinationUrination
Central Central alpha alpha agonistagonist
ClonidineClonidine Stimulates CNS Stimulates CNS alpha 2 receptoralpha 2 receptor
DepressionDepression
AnticoagulantsAnticoagulantsHEPARINHEPARIN WARFARINWARFARIN
Parenteral (SQ and IV)Parenteral (SQ and IV) OralOralAction is to enhance natural Action is to enhance natural
anti-thrombin III in the anti-thrombin III in the bloodblood
Action is to INHIBIT Vitamin-Action is to INHIBIT Vitamin-K dependent clotting factors K dependent clotting factors (10,9,7,2)(10,9,7,2)
Acts within minutesActs within minutes Acts within daysActs within days
Monitor for aPTTMonitor for aPTT Monitor for PT and INRMonitor for PT and INRLarge molecule, can be Large molecule, can be given to pregnantgiven to pregnant
Small molecule CANNOT be Small molecule CANNOT be given to pregnantgiven to pregnant
Antidote: Protamine Antidote: Protamine sulfatesulfate
Antidote: Vit. KAntidote: Vit. K
SE: bleeding, SE: bleeding, decreased plateletsdecreased platelets
SE: BleedingSE: Bleeding
The antianemics: Iron The antianemics: Iron preparations and Epoetinpreparations and Epoetin
Iron preparationsIron preparations Iron is important for hemoglobin Iron is important for hemoglobin
formation.formation.
The iron preparations are:The iron preparations are: Ferrous sulfateFerrous sulfate Ferrous fumarateFerrous fumarate Ferrous gluconateFerrous gluconate
The antianemics: Iron The antianemics: Iron preparations and Epoetinpreparations and Epoetin
Side-effects: Side-effects: GIT- constipation (usually), GIT- constipation (usually),
diarrhea, vomiting, diarrhea, vomiting, epigastric epigastric pain, gastric ulceration and pain, gastric ulceration and darkening of stools.darkening of stools.
Liquid preparation can stain the Liquid preparation can stain the teeth, and injectable iron can teeth, and injectable iron can cause tissue discolorationcause tissue discoloration
Other- dizzinessOther- dizziness
The antianemics: Iron The antianemics: Iron preparations and Epoetinpreparations and Epoetin
Drug-Drug interactionDrug-Drug interaction Tetracyclines combine with iron Tetracyclines combine with iron
preparations and render the iron preparations and render the iron unabsorbable. unabsorbable.
Antacids and cimetidine- decrease iron Antacids and cimetidine- decrease iron absorption and effectsabsorption and effects
Foods can impair iron absorption but they Foods can impair iron absorption but they should be taken with iron to reduce GI should be taken with iron to reduce GI discomfort. discomfort.
Milk containing foods, coffee, tea and Milk containing foods, coffee, tea and eggs are NOT given with iron because eggs are NOT given with iron because they delay iron absorption.they delay iron absorption.
The antianemics: Iron The antianemics: Iron preparations and Epoetinpreparations and Epoetin
ImplementationImplementation Encourage the patient to eat iron-rich foods like liver, Encourage the patient to eat iron-rich foods like liver,
lean meat, egg yolk, dried beans, green leafy vegetables.lean meat, egg yolk, dried beans, green leafy vegetables. Administer iron preparations orally with foods to decrease Administer iron preparations orally with foods to decrease
GI discomfort. GI discomfort. If increased absorption is necessary, administer IN If increased absorption is necessary, administer IN
BETWEEN meals with full glass of water or juice. BETWEEN meals with full glass of water or juice. It is best to offer citrus juices because the vitamin It is best to offer citrus juices because the vitamin
C content can increase iron absorption. C content can increase iron absorption. Instruct the patient to swallow the whole tablet and Instruct the patient to swallow the whole tablet and
remain upright for 30 minutes to prevent esophageal remain upright for 30 minutes to prevent esophageal corrosion from reflux. corrosion from reflux.
DO NOT administer iron together with or within 1 hour of DO NOT administer iron together with or within 1 hour of ingesting tetracyclines, antacids, milk and milk-ingesting tetracyclines, antacids, milk and milk-containing products. containing products.
Advise clients to increase fluid intake and consume fiber Advise clients to increase fluid intake and consume fiber rich foods if constipation becomes a problem. rich foods if constipation becomes a problem.
The antianemics: Iron The antianemics: Iron preparations and Epoetinpreparations and Epoetin
ImplementationImplementation Emphasize that the therapeutic effect of Emphasize that the therapeutic effect of
iron therapy may not be apparent until iron therapy may not be apparent until several weeks. several weeks.
If injecting a parenteral iron preparation, If injecting a parenteral iron preparation, inject DEEP IM utilizing inject DEEP IM utilizing the Z-track method the Z-track method to avoid leakage into the subcutaneous to avoid leakage into the subcutaneous tissues and skintissues and skin. .
Offer straw if giving liquid iron preparation Offer straw if giving liquid iron preparation to avoid staining the teeth. to avoid staining the teeth.
To prevent undue alarm, instruct the To prevent undue alarm, instruct the patient that the stools may turn black or patient that the stools may turn black or dark green. This is a harmless occurrence.dark green. This is a harmless occurrence.
The antianemics: Iron The antianemics: Iron preparations and Epoetinpreparations and Epoetin
EvaluationEvaluation The nurse evaluates the effectiveness The nurse evaluates the effectiveness
of the drug therapy by determining that of the drug therapy by determining that the the client is not fatigued, with absence client is not fatigued, with absence of pallor, and with hemoglobin results of pallor, and with hemoglobin results within desired rangewithin desired range. .
ErythropoietinErythropoietinThe mechanism of action of The mechanism of action of
epoetin alfaepoetin alfa
(Epogen)(Epogen) This drug acts like the natural This drug acts like the natural
glycoprotein erythropoietin to glycoprotein erythropoietin to stimulate the production of RBC in stimulate the production of RBC in the bone marrow.the bone marrow.
ErythropoietinErythropoietin
Clinical indicationsClinical indications It is given SUBCUTANEOUSLY or It is given SUBCUTANEOUSLY or
INTRAVENOUSLY INTRAVENOUSLY for the treatment of for the treatment of anemia associated with renal failure anemia associated with renal failure or for patients on dialysisor for patients on dialysis. .
It is also used in patients for blood It is also used in patients for blood transfusion to decrease the need for transfusion to decrease the need for blood in surgical patients. blood in surgical patients.
ErythropoietinErythropoietin
Pharmacodynamics: the adverse Pharmacodynamics: the adverse effects of epoetin alfaeffects of epoetin alfa
CNS- headache, fatigue, asthenia, CNS- headache, fatigue, asthenia, dizziness and seizures- these are due dizziness and seizures- these are due to the cellular response to the to the cellular response to the glycoprotein. glycoprotein.
GIT- nausea, vomiting and diarrheaGIT- nausea, vomiting and diarrhea CVS- hypertension, edema and CVS- hypertension, edema and chest chest
pain due to increase RBC numberpain due to increase RBC number
ErythropoietinErythropoietinImplementationImplementation Administer the drug SC or IV usually 3 times per Administer the drug SC or IV usually 3 times per
week.week. Monitor the IV access line if given IV. Do not mix Monitor the IV access line if given IV. Do not mix
with other solutionswith other solutions Determine periodically the level of hematocrit and Determine periodically the level of hematocrit and
iron stores during therapy. If patient does not iron stores during therapy. If patient does not respond to the drug, reevaluate the cause of respond to the drug, reevaluate the cause of anemia.anemia.
Maintain seizure precaution on stand by as seizure Maintain seizure precaution on stand by as seizure can occur.can occur.
Provide comfort measures like small frequent Provide comfort measures like small frequent feedings and pain medications for headache.feedings and pain medications for headache.
Provide thorough health teaching: need for lifetime Provide thorough health teaching: need for lifetime injectioninjection
ErythropoietinErythropoietin
EvaluationEvaluation Monitor patient response to the Monitor patient response to the
drug= increased hemoglobindrug= increased hemoglobin
Psychotrophic drugsPsychotrophic drugs
• Drugs that can:Drugs that can:
1.1. Stimulate the release of Stimulate the release of neurotransmittersneurotransmitters
2.2. Block the receptor/activity of the Block the receptor/activity of the neurotransmitter= like dopamineneurotransmitter= like dopamine
3.3. Stimulate the receptors in the CNSStimulate the receptors in the CNS
4.4. Prevents the breakdown of the Prevents the breakdown of the neurotransmitters or the re-uptake neurotransmitters or the re-uptake mechanismmechanism
Anti-Anti-Psychotics/Psychotics/
NeurolepticsNeuroleptics• Drugs used to treat PSYCHOSESDrugs used to treat PSYCHOSES
• MAIN ACTION: Blockage of the MAIN ACTION: Blockage of the DOPAMINE receptor in the CNSDOPAMINE receptor in the CNS
Anti-Anti-Psychotics/Psychotics/
NeurolepticsNeurolepticsClassClass PrototypePrototype OthersOthers
PhenothiazinesPhenothiazines ChlorpromazineChlorpromazine Thioridazine, Thioridazine, Fluphenazine, Fluphenazine, PerphenazinePerphenazine
ButyrophenonesButyrophenones HaloperidolHaloperidol droperidoldroperidol
ThioxanthinesThioxanthines ChlorprothixeneChlorprothixene thirothixenethirothixene
DibenzoxapineDibenzoxapine MolindoneMolindone
DiphenylbutlypipeDiphenylbutlypiperidineridine
PimozidePimozide
Atypical drugsAtypical drugs ClozapineClozapine OlanzapineOlanzapine
RisperidoneRisperidone quetiapinequetiapine
Anti-Anti-Psychotics/Psychotics/
NeurolepticsNeurolepticsDesired EffectsDesired Effects
11 Reduced hallucination and illusionsReduced hallucination and illusions
22 CNS sedation and emotional slowingCNS sedation and emotional slowing
33 Decreased ambivalence, reduced Decreased ambivalence, reduced delusiondelusion
44 Reduced agitation resulting to Reduced agitation resulting to calmnesscalmness
55 Relief of emotional turmoilRelief of emotional turmoil
66 Reduced flattening of affectReduced flattening of affect
Anti-Anti-Psychotics/Psychotics/
NeurolepticsNeurolepticsCommon SECommon SE Nursing InterventionsNursing Interventions
Anticholinergic Anticholinergic effectseffects
Sugarless gum, bed restSugarless gum, bed rest
Photosensitivity Photosensitivity Sunglasses, sunscreen, Sunglasses, sunscreen, avoid sunavoid sun
Postural Postural hypotensionhypotension
Change position slowly, Change position slowly, lie prone for 1 hour lie prone for 1 hour after drug intake, after drug intake, monitor BPmonitor BP
AgranulocytosisAgranulocytosis Instruct to report sore Instruct to report sore throat and fever, throat and fever, monitor WBC monitor WBC
SeizureSeizure Monitor EEGMonitor EEG
SedationSedation Safety, no machine Safety, no machine operationoperation
Anti-Anti-Psychotics/Psychotics/
NeurolepticsNeurolepticsExtra-Pyramidal Extra-Pyramidal SyndromeSyndrome
Nursing InterventionNursing Intervention
Parkinsonism-Tremor, Parkinsonism-Tremor, rigidity, bradikinesiarigidity, bradikinesia
Avoid abrupt withdrawal, Avoid abrupt withdrawal, give anti-EPS drugs like give anti-EPS drugs like CogentinCogentin
Dystonia- torticollis, Dystonia- torticollis, contraction of face and contraction of face and tonguetongue
Remain with client, Remain with client, administer anti-EPSadminister anti-EPS
Akathisia= motor Akathisia= motor restlessnessrestlessness
Verbalize understanding of Verbalize understanding of the condition, administer the condition, administer anti-EPSanti-EPS
Tardive Dyskinesia= Tardive Dyskinesia= irreversible drooling, irreversible drooling, tongue movement and tongue movement and shuffling gaitshuffling gait
No treatment except No treatment except discontinue drugdiscontinue drug
Neuroleptic Malignant Neuroleptic Malignant syndrome= elevated syndrome= elevated temp, treme muscle temp, treme muscle rigidityrigidity
Notify physician, prepare to Notify physician, prepare to administer dantroleneadminister dantrolene
Review Outline Adrenergic Agonists Adrenergic Antagonists Cholinergic Agonists Cholinergic Antagonists
Comparison of the Sympathetic and Parasympathetic Nervous systemCharacteristics Sympathetic Parasympathetic
CNS origin Thoraco-lumbar spinal cord
Cranio-Sacral spinal cord
Pre-ganglionic neuron Short axon Long axon
Pre-ganglionic NTA Acetylcholine Acetylcholine
Ganglia location Next to spinal cord Near target organ
Post-ganglionic neuron
Long axon Short axon
Post-ganglionic NTA Epi and NE Acetylcholine
Enzyme for NTA MAO, COMT Acetylcholine-ESTERASE
General response Fight or flight Rest and Digest
The autonomic drugs Pharmacologic use depends on their
EFFECTS on the body
They can STIMULATE= agonists OR mimetics
They can DECREASE THE RESPONSE= antagonists OR blockers
The autonomic drugs They can STIMULATE= agonists OR mimetics DIRECT STIMULATION by binding with
receptors
INDIRECT STIMULATION by blocking the enzymes that degrade the neurotransmitters or increasing the release of neurotransmitters
The autonomic drugs They can DECREASE THE RESPONSE=
antagonists OR blockers
DIRECT blockage by removing the neurotransmitter or competing with the neurotransmitter
Binding with the receptor and NO RESPONSE will happen
The autonomic drugs They can be
NON-SELECTIVE when they stimulate or block many receptors
SELECTIVE when they stimulate or block specific receptors
SPECIFIC when only ONE type of receptor is stimulated or blocked
The autonomic drugs: Pharmacologic use depends on their EFFECTS on the body
Effect on the body Therapeutic use
Increases BP Used for SHOCK where there is LOW BP
Decreases BP and heart rate
Used for HYPERTENSION and Tachycardia
The Adrenergic AGONISTS Also called SYMPATHOMIMETIC agents
These drugs MIMIC the effects of the sympathetic nervous system
The Adrenergic AGONISTS They usually stimulate DIRECTLY the
receptors of the adrenergic system
The Adrenergic AGONISTS Alpha and Beta agonists (non-selective)
Prototype: Epinephrine
Alpha Agonists (Selective) Prototype: Phenylephrine
Beta Agonists (Selective) Prototype: Isoproterenol
The Adrenergic AGONISTS Alpha and Beta agonists (non-selective)
Pharmacodynamics:
These agents stimulate ALL types of adrenergic receptors in the body by direct interaction or by releasing neurotransmitters from the nerve cells
The Adrenergic AGONISTS Alpha and Beta agonists
Prototype: Epinephrine
1. Ephedrine
2. Epinephrine
3. Metaraminol
4. Norepinephrine
5. Dobutamine (sometimes a B1 specific)
6. Dopamine
The Adrenergic AGONISTSAlpha and Beta agonists: Clinical Use 1. Dopamine- used in shock 2. Epinephrine- drug of choice of
anaphylaxis, Status asthmaticus 3. Norepinephrine- used in shock 4. Dobutamine- used in CHF 5. Ephedrine- used in shock, asthma and
rhinitis
The Adrenergic AGONISTS Alpha and Beta agonists: Desirable effects
Increased myocardial contractility Bronchial DILATATION Vasoconstriction Increased blood pressure Decreased intraocular pressure Pupillary dilatation
The Adrenergic AGONISTS Alpha and Beta agonists:
Contraindications Pheochromocytoma Tachyarrhythmias With halogenated anesthesia- increased
sensitivity to adrenergic drugs
The Adrenergic AGONISTS Alpha and Beta agonists: Adverse effects
Sympathetic stimulation effects
CVS- hypertension, tachycardia, palpitations
Respi- tachypnea
GI- nausea, vomiting
Others- sweating, headache, piloerection
The Adrenergic AGONISTSAlpha and Beta agonists: Nursing
considerations
1. Monitor patient response to the drug
2. Emphasize to avoid the use with MAOIs and TCA
3. Maintain phentolamine (alpha blocker) to manage extravasation of IV drug
4. Usually given IV
The Adrenergic AGONISTSAlpha and Beta agonists: Nursing
considerations
Determine effectiveness of the drug:
Increased BP in shock
Relief of anaphylaxis and asthma attack
Relief of nasal congestion
The Adrenergic AGONISTSAlpha Agonists (selective)
Prototype: phenylephrine
clonidine (alpha-2 specific)
The Adrenergic AGONISTSAlpha Agonists Pharmacodynamics:
These agents bind primarily to the alpha receptors in the body
Clonidine
Stimulating the ALPHA-2 receptor causes decreased sympathetic outflow from the CNS/ decreased release of NE
The Adrenergic AGONISTSAlpha Agonists: Clinical use
1. Phenylephrine- vasoconstricting drug, used topically to decrease the symptoms of rhinitis
2. Clonidine- for hypertension
The Adrenergic AGONISTSAlpha Agonists: Contraindication
1. Allergy to drug
2. Caution in the following conditions:• Hyperthyroidism-aggravation of symptoms• Diabetes- increased glucose levels• Tachyarrhythmias- possible additive effect
The Adrenergic AGONISTSAlpha Agonists: Adverse effects
CNS- anxiety, depression, fatigue
CVS- palpitations
GI- nausea, vomiting and anorexia
GU- oliguria, dysuria
The Adrenergic AGONISTSAlpha Agonists: Nursing considerations
1. DO NOT discontinue drug abruptly to prevent rebound effect
2. Maintain phentolamine if giving IV drug
3. Provide comfort measures- rest, quiet environment, analgesics
The Adrenergic AGONISTSAlpha Agonists: Nursing considerations
Evaluate effectiveness:
Decreased BP
Decreased Nasal congestion
The Adrenergic AGONISTSBeta Agonists (Selective): ANTI-ASTHMA
DRUGS
Prototype: isoproterenol (B1 and B2)
salbutamol (Ventolin)= B2 specific
1. Ritodrine (B2 specific)
2. “terol”- albuterol, salmeterol, bitolterol
3. Terbutaline (B2)
The Adrenergic AGONISTSBeta Agonists Pharmacodynamics
These agents bind to the BETA receptors causing the sympathetic manifestations and effects
The Adrenergic AGONISTSBeta Agonists Clinical use
1. Asthma- due to the bronchodilation!
2. Preterm labor- ritodrine is given to relax the uterine muscles
3. Shock= To increase BP
The Adrenergic AGONISTSBeta Agonists Adverse effects
CNS- restlessness, headache, anxiety , tremors
CVS- tachycardia, angina, palpitations
GI- nausea, vomiting and anorexia
Others- pupilary dilation, rash, sweating, pulmonary edema
The Adrenergic AGONISTSBeta Agonists Nursing considerations1. Monitor VS when giving the drug2. Remind mothers to lie on the left side
during ritodrine administration3. Maintain a beta blocker on stand by4. Provide comfort- quiet environment, rest,
analgesics.5. Prevent over-hydration to avoid pulmonary
edema
The Adrenergic AGONISTSBeta Agonists Nursing considerations These are given usually inhalational for
asthma attack Instruct on how to use inhalers and
nebulizers
Evaluate effectiveness:
Normal RR
Clear breath sounds
The Adrenergic ANTAGONISTS These are called adrenergic blockers
They can be Alpha Blockers (selective)
Beta Blockers (selective)
Both Alpha & Beta Blockers
(non-selective)
The Adrenergic ANTAGONISTSThe alpha blockers (selective)
Prototype: Phentolamine
Phenoxybenzamine
“zosin”- prazosin, doxazosin, terazosin- these are
alpha 1 blockers
The Adrenergic ANTAGONISTSThe alpha blockers: Pharmacodynamics
These agents have affinity for the ALPHA receptors
Blocking the alpha receptors will cause:
Vasodilation
Sphincter relaxation in the bladder
The Adrenergic ANTAGONISTSThe alpha blockers: Clinical use
1. Phenoxybenzamine- used in pheochromocytoma
2. Phentolamine- also used in pheochomocytoma
3. “zosin” drugs- are used to decrease blood pressure and to relax the urinary sphincter in BPH!
The Adrenergic ANTAGONISTSThe alpha blockers: Contraindications
1. Myocardial infarction
2. Allergy
The Adrenergic ANTAGONISTSThe alpha blockers: Adverse Effects
CVS- hypotension, reflex tachycardia, flushing
CNS- dizziness, weakness, fatigue, drowsiness
Others- nasal congestion, reddened eyes, priapism
The Adrenergic ANTAGONISTSThe alpha blockers: nursing consideration1. Monitor heart rate and BP2. Caution to change position slowly3. Advise to avoid hazardous activities4. Provide supportive measures like quiet
environment, rest and analgesics5. Monitor response to the drug- improvement
of blood pressure readings and urination
The Adrenergic ANTAGONISTSThe Beta blockers
These are agents used to treat cardiovascular problems- Hypertension, CHF, angina
Blocking beta receptor will cause
decreased heart rate
decreased BP
The Adrenergic ANTAGONISTSThe Beta blocker or The “olol”s
They can be beta 1 blockers, beta 2 blockers or Both
Prototype of non-selective: propranOLOL (beta 1 and 2)carteOLOLnadOLOL
penbutOLOLsotaLOL
The Adrenergic ANTAGONISTSThe Beta blocker or The “olol”s
They can be beta 1 blockers, beta 2 blockers or Both
Prototype of B1 selective: atenOLOL
acebutOLOL
betaxOLOL
esmOLOL
metoprOLOL
The Adrenergic ANTAGONISTSThe Beta blockers: pharmacodynamics
These agents block the beta receptors of the sympathetic system. The selective B1 antagonists block the B1 receptors, especially in the heart and the kidney
The Adrenergic ANTAGONISTSThe Beta blockers: Clinical use
1. Hypertension
2. Angina and MI
3. Cardiac arrhythmias
4. Migraine headache
5. HYPERTHYROIDISM
The Adrenergic ANTAGONISTSThe Beta blockers: Clinical use
Hypertension to decrease BP
Angina and MI to decrease cardiac workload
Cardiac tachyarrhythmias to terminate arrhythmias
Migraine headache to cause vasoconstriction in the cranial vessels
HYPERTHYROIDISM to decrease the tachycardia
The Adrenergic ANTAGONISTSThe Beta blockers: contraindications
1. Allergy
2. Heart blocks
3. Bradycardia
4. COPD
5. Precaution in DM
The Adrenergic ANTAGONISTSThe Beta blockers: Adverse effects
CVS- bradycardia, hypotension, heart block
CNS- fatigue, dizziness, depression
Respi- bronchospasm, pulmonary edema
GI- nausea, vomiting, diarrhea, hypoglycemia
GU- decreased libido, impotence, dysuria
The Adrenergic ANTAGONISTSThe Beta blockers: nursing considerations
1. Emphasize NOT to stop abruptly the drug intake
2. Give with FOODS to improve absorption
3. Provide comfort measures Adequate rest periods Avoidance of hazardous activities Change position slowly
The Adrenergic ANTAGONISTSThe Beta blockers: nursing considerations
Evaluate effectiveness:
Decreased BP in hypertension
Decreased HR in hyperthyroidism
Decreased PAIN angina
The Cholinergic Agonists These are also called
parasympathomimetic agents
Their action mimics the parasympathetic nervous system
The Cholinergic Agonists These agents INCREASE the activity of
acetylcholine in the acetylcholine receptors DIRECTLY by occupying the receptor INDIRECTLY by blocking the enzyme that
degrades the acetylcholine, preventing it from breakdown - the enzyme: acetylcholinESTERASE
The Cholinergic Agonists Direct acting cholinergic agonists
Prototype: BetaneCHOL
CarbaCHOL
Pilocarpine Indirect acting cholinergics
Prototype: Pyridostigmine
Neostigmine
Endrophonium (Tensilon)
The Cholinergic AgonistsDirect acting cholinergic agonists
Pharmacodynamics They are similar to acetylcholine and
directly act on the acetylcholine receptors
The Cholinergic AgonistsDirect acting cholinergic agonists
Parasympathetic stimulation will cause:
DUMBELS
urination
miosis (pupil constriction)
The Cholinergic AgonistsDirect acting cholinergic agonists: Clinical use
1. Post operative and post partum urinary retention and to treat neurogenic bladder
2. Relief of increased intraocular pressure of glaucoma by inducing miosis
The Cholinergic AgonistsDirect acting cholinergic agonists: Clinical use
1. The drugs INCREASE the bladder tone, RELAX the GI and urinary sphincters
2. The topical agent (pilocarpine) topically causes pupilary constriction to reduce IOP
The Cholinergic AgonistsDirect acting cholinergic agonists:
Contraindications
1. Bradycardia
2. Hypotension
3. Asthma
The Cholinergic AgonistsDirect acting cholinergic agonists: Adverse
effects (DUMBELS)
CVS- bradycardia, heart block, hypotension
GIT- nausea, vomiting, diarrhea, increased salivation, lacrimation
GUT- sense of urgency, sphincter relaxation
Others- increased sweating, headache, miosis
The Cholinergic AgonistsDirect acting cholinergic agonists: nursing
considerations
1. Assure proper administration of ophthalmic preparations
2. Administer on EMPTY stomach
3. Provide safety precautions- because of poor visual acuity
4. Promote cool environment, maintain access to the bathroom (urination)
The Cholinergic Agonists: evaluate effectiveness
Drug effectiveness
Pilocarpine Decreased IOP in glaucoma
Betanechol/Carbachol Urination/ relief of bladder distention
The Cholinergic AgonistsIndirect acting cholinergic agonists
Pharmacodynamics
These agents DO NOT react directly with the receptors but REACT chemically with the enzyme= acetylcholinesterase
The Cholinergic AgonistsIndirect acting cholinergic agonists
Pharmacodynamics
The acetylcholine breakdown is prevented so that the effect of acetylcholine is prolonged!= increased muscle contraction
They are used IN myasthenia gravis
The Cholinergic AgonistsIndirect acting cholinergic agonists
Clinical use
1. Myasthenia gravis Physostigmine, pyridostigmine, Neostigmine,
and endrophonium
2. Alzheimer's disease Tacrine and Donepezil
The Cholinergic AgonistsIndirect acting cholinergic agonists
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
The Cholinergic AgonistsIndirect acting cholinergic agonists
Nursing considerations
1. Administer IV drug slowly
2. Administer with foods BUT better BEFORE meals
3. Maintain atropine sulfate as antidote
4. Discontinue the drug if excessive salivation, diarrhea, vomiting become problematic
The Cholinergic AgonistsIndirect acting cholinergic agonists
Nursing considerations
Evaluate effectiveness
Decreased muscle weakness
Decreased dysphagia, ptosis
Increased muscular activity
The ANTI-cholinergics These are drugs that BLOCK the effect of
acetylcholine They are also called parasympatholytic
agents In effect, the sympathetic system becomes
unopposed!!!
The ANTI-cholinergics Anticholinergics:
Prototype: Atropine
dicyclomine
glycopyrrolate
propantheline
scopolamine
The ANTI-cholinergicsAnticholinergics: pharmacodynamics
These agents work by BLOCKING or COMPETING with acetylcholine for the acetylcholine receptors
BEST taken BEFORE MEALS
Atropine Depresses salivation Decreases bronchial secretions Mydriasis Cyclopedia Inhibits vagal response in the heart Reverses cholinergic toxicity
Atropineeffects Clinical use
Depresses salivation Used as pre-op med
Decreases bronchial secretions
Used as pre-op med
Mydriasis Used in cataract surgery
Cyclopledia Used in cataract surgery
Inhibits vagal response in the heart
Used in BRADYCARDIA and heart block
Constipation Used in partly to control diarrhea (in Lomotil)
Reverses cholinergic toxicity
Used in Cholinergic and Organophosphate poisoning
Scopolamine Decreases nausea and vomiting associated
with motion sickness
Anticholinergic Contraindications of anticholinergic
1. Known allergy
2. Glaucoma
3. Bladder obstruction (like PBH)
AnticholinergicAdverse effects: anticholinergic effects
CNS- blurred vision, pupil DILATION, photophobia, cycloplegia and increased Intraocular pressure
GI- dry mouth, constipation, bloatedness
CVS- tachycardia, palpitations
GU- urinary retention
Others- decreased sweating, flushing
AnticholinergicNursing considerations
1. Provide comfort measures Frequent mouth care Provide increased fluids Protect eyes form lights Advise to avoid hazardous activities Provide high-fiber diet and laxative Avoid extremes of temperature Instruct to void before administering the drug
AnticholinergicNursing considerations
2. Monitor for toxicity:
3. Ensure adequate hydration to prevent hyperpyrexia
Evaluate effectiveness of drug:
Increased HR in heart block
Decreased secretions in pre-op patients
Relief of motion sickness (scopolamine)
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