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2 Pharma Module
2 Pharma Module
UNIT I
FUNDAMENTAL CONCEPTS OF PHARMACOLOGY
CHAPTER I
Learning Objectives:
1. Identify the three core ethical principle.
2. Describe objectives of each phase of human clinical experimentation.
3. Discuss the Federal Legislation Acts related to US Food and Drug Administration
approval.
4. Describe the function of state nurse practice acts.
5. Differentiate between chemical, generic, brand names of drugs.
6. Define “över the counter” as it relates to drugs
US Food and Drug Administration (FDA) is responsible for the approval of new drugs. In
2004. to facilitate the increase in number of drug production, the FDA initiated the Critical
Path Initiative, a national strategy to drive innovation in the scientific processes through
which medical products are developed, evaluated, and manufactured.
The process of drug discovery and manufacturing takes 10-12 years and costs more than
$1 billion for each drug.
Patients should be treated as independent persons who are capable of making decisions
in their own best interests. When making healthcare decision, patients should be informed
of any alternatives available as well as the consequences of treatment. The nurse should
assess the mental status of the patients, and in the case of decreased capacity in decision
making, they should be given the privilege for protection. Patient’s choice should be
recognized if they are not capable of making decisions
Autonomy is an essential segment of respect for persons. It is the right to self subsistence.
The patient has the right to refuse any and all treatment, and in the participation in
research or withdraw without penalty, except, when decision poses threat to others.
Pt have the right to refuse/participate in research study as well as withdraw without
penalty.
In 1947 Nuremberg Code, informed consent started and its related feature is the right to
be informed and voluntary participation, not compulsive, if so, the nurse is responsible to
report the suspicion immediately. Informed consent has scopes beyond protection of the
individual patient’s choice
- It is a mutual collaboration of information, a .communication process
- It expresses respect for the person
- It gains patient’s active involvement in their care
- respects the patient’s right to self-determination
https://www.fda.gov/patients/clinical-trials-what-patients-need-know/informed-consent-
clinical-trials
It is the role of the health care provider NOT the nurse, to explain the study and what it is
expected of the patient and to respond to querries from the patient Meanwhile, in
providing written consent, it should be transcribed clearly, below the 8th grade reading
level with limited words fewer than 3 syllables, and patient should be conscious and
coherent.
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Nurses are patient advocates, nurses must be knowledgeable on all the facets of a drug
study, including all the inclusion and exclusion criteria for participants, study protocol and
study related documentation, to foster safety and quality study output.
Exclusion
• Women who are pregnant or nursing
• Women of childbearing age who do not use oral contraceptives
• Persons with symptomatic cardiac disease, hepatic dysfunction, chronic kidney
disease, neurologic disorders, or musculoskeletal disorders
• Persons with clinically significant abnormal laboratory values (chemistry and
hematology)
B. Beneficence
C. Justice
Justice requires that the selection of research subjects be fair. The distribution of benefits
and burdens is equitable (ex: must represent all racial and ethnic groups)
FDA requires that the clinical research must meet standards follow the Good Clinical
Practice Consolidation Guideline (GCP), an international ethical and scientific quality
standard for designing, conducting, monitoring, auditing, recording, analyzing, and
reporting clinical research. It is the foundation of clinical trials that involve human subjects.
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Act (BPCA) of 2002 and the Pediatric Research Equity Act (PREA) of 2003 urge
pharmaceutical companies to study drugs on children.
Clinical experimentation in drug research and development covers four phases with its
own objectives.
Phase I of drug testing
Researchers test a new drug or treatment in a small group of people for the first time to
evaluate its safety, determine a safe dosage range, and identify side effects
In 1992, Prescription Drug User Fee Act provided FDA with funds to expedite drug review
process to reduce delay. As a result,, the average drug approval has reduced from 30 to
12 months.
https://www.vox.com/2015/7/10/8928183/21st-century-cures-explained
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Food and Drug Act of 1906 is considered to be the America’s 1st law to regulate drugs
Prohibited sale of misbranded and altered drugs
1914 Harrison Narcotic Act required prescriptions for drugs that exceeded set narcotic
limits as well as increased documentation by physicians and pharmacists
1938 The Federal Food, Drug, and Cosmetic Act empowered FDA to ensure a drug
was safe prior to marketing. It is imperative that all drugs should be tested by FDA for
harmful effects, prior to approval, and all drug labels should contain accurate information
including the adverse effects
1983 Orphan Drug Act Promoted development and manufacture of drugs used on rare
diseases
(1) federal funding of grants and contracts to perform clinical trials of orphan products;
(2) a 50% tax credit for costs of clinical testing; and
(3) exclusive rights to market the drug for 7 years from the marketing approval date.
1996 HIPAA
The Health Insurance Portability and Accountability Act (HIPAA) of 1996 protects health
insurance coverage for workers who change or lose their jobs and sets the standard for
the privacy of individually identifiable health information. The act provides patients more
control over their health information, including boundaries on the use and release of
health records.
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https://www.dea.gov/drug-scheduling
2002 Best Pharmaceuticals for Children Act (BPCA) gives manufacturers a 6-month
extension of patents to evaluate drugs on the market for their safety and efficacy in
children
2003 Pediatric Research Equity Act authorizes the FDA to require that drug
manufacturers test certain drugs and biologic products for their safety and effectiveness
in children, noting that “children are not small adults.” Additionally, studies that involve
children must be conducted with the same drug and in the same disease process as
adults
007 Food and Drug Administration Amendment Act allows the FDA to do more
comprehensive reviews of potential new drugs, mandates post marketing safety studies,
and affects the distribution of drugs found to be not as safe as premarket studies
indicated.
2012 FDA Safety and Innovation Act (FDASIA) signed into law on July 9,2012 to
strengthen the FDA’s ability to safeguard and promote public health by:
• Collecting fees from industry to fund reviews of drugs with the “breakthrough therapy”
designation, medical devices, generic drugs, and biosimilar biologic products
• Expediting development of innovative, safe, and effective products
• Increasing stakeholder engagement in FDA processes
• Enhancing the safety of the global drug supply chain
In 1996 the Canadian Goverment passed the Controlled Drugs and Substances Act
Counterfeit drugs may contain the incorrect ingredients, insufficient amounts of active
ingredients, or no active ingredients. Additionally, they may contain impurities and
contaminants or may be distributed in fake packaging. It is estimated that more than 10%
of all drugs available are counterfeit. Most common counterfeited drugs are those used
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for erectile dysfunction, high cholesterol, infection, cancer and HIV,AIDS, because of its
high cost. The FDA and consumer groups are working on ways to stop this problem
Generic name
Generic name is an official, universally acceptable, nonproprietary name for drug,
written in lowercase letters and it is not owned by any drug company.
(used by the book)
-
Brand (trade) name AKA Proprietary name chosen by the drug company, usually
trademarked and should be written in capital letter
In 2002 FDA standardized OTC to postulate better labeling as well as benefits and risks.
It is one of the responsibilities of the nurse to provide heath education to clients to read
and understand the drug label before purchase, otherwise self diagnosis and self
prescribing OTC are discouraged because it may mask the seriousness of clinical
condition and may cause potential harm rather than a therapeutic effect.
Aspirin reactions and side effects can trigger an acute asthma episode. Patients may be
allergic to aspirin, or aspirin may act as a deregulator of leukotrienes. Aspirin is also not
recommended for children with influenza symptoms or chickenpox because it has been
associated with Reye syndrome. Patients with kidney disease should avoid aspirin,
acetaminophen, and 13 ibuprofen because these can further decrease kidney function,
especially with long-term use. Also, patients taking moderate to high doses of aspirin,
ibuprofen, or naproxen concurrently with an oral anticoagulant may be at increased risk
for bleeding. Be guided with the use of SAFER before taking any medication.
Speak up
Ask questions
Find the facts
Evaluate your choices
Read labels
Reading the product label is the most important part of taking care of yourself or your
family when using over-the-counter (OTC) medicines (available without a prescription).
This is especially true because many OTC medicines are taken without seeing a doctor.
The OTC medicine label has always contained important usage and safety information
for consumers, but now that information will be more consistent and even easier to read
and to understand. The U.S. Food and Drug Administration (FDA) has issued a regulation
to make sure the labels on all OTC medicines (from a tube of fluoride toothpaste to a
bottle of cough syrup) have information listed in the same order; are arranged in a simpler
eye-catching, consistent style; and may contain easier to understand words. While the
labels on a majority of OTC drug products will be appearing on store shelves soon, some
products and companies have additional time to comply with the labeling regulations. If
you read the OTC medicine label and still have questions about the product, talk to your
doctor, pharmacist, or other health care professional.
The makers of OTC medicines widely use tamper-evident packaging for their products.
This is to help protect consumers against possible criminal tampering. Drug products with
tamper-evident packaging have a statement on the packaging describing this safety
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feature. It is always important to inspect the outer packaging before you buy an OTC drug
product and to look at the product again before you take it.
All nonprescription, over-the-counter (OTC) medicine labels have detailed usage and
warning information so consumers can properly choose and use the products.
The Drug Facts labeling requirements do not apply to dietary supplements, which
are regulated as food products, and are labeled with a Supplement Facts panel.
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The label tells you what a medicine is supposed to do, who should or should not take it,
and how to use it. But efforts to provide good labeling can't help unless you read and use
the information. It's up to you to be informed and to use OTC drug products wisely and
responsibly.
• The expiration date, when applicable (date after which you should not use the
product).
• Lot or batch code (manufacturer information to help identify the product).
• Name and address of manufacturer, packer, or distributor.
• Net quantity of contents (how much of the product is in each package).
• What to do if an overdose occurs.
Many OTC medicines are sold in containers with child safety closures. Use them
properly. Remember—keep all medicines out of the sight and reach of children.
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POST TEST
2) The research nurse is meeting with a patient and determines, based on the
assessment, that the patient meets inclusion criteria for clinical research. The
patient agrees to participate in the clinical trial. The nurse advises the patient that
which member of the health care team has the responsibility to explain the study
and respond to questions?
a. Registered nurse
b. Pharmacist
c. Research associate
d. Health care provider
3) The clinical research nurse knows that only a small proportion of drugs survive
the research and development process. An appreciation of the process and
associated costs grows when the nurse is aware that approximately one in how
many potential drugs is approved by the U.S. Food and Drug Administration?
a. 100
b. 1000
c. 10,000
d. 100,000
5) The foundation of clinical trials, Good Clinical Practice, is a helpful resource for
nurses. The nurse is correct in choosing Good Clinical Practice as a reference for
standards in which areas? (Select all that apply.)
a. Design
b. Monitoring and auditing
c. Analyses
d. Reporting
e. Outcomes evaluation
6) The nurse researcher reviews the proposed informed consent form for a future
clinical trial. The nurse expects to find which in the document? (Select all that
apply.)
a. Description of benefits and risks
b. Identification of related drugs, treatments, and techniques
c. Description of outcomes
d. Statement of compensation for participants, if any
e. Description of serious risks
7) The nurse knows that the patient should be informed about the risks and benefits
related to clinical research. What ethical principle does this describe?
a. Respect for persons
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b. Justice
c. Beneficence
d. Informed consent
8) The nurse is reviewing a patient's list of medications and notes that several have
the highest abuse potential. According to U.S. standards, the highest potential for
abuse of drugs with accepted medical uses is found in drugs included in which
schedule?
a. II
b. III
c. IV
d. V
9) The nurse is reviewing the drug-approval process in the United States and learns
that the Food and Drug Administration Modernization Act of 1997 contains which
provisions? (Select all that apply.)
10) The patient has questions about counterfeit drugs. Which factors alert the
patient or nurse that a drug is counterfeit or adulterated? (Select all that apply.)
a. Variations in packaging
b. Unexpected side effects
c. Different taste
d. Different chemical components
e. Different odor.
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CHAPTER 2
Phases of Drug Action1
Learning Objectives:
1. Differentiate the three phase of drug action
2. Describe the four processes of pharmacokinetics.
3. Differentiate the agonist and antagonist effect of a drug.
4. Describe the nursing implication of pharmacokinetics and pharmacodynamics
When a drug is administered, it undergoes two phases, the pharmacokinetic and the
pharmacodynamic phase.
Pharmacokinetics the process of drug movement throughout the body that is necessary
to achieve drug action. It is composed of the four processes, namely Absorption,
Distribution, Metabolism,and Excretion or Elimination.
Absorption
the movement of the drug into the bloodstream after administration. Disintegration a
breakdown of oral drug form into small particles, in order for the body to utilize the drugs
taken by mouth (enteral) eg. tablet or capsule. Meanwhile, dissolution is a process of
combining small drug particles with liquid to form a solution, to be absorbed from the
gastro intestinal tract into the bloodstream except for drugs in liquid form which are
already in solution. Therefore drugs in liquid form are readily available for GI absorption
than solids. Mostly drugs are both disintegrated and absorbed faster in acidic fluids, the
reason why elderly and very young with less gastric acidity have slower absorption.
Enteric Coated(EC) drugs resist disintegration in the gastric acid of the stomach until it
reaches the alkaline environment in the small intestine. EC tablet or capsules and
sustained release(beaded) capsules should not be crushed because it interferes with the
absorption. Drugs that are lipid soluble and non ionized are absorbed faster than water
soluble and ionized drugs.
Factors affecting absorption may include blood circulation, pain, stress, food texture, fat
content, temperature,pH route of administration..Drugs given through intramuscular
absorbed faster in the deltoid muscles with increase blood flow than in gluteus maximus.
Subcutaneous tissue has decreased blood flow so much slower absorption but more
faster and certain than oral route. But drugs given rectally absorbed slower than orally
because the surface area in the rectum.is smaller than the stomach and it has no villi.
After the absorption of the oral drug, they will move from GI tract to liver thru the portal
vein. In the liver, some drugs are metabolized to an inactive form and at eliminated, thus
reducing the volume of active drugs available for pharmacologic effect. This is referred to
as First pass effect or first pass metabolism. Lidocaine and other nitroglycerine cannot be
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PHARMACOLOGY
given.by mouth because they have have extensive first pass metabolism and most of the
drug is inactivated.
Bioavailability is the percentage of administered drug available for activity. For orally
taken drugs, bioavailability is always less than 100% based on the rate of first pass
metabolism. (Rosuvastatin 20%, Digoxin 70-85% ), but all drugs administered
intravenously (IV), bioavailability is 100%.
Factors affecting bioavailability include the drug form, route of administration
gastric mucosa and motility, administration with food and other drugs, changes in liver
metabolism. A decrease in liver function, increases the bioavailabity, only if the drug is
metabolized by the liver.
Distribution is the movement of the drug from the circulation to body tissues.
Drug distribution is affected by the rate of the blood flow to the tissue, drug’s affinity to the
tissue, and protein binding. Drugs that are more than 90% bound to protein are highly
protein bound (Warfarin, Furosemide, Diazepam, Sertraline), 10% are weakly protein
bound (Gentamycin, Metoprolol, Metformin, Lisinopril). The protein bound drugs are
inactive, not able to interact with tissue receptors unable to produce therapeutic effect,
while the unbound drugs are free drugs, ab
le to exit the blood vessels reach their site of action causing a pharmacologic effect..
When two highly bound drugs are administered, they will compete for the protein binding
sites, leading to an increase free drug in the circulation leading to drug accumulation to
occur thus resulting to toxicity.
Blood vessels in the brain have a special endothelial lining where the cells are pressed
together(tight junction), referred to as blood brain barrier.(BBB), which protects the brain
from foreign substances. Highly lipid soluble with low molecular weight (Benziodiazepine)
can pass the BBB through diffusion and others via transport proteins.
During pregnancy, drugs can pass thru the placenta that could affect both the mother and
the fetus. 1st trimester – taken drugs can lead to spontaneous abortion, 2nd trimester –
teratogenesis or other subtler defects. 3rd trimester - may alter fetal growth and
development. Meanwhile in breastfeeding, drugs can pass into breast milk which can
affect the nursing infant.
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The drug half life(t1/2) time it takes for the amount of drug in the body to be reduced by
half. In case of liver and kidney dysfunction, half life of the drug is prolonged and less
drug is metabolized and eliminated. 94% of drug is gone by the 4th half-life. Drug has an
average of 4-5 half lives as it goes through the body.
Loading dose is significantly higher than maintenance dosing, therapeutic effects can be
obtained while steady state is reached.
Excretion is the process of elimination of drugs from the body through the kidneys.
and can be excreted also through the bile, the lungs, saliva, sweat, and breast milk.The
kidneys filter free drugs, but in healthy kidneys, drugs bound to protein are not filtered.
Drug excretion (elimination)Kidneys:
Creatinine clearance - metabolic by-product of muscle that is excreted by the kidneys
BUN - Test the metabolic breakdown of protein metabolism
Glomerular filtration rate protein and blood cells are pretty large to pass thru the
kidneys*
Pharmacodynamics
- is a study on how the drugs affect the body
- Primary effect = Desirable response
- Secondary effect = Desirable or undesirable
Therapeutic index:
describes the relationship between the therapeutic dose of a drug (ED50) and the toxic
dose of a drug (TD50)
Potency refers to the amount of drug needed to elicit a specific physiologic response to
a drug. Ex: Drug with high potency produces significant therapeutic responses at low
concentrations. Drug with low potency (like codeine) produces minimal therapeutic
responses at low concentration.
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Trough drug level: Lowest plasma concentration of a drug. Measures the rate at which
the drug is eliminated. trough levels are drawn immediately before the next dose of drug
is given, regardless of route of administration.
Peak drug level -Highest plasma concentration of drug at a specific time. Indicates the
rate of absorption. Blood sampled should be drawn at the proposed peak time, according
to the route of administration
Additive sum of effects of two drugs
Synergistic effect is much greater than effects of either drug alone
Antagonistic one drug reduces or blocks effect of other drug.
McCuition, et al (2019)
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Pharmacogenetics
- study of genetic factors that influence an individual’s response to a specific drug,
can disrupt the drug metabolism, increase or decrease drug response.
- patients at high risk of developing adverse reactions may be identified so as to
prevent complications to drug therapy by constantly monitoring for therapeutic drug
response.
Tolerance - decreased responsiveness
Tachyphylaxis - acute or rapid decrease in response to drug
Placebo effect – drug response is not attributed to the chemical properties of the drug.
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POST TEST
2. The pharmacist states that the patient's biotransformation of a drug was altered.
The nurse interprets this to mean that
A). absorption has affected the drug.
B). dilution has affected the drug.
C). excretion has affected the drug.
D). metabolism has affected the drug.
3. The nurse administers 650 mg of aspirin at 7 PM. The drug has a half-life of 3
hours. The nurse interprets this information to mean that 325 mg of the
medication will have been eliminated from the patient's system by what time?
A). 7 AM
B). 10 PM
C). 1 AM
D). 10 AM
4. The nurse realizes that a drug administered by which route will require the most
immediate evaluation of therapeutic effect?
A). Intravenous
B). Oral
C). Subcutaneous
D). Topical
5. Drugs in which state undergo the most rapid absorption? SELECT ALL THAT
APPLY.
A). Lipid soluble
B). Ionized
C). Nonionized
D). Water soluble
E). Protein bound
6. The nurse reads that the half-life of the medication being administered is 12
hours. What interpretation will guide the nurse's care of this patient?
A). This medication will be 50% eliminated in 12 hours, so the dosing will be
spread apart.
B). The medication will be administered every 6 hours to maintain consistent
blood levels.
C). The medication will not work for the first 12 hours.
D). The patient will require two doses of the medication before there is an effect.
7. Which statement best indicates that the nurse understands the meaning of
pharmacokinetics?
A). "It involves the study of physiologic interactions of drugs."
B). "It explains the distribution of the drug between various body compartments."
C). "It explains interactions between various drugs."
D). "It explains the adverse reactions to drugs."
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A). Assess the patient frequently for the risk of drug-drug interactions.
B). Administer the drugs with food.
C). Administer the drugs with 8 ounces of water.
D). Assess baseline liver function tests
10. A patient is complaining of pain rated "10" on a scale of 1 to 10. The nurse has
several choices of pain medication to administer. Which order is the best for the
nurse to administer at this time?
A). Morphine sulfate 1 mg IV (intravenous)
B). MS Contin 2 tablets PO (by mouth)
C). Transdermal patch
D). Tylenol suppository
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CHAPTER 3
Pediatric Considerations
Learning Objectives:
At the end of the course, the level II students will be able to:
1. Differentiate components of pharmacology in pediatric patients.
2. Describe the nurses’ responsibilities in pediatric drug administration.
3. Compute for the exact dose of prescribed medication.
Limited research
▪ Research risk
▪ Obtaining informed consent
▪ Drug labeling and dosing instructions
▪ Pediatric Research Equity Act in 2012
➢ Requires study of pediatric drug use
➢ Pediatric Pharmacokinetics
Absorption
▪ Influencing factors
➢ Child’s age, health status, weight, route of administration
➢ Nutritional habits, physical maturity, hormonal differences
➢ Hydration, underlying disease, GI disorders
▪ Route of administration
➢ Gastric acidity, emptying, motility, surface area, enzyme levels, intestinal
flora
▪ Intramuscular/subcutaneous
➢ Peripheral perfusion
➢ Effectiveness of circulation
▪ Topical
➢ Children’s skin is thin and porous.
Distribution
▪ Influencing factors
➢ Body fluid composition
• Neonates and infants have 75% water.
➢ Body tissue composition
• Neonates and infants have less body fat.
➢ Protein-binding capability
• Neonates and infants have less albumin and fewer protein receptor
sites.
➢ Effectiveness of barriers
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• Skin
• Blood-brain barrier
Metabolism
▪ Influencing factors
➢ Maturational level of child
➢ Liver metabolism
➢ Higher metabolic rate
Excretion
▪ Kidneys
➢ Infants have decreased
• renal blood flow.
• glomerular filtration rate.
• renal tubular function.
Pediatric Pharmacodynamics
▪ Mechanisms of action and effect of a drug on the body
▪ Includes the onset, peak, and duration of effect of a medication.
▪ Intensity of therapeutic effects and adverse effects
Nursing Implications
▪ Pediatric drug dosing and monitoring
➢ Monitoring for therapeutic effects and adverse reactions
➢ Calculations
▪ Pediatric drug administration
➢ Considering developmental and cognitive differences
• Differentiating developmental from chronologic age
➢ Maintaining safety while ensuring comfort
➢ Family-centered care - is essential to ensuring safety during and after health
care interventions, especially drug administration.
➢ Teaching is directed toward family or caregivers and patients.
➢ Side effects may be difficult to evaluate.
➢ Assess pediatric patient for ability to understand the reason for drug.
➢ Consider level of knowledge, developmental age, cultural factors, anxiety
level, when communicating with pediatric patient and family.
➢ Atraumatic care
➢ Oral administration
➢ Subcutaneous, intramuscular, and intravenous
➢ Eutectic mixture of local anesthetics
➢ Decreasing pain and anxiety
• Distraction, diversion, relaxation
• Creative imagery
➢ Intravenous sites
➢ Basic rules
• Honesty, respect
• Age-appropriate teaching and explanations
• Positive reinforcement
Adolescent Considerations
▪ Need individualized care specific to developmental stage
➢ Physical changes
➢ Cognitive level and abilities
➢ Social, reasoning, and decision-making skill development
➢ Emotional factors
➢ Independence from parents
➢ Self-care behaviors
➢ Impact of chronic illness
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Off label
drug is being used for some purpose, which it has not been approved
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Practice Test
1. Children have higher metabolic rates than adults. The nurse realizes that this
affects administration of medication for pain in children in all of the following ways
except
A. higher requirement for medication.
B. increased dosage.
C. decreased frequency.
D. increased frequency.
2. Although adolescents have physical appearance and organ structure and function
similar to that of adults, the nurse understands that their bodies continue to grow,
requiring the nurse to follow increased vigilance in monitoring what?
A. Therapeutic and toxic drug levels
B. Side effects of medications
C. Route of medication administration
D. Frequency of medication administration
4. Drug calculations for children are based on which factors? (Select all that apply.)
A. Sex
B. Age
C. Weight
D. Height
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POST TEST
1. Only half of all drugs carry federally approved indications for use in ________
2. Lack of maturation of the ________is most pronounced in infancy making the neonatal
and infancy periods those most affected by changes in absorption physiology.
3. Gastric pH is ______ at birth.
4. When does acid production begin ___________.
5. When does gastric acid secretion reach adult levels? ______________
6. Breast fed infants have faster _______ emptying than formula fed infants
7. Drug distribution is affected by ____________________________
8. ________molecules may bind with protein receptor sites, which makes the sites
unavailable to drugs or displaces drugs from binding sites, allowing large amounts of
drug to remain free and available for effect which can result in toxic effects.
9. The __________barrier in neonates is relatively immature and allows drugs to pass
easily into central nervous system (CNS) tissue.
10. Infants have reduced _______________ and ________________ however by the time
they reach 1 year of age hepatic flow has reached that of an adult; however drug-
metabolizing enzymes reach an adult level at around age 11.
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CHAPTER 4
Geriatric Considerations
Learning Objectives:
At the end of the course, level IIstudents will be able to:
1. Explain how the physiologic changes associated with aging impact drug therapy.
2. Discuss issues that affect older adults' adherence to the therapeutic regimen.
3. Formulate a nursing process related to drug therapy in older adult.
Drug dosage
Based on the patient’s weight, lab results (e.g. liver enzymes & GFR), and co-morbid
health problems.
Pharmacokinetics
Absorption
- decrease in small bowel surface area, slowed gastric emptying reduces gastric blood
flow and gastric acid production
- swallowing difficulties
- poor nutrition
- dependence on tubes feeding
Distribution
- Increase in body fat means lipid soluble drugs have a greater volume of
distribution, increased drug storage, reduced elimination, & a prolonged period of
action
- decreased albumin levels affect distribution of drugs resulting to a decreased
protein binding, increases free drug availability to exert therapeutic effects and the
risk for drug toxicity
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Metabolism
- a decrease in liver size can lead to decreased hepatic blood flow may be by 40% as
and reduction of CYP450 (enzyme responsible for drug breakdown)
- reduction of hepatic metabolism can prolong drug half life, resulting in increased drug
levels and increased risks for drug toxicity
Excretion
- excretion of drugs decreases with age due to decreased renal size and volume
- alteration in the kidney function affect many drugs, leading to a prolonged half life and
elevated drug levels
Pharmacodynamics
- Older adults experience a loss of sensitivity in adrenergic receptors, both agonists and
antagonists, leading to beta blockers and beta 2 agonists reduced response.
- diminished dopaminergic & cholinergic receptors, neurons, & available nerual
connection.
- decreased blood flow to the brain and the blood brain barrier becomes more
permeable, this puts older adults at risk for CNS drug side effects including dizziness,
seizures, confusion, sedation, & extrapyramidal effects
Polypharmacy
- polypharmacy is the use of more meds than medically necessary
- can cause an increase in geriatric syndromes such as cognitive impairment, falls,
decreased functional status, urinary continence, & poor nutrition, as well as an
increased incidence of adverse drug reactions and poor adherence.
Risk factors
- advanced age
- female sex
- multiple HCP
- use of herbal therapies
- OTC drugs
- multiple chronic diseases
number of hospitalizations and care transitions
- Blood thinners, drugs used to treat DM & seizures, cardiac drugs, & pain control
meds can produce common adverse drug events like adverse drug reactions,
medication errors, therapeutic failures, adverse drug withdrawal events, overdose
causing most consultations and hospitalizations.
Factors that enhance educational readiness and promote adherence in the older adult?
- ensure that the patient has on their glasses and working hearing aids if needed
- speak in a tone of voice that the patient can hear, sit facing the patient, limit
distractions
- treat the patient w/ respect
- use large print w/ dark print on a light background with an easy to read font
- review all meds with each visit
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POST TEST
Practice Question #1
When administering medications to the older adult population, the nurse is aware that the
physiologic changes of aging that can affect drug activity include all of the following except
A. increased fat-to-water ratio.
B. decreased liver enzyme production.
C. loss of nephrons.
D. increased gastrointestinal blood flow.
Practice Question #2
Adverse reactions and drug interactions occur frequently in older adults due to all of the
following except
A. consumption of numerous drugs owing to multiple chronic illnesses.
B. drugs ordered by several health care providers.
C. increased incidence of allergic responses.
D. self-medication with OTC preparations.
Practice Question #3
Older adults are at risk for taking many medications together. This is known as
A. tachyphylaxis.
B. drug interaction.
C. polypharmacy.
D. tolerance.
Practice Question #4
Which is a physiologic change seen in the older adult that has an effect on drug
administration?
A. Lower (acidic) gastric secretions
B. Increased first-pass effect through the liver
C. Increased glomerular filtration rate
D. Lower cardiac output
Practice Question #5
When assessing older adults’ renal function, which laboratory value will the nurse
monitor?
A. Liver enzymes
B. Serum electrolytes
C. Complete blood count
D. Blood urea nitrogen and creatinine
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PHARMACOLOGY
CHAPTER 5
Cultural Considerations
Illness can be caused by spirit possession Loss of balance within body Healing
techniques are based on: Astrology Magic Rituals Indigenous medicinal compounds
Conventional healers: play a role in practices which includes priests shamans, bone
setters, herbalists, curanderos midwives, rituals: used to seek assistance of otherworldly
forces (deities or spirits)
Pharmacogenetics The study of all the different genes that determine drug behavior
within the human body Culturally competent care integrates pharmacogenetics with social
and cultural attributes of the patient Helps predict drug responses
Transcultural Nursing Nurses must be sensitive to the beliefs and practices of immigrant
and indigenous groups concerning health and illness It is important to know what
pharmacotherapeutic agents the patient is using Patients may not reveal information and
assume that teas, herbs, etc. are not drugs
Assimilation: ex: minority group changes its ways to blend in with the dominant cultural
group Complementary health therapies: combine traditional and conventional Western
health practices Nurses should not make generalizations about beliefs or behaviors
according to their cultural group
Alternative health therapies: when a dominant culture group borrows traditional therapy
in place of conventional therapy. Acupuncture, acupressure, teas, herbs, and therapeutic
massages more popular in proving pain relief
The Giger and Davidhizar Transcultural Assessment Model Six cultural phenomena:
Communication Space Social organization Time Environmental control Biologic variation
This model is constantly reviewed to make sure that it maintains its relevance and
usefulness
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PHARMACOLOGY
Social Organization Family basic social units The definition of family and how inclusive
it is varies among individuals and among cultures American and Western European
descent: small, nuclear families Other cultural groups in the US: larger, extended families
Nurses must advocate for inclusion of family in health care settings. Limit or extend the
amount of time a patient can visit with members of a social group
Time Nurses and patients may have different perceptions of time. It moves slowly for
patients who is anxious Time moves quickly for a nurse with a demanding workload.
Vague terms regarding time (ie soon, about, or later) have different meanings among
individuals and groups Linear time: present flows into the future and is irretrievably lost
must do this Circular time: the present has more stability and the need to do things at a
particular moment has less urgency will have the opportunity to do this Cultural aspect of
time is important when it comes to dosing more than once a day. Patients with this
perception of time usually stop prescriptive therapies once they start feeling better
Environmental Control Some cultures have a desire to enlist the assistance of nature
to facilitate the needs of human beings may include otherworldly forces or beings (deities
and spirits) Healers and spiritual advisors can be beneficial in health care settings
Practice of clergy (ministers, priests, rabbis) In systems like The Indian Health and Human
Services and the Canadian health care system, traditional healers and spiritual guides
are incorporated into conventional prescriptive therapies
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PHARMACOLOGY
Pharmocogenetics
the effect of a drug varies from the predicted response because of genetic factors
Ethnopharmacology
Study of a drug responses unique to an individual as a result of social, cultural, and
biological phenomena
Culture
Learned beliefs shared by a group of people
Ethnomedicine
ways different cultures conceptualize health and illness
Polymorphisms
DNA variants that occur within a specific population at a frequency greater than 1%
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PHARMACOLOGY
POST TEST
2. Which ethnic or cultural group may experience decreased effects from codeine?
A. African descent
B. Latin American descent
C. Asian Descent
D. Native American descent
4. The pt, who is Jamaican, is currently 4 months pregnant and informs the nurse during
a prenatal visit that she eats red clay to provide nutrients to the fetus. She states that
this is a practice her grandmother told her would ensure a health pregnancy. What is
the best action by the nurse?
A. contact Child Protective Services
B. Insist that the patient stop practice immediately.
C. Determine the amount of clay that she eats daily.
D. Discuss the research about dietary intake of clay.
5. The older adult patient is newly diagnosed with diabetes and has been prescribed
metformin. The patient 's healer has recomended that the patient drink sabila tea 3
times per day to improve nutrition and help control blood sugar lvl. What is the nurse's
best action?
A. encourage the patient to drink the tea 4 times per day instead
B. Discourage the practice because sabila tea potentiates metformin.
C. Tell the patient to stop the tea immediately.
D. Advise the patient he can continue to drink the tea, but he also needs to continue
his drugs.
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PHARMACOLOGY
9. The nurse has been measuring the blood pressure of an African American pt every 4
hours for the past 3 days in a hospital setting. The BP is consistently above 140/90.
The pt has been adherent to the antihypertensive drug therapy while hospitalized. The
Nurse will initially preform which action?
A. Determine if the patient has been given high sodium foods from visitors.
B. Withhold the antihypertensive drug until the physician can be notified.
C. BP measurements every 2 hours
D. Place the patient on a restricted fluid intake.
10. A male nurse is caring for a young married woman who is an observant muslim. It is
important that the nurse initially Perform which action?
A. Delay any care that requires touching until a female nurse is available.
B. Identify the patient 's preference regarding touch.
C. Touch the patient only when her spouse is present.
D. Inform the patient that she must allow him to touch her.
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PHARMACOLOGY
CHAPTER 6
Complementary & Alternative Therapies
Learning Objectives:
At the end of the course, level II students will be able to
1. Identify at least six common herbs, its use and toxicities if any.
2. Describe recommendations for labels on herbal products,
3. Analyze the potential hazards of herbs.
Complementary and Alternative therapies
- augment or replace traditional medical therapies usually not prescribed, which include
botanicals, nutritional products, herbal supplements, CAM: complementary and
alternative medicines
-
NCCIH
- National Center for Complementary and Integrative Health provided researcher of
complementary and alternative health
DSHEA
- Dietary Supplement Health and Education Act ensure products are safe and labeled
information is truthful
CGMPs
Current Good Manufacturing Practices are standards that require package labels that
declare quality and strength of contents and that product is without contaminants and
impurities
Botanicals
additive substances that come from plants
Herbs
any plant that is used for culinary or medical purposes
Phytomedicine
therapeutic value of plants
Herbal preparations
- Decoction - Poultice
- Infusion - Essential oils
- Tinctures - Herb-infused oils
- Liniment - Percolation
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PHARMACOLOGY
Astragalus
- Boosts immune system for things such as hepatitis and cancer
- Limits cold and flu symptoms
* may interact with drugs like cyclosporine because it will alter immune function
Chamomile
- Relief of anxiety, sleeplessness, digestive complaints, skin conditions, and oral
ulcers
- May have sedative effects
- Allergic reactions of urticaria and bronchoconstriction are more likely if person is
allergic to daisy or ragweed
Cinnamon
- Used to treat bronchitis, GI problems, anorexia and diabetes
- Generally safe without allergic reactions
- May decrease blood clotting
Echinacea
- Used for colds, flu, infections and skin problems such as acne
- Stimulates immune system
Garlic
- lowers cholesterol, decreases blood pressure and reduces heart disease, prevent
stomach and colon cancer
* Side Effects: heartburn, upset stomach, body odor, decreased blood clotting
Ginger
- post-op, pregnancy related nausea, motion sickness & diarrhea; relief from pain,
swelling and arthritic stiffness
Ginkgo Biloba
- asthma, bronchitis, fatigue, tinnitus
- improves memory, decrease intermittent claudication, prevents Alzheimers
- Treats sexual dysfunction, multiple sclerosis
Ginseng
- Boosts immune system, increases stamina and increase person's sense of well being;
stress relief, digestion
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PHARMACOLOGY
Hawthorn
- heart disease, digestive issues and kidney disease
**may interact with erectile dysfunction drugs which can lead to hypotension,
nitrates (dizziness), and antihypertensives (hypotension)**
Licorice
- bronchitis, sore throat, stomach ulcers, viral hepatitis
*large amounts: elevates BP, salt and water retention and lowers potassium levels
Milk thistle
- cirrhosis, chronic hepatitis, gallbladder disorders, elevates cholesterol & insulin
resistance with type 2 diabetes
Peppermint
- nausea, indigestion, irritable bowel syndrome, cold symptoms, headaches, muscle
and nerve pain
Turmeric
- heartburn, stomach ulcers, gallstones, inflammation, cancer
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PHARMACOLOGY
Valerian
- anxiety, headache, insomnia, tremors, depression and irregular heartbeat
* Side Effects: headache, dizziness, fatigue, stomach upset
Assessment
o obtain baseline of patient's use of complementary and alternative therapies
o identify all prescription and Over The Counter(OTC) drugs and when it is taken
Nursing Diagnosis
- Knowledge Deficit related to cognitive limitation, misinterpretation of available
information/resources, lack of interest in learning
Planning
- The patient and family will verbalize understanding of herbal therapy, prescription
and OTC drugs;
- The patient and family will participate in the therapeutic regimen
Interventions
- Provide information supportive of self management and mutial goal setting.
- Monitor patient's response to prescription, OTC, and herbal therapies
- Encourage to engage in the care planning process.
- Cultural Considerations
Evaluation
- Evaluate adherence to therapeutic regimen
- Evaluate drug-herb interaction or side effects
- Evaluate the anticipated effectivity of herbal remedies for relieving symptoms.
The following are the 10 Medicinal Plants in the Philippines endorsed by DOH:
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PHARMACOLOGY
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PHARMACOLOGY
CHAPTER 7
Drug in Substance Use Disorder
Learning Objectives:
At the end o the course, level II students will be able to:
1. Define the substance abuse.
2. Identify the physical and psychological assessment findings related to most
commonly used drugs.
3. Describe the nursing interventions during drug toxicity and withdrawal.
Most drugs are used safely and within the prescribed guidelines, but in some cases and
for some reasons, drugs can be misused and abused.
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PHARMACOLOGY
Naloxone
Naltrexone
Methadone
Buprenorphine
Tobacco use disorder
➢ Short-term effects
➢ Long-term effects
➢ Treatment
• Cognitive behavior therapy
• Self-help materials
• Telephone-based counseling
• Drug-assisted treatment
Nicotine replacement drugs
Bupropion
Varinicline
• Electronic cigarettes
Cough and cold products
➢ Dextromorphan
• Psychoactive in high doses
➢ Promethazine-codeine
• Effects: euphoria, dissociation, hallucinations, relaxation
➢ Side effects
Anabolic-androgenic steroids
➢ Short-term effects
➢ Long-term effects
➢ Treatment
• Antidepressants
• Behavioral therapy
Special Needs of Patients With Substance Use Disorder
Surgical patients
➢ High-risk problems
• Drug interactions
• Postoperative complications
• Death
➢ Assess for drug use and screen for alcohol misuse
Surgical patients
➢ Postoperative period
• Monitor for signs and symptoms of drug interactions with pain
medications/anesthesia.
• Monitor for withdrawal.
➢ Adverse effects
• Delirium, delirium tremens
• Seizures
• Withdrawal syndrome
Pain management for patient with substance use disorder
➢ Treat patient with dignity and respect.
➢ Pain is a higher priority than substance use disorder.
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PHARMACOLOGY
Contributing factors
➢ Job stress, emotional demands of nursing, long hours and shift rotation,
easy access to drugs.
Characteristics
➢ Changes in personality behavior, tardiness in the workplace, incompetence,
illogical documentation
Management
➢ Non disciplinary programs designed for evaluation and treatment
NursingProcess:
Tobacco Use Disorder
Assessment
➢ Assess current smoking status and smoking history.
➢ Determine willingness of patient to attempt to quit.
➢ Identify patient’s locus of control.
Nursing diagnoses
➢ Health maintenance, ineffective related to the presence of adverse personal
habits (smoking)
➢ Powerlessness related to perceived lack of control over ability to give up
nicotine.
Planning
➢ Patient begins to identify ways to achieve control over nicotine use.
➢ The patient identifies and uses available resources.
➢ The patient demonstrates positive health maintenance behaviors as
evidenced by keeping scheduled appointments and participating in a
tobacco cessation program.
Nursing interventions
➢ Advise patient to keep list of “slips” and “near-slips” to learn to avoid their
causes.
➢ Assist patient with problem solving.
➢ Encourage patient to avoid environments and activities previously
associated with smoking.
Evaluation
➢ To prevent relapse, evaluate the cessation of plan including support system,
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PHARMACOLOGY
Practice Test
1. A patient who smoked 1 pack of cigarettes a day for 2 years abruptly stopped
smoking 2 days ago. The nurse performing an assessment on the patient identifies
manifestations of nicotine withdrawal as including
A. increased appetite and blood pressure.
B. restlessness and increased blood pressure.
C. depression and decreased blood pressure.
D. nausea, confusion, and seizures.
3. A patient with a known opioid addiction is to have surgery. In planning the patient’s
postoperative pain management, the nurse will
A. withhold opioid medications.
B. treat the addiction before managing pain.
C. provide pain management as needed.
D. anticipate that the patient will experience less pain.
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PHARMACOLOGY
UNIT II
PHARMACOTHERAPHY AND DRUG ADMINISTRATION
CHAPTER 8
The Nursing Process and Patient - Centered Care
Learning Objectives:
At the end of the course, the level II students will be able to:
1. Discuss the guidelines in relation to safe drug administration.
2. Describe the steps in nursing process and its importance in drug administration.
3. Analyze the roles of the nurse before, during and after drug administration.
Nursing Process
Five-step decision-making approach
➢ Assessment
➢ Diagnosis
➢ Planning
➢ Implementation
➢ Evaluation
Assessment
Subjective data
➢ Current health history
➢ Patient signs and symptoms
➢ Current medications and concerns
➢ Allergies
➢ Financial barriers
➢ Tobacco, alcohol, and caffeine use
➢ Cultural dietary barriers
➢ Home safety needs
➢ Caregiver needs and support system
Objective data
➢ Physical health assessment
➢ Laboratory and diagnostic test results
➢ Physician’s notes (health history)
➢ Measurement of vital signs
➢ Patient’s body language
Nursing Diagnoses
➢ Pain, acute related to post operative wound.
➢ Confusion, acute related to adverse reaction to medication
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PHARMACOLOGY
Planning
Effective goal-setting characteristics
➢ Patient centered
➢ Realistic and measurable
➢ Reasonable deadlines
➢ Acceptable to both patient and nurse
➢ Dependent on patient’s decision-making ability
➢ Shared with other health care providers, family, and caregivers
➢ Identifies components for evaluation
Implementation
➢ Education
➢ Drug administration
➢ Patient care
➢ Interventions needed for established goals
Patient teaching
➢ General
➢ Side effects
➢ Self-administration
➢ Diet
➢ Cultural considerations
Evaluation
➢ Determine if goals were met.
➢ Determine if teaching objectives were met.
➢ Determine need for follow-up.
➢ Refer to community resources.
➢ Document successful goal attainment.
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PHARMACOLOGY
Practice TEST
Which information will the nurse include in the patient teaching? (Select all that apply.)
A. Cost of drugs
B. Administration technique
C. Instructions regarding drug discontinuation
D. Foods to avoid when taking a certain drug
E. Side effects to report to health care provider
What is the first step of the nursing process when working with patients receiving drug
therapy?
A. Assessment
B. Planning
C. Implementation
D. Evaluation
Before information about drug therapy is presented to a patient, it is most important for
the nurse to
A. determine the patient’s reading level.
B. plan the number of teaching sessions.
C. assess the patient’s readiness to learn.
D. tell the patient that he or she must comply with the drug therapy.
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PHARMACOLOGY
CHAPTER 9
Safety and Quality
Learning Objectives:
At the end of the course, level II students will be able to:
1. Identify the rights in medication administration, including the nurses’rights
2. Analyze the safety risks with drug administration.
3. Discuss the safe waste disposal.
“Five-Plus-Five Rights” of
Medication Administration
Rights of medication administration
➢ Right patient
➢ Right drug
➢ Right dose
➢ Right time
➢ Right route
Five additional rights
➢ Right assessment
➢ Right documentation
➢ Patient’s right to education
➢ Right evaluation
➢ Patient’s right to refuse
Right patient
➢ Two forms of identification required
Right drug
➢ Order must be prescribed by licensed health care provider.
➢ Drug label must be read three times.
➢ Nurse should be familiar with patient’s health record, allergies, lab results,
and vital signs.
➢ Nurse should know why the patient is receiving medication.
Right dose
➢ Nurse should check dosage calculation.
Right time
➢ Use health care agency policy.
➢ Use of military time reduces errors.
“Five-Plus-Five Rights” of
Right route
➢ Necessary for adequate absorption.
➢ Assess patient’s ability to swallow oral medication.
➢ Do not crush or mix medications without properly consulting pharmacist or
reliable drug source.
➢ Check if patient is scheduled for diagnostic procedures or dialysis.
➢ Administer antibiotics at even intervals throughout the day to maintain
therapeutic drug levels.
➢ Offer patient water but not juice (iron may be taken with orange juice).
Nurse’s Responsibilities of
Medication Administration
Right assessment
➢ Collect appropriate baseline data before drug administration.
• Health history, allergies, vital signs, lab results
Right documentation
➢ Record drug administration immediately.
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PHARMACOLOGY
Right evaluation
➢ Determine drug effectiveness.
➢ Determine side effects and adverse drug reactions.
Right to refuse
➢ Nurse should explain risks involved.
➢ Nurse should reinforce reasons and benefits of the drug.
➢ Nurse should document refusal immediately.
➢ Follow-up is required.
Drug reconciliation
➢ Develop an accurate list of current medications.
➢ Advise patient to always carry a list of personal drug information in the case
of emergency.
➢ Advise patient to update drug list whenever a change occurs.
➢ Advise patient to bring a list of medications to each doctor appointment.
Disposal of medications
➢ Follow specific information on drug label or insert.
➢ Transfer drug from original container to undesirable substance (i.e., kitty
litter).
➢ Place mixture in container (i.e., sealed plastic bag).
➢ Remove all identifying information on label before disposing of empty
container.
➢ Do not flush drugs down toilet unless specifically instructed.
➢ Return drugs to community “drug take-back” program.
45
PHARMACOLOGY
Sharps safety
➢ The Occupational Safety and Health Administration (OSHA) Needlestick
Safety and Prevention Act of 2000
➢ The Consensus Statement and Call to Action (2012)
Dosage forms
➢ Always consult pharmacist, health care provider, or reliable drug source
regarding crushing a drug.
➢ Do not crush extended- or sustained-release drugs.
High-alert medications
➢ Can cause significant harm if given in error
➢ Examples: Epinephrine, insulin, opium tincture, nitroprusside, potassium
chloride injection concentrate, heparin, warfarin
Resources
➢ The Institute for Safe Medication Practices (ISMP) provides accurate
medication safety information.
➢ FDA database of medication errors helps identification, implementation,
evaluation strategies to prevent medication errors.
➢ Drug reference book, pharmacist, or acceptable technology resource
➢ FDA MedWatch Program
➢ http://www.fda.gov/safety/medwatch/default.htm
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PHARMACOLOGY
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PHARMACOLOGY
Practice Test
The nurse is required to chart the patient’s response to all of the following groups of
medications except
A. opioids.
B. antiemetics.
C. sedatives.
D. antihyperlipidemics.
A nurse reads the following order: “Take one multivitamin qod.” The nurse will
A. administer 1 multivitamin every morning.
B. give the patient 1 multivitamin every other day.
C. call the prescriber to clarify the order.
D. refuse to administer the multivitamin and document it as not administered.
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PHARMACOLOGY
Chapter 10
Drug Administration
Learning Objectives:
At the end of the course, students will be able
1. Identify the various routes of administration.
2. Analyze the nursing interventions associated with the different routes of
administration.
3. Apply the nursing process to the drug administration.
:
Self-administration in medication
➢ Institute for Safe Medication Practices provided the Free booklet: “Your
Medicine: Play It Safe” (https://www.ismp.org/consumers/safemeds.pdf)
➢ Oral
• most common and convenient
• Tablets, capsules; liquids, suspensions, elixirs
• not given for clients who are vomiting
• enteric coated should not be crushed
➢ Transdermal, topical
• stored in a patch placed and absorbed on a skin to produce a
systemic effect.
• can be left in place for 12hrs or 7 days depending on the drug.
• sites should be rotated to avoid skin breakdown.
➢ Instillation
• liquid drugs usually given as Drops, sprays, ointments
➢ Inhalation
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PHARMACOLOGY
➢ Suppositories
• solid medical preparation cone or spindle shaped for rectal insertion
➢ Parenteral
Eye ointment
50
PHARMACOLOGY
Eardrops
51
PHARMACOLOGY
Suppositories
➢ Vaginal
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PHARMACOLOGY
Intradermal
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PHARMACOLOGY
Subcutaneous
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PHARMACOLOGY
Intramuscular
➢ Ventrogluteal
Intramuscular
➢ Deltoid
55
PHARMACOLOGY
Intramuscular
➢ Vastus lateralis
Intramuscular
➢ Z-track injection
56
PHARMACOLOGY
• Technological Advances
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PHARMACOLOGY
Nursing diagnoses
- Risk for injury related to possible drug reaction
- Readiness for Enhanced learning management related to medication regimen
Planning
- Promote therapeutic response thus preventing or minimizing adverse reaction.
- Promote adherence to drug regimen
Nursing interventions
➢ Verify the patient using two identifiers
➢ Assess for history f allergy
➢ Compute for the right dose, verify with another nurse
➢ Check drug label 3x, rights in giving medication
➢ Do not give what you do not prepare
➢ Assist in proper position
➢ Discard the needles ang syringes in needlestick container, do not recap
➢ Health teaching
➢ Cultural considerations
Evaluation
- Evaluate the drug effectiveness
- Identify the expected time frame of the desired outcome.
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PHARMACOLOGY
POST TEST
1. An 18-year-old has an external ear infection to be treated with eardrops. The nurse
correctly instructs the patient to angle the ear
A. down and back.
B. up and out.
C. down and forward.
D. up and forward.
4. The Z-track method is the preferred method of administration for which drug?
A. Vitamin B12
B. Iron dextran
C. Penicillin
D. Morphine
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PHARMACOLOGY
Chapter 11
Drug Calculations
Learning Objectives:
At the end of the course, level 2 students will be able to:
1. Discuss the metric and household system of management
2. Convert larger units to smaller units ad smaller units to larger units within the metric
and household system.
3. Convert between metric and household measurement.
Metric system
➢ Gram =
➢ Liter
➢ Meter
Household system
➢ Not as accurate as metric system
➢ 1 teaspoon = 5 mL
➢ 3 teaspoons = 1 tablespoon
➢ 2 tablespoons = 1 ounce
Interpreting drug labels
➢ Trade name
➢ Generic name
➢ Drug amount
➢ Lot number
➢ Expiration date
➢ Proper storage
➢ Whether it is a controlled substance
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PHARMACOLOGY
Methods of calculation
➢ Body weight
➢ Convert pounds to kilograms, 2.2 lb = 1 kg
➢ Drug dose X body weight = patient’s dose
Method 5: Body Weight
D (desired) × kg × 1 day or dose =
Order: Cipro 20 mg × kg × day in 2 divided doses
Patient’s weight: 88 pounds (88 lb ÷ 2.2 = 40 kg)
Available: Cipro 100 mg/mL in oral suspension
20 mg × 40 kg × day = 800 mg/day or 400 mg/dose
Give: 4 mL of oral suspension of Cipro.
Methods of calculation
➢ Body surface area
➢ Find body surface area on the West Nomogram.
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PHARMACOLOGY
➢ Syringes
➢ Vials and ampules
Intravenous therapy
➢ Methods of IV administration
• Intermittent bolus, IV push, IV piggyback, primary IV fluid
➢ IV administration sets
➢ Secondary IV administration sets
➢ Intermittent infusion adapters and devices
➢ Electronic infusion devices
• IV pumps, patient-controlled analgesia, syringe pumps
➢ Safety considerations for IV infusions
• Infiltration
• Free flow rate
1
125 mL x 10 gtt/mL = 125 = 20.8 or 21 gtt/min
60 min 6
6
Calculating intravenous flow rate: drops per minute
➢ Nurse must calculate gtts/min.
Calculating Intravenous Flow Rate: Drops Per Minute (Cont.)
Amount of solution × gtt/mL (IV set) = gtt/min
minutes to administer
Order: ticarcillin (Ticar) 500 mg, IV, q6h
Available: Ticar 1 g (add 4 mL of diluent)
Set and solution: calibrated cylinder, drop factor: 60 gtt/mL
Instruction: dilute drug in 75 mL of D5W and infuse over 40 min.
3
75 mL × 60 gtt/mL = 225 = 112.5 or 113 gtt/min
40 min to admin 2
2
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PHARMACOLOGY
Practice Test
A nurse is adding up a patient’s intake and output. Intake includes 180 mL of coffee, 4
ounces of gelatin, a 12-ounce can of soda, and 120 mL of water. The intake totals
A. 540 mL.
B. 700 mL.
C. 780 mL.
D. 880 mL.
A patient is to receive 100 mL of a fluid bolus over 2 h. The drip factor for the IV set is 15
gtt/mL. At what rate should this bolus be administered?
A. 12.5 gtt/min
B. 25 gtt/min
C. 30 gtt/min
D. 50 gtt/min
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PHARMACOLOGY
CHAPTER 12
TYPES OF INTRAVENOUS SOLUTION
Fluid Volume and Electrolytes
Homeostasis
Maintenance of proper equilibrium
➢ Intracellular fluid
➢ Extracellular fluid
• Interstitial compartment
• Intravascular compartment
• Transcellular compartment (third-space)
Fluid Volume and Electrolyte Replacement
Osmolality of body fluids
➢ Isoosmolar
➢ Hypoosmolar
➢ Hyperosmolar
Tonicity
➢ Measurement of concentration of IV solutions compared with osmolality of
body fluids
Homeostasis
➢ Anions and cations balanced
➢ Fluid compartments in osmotic equilibrium
➢ Fluid and particle movement
• Osmosis
• Diffusion
• Hydrostatic pressure
• Active transport
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PHARMACOLOGY
➢ Surgery
Types of IV solutions
➢ Crystalloids
• Isotonic
• Hypotonic
• Hypertonic
➢ Colloids
➢ Blood and blood products
➢ Lipid emulsion
Crystalloids uses
➢ Short-term maintenance therapy
➢ Treat dehydration and electrolyte imbalance
➢ May be isotonic, hypotonic, hypertonic
Examples
➢ Dextrose5 in water (D5W)
• Isotonic (unless continuous or rapid)
➢ Normal saline solution (0.9% NSS)
• Isotonic solution
➢ Lactated Ringers
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PHARMACOLOGY
➢ Assess patient’s vital signs, lab values, and note baseline values
Nursing diagnoses
➢ Fluid volume, deficient related to fluid loss, and/or inadequate fluid intake
➢ Fluid volume, deficient related to altered regulatory mechanisms, and
excess fluid or sodium intake
Planning
➢ The patient will exhibit balanced fluid volume.
➢ The patient will have balanced intake and output over 24-hour period.
Nursing interventions
➢ Ensure prescribed amount of IV fluid infuses hourly.
➢ Monitor for signs and symptoms of fluid volume deficit.
Evaluation
Fluid Volume and Electrolyte Replacement
Electrolytes
➢ Potassium
• Major intracellular cation
➢ Sodium
• Major ECF cation
➢ Calcium
➢ Magnesium
➢ Chloride
➢ Phosphorus (phosphate)
Electrolyte functions
➢ Transmission and conduction of nerve impulses
➢ Contraction of cardiac, skeletal, and smooth muscles
➢ Normal kidney function
➢ Change carbohydrates to energy
➢ Change amino acids to protein
➢ Role in acid–base balance
➢ Regulates osmolality of cellular fluids
Potassium normal serum range
➢ 3.5 to 5.0 mEq/L
Functions
Hypokalemia
➢ Less than 3.5 mEq/L
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Practice Test
1. Which are manifestations of hypocalcemia? (Select all that apply.)
A. Twitching of the mouth
B. Seizures
C. Urinary retention
D. Carpopedal spasms
2. Which foods would not be recommended for a patient who needs to eat a diet
high in potassium?
A. Dried fruits
B. Bananas and plums
C. Broccoli and peanut butter
D. Eggs and whole-grain breads
3. A patient sustains a significant blood loss secondary to a trauma. The nurse
anticipates using which fluid to best replace the losses?
A. Crystalloids
B. Colloids
C. Blood products
D. Lipids
4. A patient is noted to have a serum potassium level of 5.6 mEq/L. The first action
the nurse would anticipate would be to
A. provide IV hydration to dilute the potassium.
B. administer sodium polystyrene sulfonate (Kayexalate).
C. institute potassium restriction.
D. administer a potassium-wasting diuretic.
5. A nurse is caring for a patient who was admitted with multiple fractures and
hypercalcemia. Which symptom would the nurse expect to find during an
assessment of the patient with hypercalcemia?
A. Tetany
B. Flabby muscles
C. Irritability
D. Anxiety
6. What is probably the most undiagnosed electrolyte deficiency?
A. Hypokalemia
B. Hypocalcemia
C. Hypomagnesemia
D. Hyponatremia
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Unit III
Drugs Affecting the Body System
CHAPTER 13
• The autonomic nervous system (ANS), also called the visceral system, acts on
smooth muscles and glands.
• Its functions include control and regulation of the heart, respiratory system,
gastrointestinal tract, bladder, eyes, and glands.
• The ANS is an involuntary nervous system over which we have little or no
control. We breathe, our hearts beat, and peristalsis continues without us
realizing it.
• However, unlike the ANS, the somatic nervous system is a voluntary system
that innervates skeletal muscles over which there is control.
The two sets of neurons in the autonomic component of the PNS are the:
(1) afferent (sensory) neurons - send impulses to the CNS, where they are interpreted.
(2) efferent (motor) neurons - receive the impulses (information) from the brain and
transmit these impulses through the spinal cord to the effector organ cells.
• The efferent pathways in the ANS are divided into two branches:
A. sympathetic nervous system - also called the adrenergic system
(norepinephrine – neurotransmitter)
4 adrenergic receptors are
1. alpha 1 3. beta 1
2. alpha 2 4. beta 2
Objective:
⚫ Identify the general indications of adrenergic agonists and adrenergic antagonists
⚫ Differentiate the side effects of adrenergic agonists and adrenergic antagonists
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⚫ Analyze the nursing interventions and health teachings to patient associated with
adrenergic agonists and antagonists
⚫ Create a nursing process for the patient taking beta adrenergic agonist
ADRENERGIC AGONISTS
⚫ Drugs that stimulate the sympathetic nervous system are called adrenergics,
adrenergic agonists, or sympathomimetics because they mimic the sympathetic
neurotransmitters norepinephrine and epinephrine.
⚫ They act on one or more adrenergic receptor sites located in the effector cells of
muscles, such as the heart, bronchiole walls, gastrointestinal (GI) tract, urinary
bladder, and ciliary muscle of the eye. There are many adrenergic receptors. The
four main receptors are alpha1, alpha2, beta1, and beta2, which mediate the
major responses.
• The alpha-adrenergic receptors are located in blood vessels, eye, bladder, and
prostate.
• When the alpha1 receptors in vascular tissues (vessels) of muscles are stimulated:
o the arterioles and venules constrict, increasing peripheral resistance and
blood return to the heart.
o Circulation is improved, and blood pressure is increased.
o When there is too much stimulation, blood flow is decreased to the vital
organs.
• The alpha2 receptors are located in the postganglionic sympathetic nerve
endings. When stimulated:
o inhibit the release of norepinephrine,→vasodilation →decrease in blood
pressure
• The beta1 receptors are located in the kidney but primarily in the heart. When
stimulated:
o increases myocardial contractility and heart rate.
• The beta2 receptors are found mostly in the smooth muscles of the lung,
gastrointestinal tract, the liver, and the uterine muscle. Stimulation causes:
o relaxation of the smooth muscles of the lungs, resulting in bronchodilation;
o a decrease in gastrointestinal tone and motility;
o activation of glycogenolysis in the liver and increased blood glucose; and
o relaxation of the uterine muscle, resulting in a decrease in uterine contraction
• Another adrenergic receptor is dopaminergic and is located in the renal,
mesenteric, coronary, and cerebral arteries (Only dopamine can activate this
receptor). When this receptor is stimulated:
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The figure shows sympathetic responses. Stimulation of the sympathetic nervous system
or use of sympathomimetic (adrenergic agonist) drugs, can cause the pupils and
bronchioles to dilate; heart rate to increase; blood vessels to constrict; and muscles of the
gastrointestinal tract, bladder, and uterus to relax, thereby decreasing contractions.
(Pharmacology book 9th edition)
Inactivation of Neurotransmitters
After the neurotransmitter (e.g., norepinephrine) has performed its function, the action
must be stopped to prevent prolonging the effect. Transmitters are inactivated by:
• reuptake of the transmitter back into the neuron (nerve cell terminal)
• enzymatic transformation or degradation, and
• diffusion away from the receptor.
The two enzymes that inactivate norepinephrine are:
• monoamine oxidase (MAO), which is inside the neuron
• catechol-O-methyltransferase (COMT), which is outside of the neuron.
The action of the neurotransmitter (e.g., norepinephrine) can be prolonged by either:
• inhibiting the norepinephrine reuptake, which prolongs the action of the
transmitter or
• inhibiting the degradation of norepinephrine by enzyme action
Classification of Sympathomimetics
Sympathomimetic drugs stimulate adrenergic receptors and are classified into three
categories:
1. direct acting sympathomimetics, which directly stimulate the adrenergic receptor
(e.g., epinephrine or norepinephrine)
2. indirect acting sympathomimetics, which stimulate the release of norepinephrine
from the terminal nerve endings (e.g., amphetamine)
3. mixed-acting sympathomimetics (both direct and indirect acting), which stimulate
the adrenergic receptor sites and stimulate the release of norepinephrine from
the terminal nerve endings (e.g., ephedrine, Pseudoephedrine)
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Example of adrenergic agonists that stimulate more than one of the adrenergic receptor
sites is
epinephrine (Adrenalin), acts on alpha1-, alpha 2-, beta1-, and beta2
Epinephrine
Pharmacokinetics Epinephrine can be administered:
• subcutaneously
• intravenously
• topically, or by inhalation
• intracardiac, and instillation methods.
• It is not given orally, because it is rapidly metabolized in the GI tract and liver
resulting in unstable serum levels.
Side Effects and Adverse Reactions Undesirable side effects occurs when the
adrenergic drug dosage is increased.
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Nursing interventions
• Monitor BP, heart rate, urine output.
• Report tachycardia, palpitations, tremors, dizziness, hypertension.
• Monitor IV site for infiltration.
• Prepare Antidote: phentolamine mesylate (Regitine)
• Avoid cold medicines and diet pills if hypertensive, diabetic, CAD, or dysrhythmic.
• Avoid adrenergics when breastfeeding.
• Avoid continuous use of adrenergic nasal sprays.
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•
half-life of the drug differs slightly according to the route of administration
o (oral route is 2.7 to 6 hours; inhalation route is 3.5 hours).
Pharmacodynamics - primary use of albuterol is to prevent and treat bronchospasm.
• Inhalation – 5 -15 min, onset of action is faster than with oral administration
• duration of action – 2 -6 hours same for both oral and inhalation preparations.
Therapeutic Effects/Uses
To treat asthma, bronchitis, for prophylaxis and treatment of bronchospasm
Mode of Action: Stimulates beta2-adrenergic receptors in the lungs, which relaxes the
bronchial smooth muscle, thus causing bronchodilation
Side Effects Tremor, dizziness, Adverse Reactions
drowsiness, nervousness, restlessness, Palpitations, tachycardia, hypertension,
agitation, anxiety, sweating, headache, infection, hyperglycemia, hypokalemia
nasopharyngitis, insomnia, weakness, Life-threatening: Cardiac dysrhythmias,
nausea, diarrhea, muscle cramps angioedema, bronchospasm, Stevens-
Johnson syndrome
*Pregnancy categories have been revised. See http://www.fda.gov/drugs/Development
Approval process/DevelopmentResources/Labelling/ucm093307.htm for more
information. A, adult; adol, adolescent; C, child; d, day; h, hour; GI, gastrointestinal;
inhal, inhalation; MAOI, monoamine oxidase inhibitor; MDI, metered-dose inhaler, PO,
by mouth; q4-6h, every 4 to 6 hours; qid, four times a day; min, minute; PB, protein
binding; t1/2, half-life; TCA, tricyclic antidepressant; tid, three times a day; UK,
unknown; y, year
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Assessment
• Determine the patient’s health history.
• Assess the patient’s drug history.
Nursing diagnosis
• Sleep pattern, disturbed related to the adverse drug effect of insomnia
• Knowledge, deficient related to drug administration
Planning
• Patient’s vital signs will be within acceptable range
• Patient’s will experience therapeutic effects by improved blood pressure and
breathing pattern
Nursing interventions
• Monitor IV site frequently when administering norepinephrine or dopamine
because extravasation of these drugs causes tissue damage and necrosis within
12 hours.
• Monitor ECG for dysrhythmias when adrenergic agonists are given IV.
• Explain that continuous use of nasal sprays or drops that contain an adrenergic
agonist may result in rebound nasal congestion.
Evaluation
• Evaluate the patient’s response to the administered adrenergic agonist
• Evaluate vital signs, and report abnormal findings
• Report possible drug-drug interactions.
2. Beta-Adrenergic Blockers
• Beta-adrenergic blockers, commonly called beta blockers, decrease heart rate,
and a decrease in blood pressure usually follows.
• Some beta blockers are nonselective, blocking both beta1 and beta2 receptors.
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• Not only does the heart rate decrease because of beta1 blocking, but
bronchoconstriction also occurs.
• Nonselective beta blockers (block both beta1 and beta2) should be used with
extreme
caution in any patient who has chronic obstructive pulmonary disease (COPD)
or asthma.
• Propranolol hydrochloride (Inderal) nonselective, was the first beta blocker
prescribed to treat:
o Angina
o cardiac dysrhythmias
o hypertension
o heart failure.
• A selective adrenergic blocker has a greater affinity for certain receptors. Its
Desired effect is to decrease pulse rate and blood pressure.
• Example of selective beta1 blocker
o atenolol (Tenormin)
o metoprolol tartrate (Lopressor)
• Intrinsic sympathomimetic activity (ISA) is the ability of certain beta blockers to
bind with a beta receptor to prevent strong agonists from binding to that receptor
producing complete activation.
• Nonselective beta blockers (block both beta1 and beta2) that have ISA include:
o Carvedilol
o Penbutolol
o and pindolol.
• The selective blocker (blocks beta1 only) that has ISA is
o Acebutolol – recommended for patients experiencing bradycar
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Adrenergic Neuron Blockers - drugs that block the release of norepinephrine from the
sympathetic terminal neurons are called adrenergic neuron blockers
Assessment
• Obtain baseline vital signs and electrocardiogram for future comparison.
• Determine the drugs that the patient currently takes.
• Report if any are diuretics, NSAIDs, digoxin, MAOIs, or CNS depressants.
• Obtain patient’s health history of depression, peptic ulcer, and heart failure may
result from taking an adrenergic neuron blocker, and these drugs could potentiate
preexisting conditions.
Nursing Diagnoses
• Decreased cardiac output related to hypotension and bradycardia
• Risk for falls related to dizziness
• Fatigue related to medication adverse effects
• Sexual dysfunction related to adverse effects of erectile and ejaculatory
dysfunction
• Noncompliance related to undesired adverse effects of erectile dysfunction
Planning
• Patient will adhere to the drug regimen.
• Patient’s vital signs will be within the desired range.
Nursing Interventions
• Monitor patient’s vital signs before and after drug administration.
• Report changes such as:
o marked decrease in blood pressure and heart rate.
o any complaints of excessive dizziness, lightheadedness, early morning
insomnia, mental depression, or chest pain.
• Assist patient with ambulation to avoid falls from orthostatic hypotension, common
with high doses.
• Note any complaint of stuffy nose, because vasodilation may result, and nasal
congestion can occur.
Patient Teaching
General
• Encourage patient to adhere to the drug regimen.
• Advise patient that therapeutic effects of reserpine may not occur for 2 to 3 weeks
after initiation of therapy.
Self-Administration
• Teach patient and family how to take pulse and blood pressure.
• Encourage patient to take reserpine at the same time every day and not to
discontinue without permission of health care provider.
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Side Effects
• Encourage patient to avoid orthostatic (postural) hypotension by slowly rising from
supine or sitting positions to standing.
• Inform patient and family of possible mood changes when taking reserpine due to
catecholamine depletion.
• Mood changes can include depression, detachment, inability to concentrate,
nightmares, and suicidal tendencies.
• Warn patient that reserpine may cause impotence or decreased libido, which is
usually dose related.
• Advise patient not to drive or engage in operation of dangerous equipment until
the drug response is known.
Cultural Considerations
• Obtain interpreter when necessary. Do not rely on family members, who may not
fully disclose because of honor or shame.
• Discuss ethnicity of interpreter, as well as the language desired when translation
is needed. Provide an interpreter with the same ethnic background and gender if
possible, especially when sensitive topics are being addressed.
Evaluation
• Evaluate effectiveness of the adrenergic neuron blocker.
• Vital signs must be stable within the desired range.
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Chapter 14
Central and Peripheral Nervous System Stimulants
OBJECTIVES
⚫ Explain the effects of stimulants on the central nervous system (CNS).
⚫ Compare attention deficit/hyperactivity disorder and narcolepsy.
⚫ Differentiate the action of drugs used for attention deficit/hyperactivity disorder and
narcolepsy.
⚫ Contrast the common side effects of amphetamines, anorexiants, analeptics,
doxapram, and caffeine.
⚫ Compare the pharmacology of drugs used in the treatment of migraine headaches.
⚫ Apply the nursing process for the patient taking CNS stimulants.
⚫ Apply the nursing process for the patient taking doxapram (Dopram).
Numerous drugs can stimulate the central nervous system which involves the brain
and spinal cord that regulates body functions. Medically approved use of CNS stimulants
is limited to the treatment of attention deficit/hyperactivity disorder (ADHD) in children,
narcolepsy, and the reversal of respiratory distress.
Major group of CNS stimulants includes
➢ amphetamines and caffeine - stimulate the cerebral cortex of the brain
➢ analeptics and caffeine - act on the brainstem and medulla to stimulate respiration
➢ anorexiants such as diethylpropion - suppress appetite by stimulating the satiety
center in the hypothalamic and limbic areas of the brain.
AMPHETAMINES
➢ stimulate the release of neurotransmitters— norepinephrine and dopamine from the
brain and sympathetic nervous system (peripheral nerve terminals).
➢ cause euphoria and alertness, sleeplessness, restlessness, tremors, and irritability.
➢ problems such as increased heart rate, palpitations, cardiac dysrhythmias, and
increased blood pressure can result from continuous use of amphetamines.
➢ half-life of amphetamines varies from 4 to 30 hours.
➢ prescribed for narcolepsy and in some cases for ADHD,
Side Effects and Adverse Reactions
➢ Amphetamines can cause adverse effects in the central nervous system and the
cardiovascular, gastrointestinal (GI), and endocrine systems.
➢ Side effects and adverse reactions include:
⚫ restlessness, insomnia, tachycardia, hypertension, heart palpitations, dry
mouth, anorexia, weight loss, diarrhea, constipation, and impotence.
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Modafinil (Provigil)
➢ drug prescribed for narcolepsy -> increases the amount of time patients with
narcolepsy feel awake.
➢ mechanism of action is not fully known.
Pharmacokinetics
➢ Methylphenidate is well absorbed from the GI mucosa.
➢ Methylphenidate is usually administered to children twice a day
before breakfast and lunch - 30 to 45 minutes before meals
➢ should be given 6 hours or more before sleep - may cause insomnia.
➢ Transdermal patches may be worn for 9 hours.
➢ excreted in the urine; 40% of methylphenidate is excreted unchanged.
Pharmacodynamics
➢ Methylphenidate helps to correct ADHD by decreasing hyperactivity and
improving attention span.
➢ also be prescribed for treating narcolepsy.
➢ Amphetamine-like drugs are considered more effective in treating ADHD than
amphetamines, except for Adderall.
➢ Amphetamines are generally avoided because they have a higher potential for
abuse, habituation, and tolerance.
➢ Sympathomimetics (e.g., pseudoephedrine) and psychostimulants (e.g., caffeine)
taken concurrently with methylphenidate increase stimulatory effects of irritability,
nervousness, tremors, and insomnia.
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Pharmacokinetics Pharmacodynamics
Absorption: Well absorbed from GI tract PO: Onset: 0.5-1 h
Distribution: PB: 10%-33% Peak: 2 h
Metabolism: t 12 : 1.3-7.7 h Sustained-release: 5 h; transdermal: 8 h
Excretion: 40% excreted unchanged in urine Duration: 3-6 h; Sustained-release: 8 h
Sustained-release: 4-8 h
Therapeutic Effects/Uses
To correct hyperactivity caused by ADHD, increase attention span, and control narcolepsy
Mode of Action: Research suggests modulation of serotonergic pathways occurs by affecting
changes in dopamine transport
Side Effects Adverse Reactions
Anorexia, vomiting, diarrhea, insomnia, Tachycardia, hypertension, growth suppression,
dizziness, nervousness, restlessness, palpitations, seizures,
irritability, tremors, euphoria, blurred vision, transient weight loss in children; life-threatening:
headache, increased Exfoliative dermatitis,
hyperactivity, abdominal pain, anemia, upper stroke, thrombocytopenia, hepatotoxicity
respiratory infection
A, Adult; ADHD, attention deficit/hyperactivity disorder; C, child; CD, controlled dose; CNS, central nervous system; CSS, Controlled
Substances Schedule; d, day; GI, gastrointestinal; h, hour; MAOI, monoamine oxidase inhibitor; min, minute; PB, protein-binding; PO, by
mouth; t 12, half life; UK, unknown; y, year.
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➢ Advise patient to avoid driving and using hazardous equipment when experiencing
tremors, nervousness, or increased heart rate.
➢ Teach patient not to abruptly discontinue the drug; dose must be tapered off to
avoid withdrawal symptoms.
➢ Consult health care provider before modifying dose.
➢ Encourage patient to read labels on over-the-counter (OTC) products, because
many contain caffeine. A high plasma caffeine level could be fatal
➢ Teach nursing mothers to avoid taking all CNS stimulants (e.g., caffeine). These
drugs are excreted in breast milk and can cause hyperactivity or restlessness in
infants.
➢ Direct family to seek counseling for children with attention deficit/hyperactivity
disorder. Drug therapy alone is not an appropriate therapy program. Notify school
nurse of drug therapy regimen.
➢ Explain to patient and family that long-term use may lead to drug abuse.
Diet
➢ Advise patient to avoid foods that contain caffeine.
➢ Encourage parents to provide children with a nutritious breakfast because the drug
may have anorexic effects.
Side Effects
➢ Teach patient about drug side effects and the need to report tachycardia and
palpitations. Monitor children for onset of Tourette’s syndrome.
Cultural Considerations
➢ Decrease language barriers by decoding the jargon of the health care environment
for those who have language difficulties or are not in the health care field.
Evaluation
➢ Evaluate effectiveness of drug therapy, level of hyperactivity, and presence of
adverse effects.
➢ Monitor weight, sleep patterns, and mental status.
➢ Evaluate patient’s knowledge of Ritalin therapy
ANOREXIANTS
Amphetamines were once freely prescribed as anorexiants (appetite suppressants) for
short-term use (4 to 12 weeks), but because of tolerance, psychological dependence,
and abuse, they are no longer recommended for use as appetite suppressants.
⚫ The U.S. Food and Drug Administration (FDA) has ordered the removal of
phenylpropanolamine from OTC weight-loss drugs and cold remedies.
⚫ There is increased risk of hemorrhagic stroke in young women who take drugs
containing phenylpropanolamine and a 16-times greater risk in women who take the
drugs as appetite suppressants. (This drug has not been associated with an
increased risk of stroke in men.)
⚫ phenylpropanolamine might also cause renal failure, psychosis, hypertension, and
cardiac dysrhythmias. Topical use of the drug has not been associated with
systemic effects.
⚫ Anorexiants Cause stimulant effect on hypothalamic and limbic areas of brain to
suppress appetite
⚫ For weight-loss attempts, emphasis should be placed on nutritious diet, exercise,
and behavior modification.
⚫ Reliance on appetite suppressants should be discouraged. Individuals who take
anorexiants should be under the care of a health care provider.
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Side effects
⚫ Side effects from caffeine are similar to those from anorexiants:
⚫ Palpitations, tachycardia, dysrhythmias, Insomnia, nervousness, restlessness,
Tremors, seizures
Other side effects
⚫ diuresis (increased urination), GI irritation (e.g., nausea, diarrhea),
⚫ rarely, tinnitus (ringing in the ear).
⚫ More than 300 mg of caffeine affects the CNS and heart (i.e., dysrhythmias,
convulsions).
⚫ High doses of caffeine in coffee, chocolate, and cold-relief medications can
cause psychological dependence.
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1.Antiinflamatories
2Analgesics
Antiparkinson-Anticholinergic Drugs
⚫ atropine was given to patients with Parkinson’s disease to decrease salivation and
drooling.
⚫ found to have some effect on the motor manifestation of this disease by decreasing
tremors and rigidity.
⚫ Additional studies indicate that anticholinergic (antimuscarinic) agents affect the CNS
as well as the parasympathetic nervous system.
⚫ affect the CNS by suppressing the tremors and muscular rigidity of parkinsonism,
⚫ but they have little effect on mobility and muscle weakness.
⚫ Developed drugs for the treatment of Parkinson’s disease (e.g., trihexyphenidyl
hydrochloride [Artane], biperiden [Akineton], and benztropine [Cogentin]). These
drugs can be used alone in early stages of parkinsonism.
may be used in combination with levodopa/carbidopa to control parkinsonism
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CHAPTER 15
MENTAL AND BEHAVIORAL HEALTH DRUGS
Schizophrenia is a
• Chronic psychotic disorder that Usually occurs in adolescence or early adulthood
with
• 3 Major categories of symptoms
1. Cognitive symptoms – are characterized by disorganized thinking, memory
difficulty, and decreased ability to focus attention
2. Positive symptoms – characterized by exaggeration of normal function (ex.
Agitation), incoherent speech, hallucinations, delusions, and paranoia
3. Negative symptoms – tend to be more chronic and persistent characterized
by a decrease or loss in function and motivation apparent with simplicity of
speech, blunted affect, inertia, poor self-care, and social withdrawal
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Antipsychotics - compose the largest group of drugs used to treat Mental illness to
improve thought processes and behavior of patient’s with psychotic symptoms
especially those with schizophrenia
Action of this drug is, it Blocks the dopamine receptors (Dopamine antagonist) in the
brain to reduce psychotic symptoms
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Typical Antipsychotics
Phenothiazine groups
➢ 3 groups division
1. Alipathic – produce a strong sedative effect orthostatic
hypotension, moderate EPS
• chlorpromazine – hydrochloride the first phenothiazine
introduced for treating psychotic behavior of patients in the
psychiatric hospitals
2. Piperazine phenothiazines – these drugs produce more EPS than
other phenothiazines.
Side effects; Dry mouth, urinary retention, agranulocytosis, severe
EPS
Ex. Fluphenazine and perphenazine
3. Piperidine – these drugs have a strong sedative effect, but cause
few EPS, with a low to moderate effect on BP and have no
antiemetic effect
Ex, thioridazine
Fluphenazine Interactions
Increase depression when taken with alcohol or other CNS depressants; may
increase EPS
Increased effects with MgSO4, lithium, and beta blockers
antacids and antiparkisonism drugs may decrease the effects
Side effects
Sedation, dizziness, headache, seizures
Dry mouth, nasal congestion, blurred vision, photosensitivity, urinary retention
GI distress, peripheral edema, tachycardia, EPS
Complimentary and alternative therapy Kava kava may increase dystonia
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PHARMACOLOGY
Atypical Antipsychotics
2 Advantages
1. Effective in treating both positive and negative symptoms of schizophrenia
unlike the typical antipsychotic which have not been effective in the treatment of
negative symptoms
2. Less likely to cause EPS or tardive dyskinesia
Action
have a greater affinity for Blocking serotonin and dopaminergic D4 receptors
Clozapine
the first atypical antipsychotic agent Use to treat schizophrenia and other
psychosis condition
indicated only to Severe schizophrenic patients unresponsive to traditional
antipsychotics
need to be discontinued if WBC count -> leukocyte level falls below 3000 mm3
Risperidone
Atypical agent Use to Treats positive and negative symptoms of schizophrenia
and bipolar disorder
Mode of action -> similar to clozapine
Occurrence of EPS and Tardive dyskinesia is low
Aripiprazole
Use
Manage symptoms of schizophrenia bipolar disorder, autism, depression, Tourette
syndrome
Mode of action interferes with the binding of dopamine to dopamine D2 and serotonin
receptors
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Assessment
Assess baseline vital signs for future comparison
Obtain a health history including present drugs. Include the present drug therapy
Assess cardiac and mental status, and respiratory disorder before starting drug therapy
Nursing diagnosis
Relationship, ineffective related to social withdrawal
Sleep pattern, disturbed related to medication adverse effects
Activity intolerance related to sedation
Self-care deficit related to loss of motivation
Planning
Patient’s psychotic behavior will improve with medication, psychotherapy, and adjunct
therapies.
Nursing interventions
Monitor vital signs. Orthostatic hypotension is likely to occur
remain with patient while medication is taken and swallowed bec some patients hide
antipsychotic in the mouths
Observe for EPS.
Assess for symptoms of NMS.
Inform patients that medication may take 6 weeks or longer to achieve full clinical effect.
Caution patients not to consume alcohol or other CNS depressants such as opioids.
Evaluation
Evaluate the effectiveness of the drug regimen
Anxiety
Types
Primary- It is not caused by a medical condition or drug use.
It is managed with short-term anxiolytics.
Secondary- It is related to selected drug use, medical, or psychiatric conditions.
Medications are not usually given for secondary anxiety unless the medical problem is
untreatable, severe or causes disability
ANXIOLYTICS
Lorazepam
Action
Inhibits GABA neurotransmission by binding to specific benzodiazepine receptors
Use - to control anxiety and to treat status epilepticus, for sedation induction and for
insomnia
Anxiolytic, antiseizure, sedative-hypnotic, preoperative drug, substance abuse
withdrawal
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Side effects
Drowsiness, dizziness, ataxia, restlessness, weakness
Headache, confusion, amnesia, blurred vision
GI distress, sleep disturbance, hallucinations
Bradycardia, hypotension/hypertension
Seizures, suicidal ideation, NMS, respiratory depression
Discontinuation
Gradually decrease dose over several days
Withdrawal symptoms
Develops slowly, in 2 to 10 days, and may last several weeks
Withdrawal symptoms
Tremor, agitation, nervousness
Sweating, insomnia
Anorexia, muscle cramps
Evaluation
Evaluate the effectiveness of the drug therapy by determining whether the patient is
less anxious And more able to cope with stresses and anxieties
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PRACTICE TEST
1. The nurse realizes more medication teaching is necessary when the 30-year-old
patient taking lorazepam states
A. “I must stop drinking coffee and colas.”
B. “I can stop this drug after 3 weeks if I feel better.”
C. “I must stop drinking alcoholic beverages.”
D. “I should not become pregnant while taking this drug.”
2. A young woman is being treated for psychosis with fluphenazine. Which sign
would indicate the need to add an anticholinergic to the patient’s medication
regimen?
A. A decrease in pulse and respiratory rate
B. Facial grimacing and tongue spasms
C. An increase in hallucinations
D. A decrease in the patient’s level of orientation
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PHARMACOLOGY
CHAPTER 16
PAIN AND INFLAMATION MANAGEMENT DRUGS
Antiinflammatory Drugs
Inflammation
Pathophysiology
3.heat-caused by accumulation and may result to pyrogens that may interfere with
the temperature-regulating center in the hypothalamus.
2 phases of inflammation
2.The delayed phase -occurs when leukocytes infiltrate the inflammed tissue.
Various chemical mediators released during the inflammation process:
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Prostaglandins
-chemical mediators;have many effects: vasodilation, relaxation of smooth
muscle, increased capillary permeability, and sensitizationof nerve cells to pain.
Cyclooxygenase(COX)
-the enzyme responsiblefor converting arachidonic into carbonic acid into
prostaglandins and their products.
There are two enzyme forms of COX:
COX-1 protects the stomach lining and regulates blood platelets.
COX-2 triggers inflammation and pain at the injured site.
Antiinflammatory agents
Prostaglandin inhibitors
Drugs that inhibit the biosynthesis of prostaglandin,because prostaglandin inhibitor
affect the inflammatory process they are called Antiinflammatory agents.
>Most NSAID’s are used to decrease inflammation and pain for clients.
>These drugs may be called prostaglandin inhibitors with varying effect degrees of
analgesic and antipyretic effect but they are used primarily as antiinflammatory agents
to relieve inflammation and pain.
NOTE:
NSAID’s preparation are not suggested for used in alleviating mild headaches and
mildly elevated temperature.
Preferred drugs for heaches and fever are aspirin,acetaminophen and ibuprofen.
NSAID’s are appropriate for reducing pain,swelling and stiffness in joints.
The first six NSaID’s on the list are now known as “first-generation NSAID’s and the
COX-2 inhibitors are called as the”second generation NSAID’s.
Salicylates:
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Aspirin comes from the family of salicylates derived from salicylic acid.Aspirin is also
called acetysalicylic acid (ASA).Aspirin is a prostaglandin inhibitor that decreases the
inflammatory process,it is also considered anti-platelets drugas for clients with cardiac
or CVA disorders.Aspirin should not be taken with other NSAID’s because it decrease
the blood level and effectiveness of NSAID’s. Aspirin and other NSAID’s relieves pain
by inhibiting the enzyme COX,which is needed for the biosynthesis of prostaglandins.
Newer NSAID’s blocks only COX-2 and not COX-1.COX-2 inhibitor approved by the
FDA is “celebrex manufactures by Pfizer.Hypersensitivity to salicylate products(aspirin)
Tinnitus,Vertigo,and bronchospasm –especially in asthmatic patient.Clients should not
take diflunisal if they are hypersensitive to aspirin.Diflunisal-is a derivative of salicylate
acid,although it is not converted to salicylic acid in the body.Salicylates are present in
numerous foods(e.g prunes raisins licorice and in spices-curry powder and paprika.
Salicylate: Aspirin
A history of gastric upset,gastric bleeding, or liver disease.
Nursing diagnosis
-Risk for injury related to vertigo
Chronic pain related to tissue swelling of rheumatoid arthritis.
Nursing Interventions
-Monitor serum salicylate (aspirin) level when client take high dose of aspirin for chronic
conditions such as arthritis.
-Observe client for signs of bleeding such as dark (tarry) stools, bleeding gums,
petechiae (round red spots).
Side Effects
-direct Client to report side effects such as drowsiness, tinnitus (ringing in the
ears),headache,GI symptoms,visual changes,and seizures.
Diet
1. Instruct client to take aspirin (also ibuprofen) with food, at mealtime.or with plenty of
fluids.
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5.Fenamates
NSAID’s used for acute and chronic arthritis condition.Like most NSAIDs gastric
irritation is a common side effects of fenamates and client with history of peptic ulcer
should avoid taking this group of drugs.
Other SE include:edema,dizziness,tinnitus and pruritus.
Two fenamates are Meclomen and Mefenamic acid (Ponstel)
6. Oxicams
(Piroxicam) an oxicam,is indicated for long term arthritis and osteoarthritis.It can too
cause gastric problems like ulceration and epigastric distress but the incidence is lower
than some other NSAID’s.
It is well tolerated and its major advantages over other NSAID’s is its long half-life,which
allows it to be taken only once daily.
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NSAID’s:Ibuprofen
Assessment:(CODA)
Check Client’s history of allergy to NSAID’s,if allergy is present,notify the health care
provider.
Obtain a drug and herbal history,Most NSAID’s are highly protein bound and can
displace other highly protein bound drugs like warfarin.
Determine a medical History.NSAID’s are contraindicated if client’s has a severe renel
or liver disease,peptic ulcer etc..
Assess client for GI upset and peripheral edema,which are common side effects of
NSAID’s.
Nursing Responsibilities:DORM
Do not give direction such as take one “blue”pill at the specified time.Instead provide the
name and the dosage of meds.
Observe client for bleeding gums,petechiae,ecchymoses orblack tarry stools.
Report if client has GI discomfort.Administer the NSAID’s at mealtime or with food to
prevent GI upset.
Monitor Vital signs and check for peripherak edema,especially in the am.
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CHAPTER 17
ANTIMICROBIAL DRUGS
This chapter will discuss the antibacterial drugs and their effects which includes the
mechanisms of antibacterial action, body defenses, patient resistance to antibacterial,
the use of antibacterial combinations, general adverse reactions to antibacterial,
narrow-and broad-spectrum antibiotics
Pathophysiology
Bacteria – (are single-celled organisms mostly with rigid cell wall) produce toxins that
cause cell lysis ( cell breakdown or cell death) Bacteria reproduce by cell division about
every 20 minutes.
ex. beta-lactamase-> destroys beta lactam antibiotics such as penicillin and
cephalosporins
• Bacteria such as Prokaryotes – a single celled organisms that lack a true nucleus
and nuclear membrane
• classifications acc. to appearance or shape: ( can be seen under a
microscope)
o Bacilli: elongated or rod-shaped organism
o Cocci: spherical; when cocci appear in clusters, they are called
staphylococci;
o when cocci are arranged in chains, they are called streptococci.
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Antibacterial/Antibiotics
• The difference between the terms antibacterial, antimicrobial, and antibiotic
which are frequently used interchangeably are
• Antibacterial and antimicrobials - are substances that inhibit bacterial growth
or kill bacteria
and other microorganisms. Antibacterial is either obtained from natural
resources or are manufactured ( ex. mold Penicillin notatum - Alexander
Fleming- purified penicillin to be used commercially) Inhibit bacterial growth or kill
bacteria and other microorganisms
• Antibacterial drugs do not act alone in destroying bacteria. The natural body
defenses, surgical procedures to excise infected tissues and dressing changes
are needed along with antibacterial drugs to eliminate the infecting bacteria
• Antibiotics - refers to chemicals produced by one kind of microorganisms that
inhibit the growth of or kill another. Inhibit bacterial growth or kill bacteria
• Bacteriostatic drugs - Inhibit growth of bacteria
• Bactericidal drugs- Kill bacteria
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Body defenses
⚫ Body defenses and antibacterial drugs work together to stop the infectious process.
The effect that antibacterial drugs have on an infection depends not only on the
drug but also on the host’s defense mechanisms
⚫ Factors such as age, nutrition, immunoglobulins, white blood cells (WBCs),
organ function, and circulation influence the body’s ability to fight infection.
⚫ Age - an older adults and undernourished individuals have less resistance to
infection than younger, well-nourished populations.
⚫ If the host’s natural body defense mechanisms are inadequate, drug therapy might
not be as effective. As a result, drug therapy may need to be closely monitored or
revised.
⚫ When circulation is impeded, an antibacterial drug may not be distributed properly
to the infected area.
⚫ immunoglobulins (antibody proteins such as IgG and IgM) and other elements of
the immune response system (WBCs) needed to combat infections may be
depleted in individuals with poor nutritional status.
Resistance to Antibacterials
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Antibiotic misuse is
a major problem today bec. It increases antibiotic resistance. Maybe due to:
⚫ Antibiotics taken unnecessarily (For viral infections When no infection is present
actually)
⚫ Taking antibiotics incorrectly (skipping doses, or not taking the full antibiotic
regimen) Increases antibiotic resistance
⚫ The nurse should teach patients about the proper use of antibiotics to prevent
situations that promote drug resistance to bacteria.
⚫ Cross-resistance- Can occur between antibacterial drugs with similar actions such
as the penicillins and cephalosporins.
⚫ To ascertain the effect antibacterial drugs have on a specific microorganism, culture
and sensitivity or antibiotic susceptibility laboratory testing is performed.
⚫ A culture and sensitivity test (C&S) can detect the infective microorganism present
in a sample (e.g., blood, sputum, swab) and what drug can kill it. The organism
causing the infection is determined by culture, and the antibiotics the organism is
sensitive to are determined by sensitivity
Antibiotic Combination Effects
⚫ When there is a severe infection that persists and is of unknown origin or has been
unsuccessfully treated with several single antibiotics, a combination of two or three
antibiotics may be suggested.
⚫ Combination antibiotics should not be routinely prescribed or administered except
for specific uncontrollable infections.
⚫ Before beginning antibiotic therapy, a culture or cultures should be taken to identify
the bacteria.
⚫ Additive - two antibiotics are combined,Effect is doubled.(The additive effect is
equal to
the sum of the effects of two antibiotics)
⚫ Potentiative - potentiative effect occurs when one antibiotic potentiates the effect
of the
second antibiotic, increasing their effectiveness, One potentiates effect of other.
⚫ Antagonistic - antagonistic result is a combination of a drug that is bactericidal,
such as penicillin, and a drug that is bacteriostatic, such as tetracycline. When
these two drugs are used together, the desired effect may be greatly reduced.
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Penicillins
⚫ a natural antibacterial agent obtained from the mold genus Penicillium
⚫ mainly referred to as beta-lactam antibiotics.
⚫ Penicillin’s beta-lactam structure (beta-lactam ring) interferes with bacterial cell-
wall synthesis by inhibiting the bacterial enzyme that is necessary for cell
division and cellular synthesis. (bacteria die of cell lysis (cell breakdown)
⚫ Both Bacteriostatic and bactericidal - Penicillin G is primarily bactericidal.
Depending upon drug and dosage
Types of penicillins
Cephalosporins
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Macrolides: Erythromycin
Oxazolidinones
Action is like macrolides
⚫ It Inhibit protein synthesis on 50S ribosomal subunit of bacteria. (this action
prevents formation of 70S initiation complex which is necessary for bacterial
reproduction
⚫ Effective against gram-positive bacteria.
⚫ Both Bacteriostatic and bactericidal Dependent on dosage
Use
◼ Bacteremia, sepsis, MRSA, VREF
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Glycopeptides
Action
◼ Like erythromycin, lincosamides inhibit bacterial protein synthesis
◼ have both bacteriostatic and bactericidal actions, depending on drug dosage.
◼ Effective against gram-positive MRSA
Use
◼ Respiratory, skin, and bone/joint infections Bacteremia, septicemia, and
endocarditis
◼ MRSA, Clostridium difficile-associated diarrhea
Drug Interaction
◼ Clindamycin and lincomycin are incompatible with aminophylline, phenetoin,
barbiturates, and ampicillin
Ketolides
⚫ Structurally related to macrolides. The firs drug in this class is telithromycin
(Ketek)
Action
⚫ Inhibits protein synthesis in microorganisms by binding to the bacterial ribosomal
RNA site of the 50S subunit, resulting in bacterial cell death.
Use
⚫ Treats community-acquired pneumonia, MRSA
⚫ Effective against Streptococcus pneumoniae, Haemophilus influenzae
amikacin Amikin
gentamicin Garamycin
kanamycin Kantrex
Aminoglycosides
neomycin Mycifradin
streptomycin generic
Doripenem Doribax
Ertapenem Invanz
Carbapenems
Imipenem-cilastatin Primaxin
meropenem Merrem IV
Cephalosporins
cefadroxil generic
cephalexin Keflex
cefaclor Ceclor
cefoxitin generic
• Second-
Generation cefprozil generic
cefuroxime Zinacef
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cefotaxime Claforan
cefpodoxime Vantin
ceftibuten Cedax
ceftizoxime Cefizox
ceftriaxone Rocephin
cefditoren Spectracef
ceftaroline Teflaro
ciprofloxacin Cipro
gemifloxacin Factive
levofloxacin Levaquin
Fluoroquinolones
moxifloxacin Avelox
norfloxacin Noroxin
penicillin V Veetids
• Penicillinase- nafcillin
Resistant
Antibiotics oxacillin
sulfadiazine generic
demeclocycline Declomycin
Tetracyclines
doxycycline Doryx, Periostat
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minocycline Minocin
tetracycline Sumycin
Antimycobacterials
Antituberculosis
ethambutol Myambutol
pyrazinamide Nydrazid
streptomycin generic
capreomycin Capastat
cycloserine Seromycin
• Second-line
ethionamide Trecator-SC
rifabutin Mycobutin
Other Antibiotics
clindamycin Cleocin
Lincosamides
lincomycin Lincocin
azithromycin Zithromax
Here is a table of commonly encountered antibiotics, their generic names, and brand
names:
• Bacteria are microorganisms that invade the human body through many routes
like respiratory, gastrointestinal, and skin.
• Human immune response is activated once bacteria invade the body. As the
body tries to rid itself of bacteria, classic signs of inflammation (e.g. swelling,
heat, redness, and pain), fever, and lethargy begin to show up.
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Aminoglycosides
Therapeutic Action
Indications
Here are some important aspects to remember for indication of antibiotics in different age
groups:
Children
This age group is very sensitive to GI and CNS adverse effects of antibiotics. Therefore,
it is important to monitor their nutritional and hydration status while on therapy. Oral
candidiasis as a superinfection is common in this age group which makes eating and
drinking difficult. Fluoroquinolones are associated with damage to developing cartilage
and are not recommended for growing children. In addition to this, pediatric dosages
should be double-checked to decrease the risk for adverse effects. Most of all, parent
education is important in cutting down the unnecessary use of antibiotics in children.
Adults
This age group has the tendency to cure simple manifestations with antibiotics. Therefore,
it is important to educate them that antibiotics are effective only for certain bacteria and
not for simple manifestations like common colds, which may be viral. Storage of unused
pills for future infections and sharing antibiotics with symptomatic friends should be
avoided and emphasized in health teachings.
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Older adults
Assessing the problem and obtaining appropriate specimens for culture is especially
important with this population. Older patients may be more susceptible to adverse effects
of antibiotic therapy.
The following are contraindications and cautions for the use of aminoglycosides
Adverse Effects
Interactions
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Carbapenems
Therapeutic Action
Indications
• Serious intra-abdominal, urinary tract, skin and skin structure, bone and joint,
and gynecological infections.
• Infections caused by susceptible strains: S.pneumoniae, H.influenzae, E.coli,
K.pneumoniae, B.fragilis, P.mirabilis, P.aeruginosa, and P.bivia.
The following are contraindications and cautions for the use of carbapenems:
Adverse Effects
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Interactions
• Valproic acid: Carbapenems reduce serum valproic acid and this can increase
risk of seizures.
• Imipenem and ganciclovir can cause seizures.
• Meropenem and probenecid can lead to toxic levels of meropenem.
Cephalosporins
• Cephalosporins were first introduced in the 1960s. There are currently four
generations of cephalosporins, each with specific spectrum of activity.
• These drugs are similar to penicillins in structure and activity.
Therapeutic Action
Indications
The following are contraindications and cautions for the use of cephalosporins:
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• Pregnancy and lactation. Potential effects on the fetus and infant are not
known; use only if benefits clearly outweigh the potential risk of toxicity to the
fetus or infant.
• Reserve cephalosporins for appropriate situations because cephalosporin-
resisant bacteria are appearing in increasing numbers. Perform culture and
sensitivity test before start of therapy.
Adverse Effects
Interactions
Fluoroquinolones
Therapeutic Action
• Interfere with the action of DNA enzymes necessary for growth and
reproduction of the bacteria.
• Has little cross-resistance but misuse of this drug for a short time will lead to
existence of resistant strains.
Indications
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The following are contraindications and cautions for the use of fluoroquinolones:
Adverse Effects
Interactions
• Penicillin was the first antibiotic introduced for clinical use. Various
modifications were subsequently made to address resistant strains and to
decrease drug adverse effects.
• Penicillinase-resistant antibiotics were developed to address penicillin-resistant
bacteria.
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Therapeutic Action
The desired and beneficial action of penicillins and penicillinase-resistant antibiotics is:
Indications
Penicillins and penicillinase-resistant antibiotics are indicated for the following medical
conditions:
The following are contraindications and cautions for the use of penicillins and
penicillinase-resistant antibitiotics:
Adverse Effects
Interactions
The following are drug-drug interactions involved in the use of penicillins and
penicillinase-resistant antibiotics:
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Sulfonamides
Therapeutic Action
• Inhibit folic acid synthesis required as precursors of RNA and DNA. They
competitively block paraaminobenzoic acid to prevent synthesis of folic acid in
susceptible bacteria that synthesize their own folates for the production of RNA
and DNA.
Indications
The following are contraindications and cautions for the use of sulfonamides:
Adverse Effects
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Interactions
Tetracyclines
Therapeutic Action
Indications
The following are contraindications and cautions for the use of tetracyclines:
Adverse Effects
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• Skeletal and bones: weakening the structure and causing staining and pitting of
teeth and bones
• Dermatological: photosensitivity and rash
• Superinfection
• Local: pain and stinging with topical or ocular applications
• Hematologic: hemolytic anemia, bone marrow depression
• Hypersensitivity reactions: urticaria, anaphylaxis
• Intracranial hypertension
Interactions
Antimycobacterials
Therapeutic Action
• Act on the DNA and/or RNA of the bacteria, leading to lack of growth and
eventually to bacterial death.
Indications
The following are contraindications and cautions for the use of antimycobacterials:
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Adverse Effects
Interactions
Other Antibiotics
Therapeutic Action
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PHARMACOLOGY
The following are contraindications and cautions for the use of other antibiotics:
Adverse Effects
Interactions
The following are drug-drug interactions involved in the use of other antibiotics:
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Nursing Assessment
These are the important things the nurse should include in conducting assessment,
history taking, and examination:
• Assess for the mentioned cautions and contraindications (e.g. drug allergies,
CNS depression, CV disorders, etc.) to prevent any untoward complications.
• Perform a thorough physical assessment (other medications taken, CNS, skin,
respirations, and laboratory tests like renal functions tests and complete blood
count or CBC) to establish baseline data before drug therapy begins, to
determine effectiveness of therapy, and to evaluate for occurrence of any
adverse effects associated with drug therapy.
• Perform culture and sensitivity tests at the site of infection to ensure appropriate
use of the drug.
• Conduct orientation and reflex assessment, as well as auditory testing to
evaluate any CNS effects of the drug (aminoglycosides).
Nursing Diagnoses
Here are some of the nursing diagnoses that can be formulated in the use of this drug for
therapy:
These are vital nursing interventions done in patients who are taking antibiotics:
• Check culture and sensitivity reports to ensure that this is the drug of choice for
this patient.
• Ensure that patient receives full course of aminoglycosides as prescribed,
divided around the clock to increase effectiveness and decrease the risk for
development of resistant strains of bacteria.
• Monitor infection site and presenting signs and sympoms throughout course of
drug therapy because failure of these manifestations to resolve may indicate
the need to reculture the site.
• Provide safety measures to protect the patient if CNS effects (e.g. confusion,
disorientation, numbness) occur.
• Educate client on drug therapy to promote understanding and compliance.
• Provide the following patient teaching: safety precautions (e.g. changing
positions, avoiding hazardous tasks, ec.), drinking lots of fluids and to maintain
nutrition even though nausea and vomiting may occur, report difficulty
breathing, severe headache, fever, diarrhea, and signs of infection.
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Evaluation
Here are aspects of care that should be evaluated to determine effectiveness of drug
therapy:
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CHAPTER 18
Immunologic Drugs
Learning Outcomes:
After this lesson, you will be able to:
1. Identify the the major classes of antiretroviral medications and describe the
mechanism of action with each class of drugs
2. Identify the need for immunosuppressants and the transplant medications and
describe the mechanism of action with each class of drugs.
3. Describe clinically significant possible adverse effects associated with transplant
medications.4.
4. Discuss appropriate monitoring and management strategies for transplant
medications adverse effects
5. Develop a nursing care plan for a child undergoing transplant medication
treatment
INTRODUCTION
HIV Infection has been a global health problem since 1983. At the end of 2016,
approximately 36.7 million people worldwide were HIV-positive. In mid-2017,
approximately 20.9 million people were receiving antiretroviral (ARV) drugs.AIDS
represents the infection’s advanced clinical stage. To treat HIV, numerous ARVs have
been developed that act on different phases of viral replication and are used in
combination as antiretroviral therapy (ART).
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Inhibitors (NNRTIs)
These are also called "non-nukes." NNRTIs bind to a specific protein so the HIV
virus can't make copies of itself, similar to jamming a zipper.
A group of antiretroviral (ARV) HIV drugs that includes CCR5 antagonists, and
post-attachment inhibitors. Entry inhibitors block HIV from entering a host CD4
T lymphocyte (CD4 cell).
Fusion Inhibitors
Unlike NRTIs, NNRTIs, PIs, and INSTIs -- which work on infected cells -- these
drugs help block HIV from getting inside healthy cells in the first place.
⚫ Enfuvirtide, or ENF or T-20 (Fuzeon)
CCR5 Antagonist
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PHARMACOLOGY
CASE STUDY:
Nursing Responsibilities
• Safe sex. Other than abstinence, consistent and correct use of condoms is
the only effective method to decrease the risk of sexual transmission of HIV
infection.
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• In March 2007, based on the results of three clinical trials, the WHO and
UNAIDS recommended that circumcision be recognized as an effective
strategy to reduce the risk of HIV acquisition in men.
• Sex partners. Avoid sexual contact with multiple partners or people who are
known to be HIV positive or IV/injection drug users.
• Blood and blood components. People who are HIV positive or who use
injection drugs should be instructed not to donate blood or share drug
equipment with others.
Transplant Drugs
What are immunosuppressants?
Immunosuppressants are drugs or medicines that lower the body's ability to reject a
transplanted organ. Another term for these drugs is anti-rejection drugs.
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Nursing Assessment
These are the important things the nurse should include in conducting assessment,
history taking, and examination:
Nursing Diagnoses
Here are some of the nursing diagnoses that can be formulated in the use of these
drugs for therapy:
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Nursing Interventions
These are vital nursing interventions done in patients who are taking
immunosuppressants:
• Arrange for laboratory tests before and periodically during therapy, including
CBC and differential, to monitor for drug effects and adverse effects.
• Administer drug as indicated; instruct patient and significant other if injections
are required to ensure that the drug will be given if the patient is not able to
administer it.
• Protect the patient from exposure to infections and maintain strict aseptic
technique for any invasive procedures to prevent infections during
immunosuppression.
• Arrange for supportive care and comfort measures (e.g., rest, environmental
control) to decrease patient discomfort and increase therapeutic compliance.
• Provide patient education about drug effects and warning signs to increase
knowledge about drug therapy and to increase compliance with drug.
Evaluation
Here are aspects of care that should be evaluated to determine effectiveness of drug
therapy:
Vaccines
Immunology and Vaccine-Preventable Diseases
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Immunity
⚫ Self vs. Nonself
⚫ Protection from infectious disease
⚫ Usually indicated by the presence of antibody
⚫ Generally specific to a single organism
Active Immunity
⚫ Protection produced by the person’s own immune system
⚫ Often lifetime
Passive Immunity
⚫ Protection transferred from another animal or human
⚫ Effective protection that wanes with time
⚫ Transplacental most important source in infancy
Antigen
⚫ A live (e.g., viruses and bacteria)
or inactivated substance capable of producing an immune response
Antibody
⚫ Protein molecules (immunoglobulins) produced by
B lymphocytes to help eliminate an antigen
Classification of Vaccines
Inactivated Vaccines
⚫ Cannot replicate
⚫ Less affected by circulating antibody than live vaccines
⚫ Always require multiple doses
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Polysaccharide Vaccines
Pure polysaccharide
⚫ pneumococcal
⚫ meningococcal
⚫ Salmonella Typhi (Vi) Conjugate polysaccharide
⚫ Haemophilus influenzae type b (Hib)
⚫ pneumococcal
⚫ meningococcal
General Rule: The more similar a vaccine is to the disease-causing form of the organism,
the better the immune response to the vaccine
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CHAPTER 19
Antineoplastic and Biologic Response Modifiers
Anticancer Drugs
Learning Outcomes:
After this lesson, you will be able to:
1.Identify the anticancer or antineoplastic drugs and describe the mechanism of action
with each class of drugs. Identify the different targeted therapies to treat cancer
2. Describe clinically significant possible adverse effects associated with antineoplastic
drugs
3.Develop a nursing care plan for a patient undergoing anticancer medication treatment
4.Differentiate the various cancer treatments from each other.
5.Discuss appropriate monitoring and management strategies for each cancer treatment.
6.Develop a nursing care plan for a patient undergoing cancer treatment.
Antineoplastic drugs are medications used to treat cancer. Antineoplastic drugs are also
called anticancer, chemotherapy, chemo, cytotoxic, or hazardous drugs.
These drugs come in many forms. Some are liquids that are injected into the patient and
some are pills that patients take.
• We know that cancer patients who are taking antineoplastic drugs have an
increased risk of infertility. If they are treated during pregnancy, these patients
have an increased risk of miscarriage or having a child with a birth defect.
• People who work with these drugs have also been found to have an increased
risk of having a miscarriage or a child with a birth defect.
• Antineoplastic drugs work by targeting and killing rapidly dividing cancerous cells,
but they can also be harmful to healthy dividing cells, including the cells of a
developing baby.
Antineoplastic Medications
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Antimetabolites
The goal of cancer treatment is to achieve a cure for cancer, allowing a patient to live
a normal life span. This may or may not be possible, depending on their specific situation.
If a cure isn't possible, the treatments may be used to shrink the cancer or slow the growth
of the cancer to allow the patient to live symptom free for as long as possible.
Any cancer treatment can be used as a primary treatment, but the most common
primary cancer treatment for the most common types of cancer is surgery. If the cancer
is particularly sensitive to radiation therapy or chemotherapy, the patient may receive one
of those therapies as your primary treatment.
Adjuvant treatment. The goal of adjuvant therapy is to kill any cancer cells that may
remain after primary treatment in order to reduce the chance that the cancer will recur.
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Neoadjuvant therapy is similar, but treatments are used before the primary treatment
in order to make the primary treatment easier or more effective.
Palliative treatment. Palliative treatments may help relieve side effects of treatment
or signs and symptoms caused by cancer itself. Surgery, radiation, chemotherapy and
hormone therapy can all be used to relieve symptoms. Other medications may relieve
symptoms such as pain and shortness of breath.
Palliative treatment can be used at the same time as other treatments intended to
cure cancer.
Many cancer treatments are available. The treatment options will depend on several
factors, such as the type and stage of cancer, general health, and patient preferences.
Together,the patient and his doctor can weigh the benefits and risks of each cancer
treatment to determine which is best for himself.
• Surgery. The goal of surgery is to remove the cancer or as much of the cancer as
possible.
• Chemotherapy. Chemotherapy uses drugs to kill cancer cells.
• Radiation therapy. Radiation therapy uses high-powered energy beams, such as
X-rays or protons, to kill cancer cells. Radiation treatment can come from a machine
outside your body (external beam radiation), or it can be placed inside your body
(brachytherapy).
• Bone marrow transplant. The bone marrow is the material inside the bones that
makes blood cells from blood stem cells. A bone marrow transplant, also known as
a stem cell transplant, can use the patient’s own bone marrow stem cells or those
from a donor. A bone marrow transplant allows the doctor to use higher doses of
chemotherapy to treat cancer. It may also be used to replace diseased bone marrow.
• Immunotherapy. Immunotherapy, also known as biological therapy, uses the
body's immune system to fight cancer. Cancer can survive unchecked in the body
because the immune system doesn't recognize it as an intruder. Immunotherapy can
help your immune system "see" the cancer and attack it.
• Hormone therapy. Some types of cancer are fueled by the body's hormones.
Examples include breast cancer and prostate cancer. Removing those hormones
from the body or blocking their effects may cause the cancer cells to stop growing.
• Targeted drug therapy. Targeted drug treatment focuses on specific abnormalities
within cancer cells that allow them to survive.
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• Cryoablation. This treatment kills cancer cells with cold. During cryoablation, a thin,
wandlike needle (cryoprobe) is inserted through your skin and directly into the
cancerous tumor. A gas is pumped into the cryoprobe in order to freeze the tissue.
Then the tissue is allowed to thaw. The freezing and thawing process is repeated
several times during the same treatment session in order to kill the cancer cells.
• Radiofrequency ablation. This treatment uses electrical energy to heat cancer
cells, causing them to die. During radiofrequency ablation, a doctor guides a thin
needle through the skin or through an incision and into the cancer tissue. High-
frequency energy passes through the needle and causes the surrounding tissue to
heat up, killing the nearby cells.
• Clinical trials. Clinical trials are studies to investigate new ways of treating cancer.
Thousands of cancer clinical trials are underway.
1. Anticipatory Grieving
May be related to
Anticipated loss of physiological well-being (e.g., loss of body part; change
in body function); change in lifestyle
Perceived potential death of patient
Possibly evidenced by
Changes in eating habits, alterations in sleep patterns, activity levels, libido,
and communication patterns
Denial of potential loss, choked feelings, anger
Desired Outcomes
Identify and express feelings appropriately.
Continue normal life activities, looking toward/planning for the future, one
day at a time.
Verbalize understanding of the dying process and feelings of being
supported in grief work.
Nursing Interventions
⚫ Expect initial shock and disbelief following diagnosis of cancer
and traumatizing procedures (disfiguring surgery, colostomy, amputation).
Rationale: Few patients are fully prepared for the reality of the changes that
can occur.
⚫ Assess patient and SO for stage of grief currently being experienced.
Explain process as appropriate.
Rationale: Knowledge about the grieving process reinforces the normality of
feelings and reactions being experienced and can help patient deal more
effectively with them.
⚫ Provide open, nonjudgmental environment. Use therapeutic
communication skills of Active-Listening, acknowledgment, and so on.
Rationale: Promotes and encourages realistic dialogue about feelings and
concerns.
⚫ Encourage verbalization of thoughts or concerns and accept expressions
of sadness, anger, rejection. Acknowledge normality of these feelings.
Rationale: Patient may feel supported in expression of feelings by the
understanding that deep and often conflicting emotions are normal and
experienced by others in this difficult situation.
⚫ Be aware of mood swings, hostility, and other acting-out behavior. Set limits
on inappropriate behavior, redirect negative thinking.
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Administration
Biologic response modifier therapy is administered either by intravenous (IV) or
subcutaneous (SC) route. IV is usually done in the hospital or outpatient setting, while SC
is generally self-administered by patients or by health care professionals. The
administration could be weekly, biweekly, monthly, or bimonthly depending on the
indication and half-life of the medication.
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Oral tofacitinib
Biological response modifiers can produce several toxic effects that may have a
significant impact on the patient's quality of life. Additionally, biotherapy is being delivered
more frequently in the ambulatory and home care settings.
As the role of biotherapy expands in the treatment of cancer, oncology nurses must be
attuned to the special needs of patients receiving this therapy. Nurses must be
knowledgeable of not only symptom management but reimbursement and managed care
issues as well.
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CHAPTER 20
Respiratory agents
Learning Outcomes:
After this lesson, you will be able to:
1. Identify the need for respiratory agents and describe the mechanism of action with
each class of drugs
2. Understand the characteristics and causes of Upper and Lower Respiratory
Disorders
3. Describe clinically significant possible adverse effects associated with respiratory
agents
4. Discuss appropriate monitoring and management strategies for respiratory agents
1. Develop a nursing care plan for a patient undergoing respiratory medication
treatment.
• antiasthmatic combinations
• antihistamines
• antitussives
• bronchodilators
o adrenergic bronchodilators
o anticholinergic bronchodilators
o bronchodilator combinations
o methylxanthines
• decongestants
• expectorants
• leukotriene modifiers
• lung surfactants
• miscellaneous respiratory agents
• respiratory inhalant products
o inhaled anti-infectives
o inhaled corticosteroids
o mast cell stabilizers
o mucolytics
• selective phosphodiesterase-4 inhibitors
• upper respiratory combinations
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✓ Upper respiratory infections (URIs) are one of the most common reasons for doctor
visits.
✓ Upper respiratory infections are the most common illness resulting in missed work or
school.
✓ Upper respiratory tract infections can happen at any time, but are most common in
the fall and winter.
✓ The vast majority of upper respiratory infections are caused by viruses and are self-
limited.
✓ Symptoms of upper respiratory infection include:
▪ cough,
▪ sneezing,
▪ nasal discharge,
▪ nasal congestion,
▪ runny nose,
▪ fever,
▪ scratchy or sore throat, and
▪ nasal breathing.
✓ Antibiotics are rarely needed to treat upper respiratory infections and generally
should be avoided, unless the doctor suspects a bacterial infection.
✓ Simple techniques, such as, proper hand washing and covering face while
coughing or sneezing, may reduce the spread of respiratory tract infections.
✓ General outlook for upper respiratory infections is favorable, although, sometimes
complication can occur.
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Lower respiratory tract infections are any infections in the lungs or below the
voice box. These include pneumonia, bronchitis, and tuberculosis.
Symptoms
Symptoms of lower respiratory tract infections vary and depend on the severity of the
infection.
Less severe infections can have symptoms similar to the common cold, including:
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PHARMACOLOGY
•
a severe cough that may produce phlegm
•
fever
•
difficulty breathing
•
a blue tint to the skin
•
rapid breathing
•
chest pain
•
wheezing
Diagnosis
A doctor will usually diagnose a lower respiratory infection during an exam and after
discussing the symptoms a person has and how long they have been present.
During the exam, the doctor will listen to the person’s chest and breathing through a
stethoscope.
The doctor may order tests to help diagnose the problem, such as:
• pulse oximetry to find how much oxygen is in the blood
• chest X-rays to check for pneumonia
• blood tests to check for bacteria and viruses
• mucus samples to look for bacteria and viruses
Nursing Assessment
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• Relieve GI upset. Administer oral drug with food or milk to relieve GI irritation
if GI upset is a problem.
• Monitor drug response. Monitor patient response to the drug (e.g., relief of
respiratory difficulty, improved airflow) to determine the effectiveness of the
drug dose and to adjust dose as needed.
• Provide comfort. Provide comfort measures including rest periods, quiet
environment, dietary control of caffeine, and headache therapy as needed, to
help the patient cope with the effects of drug therapy.
• Provide follow-ups. Provide periodic follow-up, including blood tests, to
monitor serum theophylline levels.
• Individual drug response. Reassure patient that the drug of choice will vary
with each individual; these sympathomimetics are slightly different chemicals
and are prepared in a variety of delivery systems; a patient may have to try
several different sympathomimetics before the most effective one is found.
• Proper administration and dosage. Advise the patient to use the minimal
amount needed for the shortest period necessary to prevent adverse effects
and accumulation of drug levels.
• Proper use of sympathomimetics. Teach the patients who use one of these
drugs for exercise-induced asthma to use it 30 to 60 minutes before exercising
to ensure peak therapeutic effects when they are needed.
• Use of adrenergic blockers. Alert the patient that long-acting adrenergic
blockers are not for use during acute attacks because they are slower acting
and will not provide the necessary rescue in a state of acute bronchospasm.
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Evaluation
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PHARMACOLOGY
CHAPTER 21
Cardiovascular System Drugs
Cardiac Glycosides
• Cardiac glycosides are cardiotonic agents from foxglove or digitalis plants. They
exert their effects on the cardiac muscles by affecting levels of intracellular
calcium. In turn, the contractility of the muscles is increased.
Therapeutic Action
Indications
• Primarily indicated for decreasing workload of the heart and relieving HF.
• Digoxin is especially indicated for atrial flutter, atrial fibrillation, and
paroxysmal atrial tachycardia.
Children
• Widely used in the treatment of heart defects in children but the margin of
safety for drug dosage is small so the nurse should recalculate and re-
validate the dose with another nurse before administration.
• Serum level of digoxin and signs of digitalis toxicity should be monitored
carefully.
Adults
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Pharmacokinetics
T1/2: 30-40 h
Metabolism: N/A
Excretion: urine (unchanged)
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PHARMACOLOGY
Adverse Effects
Interactions
Nursing Considerations
Nursing Assessment
These are the important things the nurse should include in conducting assessment,
history taking, and examination:
• Assess for the mentioned contraindications to this drug (e.g. renal insufficiency,
acute MI, hypersensitivity, etc.) to prevent potential adverse effects.
• Conduct thorough physical assessment before beginning drug therapy to
establish baseline status, determine effectivity of therapy and evaluate potential
adverse effects.
• Obtain baseline status for weight while noting recent manifestations that
increase or decreases to determine patient’s fluid status.
• Assess closely patient’s heart rate and blood pressure to identify cardiovascular
changes that may warrant a change in digoxin drug dose.
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PHARMACOLOGY
• Auscultate heart sounds to note the presence of abnormal sounds and possible
conduction problems.
• Determine urinary pattern and output to assess gross indication of renal
function.
• Obtain baseline electrocardiogram (ECG) to identify heart rate and rhythm.
• Monitor serum electrolyte and renal function test results to determine whether
changes in drug dose is needed or not.
Nursing Diagnoses
Here are some of the nursing diagnoses that can be formulated in the use of this drug for
therapy:
• Risk for fluid volume deficit related to increased renal perfusion as effect of the
drug
• Decreased cardiac output related to inefficient myocardial contractility
• Ineffective tissue perfusion related to decreased blood flow to different parts of
the body
These are vital nursing interventions done in patients who are taking cardiac glycosides:
o Drug is withheld if pulse is less than 60 beats per minute in adults and
90 beats per minute in infants.
o Apical pulse is taken after one hour and if it remains low, nurse must
document it, withhold the dose, and inform doctor.
• Assess pulse rhythm to detect arrhythmias which are early signs of drug toxicity.
• Weigh the patient daily to monitor for fluid retention and HF. Assess dependent
areas for presence of edema and note its degree of pitting to assess severity of
fluid retention.
• Monitor serum digoxin level as ordered (normal: 0.5-2 ng/mL) to evaluate
therapeutic dosing and development of adverse effects.
• Provide comfort measures (e.g. small frequent meals for GI upset, instituting
safety measures for drowsiness and weaknesses, and providing adequate
room lighting for patients with visual disturbances) to help patient tolerate drug
effects.
• Promote rest periods and relaxation techniques to balance supply and demand
of oxygen.
• Ensure maintenance of emergency drugs and equipment at bedside (e.g.
potassium salts and lidocaine for arrhythmias, phenytoin for
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PHARMACOLOGY
seizures, atropine in case of clinically significant low heart rate, and cardiac
monitor) to promote prompt treatment in cases of severe toxicity.
• Educate patient on drug therapy including drug name, its indication, and
adverse effects to watch out for to enhance patient understanding on drug
therapy and thereby promote adherence to drug regimen.
Evaluation
Here are aspects of care that should be evaluated to determine effectiveness of drug
therapy:
Antianginal drugs are used primarily to restore the balance between the oxygen supply
and demand of the heart. These drugs dilate the coronary vessels to increase the flow of
oxygen to the ischemic regions. Other than that, they also decrease the workload of the
heart so the organ would have less demand for oxygen.
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Others:
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To understand the action of diuretics, it is first necessary to review how the kidney
filters fluid and forms urine. The following discussion and accompanying illustration
provide a simple overview of how the kidney handles water and electrolytes.
As blood flows through the kidney, it passes into glomerular capillaries located within
the cortex (outer zone of the kidney). These glomerular capillaries are highly permeable
to water and electrolytes. Glomerular capillary hydrostatic pressure drives (filters) water
and electrolytes into Bowman's space and into the proximal convoluting tubule (PCT).
About 20% of the plasma that enters the glomerular capillaries is filtered (termed filtration
fraction). The PCT, which lies within the cortex , is the site of sodium, water and
bicarbonate transport from the filtrate (urine), across the tubule wall, and into the
interstitium of the cortex. About 65-70% of the filtered sodium is removed from the urine
found within the PCT (this is termed sodium reabsorption). This sodium is reabsorbed
isosmotically, meaning that every molecule of sodium that is reabsorbed is accompanied
by a molecule of water. As the tubule dives into the medulla, or middle zone of the kidney,
the tubule becomes narrower and forms a loop (Loop of Henle) that reenters the cortex
as the thick ascending limb (TAL) that travels back to near the glomerulus. Because the
interstitium of the medulla is very hyperosmotic and the Loop of Henle is permeable to
water, water is reabsorbed from the Loop of Henle and into the medullary interstitium.
This loss of water concentrates the urine within the Loop of Henle.
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PHARMACOLOGY
The TAL, which is impermeable to water, has a cotransport system that reabsorbs
sodium, potassium and chloride at a ratio of 1:1:2. Approximately 25% of the sodium load
of the original filtrate is reabsorbed at the TAL. From the TAL, the urine flows into the
distal convoluting tubule (DCT), which is another site of sodium transport (~5% via a
sodium-chloride cotransporter) into the cortical interstitium (the DCT is also impermeable
to water). Finally, the tubule dives back into the medulla as the collecting duct and then
into the renal pelvis where it joins with other collecting ducts to exit the kidney as the
ureter. The distal segment of the DCT and the upper collecting duct has a transporter that
reabsorbs sodium (about 1-2% of filtered load) in exchange for potassium and hydrogen
ion, which are excreted into the urine. It is important to note two things about this
transporter. First, its activity is dependent on the tubular concentration of sodium, so that
when sodium is high, more sodium is reabsorbed and more potassium and hydrogen ion
are excreted. Second, this transporter is regulated by aldosterone, which is a
mineralocorticoid hormone secreted by the adrenal cortex. Increased aldosterone
stimulates the reabsorption of sodium, which also increases the loss of potassium and
hydrogen ion to the urine. Finally, water is reabsorbed in the collected duct through
special pores that are regulated by antidiuretic hormone, which is released by the
posterior pituitary. ADH increases the permeability of the collecting duct to water, which
leads to increased water reabsorption, a more concentrated urine and reduced urine
outflow (antidiuresis). Nearly all of the sodium originally filtered is reabsorbed by the
kidney, so that less than 1% of originally filtered sodium remains in the final urine.
Diuretic drugs increase urine output by the kidney (i.e., promote diuresis). This is
accomplished by altering how the kidney handles sodium. If the kidney excretes more
sodium, then water excretion will also increase. Most diuretics produce diuresis by
inhibiting the reabsorption of sodium at different segments of the renal tubular system.
Sometimes a combination of two diuretics is given because this can be significantly more
effective than either compound alone (synergistic effect). The reason for this is that one
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PHARMACOLOGY
nephron segment can compensate for altered sodium reabsorption at another nephron
segment; therefore, blocking multiple nephron sites significantly enhances efficacy.
Thiazide diuretics, which are the most commonly used diuretic, inhibit the
sodium-chloride transporter in the distal tubule. Because this transporter
normally only reabsorbs about 5% of filtered sodium, these diuretics are less
efficacious than loop diuretics in producing diuresis and natriuresis.
Nevertheless, they are sufficiently powerful to satisfy many therapeutic needs
requiring a diuretic. Their mechanism depends on renal prostaglandin
production.
Because loop and thiazide diuretics increase sodium delivery to the distal
segment of the distal tubule, this increases potassium loss (potentially
causing hypokalemia) because the increase in distal tubular sodium
concentration stimulates the aldosterone-sensitive sodium pump to increase
sodium reabsorption in exchange for potassium and hydrogen ion, which are lost
to the urine. The increased hydrogen ion loss can lead to metabolic alkalosis.
Part of the loss of potassium and hydrogen ion by loop and thiazide diuretics
results from activation of the renin-angiotensin-aldosterone system that occurs
because of reduced blood volume and arterial pressure. Increased aldosterone
stimulates sodium reabsorption and increases potassium and hydrogen ion
excretion into the urine.
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PHARMACOLOGY
Through their effects on sodium and water balance, diuretics decrease blood volume and
venous pressure. This decreases cardiac filling (preload) and, by the Frank-Starling
mechanism, decreases ventricular stroke volume and cardiac output, which leads to a fall
in arterial pressure. The decrease in venous pressure reduces capillary hydrostatic
pressure, which decreases capillary fluid filtration and promotes capillary fluid
reabsorption, thereby reducing edema if present. There is some evidence that loop
diuretics cause venodilation, which can contribute to the lowering of venous pressure.
Long-term use of diuretics results in a fall in systemic vascular resistance (by unknown
mechanisms) that helps to sustain the reduction in arterial pressure.
Therapeutic Uses
Hypertension
Most patients with hypertension, of which 90-95% have hypertension of unknown origin
(primary or essential hypertension), are effectively treated with diuretics. Antihypertensive
therapy with diuretics is particularly effective when coupled with reduced dietary sodium
intake. The efficacy of these drugs is derived from their ability to reduce blood volume,
cardiac output, and with long-term therapy, systemic vascular resistance. Thiazide
diuretics, particularly chlorthalidone, are considered "first-line therapy" for stage 1
hypertension. Potassium-sparing, aldosterone-blocking diuretics (e.g., spironolactone or
eplerenone) are used in secondary hypertension caused by primary hyperaldosteronism,
and sometimes as an adjunct to thiazide treatment in primary hypertension to prevent
hypokalemia.
Heart failure
Most patients in heart failure are prescribed a loop diuretic because they are more
effective in unloading sodium and water than thiazide diuretics. In mild heart failure, a
thiazide diuretic may be used. Potassium-sparing, aldosterone-blocking diuretics (e.g.,
spironolactone) are being used increasingly in heart failure.
Capillary hydrostatic pressure and therefore capillary fluid filtration is strongly influenced
by venous pressure. Therefore, diuretics, by reducing blood volume and venous pressure,
lower capillary hydrostatic pressure, which reduces net capillary fluid filtration and tissue
edema. Because left ventricular failure can cause life-threatening pulmonary edema,
most heart failure patients are treated with a loop diuretic to prevent or reduce pulmonary
edema. Diuretics may also be used to treat leg edema caused by right-sided heart failure
or venous insufficiency in the limb.
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PHARMACOLOGY
Class Class
hydrochlorothiazide furosemide
hydroflumethiazide torsemide
methyclothiazide eplerenone
metolazone spironolactone
polythiazide triamterene
CA inhibitors acetazolamide
dichlorphenamide
methazolamide
The most important and frequent problem with thiazide and loop diuretics is hypokalemia.
This sometimes requires treatment with potassium supplements or with a potassium-
sparing diuretic. A potentially serious side effect of potassium-sparing diuretics is
hyperkalemia. Other side effects and drug interactions are list below:
• hypokalemia
• metabolic alkalosis • hypokalemia
• dehydration potentiates digitalis
(hypovolemia), leading toxicity
to hypotension • non-steroidal anti-
• hyponatremia inflammatory drugs:
• hyperglycemia in reduced diuretic
Thiazide diabetics efficacy
• hypercholesterolemia; • beta-blockers:
hypertriglyceridemia potentiate
• increased low-density hyperglycemia,
lipoproteins hyperlipidemias
• hyperuricemia (at low • corticosteroids:
doses) enhance
• azotemia (in renal hypokalemia
disease patients)
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PHARMACOLOGY
• hypokalemia
potentiates digitalis
• hypokalemia toxicity
• metabolic alkalosis • non-steroidal anti-
• hypomagnesemia inflammatory drugs:
• hyperuricemia reduced diuretic
Loop • dehydration efficacy
(hypovolemia), leading • corticosteroids:
to hypotension enhance
• dose-related hearing hypokalemia
loss (ototoxicity) • aminoglycosides:
enhance ototoxicity,
nephrotoxicity
• hyperkalemia • ACE inhibitors:
• metabolic acidosis potentiate
• gynecomastia hyperkalemia
K+-sparing (aldosterone • non-steroidal anti-
antagonists) inflammatory drugs:
• gastric problems reduced diuretic
including peptic ulcer efficacy
Carbonic
anhydrase • hypokalemia
inhibitors • metabolic acidosis
Anti hypertensives
Antihypertensive drugs affect different areas of blood pressure control so in most cases,
these agents are combined for synergistic effect.
Ninety percent of cases of hypertension have no known cause. Therefore, the main action
of antihypertensive agents is to alter the body’s regulating mechanisms (e.g.
baroreceptors, renin-angiotensin-aldosterone system, etc.) responsible for maintaining
normal blood pressure.
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PHARMACOLOGY
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hydralazine Apresoline
Vasodilators
used when the previous drugs minoxidil Loniten
mentioned are not effective.
nitropruisside Nitropress
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PHARMACOLOGY
Others:
Aspro Clear,
aspirin
Disprin
dipyridamole Persantine
tirofiban Aggrastat
warfarin Coumadin
rivaroxaban Xarelto
alteplase Activase
reteplase Retavase
Thrombolytic Agents
tenecteplase TNKase
urokinase Abbokinase
Others:
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PHARMACOLOGY
dalteparin Fragmin
Low-molecular weight
enoxaparin Lovenox
heparins
tinzaparin Innohep
lepirudin Refludan
Anticoagulant adjunctive
protamine sulfate
therapy
vitamin K
Disorders that directly affect coagulation process are divided into two main categories: 1)
thromboembolic disorders, which involve overproduction of clots; and
2) hemorrhagic disorders, which is characterized by ineffective clotting process leading
to excessive bleeding.
Antiplatelet Agents
• This drug class exerts its action by decreasing the responsiveness of platelets
to stimuli that cause it to clump or aggregate. Through this, formation of platelet
plug is decreased.
Therapeutic Action
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PHARMACOLOGY
Indications
• Only heparin and warfarin are indicated for children but these drugs alone
require careful dose calculation.
Adults
• Caution is particularly important to prevent injury (e.g. using electric razor and
soft-bristled toothbrush).
• It is also important that adults are educated on what to do should bleeding
occurs (e.g. applying firm pressure) as well as what signs of bleeding should be
watched out for.
• Other drugs taken should be documented because there are a lot of drug
interactions with these drug class. It should also be emphasized that periodic
blood tests is expected to monitor the effect of therapy.
Pregnant women
• For pregnant women, it is not advisable unless the benefit to the mother would
clearly outweigh the risk for the fetus. On the other hand, for lactating women,
it is generally inadvisable.
Older adults
Pharmacokinetics
T1/2: 15 min – 12 h
Metabolism: liver
Excretion: bile
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PHARMACOLOGY
Adverse Effects
Interactions
• Increased risk of bleeding if combined with another drug that affects blood
clotting.
Nursing Considerations
Nursing Assessment
These are the important things the nurse should include in conducting assessment,
history taking, and examination:
Nursing Diagnoses
Here are some of the nursing diagnoses that can be formulated in the use of this drug
for therapy:
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PHARMACOLOGY
These are vital nursing interventions done in patients who are taking antiplatelet agents:
Evaluation
Here are aspects of care that should be evaluated to determine effectiveness of drug
therapy:
Anticoagulants
Therapeutic Action
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PHARMACOLOGY
Indications
• Among the many indications for this drug class include: stroke and systemic
emboli risk reduction, nonvalvular atrial fibrillation, and deep vein thrombosis.
• Heparin is used for prevention of blood clots in blood samples, dialysis, and
venous tubing. It also does not enter breastmilk so it is the anticoagulant of
choice for lactating women.
• Antithrombin is a naturally-occurring anticoagulant and is a natural safety
feature in the clotting system.
Children
• Only heparin and warfarin are indicated for children but these drugs alone
require careful dose calculation.
Adults
• Caution is particularly important to prevent injury (e.g. using electric razor and
soft-bristled toothbrush).
• It is also important that adults are educated on what to do should bleeding
occurs (e.g. applying firm pressure) as well as what signs of bleeding should
be watched out for.
• Other drugs taken should be documented because there are a lot of drug
interactions with these drug class. It should also be emphasized that periodic
blood tests is expected to monitor the effect of therapy.
Pregnant women
• For pregnant women, it is not advisable unless the benefit to the mother would
clearly outweigh the risk for the fetus. On the other hand, for lactating women,
it is generally inadvisable.
Older adults
Pharmacokinetics
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PHARMACOLOGY
Adverse Effects
Interactions
Nursing Considerations
Nursing Assessment
These are the important things the nurse should include in conducting assessment,
history taking, and examination:
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PHARMACOLOGY
Nursing Diagnoses
Here are some of the nursing diagnoses that can be formulated in the use of this drug
for therapy:
These are vital nursing interventions done in patients who are taking anticoagulants:
• Assess for signs signifying blood loss (e.g. petechiae, bruises, dark-colored
stools, etc.) to determine therapy effectiveness and promote prompt
intervention for bleeding episodes.
• Establish safety precautions (e.g. raising side rails, ensuring adequate room
lighting, padding sides of bed, etc.) to protect patient from injury.
• Maintain antidotes on bedside (e.g. protamine sulfate for heparin, Vitamin K for
warfarin) to promptly treat drug overdose.
• Evaluate effectiveness by monitoring the following blood tests: prothrombin time
(PT) and international normalized ratio (INR) for warfarin; and whole blood
clotting time (WBCT) and activated partial thromboplastin time (APTT) for
heparin.
• Educate patient on drug therapy including drug name, its indication, and
adverse effects to watch out for to enhance patient understanding on drug
therapy and thereby promote adherence to drug regimen.
Evaluation
Here are aspects of care that should be evaluated to determine effectiveness of drug
therapy:
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PHARMACOLOGY
Thrombolytic Agents
Therapeutic Action
Indications
• For treatment of acute MI, pulmonary embolism, and acute ischemic stroke.
• Also for clearing of occluded intravenous catheters and central venous access
devices.
Children
• Caution is particularly important to prevent injury (e.g. using electric razor and
soft-bristled toothbrush).
• It is also important that adults are educated on what to do should bleeding
occurs (e.g. applying firm pressure) as well as what signs of bleeding should be
watched out for.
• Other drugs taken should be documented because there are a lot of drug
interactions with these drug class.
• It should also be emphasized that periodic blood tests is expected to monitor
the effect of therapy.
Pregnant women
• For pregnant women, it is not advisable unless the benefit to the mother would
clearly outweigh the risk for the fetus.
• On the other hand, for lactating women, it is generally inadvisable.
Older adults
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PHARMACOLOGY
• Therapy is always started at the lowest level possible and adjusted accordingly.
Pharmacokinetics
T1/2: unknown
Metabolism: plasma
Excretion: unknown
Adverse Effects
Interactions
Nursing Considerations
Nursing Assessment
These are the important things the nurse should include in conducting assessment,
history taking, and examination:
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PHARMACOLOGY
• Obtain baseline status for complete blood count, fecal occult blood test (FOBT),
and clotting studies to determine any potential adverse effects.
Nursing Diagnoses
Here are some of the nursing diagnoses that can be formulated in the use of this drug for
therapy:
These are vital nursing interventions done in patients who are taking thrombolytics:
• Assess for signs signifying blood loss (e.g. petechiae, bruises, dark-colored
stools, etc.) to determine therapy effectiveness and promote prompt
intervention for bleeding episodes.
• Establish safety precautions (e.g. raising side rails, ensuring adequate room
lighting, padding sides of bed, etc.) to protect patient from injury.
• Evaluate effectiveness by monitoring coagulation studies to adjust drug dose
appropriately.
• Educate patient on drug therapy including drug name, its indication, and
adverse effects to watch out for to enhance patient understanding on drug
therapy and thereby promote adherence to drug regimen.
Evaluation
Here are aspects of care that should be evaluated to determine effectiveness of drug
therapy:
• Monitor patient response to therapy (e.g. dissolution of blood clot and return of
blood flow)
• Monitor for adverse effects (e.g. bleeding, anemias, hypotension, etc.).
• Evaluate patient understanding on drug therapy by asking patient to name the
drug, its indication, and adverse effects to watch for.
• Monitor patient compliance to drug therapy.
Chapter 22
Gastrointestinal Drugs
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PHARMACOLOGY
Antacids are used to chemically react with and neutralize the acid in the stomach. They
can provide rapid relief from increased acid levels. They are known to cause GI alterations
such as diarrhea or constipation and can alter the absorption of many drugs.
Here is a list of the most commonly encountered antacids and their brand names.
Erosions in the lining of the stomach and adjacent areas of the GI tract are
called peptic ulcer.
• Antacids are available OTC, and many patients use them to self-treat a variety
of GI symptoms.
• The choice of an antacid depends on adverse effects and absorption factors.
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Therapeutic actions
Indication
Pharmacokinetics
Many of these antacids are available in combination forms to take advantage of the
acid-neutralizing effect and block adverse effects.
T 1/2: Unknown
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Adverse effects
Interactions
Antacids can greatly affect the absorption of drugs from the GI tract.
• Alkalinity. Most drugs are prepared for an acidic environment, and an alkaline
environment can prevent them from being broken down for absorption or can
actually neutralize them so that they cannot be absorbed.
Nursing considerations
Nursing Assessment
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• Monitor laboratory test results, including serum electrolyte levels and renal
function tests, to monitor for adverse effects of the drug and potential alterations
in excretion that may necessitate dose adjustment.
• Adequate drug absorption. Administer the drug apart from any other oral
medications approximately 1 hour before or 2 hours after to ensure adequate
absorption of the other medications.
• Ensure therapeutic levels. Have the patient chew tablets thoroughly and follow
with water to ensure that therapeutic levels reach the stomach to decrease
acidity.
• Perform diagnostic testing. Obtain specimens for periodic monitoring of
serum electrolytes to evaluate drug effects.
• Prevent imbalances. Assess the patient for any signs of acid-base or
electrolyte imbalance to ensure early detection and prompt interventions.
• Institute a bowel program. Monitor the patient for diarrhea or constipation to
institute a bowel program before severe effects occur.
• Ensure adequate nutritional status. Monitor the patient’s nutritional status if
diarrhea is severe or constipation leads to decreased food intake to ensure
adequate fluid and nutritional intake to promote healing and GI stability.
• Provide patient support. Offer support and encouragement to help the patient
cope with the disease and the drug regimen.
• Educate the patient. Provide thorough patient teaching, including the drug
name and prescribed dose, schedule for administration, signs and symptoms
of adverse effects and measures to prevent or minimize them, warning signs
that may indicate possible problems and the need to notify the health care
provider immediately.
Evaluation
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• Monitor for adverse effects (GI effects, imbalances in serum electrolytes, and
acid-base status).
• Evaluate the effectiveness of the teaching plan (patient can name the drug
and dosage, as well as describe the adverse effects to watch for, specific
measures to avoid them, and measures to take to increase the effectiveness
of the drug).
• Monitor the effectiveness of comfort measures and compliance with the
regimen.
Histamine-2 Antagonist
Histamine-2 (H2) receptor antagonists block the release of acid in response to gastrin or
parasympathetic release.Here is a table of the most commonly used H2 antagonists.
cimetidine Tagamet
ranitidine Zantac
Histamine-2 antagonists
famotidine Pepcid
nizatidine Axid
Therapeutic actions
Indication
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Pharmacokinetics
Cimetidine, ranitidine, and famotidine are available in oral and parenteral forms
T 1/2: 2 hours
Metabolization: Liver
Excretion: Urine
• Allergy. The H2 antagonists should not be used with known allergy to any
drugs of this class to prevent hypersensitivity reactions.
• Pregnancy or lactation. Caution should be used during pregnancy or lactation
because of the potential for adverse effects on the fetus or nursing baby.
• Hepatic or renal dysfunction. Caution should be used in patients with hepatic
or renal dysfunction, which could interfere with drug metabolism and
excretion.
• Prolonged or continual use. Care should also be taken if prolonged or
continual use of these drugs is necessary because they may be masking
serious underlying conditions.
Adverse effects
The adverse effects associated with H2 antagonists are:
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• Misc: Gynecomastia.
Interactions
Cimetidine, famotidine, and ranitidine can slow down the metabolism of the following
drugs, leading to increased serum levels and possible toxic reactions:
• Warfarin.
• Anti-coagulants.
• Phenytoin.
• Beta-adrenergic blockers.
• Alcohol.
• Quinidine.
• Lidocaine.
• Theophylline.
• Chloroquine.
• Benzodiazepines.
• Nifedipine.
• Pentoxifylline.
• TCAs.
• Procainamide.
• Carbamazepine.
Nursing Considerations
Nursing Assessment
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• Inspect the skin for evidence of lesions or rash to monitor for adverse
reactions.
• Evaluate neurological status, including orientation and affect, to assess CNS
effects of the drug and to plan for protective measures.
• Assess cardiopulmonary status, including pulse, blood pressure, and
electrocardiogram (if IV use is needed), to evaluate the cardiac effects of the
drug.
• Perform abdominal examination, including assessment of the liver, to
establish a baseline and rule out underlying medical problem.
• Monitor the results of laboratory tests, including liver and renal function tests,
to predict changes in metabolism or excretion of the drug that might require
dose adjustment.
Nursing diagnosis related to the drug therapy might include the following:
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• Provide support. Offer support and encouragement to help patients cope with
the disease and the drug regimen.
• Educate the client. Provide patient teaching regarding drug name, dosage,
and schedule for administration; importance of spacing administration
appropriately as ordered; need for readily available access to bathroom; signs
and symptoms of adverse effects and measures to minimize or prevent them.
Evaluation
The gastric acid pump or proton pump inhibitors suppress gastric acid secretion by
specifically inhibiting the hydrogen-potassium adenosine triphosphate enzyme system on
the secretory surface of the gastric parietal cells.Here is a table of the most commonly
encountered proton pump inhibitor:
dexlansoprazole Kapidex
esomeprazole Nexium
lansoprazole Prevacid
Proton pump inhibitors
omeprazole Prilosec
pantoprazole Protonix
rabeprazole Aciphex
Gastroesophageal reflux disease (GERD) occurs when stomach acid frequently flows
back into the tube connecting the mouth and the stomach (esophagus).
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• GERD is a mild acid reflux that occurs at least twice a week, or moderate to
severe acid reflux that occurs at least once a week.
• Common signs and symptoms of GERD include a burning sensation in the
chest (heartburn), usually after eating, which might be worse at night;
chest pain; difficulty swallowing; regurgitation of food or sour liquid; and a
sensation of a lump in your throat.
Proton pump inhibitors suppress the secretion of hydrochloric acid into the lumen of the
stomach.
Therapeutic actions
• Blocks the final step of acid production, lowering the acid levels in the stomach.
• Inhibits the hydrogen-potassium adenosine triphosphate enzyme system on the
secretory surface of the gastric parietal cells.
Indication
Pharmacokinetics
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T 1/2: 30 to 60 mins
Metabolization: Liver
The following are contraindications and cautions when using proton pump inhibitors:
Adverse effects
Interactions
Clinically important drug to drug interactions for proton pump inhibitors include the
following drugs:
Nursing considerations
Nursing considerations when using proton pump inhibitors include the following:
Nursing Assessment
History taking and physical examination of a patient using proton pump inhibitors include:
Nursing interventions for patients using proton pump inhibitors include the following:
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PHARMACOLOGY
• Proper administration. Administer drug before meals to ensure that the patient
does not open, chew, or crush capsules; they should be swallowed whole to
ensure the therapeutic effectiveness of the drug.
• Safety and comfort measures. Provide appropriate safety and comfort
measures if CNS effects occur to prevent patient injury.
• Institute a bowel program. Monitor the patient for diarrhea or constipation in
order to institute an appropriate bowel program as needed.
• Monitor nutritional status. Monitor the patient’s nutritional status; use of small
frequent meals may be helpful if GI upset is a problem.
• Ensure follow-up. Arrange for medical follow-up if symptoms are not resolved
after 4 to 8 weeks of therapy because serious underlying conditions could be
causing the symptoms.
• Provide patient support. Offer support and encouragement to help the patient
cope with the disease and the drug regimen.
• Educate the patient and folks. Provide thorough patient teaching, including the
drug name and prescribed dosage; the importance of taking the drug whole
without opening, chewing, or crushing it; signs and symptoms of possible
adverse effects and measures to minimize or prevent them.
Evaluation
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CHAPTER 23
EYE, EAR AND SKIN DRUGS
OBJECTIVE:
To describe the drug groups that are commonly used for the disorders of the eye, ear and skin.
EYE
The eye is consist of different intricate sensory organ which are responsible sight. Vison loss can result
from ocular system injury or disease. Medication is a key role in the asministration of different eye condition
and diseases such as chronic dry-eye, diabetic retinopathy, glaucoma, infection, inflammation, and macular
degeneration. Wherein variety of ophthalmic preparations (topical, parenteral, and oral) are made accessible
The eye has a complex structural anatomy which makes pharmacological treatment a unique challenge. The
cornea comprises of different layers contained hydrophobic and hydrophilic properties which can modify
skin drug retention. Although systemic absorption of ophthalmic agents can occur (mentioned in topics
below), it is typically negligible on the grounds that the eye is separated from the foundational vascular
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PHARMACOLOGY
• Eye drop
• Ointment
• Injection
• Periocular injection
• Intraocular injection
Systemically:
• Orally
• IV
Eye drops
• one drop = 50 µl
Ointment
• Increase the contact time of ocular medication to ocular surface thus better effect
Disadvantages
• The drug has to be high lipid soluble with some water solubility to have the
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PHARMACOLOGY
Intracameral or intravitreal
Peri-ocular injections
• bypass the conjunctival and corneal epithelium which is good for drugs with low
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PHARMACOLOGY
Systemic drugs
• Oral or IV
• lipid solubility of the drug: more penetration with high lipid solubility
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PHARMACOLOGY
Autonomic drugs:
✓ Miotics - Miotics work by contraction of the ciliary muscle, tightening the trabecular
pathways.
✓ Mydriatics- are a type of medicine that make the pupil of the eye dilate (open up).
Mydriatics also tend to relax the focusing muscles of the eye, which means that
• Anti-inflammatory drugs:
✓ Glucocorticoids
✓ NSAIDs
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PHARMACOLOGY
Parasympathetic N.S.
✓ Increased lacrimation
✓ Conjunctival Vasodilatation
Sympathetic N.S.
✓ Lacrimation α1
humour.
cholinergic agonists that reduce IOP by improving fluid outflow through the trabecular
meshwork. Activation of muscarinic (M3) receptors allows for contraction of ciliary muscle
fibers, which expands the pores of the trabecular meshwork to enhance outflow.
Ophthalmic agents within this class include carbachol and pilocarpine. Adverse effects
include sweating, salivation, eye pain, blurred vision, abdominal pain, and headache.
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PHARMACOLOGY
Cholinergic agonists
✓ Direct agonists
– Reversible :Physostigmine
– Irreversible: Ecothiophate
USES:
– To break adhesions
• Miosis
• Salivation
• Sweating
• bronchial constriction
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PHARMACOLOGY
✓ Bronchial asthma.
✓ Peptic ulcer.
✓ Angina pectoris
✓ Incontinence
✓ Intestinal obstruction
Cholinergic drugs
Carbachol Glaucoma
Methacholine
✓ Passive mydriasis
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PHARMACOLOGY
USES:
Side effects:
EAR
This chapter discusses the pharmacology of several agents used to treat sensorineural
hearing loss and vertigo and offers perspectives for the future for drug delivery to the
inner ear.
Drugs acting on the ear
Otitis externa
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PHARMACOLOGY
Anti-infective preparations
Use of gentamicin is contraindicated in those with perforated ear- drum.
Gentamicin ear/eye drops 0.3%
Clotrimazole 1% drops (specialist use only)
Antibiotics
➢ Chloramphenicol
➢ Chloromycetin Otic
➢ gentamicin sulfate otic
➢ Garamycin
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➢ Glycerin
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PHARMACOLOGY
SKIN
DRUGS ACTING ON THE SKIN AND MUCOUS MEMBRANES
Objectives
To have a clear understanding on:
The basic and clinical pharmacology of drugs acting on the skin and mucous
membranes
Different formulations available
Pharmacotherapeutics of skin and mucous membrane disorders
Introduction
The integument or skin is the largest organ of the body, making up 16% of body weight,
with a surface area of 1.8m2.It has several functions, the most important being to form a
physical barrier to the environment, allowing and limiting the inward and outward passage
of water, electrolytes and various substances while providing protection against micro-
organisms, ultraviolet radiation, toxic agents and mechanical insultsThere are three
structural layers to the skin: the epidermis ; the epidermis and subcutisThe skin is an area
of the body that gives a disproportionate number of therapeutic problems, particularly in
small animals. The underlying cause of persistent eczemas is often obscure, leaving the
veterinary surgeon little choice but to attempt symptomatic treatment with what agents
he/she has at his/her disposal.
Skin and drugs
“It is easy to do more harm than good with potent drugs, and this is particularly true
in skin diseases. Many skin lesions are caused by systemic or topical use of drugs,
often taking the form of immediate or delayed hypersensitivity”
If its wet, dry it; if its dry, wet it. The traditional advice contains enough truth to be
worth repeating. One or two applications a day are all that is usually necessary
unless common sense dictates otherwise”
Drugs acting on the skin and mucous membranes can be broadly classified in to
the following categories:
• Dermatological vehicles
• Preparations for allergic, inflammatory and other immune mediated skin
conditions. These include:
a). Corticosteroids
b).Immunosuppressant’s
c). Antihistamines
d).Essential fatty acid preparations
e). Prostaglandin E1 analogues
- Sunscreens
- Anti-infective skin preparations
- Keratolytics and Keratoplastic agents
- Shampoos
- Preparations for the ear
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PHARMACOLOGY
• Systemic disorders may also be responsible for clinical signs affecting the skin-
e.g. hormonal disturbances including hypothyroidism or hyper-adreno-corticism,
nutritional deficiency of for example zinc (Leading to parakeratosis-
• defined as hyper keratinization of the epithelial cells of skin and esophagus (Dr.
Nguta, J.M (Pharmacology/Toxicology)
Dusting powders
b) Dusting powders are finely divided powders that contain one or more active
ingredients. Generally, they absorb moisture, which discourages bacterial
growth. Dusting powders should not be used on wet, raw surfaces because
adherent crusts and caking may result: they may be used in the treatment
of wound infections.
Lotions
c) Lotions are usually aqueous solutions or suspensions for application
without friction to inflamed unbroken skin. They cool by evaporation of
solvents, require frequent application, and may leave a thin film of drug on
the skin (not easily calamine lotion). Lotions are used in hairy areas and for
lesions with minor exudation and ulceration. Care must be taken with
nervous or excitable animals because lotions containing volatile
substances can sting on application. Available preparations include:
- Calamine (Non-proprietary)
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PHARMACOLOGY
f). Gels are semi solid aqueous solutions that are easy to apply, not greasy,
miscible with water and wash off easily.
Sprays
g). Sprays are used as pressurized aerosols or in spraying units. They may be
economical to use because of the ease of application with little waste, and can
be easily directed.
- Sealed packaging means the risk of contamination of the remaining
constituents is minimized. Additionally, the cooling effect produced by the
evaporation of solvents may be beneficial in certain conditions.
- Some animals may show signs of anxiety in response to the noise produced
by the spray.
Shampoos
h.) Shampoos are used as complementary therapy in association with other
treatment or as sole preparations in the long term management of certain
disorders such as seborrhea (a skin condition in which there is excessive
secretion by the sebaceous glands, forming crusts with scales from the skin
and dirt. (Also known as hypersteatosis or seborrhoeic dermatitis).
- Shampoos are indicated as vehicles for antipruritic and keratolytic drugs
and for skin dis-infecting and cleansing preparations.
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A wide variety of causative factors may be involved in these skin conditions. The selection
of the type and duration of treatment depends on the inflammatory disease present. In
every case, the underlying cause(s) should be identified and eliminated, if possible. If this
can be done, long-term anti-inflammatory therapy is unnecessary.
The following drug classes are used:
1. Corticosteroids
2. Immunosuppressants
3. Antihistamines
4. Topical anti-inflammatory skin preparations
5. Essential fatty acid preparations
6. Prostaglandin E1 analogues
1.Corticosteroids
• Systemic corticosteroids are of great value in the treatment of inflammatory and
immune-mediated skin conditions.
• Oral preparations with a short duration of action are preferred because therapy
can be discontinued swiftly if adverse effects are seen. This is not possible with
longer acting, injectable agents.
• In addition, fewer side-effects are associated with the use of short acting oral drugs
than with other formulations of corticosteroids.
• However in severe acute diseases, short acting injectable corticosteroid
formulations may be favored.
• In chronic diseases where corticosteroids are indicated, alternate day therapy
should be used to minimize the risk of adrenal suppression.
• Depot corticosteroids such as methylprednisolone acetate should be reserved for
cases in which the use of short acting preparations is impaired, for example in dogs
or cats that will not tolerate oral dosing and the patient cannot be medicated by
mouth.
• The dose and the type of corticosteroid used depend on the form and severity of
the disease present.
2. Immunosuppressants
Ciclosporin (Cyclosporin):
• Ciclosporin blocks the transcription of the genes encoding several cytokines.
• Its main effect is achieved by blocking transcription of IL-2 and subsequently its
synthesis.
• Secondary effects include inhibition of IFN gamma (Interferon gamma); IL-3, IL-4,
IL-5, IL-8 and granulocyte macrophage colony stimulating factor (GM-CSF).
• As a result, ciclosporin affects the function of mast cells, eosinophils, and antigen
presenting cells.
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PHARMACOLOGY
Indications
• Atopic dermatitis; ocular disease; immune-mediated diseases as an
immunosuppressant; peri-anal fistula; furunculosis; sebaceous adenitis.
• Contra-indications
• Dogs less than six months of age or less than 2kg body weight
• Animals with history of malignant disease or progressive malignant dis-orders
• Vaccination during or within 2 weeks of treatment
• Diabetes mellitus
• Concomitant use of other immunosuppressants
3. Antihistamines
• Antihistamines are antagonists of the histamine H1 receptor and include:
chlorphenamine; clemastine; diphenhydramine; hydroxyzine; promethazine;
mepyramine; tripelennamine and alimemazine. H2 receptor antagonists are
ineffective.
• Antihistamines diminish or abolish the main actions of histamine in the body by
competitive reversible blockade of histamine receptor sites.
• Histamine is only one of many autacoids involved in hypersensitivity reactions and
so antihistamines have limited use in the treatment of allergic dis-orders in animals.
• The effects of antihistamines may not be observed for 1 to 2 weeks and they are
most effective for preventing rather than for rapidly reducing pruritus.
• Some authorities indicate initial use of glucocorticoids in conjunction with
antihistamines. Glucocorticoid therapy is stopped when pruritus is eliminated;
antihistamine treatment is continued.
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C). Sunscreens
• Exposure of the skin to ultra-violet light causes damage that is related to the light
intensity, duration of exposure and skin sensitivity.
• Phototoxic reactions occur in skin with low levels of pigmentation which are not
protected by the coat.
• The resulting solar dermatitis varies from a mild erythematous and scaling reaction
to swelling with associated cysts, bullae, folliculitis, furunculosis, and scarring.
• Chronic light exposure may lead to the development of squamous cell carcinoma.
• Photosensitivity reactions are caused when photodynamic agents in the skin are
exposed to ultraviolet light and cause tissue damage.
• Photodynamic agents may be generated by abnormalities of hepatic function,
aberrant pigment synthesis, or may be derived from substances, ingested,
injected, or absorbed through the skin.
• The increasing levels of ultraviolet light penetration, which are now being
experienced, are leading to an increasing amount of damage to the skin.
• Animals that spend a lot of time outdoors and which are sparsely coated or lacking
in pigmentation are especially at risk.
• Sun avoidance is the best solution but protective clothing and use of topically
applied stains for example felt-tipped pen on depigmented skin are effective.
• Sunscreens which are water resistant and have a sun protection factor (SPF) of
over 15 are useful and should be applied at least once daily but they do not
eliminate damage totally and chronic effects may still occur.
• Pigs kept outdoors should be provided with a mud bath.
D). Anti-infective skin preparations
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PHARMACOLOGY
An infection may be the principle cause of a skin condition or may be secondary to skin
trauma or an underlying dis-order. These can include: endocrine imbalances;
hypersensitivity; immunosuppression or nutritional imbalances.
Topical antibacterial skin prep.
• Topical treatment is often employed using topical antibacterials, zinc sulfate, lime
sulfur, and iodine containing compounds.
• Dermatophilus congolensis is susceptible to many antibacterials.
• Antibacterials incorporated into topical preparations include: chlortetracycline;
oxytetracycline, which may be effective against superficial infections caused by
bacteria including: Bacillus; Actinomyces; Clostridium; Streptococci and
Staphylococci.
• Fusidic acid is particularly effective against infections caused by Staphylococci;
Actinomyces; Neisseria and some Clostridium species.
Topical antifungal skin prep.
• The success of drug therapy depends on additional management aimed at
reducing and limiting infection such as careful clipping around the lesions in dogs
and cats, limiting grooming, isolating the animal and using antifungal washes on
the affected animal and local environment.
• Griseofulvin and ketoconazole are used for systemic treatment of ringworm.
• Ketoconazole is effective in Malassezia pachydermatis infection of the skin.
• Itroconazole is also effective against ringworm in dogs and cats and appears to be
much less hepatotoxic and associated with fewer side effects than ketoconazole.
• Topical antifungals may be used for the treatment of ringworm, although drug
toxicity, due to ingestion through self-grooming, the necessity for clipping of the fur
and repeated application and limited efficacy of the preparation should be taken
into account.
Topical antifungal skin preparations
• Topical enilconazole, clotrimazole and ketoconazole are effective for Malassezia
pachydermatis infection.
• However, the treatment of choice is a shampoo containing chlorhexidine and
miconazole (shampoo containing selenium sulfide may also be effective).
• Topical enilconazole or miconazole may be used in conjunction with systemic
griseofulvin for the treatment of ringworm. Povidone iodine is also used as a
fungicide.
• Natamycin is a polyene antifungal antibacterial, which may be used for topical
treatment and also for disinfection of the ringworm-contaminated environment and
horse tackle (accessories worn by horses in the course of their use as
domesticated animal).
• A vaccine is available for immunization against ringworm in cattle
3.Prep. For minor cuts and abrasions
• These preparations are used to treat minor skin infections and abrasions, and to
prevent infection following surgery or when dehorning.
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PHARMACOLOGY
• They are applied as necessary in the form of dusting powder, ointments or sprays.
• Preparations containing benzoic acid, cresol or phenols should not be used on cats
(Cats have significantly lower tolerance to the preparations).
Indications
• Minor cuts and abrasions.
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PHARMACOLOGY
• Animal wounds occur frequently and need to be assessed and treated similarly to
wounds in humans.
• The objective of any wound management regimen is to heal the wound in the
shortest time possible and with minimum pain, discomfort and scarring for the
patient.
• Open wounds such as abrasions, lacerations, avulsions, ballistic, penetrating,
hernias and excised or surgical wounds are most common in the domestic species
and are characterized by a break in the skin.
• Closed wounds include contusions, bruises, ruptures and sprains.
1.Skin cleansers and Disinfectants
• Alcohol (70%) is commonly used for its solvent properties for the removal of
superficial contamination.
• Cetrimide, Chlorhexidine, and Povidone-iodine are used for skin dis-infection.
• Contaminated wounds should be thoroughly lavaged with isotonic solutions such
as sodium chloride 0.9% solution (Normal saline) or ringer’s solution.
• If the wound is less than three hours old, antibacterials in the lavage solution will
decrease the occurrence of wound infection.
• After three hours, antibacterials in lavage are no more effective than lavage alone.
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PHARMACOLOGY
CHAPTER 24
Endocrine System Drugs
Endocrine system
– Controls, integrates body functions
– Information from various parts of body carried via blood-borne hormones to distant sites
Hormones are natural chemical substances
– Act after secreted into bloodstream from endocrine glands
– Glands include
• Anterior and posterior pituitary
• Thyroid
• Parathyroid
• Adrenal glands
• Thymus
• Pancreas
• Testes
• Ovaries
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PHARMACOLOGY
• Disorders of parathyroid
– Hypoparathyroidism
– Hyperparathyroidism
Thyroid drugs
– Treat hypothyroidism
• Thyroid
• Iodine products
• Levothyroxine (Synthroid, Levoxyl)
Parathyroid drugs
– Treat hyperparathyroidism
• Vitamin D
• Calcium supplements
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PHARMACOLOGY
• Calcium supplements
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PHARMACOLOGY
CHAPTER 25
Renal and urologic drugs
Diuretics
These are drugs which cause a total deficit of Na+ and water in urine. In view of the diuretic action of
calomel, organomercurials given by injection were presented during the 1920s and overwhelmed for almost
40 years. The case inhibitors were created presented during the 1920s and overwhelmed for almost 40
yearsin the 1950s from the perception that early sulfonamides caused acidosis and mild diuresis. The first
modern orally active diuretic chlorothiazide was discovered in 1957, and by early 1960s its congeners
(thiazide diuretics) were already in common use. Availability of furosemide and ethacrynic acid by mid
1960s revolutionized the pattern of diuretic use. The K+ sparing diuretics spironolactone and triamterene
were developed in parallel to these. Diuretics are among the most generally recommended drugs. Utilization
of diuretics to the management of hypertension has exceeded their utilization in edema.
HIGH CEILING (LOOP) DIURETICS
Furosemide (Frusemide)
Prototype drug is the development of this orally and rapidly acting highly efficacious diuretic was a
breakthrough. Its has maximal natriuretic effect which is much greater than that of other classes. The
diuretic response goes on increasing with increasing dose: up to 10 L of urine may be produced in a day.
It is dynamic even in patients with moderately extreme renal disappointment.
Intravenous furosemide causes brief expansion in fundamental venous capacitance and diminishes left
ventricular filling pressure, even before the saluretic reaction is obvious. This action is additionally seen
of being PG intervened and is liable for the speedy help it manages in LVF and pulmonary edema.
Bumetanide
It is similar to furosemide in all respects, but is 40 times more potent. It induces very rapid diuresis and is
highly effective in pulmonary edema
Torasemide (Torsemide)
Another high ceiling diuretic with properties similar to furosemide, but 3 times more potent. Oral
absorption is more rapid and more complete. The elimination t½ (3.5 hours) and duration of action (4–8
hours) are longer. Torasemide has been used in edema and in hypertension
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PHARMACOLOGY
4. Hypertension High ceiling diuretics are indicated only in presence of renal insufficiency, CHF, in
resistant cases or hypertensive emergencies; otherwise thiazides are preferred.
5. Along with blood transfusion in severe anaemia, to prevent vascular overload.
6. Hypercalcaemia and renal calcium stones: because furosemide and its congeners increase calcium
excretion and urine flow, they may help to reduce serum calcium level.
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PHARMACOLOGY
The side effects are drowsiness, confusion, abdominal upset, hirsutism, gynaecomastia, impotence and
menstrual irregularities. The most serious effect is hyperkalaemia that may occur especially if renal function
is inadequate. Acidosis is a risk, particularly in cirrhotics. Peptic ulcer may be aggravated. While eplerenone
is a recently developed more selective aldosterone antagonist, that is less likely to cause hormonal
disturbances like gynaecomastia, impotence and menstrual irregularities.
OSMOTIC DIURETICS Mannitol Mannitol is a nonelectrolyte of low molecular weight (182) that is
pharmacologically inert— this can be taken in large quantities sufficient to raise osmolarity of plasma and
tubular fluid. It is not metabolized in the body; freely filtered at the glomerulus and undergoes limited
reabsorption: therefore excellently suited to be used as osmotic diuretic. Mannitol appears to limit tubular
water and electrolyte reabsorption in a variety of ways:
1. Retains water isoosmotically in PT— dilutes luminal fluid which opposes NaCl reabsorption.
2. Inhibits transport processes in the thick AscLH by an unknown mechanism. Quantitatively this appears
to be the most important cause of diuresis.
3.Expands extracellular fluid volume (because it does not enter cells, mannitol draws water from the
intracellular compartment)—increases g.f.r. and inhibits renin release.
4. Increases renal blood flow, especially to the medulla—medullary hypertonicity is reduced—
corticomedullary osmotic gradient is dissipated—passive salt reabsorption is reduced. Uses Mannitol is
never used for the treatment of chronic edema or as a natriuretic.
Its indications are:
1. Increased intracranial or intraocular tension (acute congestive glaucoma, head injury, stroke, etc.): by
osmotic action it encourages movement of water from brain parenchyma, CSF and aqueous humour; 1–1.5
g/kg is infused over 1 hour as 20% solution to transiently raise plasma osmolarity. It is also used before and
after ocular/brain surgery to prevent acute rise in intraocular/intracranial pressure.
2. To maintain g.f.r. and urine flow in impending acute renal failure, e.g. in shock, severe trauma, cardiac
surgery, haemolytic reactions: 500–1000 ml of the solution may be infused over 24 hours. However,
prognostic benefits in conditions other than cardiac surgery are still unproven. If acute renal failure has
already set in, kidney is incapable of forming urine even after an osmotic load; mannitol is contraindicated:
it will then expand plasma volume → pulmonary edema and heart failure may develop.
3. To counteract low osmolality of plasma/e.c.f. due to rapid haemodialysis or peritoneal dialysis (dialysis
disequilibrium).
• Betamethasone (Celestone)
• Dexamethasone (Decadron)
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PHARMACOLOGY
• Methylprednisolone (Solu-Medrol)
• Triamcinolone (Aristocort)
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PHARMACOLOGY
CHAPTER 26
REPRODUCTIVE AND GENDER RELATED DRUGS
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PHARMACOLOGY
• Endometriosis
• Specific cancers
• Prevent pregnancy when used properly
There are three kinds of medicines your provider may give you if you’re having preterm labor:
➢ These speed up your baby’s lung development. These also aid in averting the chance
of a baby in having certain health problems after birth, including respiratory distress
syndrome (also called RDS), intraventricular hemorrhage (also called IVH) and
necrotizing enterocolitis (also called NEC).
2. Antibiotics.
3. Tocolytics.
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PHARMACOLOGY
➢ These slow or stop labor contractions. Tocolytics may delay labor, often for just a few
days. This delay may give you time to get treatment with ACS or to get to a hospital
with a neonatal intensive care unit (also called a NICU)
➢ Low levels of calcium and bone problems in your baby can be a result when medicine
is taken for a longer time. And if you have a health condition, like a heart problem or
severe preeclampsia, some tocolytics may not be safe for you. Are there other kinds of
treatments for preterm labor?
Do medicines used during preterm labor have side effects for mom and baby?
Sometimes. A side effect is an effect of a drug or medicine that is not the intended result. Medicines used
on the preterm labor may do what they were supposed to do to help you or your baby, but side effects may
occur, too. Side effects differ for every woman and also depends on the kind of medicine. Talk to your
provider about what kind of medicine is right for you.
Antenatal corticosteroids include medicines likes betamethasone and dexamethasone. Possible side effects
for mom for both of these medicines may include fluid build-up in the body and increased blood
pressure. There are no side effects for your baby.
Several kinds of tocolytics may be used during preterm labor, each with different side effects.
Beta-adrenergic receptor agonists, like terbutaline. Possible side effects for your baby may include
having a fast heartbeat. Possible side effects for you may include:
• Fever, headache
Calcium channel blockers, like nifedipine. There are no side effects for your baby. Possible side effects
for you may include:
• Headache
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PHARMACOLOGY
• Slowed breathing
• Weak muscles
• Low levels of calcium and bone problems, if the drug is used for more than 5 to 7 days.
• Dry mouth
• Heart attack
• Nausea or throwing up
Nonsteroidal anti-inflammatory drugs (also called NSAIDs), like indomethacin. Side effects for your
baby may include:
• Patent ductus arteriosus, also called PDA. This is a heart problem that’s common in premature babies.
• Jaundice. This is a common condition caused by the build-up of a substance called bilirubin in the
blood that makes a baby’s skin and the white parts of his eyes look yellow.
• Feeling dizzy
• Heartburn
• Nausea or throwing up
• Oligohydramnios. This is when you have too little amniotic fluid. Amniotic fluid is the fluid that
surrounds your baby in the womb.
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PHARMACOLOGY
• Vaginal bleeding
CHAPTER 27
COMMON EMERGENCY DRUGS
Emergency drugs are chemical compounds used when life threatening conditions occur to controll the
symptoms and save the life of a patien. Short onset of action and can be administered in such a way as to
facilitate rapid onset of actoom is a must for a drug to be useful in during emergency.
PURPOSE
1. To provide initial treatment for broard spectrum of illness and injuries, most of which may
be life threatening.
2. To control the symptoms of patient.
3. To save the life of the patient.
4. To reach the site of action as soon as possible.
5. To normalize the vital bodily functions.
6. To diverge the patient from the possible risks
List of Drugs
✓ Atropine
✓ Sodium Nitroprusside
✓ Amiodarone
✓ Aminophylline
✓ Mannitol
✓ Magnesium Sulfate
✓ Epinephrine
✓ Hydrocortisone
✓ Heparin
✓ Diazepam
✓ Dextrose 50%
Atropine
Indications and dose of the drug:
SINUS BRADYCARDIA: 0.5-1mg(or 5-10ml of 0.1mg/ml) repeated every 3-5 min when necessary in
adults.
BRONCHOSPASM: 0.025mg/kg in2.5ml NS via nebulizer every 6-8hrs
Organophosphate poisoning: 2mg iv/im every 3 min. according to clinicalresponse in adult.
Cardiac arrest: 1mg every 3-5 minutes.
Mechanism of Action:
It competitively obstructs the muscarinic receptors in peripheral tissues (heart, intestines, bronchial
muscles, iris, secretory glands) and ease the smooth muscles.
The main action of vagus nerve of the parasympathetic system on the heart is to slow it down and atropine
blocks that action and speeds up the heart rate.
Drug Interactions:
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PHARMACOLOGY
Contraindications
✓ Palpitation
✓ Dry mouth
✓ Blurred vision
✓ Urinary retention and constipation
✓ Tachycardia
✓ Dysphagia
✓ Arrhythmias
✓ Hallucinations
Raise intraocular pressure
Sodium
Nitroprusside(Nitropress)
Indications and Dose of the drug:
Sodium nitroprusside is indicated for the immediate reduction of blood pressure of patients in hypertensive
crises. Concomitant longer-acting antihypertensive medication should be administered so that the duration
of treatment with sodium nitroprusside can be lessen.
Dosage: 0.5-10 mcg/kg/min IV infusion
Mechanism Of Action:
The principal pharmacological actionof sodium nitroprusside is relaxation ofvascular smooth muscle and
consequent dilatation of peripheral arteriesand veins by producing Nitric Oxide thusreducing preload and
afterload
Drug Interactions:
Contraindications:
✓ Hypersensitivity
✓ Congenital (Leber's) optic atrophy
✓ Tobacco amblyopia
✓ Acute congestive heart failure with reduced peripheral vascular resistance
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PHARMACOLOGY
Adverse Effects
➢ Excessive hypotension
➢ Cyanide Toxicity
➢ Thyroid Suppression
➢ Thiocyanate Poisoning
➢ Metabolic Acidosis
➢ Raised intracranial Pressure
➢ Bowel Obstruction
Amiodarone
Indication and dose of the drug:
Mechanism of Action:
Amiodarone is generally considered aclass III antiarrhythmic, which hinders adrenergic stimulation; affects
sodium,potassium and calcium channels; markedly prolongs action potential and repolarization and
decreases AV conduction and sinus node function
Interactions:
Contraindications:
Adverse Effects:
✓ Hypotension
✓ AV BLOCK
✓ Congestive Heart Failure
✓ Bradycardia
✓ Cardiogenic Shock
Aminophylline
Indications and Dose of the Drug:
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PHARMACOLOGY
Acute exacerbations of the symptoms of reversible airflow obstruction associated with asthma and other
chronic lung diseases, e.g.,emphysema and chronic bronchitis.
Dose: 5 – 7mg/kg IV/PO for over20minutes
Mechanism Of Action:
Smooth muscle relaxation(i.e., bronchodilation) suppression of the response of the airways to stimuli (i.e.,
nonbronchodilator prophylactic effects).
Interactions:
✓ Dipyridamole
✓ Febuxostat
✓ Riociguat
✓ Cimetidine
✓ Ciprofloxacin
✓ Cigarrete smoking
✓ Aminophylline
Contraindications:
✓ Hypersensitivity
✓ Active peptic ulcer disease
✓ Underlying uncontrolled seizure disorder
Adverse Effect:
Serum Concentration< 20mcg/ml
➢ Diarrhea,Nausea,Vomiting
➢ Diuresis
➢ Exfoliative Dermatitis
➢ Skeletal Muscle Tremors
➢ Tachycadia, Flutter
➢ Serum Concentration>30mcg/ml
➢ Acute Myocardial Infarction
➢ Seizures(resistant to anticonvulsants)
Mannitol
Mechanism Of Action:
Mannitol is an osmotic diuretic. It induces diuresis by elevating the osmolarity of the glomerular filtrate
and thereby hindering tubular reabsorption of water. Excretion of chloride and sodium is also enhanced
Drug interaction
➢ Tobramycin
➢ Lurasidone
➢ Nitroglycerin
➢ Trobramycin inhaled
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PHARMACOLOGY
Contra-indication
➢ Pulmonary oedema
➢ Severe congestive heart failure
➢ Severe dehydration
➢ Renal failure
Adverse effect
Magnesium Sulfate
Indications and Dosage:
Convulsions (treatment) – Intravenous magnesium sulfate (magnesium sulfate(magnesium sulfate
injection) injection) is indicated for immediate control of life-threatening convulsions in the treatment of
severe toxemias(pre-eclampsia and eclampsia) of pregnancy1 to 4 g magnesium sulfate (magnesium
sulfate(magnesium sulfate injection) injection) may begiven intravenously in 10% to 20% solution
Mechanism Of Action:
Interactions:
• Doxycycline
• Tetracycline
• Minocycline
• Ciprofloxacin
Contraindication:
• Hypersensitivity
• Myocardial damage
• Heart block
• Hypermagnesemia
• Hypercalcemia
• Pregnancy Category: D
Adverse Effects:
• Circulatory Collapse
• Respiratory paralysis
• Hypotension
• Flushing
• Depressed cardiac function
• Drowsiness
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PHARMACOLOGY
HEPARIN
Indications And Dosage:
INDICATION ; Deep Vein Thrombosisthrombosis, emboli, unstable anginaDose ;Treatment of deep-vein
thrombosis and pulmonary embolism ; by injection Adult loadingdose of 500units [in severe pulmonary
embolism1000 units
Prophylaxis in general surgery ,by SC injectionAdult 2000units before surgery and then every 8-12hrs for 7
days.
Mechanism Of Action:
• Inactivates the active form of other clotting factors like IX, X, XI and XII
Interactions:
Argatroban
• Bivalirudin
• Dabigatran
• Desirudin
Contraindication:
• Haemophilia
• Thrombocytopenia
• Peptic ulcer
• Cerebral haemorrhage
• Severe hypertension
• Renal & liver disease
•
Adverse Effects:
Epinephrine
Mechanism of action
It acts by stimulating the à and ß-receptors of the adrenergic neurons of sympathetic nervous
system. Its alpha adrenergic effects is much strongerthan the beta adrenergic effects
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PHARMACOLOGY
Drug Interactions:
• Tranylcypromine
• Quinidine
• Amiodarone
• Amitriptyline
• Chlorpromazine
• Phenelzine
Contraindications:
Hydrocortisone
Mechanism of action:
• It reduces the inflammatory reaction by limiting the capillary dilatation and permeability
of the vascular structures.
• It also restrict the accumulation of polymorphonuclear leukocytes and macrophages and
reduce the release of vasoactive kinins.
• It also inhibit the release of destructiveenzymes that attack the injury debris anddestroy
normal tissue indiscriminately.
*The initial dose of hydrocortisone is 100 mg to 500 mg, depending on the severity of the condition. This
dose may be repeated at intervals of 2, 4 or 6hours as indicated by the patient’s response and clinical
condition.
Drug interactions:
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PHARMACOLOGY
Contraindications:
• Premature infants
• Systemic fungal infections
• Hypersensitivity
• Sodium retention
• Congestive heart failure in susceptible patients
• Potassium loss
• Hypokalemic alkalosis
• Hypertension
• Convulsions
• Headache
• Abdominal distention
• Loss of muscle mass
Diazepam
Mechanism of action:
Drug interactions:
✓ Sodium Oxybate
✓ Carbamezipine
✓ Cimetidine
✓ Clamithromycin
✓ Rifampin
Contraindications:
✓ Hypersensitivity
✓ Acute alcohol intoxication
✓ Children < 6 months
✓ Breastfeeding
✓ Sleep Apnea
✓ Severe Respiratory Depression
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PHARMACOLOGY
✓ Hypotension
✓ Fatigue
✓ Respiratory depression
✓ Blurred vision
✓ Headache
✓ Dysarthria
Dextrose 50%
Indication and dose of the drug:
✓ Documented hypoglycemia
✓ Seizures of unknown etiology
✓ Cerebral/meningeal edema related to eclampsia
✓ Coma of unknown cause
✓ Refractory cardiac arrest
Drug interaction:
Minor interactions include:
Magnesium Chloride
Magnesium citrate
Magnesium Hydroxide
Contrainidications:
✓ Hyperglycemia
✓ Anuria
✓ Intracranial or Intraspinal haemorrhage
✓ Diabetic coma
✓ Hyperosmolarity
✓ Edema
✓ Phlebitis at injection site
✓ Hyperglycemia and glycosuria
✓ Fluid overload
✓ Cerebral Haemorrhage
References:
Baynes, J., Dominiczak, M., Medical Biochemistry. Elsevier Limited; Third Edition (2009)
Goodman E (2010). Ketchum J, Kirby R. ed. Historical Contributions to the Human
Toxicology of Atropine. Eximdyne. pp. 120.
Britto MR, Hussey EK, Mydlow P, et al. Effect of enzyme inducers on ondansetron (OND)
metabolism in humans. Clin Pharmacol Ther 1997;61:228.
Villikka K, Kivisto KT, Neuvonen PJ. The effect of rifampin on the pharmacokinetics of
oral and intravenous ondansetron. Clin Pharmacol Ther 1999;65:377-381.
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PHARMACOLOGY
Bryan E, Bledsoe; Robert S. Porter, Richard A. Cherry (2004). "Ch. 3". Intermediate
Emergency Care. Upper
Saddle River, NJ: Pearson Prentice Hill. pp. 26.
Essentials of Medical Pharmacology Sixth Edition KD TRIPATHI MD Ex-Director-
Professor and Head of Pharmacology Maulana Azad Medical College and associated LN
and GB Pant Hospitals New Delhi
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