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Monday, November 12, 2007

Pharmacology Bullet Review :: Nursing Pharmacology :: Review For Nursing Licensure Examination

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Pharmacology Bullet Review :: Nursing Pharmacology :: Review For Nursing Licensure Examination Slide Transcript
Slide 1: Pharmacology Bullet Review Nursing Board Examination Review

Slide 2: Drug classification Pharmacodynamic s Nursing process Pharmacokinetics applied to pharmacology

Slide 4: Diuretics Comparison Diuretic class Major site of action Special Side effect (s) 1. Carbonic Proximal tubule Acidosis anhydrase inhibitor 2. Thiazide and Proximal tubule Hyperuricemia thiazide like Hypokalemia 3. Loop diuretics Loop of Henle Hypokalemia Ototoxicity 4. Potassium Distal tubule Hyperkalemia sparing 5. Osmotic Glomerulus Hypovolemia & diuretic hypotension

Slide 5: Diuretics Comparison Diuretic class Special Uses 1. Carbonic Mountain sickness anhydrase inhibitor Meniere’s disease Nephrolithiasis due to calcium stones 2. Thiazide and thiazide like Hypocalcemia Hypercalcemia 3. Loop diuretics 4. Potassium CHF taking digoxin sparing 5. Osmotic diuretic Increased ICP LITHIUM TOXICITY

Slide 6: Thiazides Prototype: Hydrochlorothiazide 1. Bendroflumethiazide  2. Benthiazide  3. Chlorothiazide (Diuril)  4. Hydroflumethiazide  5. Methylclothiazide  6. Trichlormethiazide 

Slide 7: Thiazide-like 1. Indapamide  2. Quinethazone  3. Metolazone  4. Chlorthalidone 

Slide 8: Thiazides Pharmacodynamics  These drugs BLOCK the chloride pump  This will keep the Chloride and Sodium in the distal tubule to be excreted into the urine  Potassium is also flushed out!!

Slide 9: Thiazide Special Pharmacodynamics: Side effects  Hypokalemia   DECREASED calcium excretion hypercalcemia  DECREASED uric acid secretion hyperuricemia  Hyperglycemia

Slide 10: Loop Diuretics Prototype: Furosemide 1. Bumetanide  2. Ethacrynic acid  3. Torsemide 

Slide 11: Loop Diuretics Pharmacodynamics  High-ceiling diuretics  BLOCK the chloride pump in the ascending loop of Henle  SODIUM and CHLORIDE reabsorption is prevented  Potassium is also excreted together with Na and Cl

Slide 12: Loop Diuretics

Slide 13: Loop Diuretics Special Pharmacodynamics: side-effects  Hypokalemia   Bicarbonate is lost in the urine  INCREASED calcium excretion Hypocalcemia  Ototoxicity- due to the electrolyte imbalances

Slide 14: Potassium sparing diuretics Prototype: Spironolactone 1. Amiloride  2. Triamterene 

Slide 15: Potassium sparing diuretics Pharmacodynamics  Spironolactone is an ALDOSTERONE antagonist  Triamterene and Amiloride BLOCK the potassium secretion in the distal tubule  Diuretic effect is achieved by the sodium loss to offset potassium retention

Slide 16: Potassium sparing diuretics

Slide 17: Potassium sparing diuretics Pharmacokinetics: Side effects HYPERkalemia!  Avoid high potassium foods:  Bananas  Potatoes  Spinach  Broccoli  Nuts  Prunes  Tomatoes  Oranges  Peaches 

Slide 18: Osmotic Diuretics Prototype: Mannitol 1. Glycerin  2. Isosorbide  3. Urea 

Slide 19: Osmotic Diuretics Pharmacodynamics  Mannitol is a sugar not well absorbed in the nephron osmotic pull of water diuresis

Slide 20: Osmotic Diuretics Pharmacokinetics: side effects Sudden hypovolemia  Important for the nurse to warm the solution to allow the crystals to DISSOLVE in the bottle!

Slide 21: Carbonic Anhydrase Inhibitors Prototype: Acetazolamide 1. Methazolamide 

Slide 22: Carbonic Anhydrase Inhibitors Pharmacodynamics  Carbonic Anhydrase forms sodium bicarbonate  BLOCK of the enzyme results to slow movement of hydrogen and bicarbonate into the tubules  plus sodium is lost in the urine

Slide 23: Carbonic Anhydrase Inhibitors Pharmacokinetics: side effects Metabolic ACIDOSIS happens when  bicarbonate is lost  Hypokalemia

Slide 24: The Nursing Process and the diuretics ASSESSMENT  Assess the REASON why the drug is given: ______ ______ ______ ______

Slide 25: The Nursing Process and the diuretics ASSESSMENT  The nurse must elicit history of allergy to the drugs Allergy to sulfonamides may contraindicate the  use of thiazides Assess fluid and electrolyte balance  Assess other conditions like gout, diabetes,  pregnancy and lactation

Slide 26: The Nursing Process and the diuretics ASSESSMENT  Physical assessment Vital signs   Special electrolyte and laboratory examination Assess symptom of body weakness which may  indicate hypokalemia

Slide 27: The Nursing Process and the diuretics Nursing Diagnosis Fluid volume deficit related to diuretic effect   Alteration in urinary pattern  Potential for injury (ototoxocity, hypotension)  Knowledge deficit

Slide 28: The Nursing Process and the diuretics IMPLEMENTATION  Administer IV drug slowly  Safety precaution for dizziness/hypotension  Provide potassium RICH foods for most diuretics, with the exception of spironolactone  Provide skin care, oral care and urinary care

Slide 29: The Nursing Process and the diuretics IMPLEMENTATION  Monitor DAILY WEIGHT- to evaluate the effectiveness of the therapy  Monitor urine output, cardiac rhythm. Serum electrolytes  ADMINISTER in the MORNING!  Administer with FOOD!

Slide 30: The Nursing Process and the diuretics EVALUATION: for effectiveness of therapy Weight loss Increased urine output Resolution of edema Decreased congestion Normal BP

Slide 32: The ANXIOLYTICS AND HYPNOTICS These drugs are used to change the individual’s responses to the environment.

Slide 33: The ANXIOLYTICS AND HYPNOTICS The medications that can prevent the feelings of tension and fear are called ANXIOLYTICS. – Anti-anxiety drugs

Slide 34: The ANXIOLYTICS AND HYPNOTICS The drugs that can calm individuals making them unaware of the environment are called SEDATIVES.

Slide 35: The ANXIOLYTICS AND HYPNOTICS The drugs that can induce sleep are called HYPNOTICS.

Slide 36: The ANXIOLYTICS AND HYPNOTICS The drugs in this class are the – BENZODIAZEPINES – BARBITURATES

Slide 37: Use of The Drugs Clinical indications for the use of the anxiolytics, sedatives and hypnotics 1. Prevention of anxiety 2. Formation of sedative state 3. Induction of sleep

Slide 38: The BENZODIAZEPINES The benzodiazepines are the most frequently used anxiolytic drugs. These agents prevent anxiety states without causing much sedation, with less physical dependence than other agents.

Slide 39: The BENZODIAZEPINES The following are the benzodiazepines Alprazolam (Xanax) Chlordiazepoxide (Librium) clonazepam clorazepate Diazepam (Valium) estazolam flurazepam lorazepam midazolam oxazepam quazepam temazepam triazolam

Slide 40: The BENZODIAZEPINES Special uses Diazepam Status epilepticus (Valium) Chlordiazepoxide Alcohol (Librium) withdrawal Alprazolam Panic attack (Xanax)

Slide 41: The BENZODIAZEPINES The Mechanism of Action of the Benzodiazepines These agents act on the Limbic system and the RAS (reticular activating system) to make the GABA ( Gamma- aminobutyric acid) more effective causing interference with neuron firing.

Slide 42: The BENZODIAZEPINES The Mechanism of Action of the Benzodiazepines The GABA is an inhibitory neurotransmitter. This will result to an anxiolytic effect at lower doses than required for sedation/hypnosis.

Slide 43: The BENZODIAZEPINES These agents are indicated for the treatment of • anxiety disorders • alcohol withdrawal • hyperexcitability, and agitation • pre-operative relief of anxiety and tension and in induction of balanced anesthesia.

Slide 44: The BENZODIAZEPINES Pharmacodynamics: The adverse effects CNS effects= sedation, drowsiness, depression, lethargy, blurred vision GIT= dry mouth, constipation, nausea, vomiting CVS= Hypotension or hypertension, arrhythmias, palpitations, and respiratory difficulties. Hematologic= blood dyscrasias and anemia GU= urinary retention, hesitancy, loss of libido and sexual functions changes.

Slide 45: The BENZODIAZEPINES Nursing Considerations: Maintain patients on bed for at least 3 hours after drug administration. Instruct to avoid hazardous activities like driving and machine operation. Instruct to avoid consuming ALCOHOL while taking the drug.

Slide 46: The BENZODIAZEPINES Nursing Considerations: Provide comfort measures to help patients tolerate drug effects- – instruct to urinate before taking drug – give high fiber foods – use side-rails and assistance with ambulation. Have available FLUMAZENIL as an antidote for benzodiazepine overdose.

Slide 47: The BARBITURATES These are also anxiolytics and hypnotics with a greater likelihood of producing sedation, with increase risk of addiction and dependence.

Slide 48: The BARBITURATES The following are the barbiturates amobarbital aprobarbital butabarbital mephobarbital pentobarbital Phenobarbital secobarbital

Slide 49: The BARBITURATES The Mechanism of Action of the Barbiturates They depress the motor output from the brain. The results of their MOA are sedation, hypnosis and anesthesia, and if extreme, coma.

Slide 50: The BARBITURATES Clinical indications of the Barbiturates • Relief of anxiety manifestations • For sedation • For patients with insomnia • For pre-anesthesia • seizures/epilepsy • The rapid acting barbiturates are also used for the treatment of acute manic reactions and status epilepticus

Slide 51: The BARBITURATES Pharmacodynamics: The Adverse effects CNS= CNS depression, somnolence, vertigo, lethargy, ataxia, paradoxical excitement, anxiety and hallucinations. GIT= nausea, vomiting, constipation/diarrhea and epigastric pain CVS= bradycardia, Hypotension and syncope. Respi= serious hypoventilation, respiratory depression and laryngospasms Others= hypersensitivity and Stevens- Johnson syndrome.

Slide 52: The BARBITURATES Nursing Considerations Provide stand-by life support facilities in cases of severe respiratory depression or hypersensitivity reaction. Taper the drug gradually after long- term therapy to avoid withdrawal syndrome. Provide comfort measures including small frequent meals, access to bathroom facilities, high-fiber foods, environmental control, safety precaution and skin care.

Slide 53: The CNS stimulants These are drugs used to treat certain disorders • exogenous obesity • attention-deficit hyperactivity disorders (ADHD) • narcolepsy

Slide 54: The CNS stimulants What is unusual is the ability of the CNS stimulants to CALM hyperactive children, which allows them to focus on one activity for a longer period.

Slide 55: The CNS stimulants The following are the CNS stimulants: 1. Methylphenidate (Ritalin)= most commonly used for ADHD 2. Dextroamphetamine= a CNS stimulant that is used for short tem therapy for obesity. 3. Modafinil= used for narcolepsy 4. Pemoline= used for ADHD

Slide 56: The CNS stimulants The Mechanism of Action These agents act as to stimulate the cortical and reticular activating system (RAS) of the brain. This is by releasing neurotransmitters from the nerve cells leading to increased stimulation of the post-synaptic neurons.

Slide 57: The CNS stimulants The paradoxical effect of calming hyperexcitability through CNS stimulation seen in ADHD is believed to be related to the increased stimulation of an IMMATURE Reticular Activating System leading to the ability to be more selective in response to incoming stimuli.

Slide 58: The CNS stimulants Pharmacodynamics: Adverse effects of the CNS stimulants CNS= nervousness, insomnia, dizziness, headache, and blurred vision GIT= anorexia, nausea and weight loss CVS= hypertension, tachycardia arrhythmias, and angina Others= rashes, physical/psychological dependence.

Slide 59: The CNS stimulants Implementation The nurse must ensure that the drug is only given to the indicated conditions Administer the drug before 6 pm to reduce the effect of insomnia BEST given AFTER meals to prevent the effect of anorexia Consult with school personnel to monitor the patient under therapy Provide safety measures such as side-rails and assisted ambulation

Slide 60: The CNS stimulants Evaluation Evaluate the effectiveness of the drug: • Calming effect in the patient with ADHD • Alertness for patients with narcolepsy

Slide 61: The Anti-epileptics These agents, also called anticonvulsants, are used to treat epileptic conditions. Hydantoins, Barbiturates, benzodiazepines, Succinimides and many others are given to a specific type of seizure.

Slide 62: Anti-epileptics Agents for treating TONIC-CLONIC SEIZURES 1. Hydantoins – Phenytoin – Ethotoin – Fosphenytoin – Mephenytoin 2. Benzodiazepines – Diazepam – Clonazepam – Clorazepate 3. Barbiturates – Phenobarbital

Slide 63: Anti-epileptics Agents for treating ABSENCE SEIZURES 1. Succinimides a. Ethosuximide b. Methsuximide c. Phensuximide 2. Valproic Acid 3. Zosinamide

Slide 64: Anti-epileptics Agents for treating Partial FOCAL SEIZURES 1. Carbamazepine 2. Gabapentin 3.Lamotrigine 4. Tiagabine 5. Topiramate

Slide 65: The hydantoins These agents are utilized for general seizures because they can depress the central nervous system. They affect the entire brain and reduce the chance of sudden electrical outburst that causes seizures. These agents generally are less sedating than other anti-epileptics.

Slide 66: The hydantoins Mechanism of Action of the Hydantoins These agents STABILIZE the nerve cell membrane throughout the brain reducing and limiting the excitability and conduction through nerve pathways.

Slide 67: The hydantoins Clinical Indications of the hydantoins • Tonic-clonic seizures • Status epilepticus • For the prevention of seizures in neurosurgery • For muscle relaxation.

Slide 68: The hydantoins Contraindications and Precautions Hydantoins are NOT given to pregnant patient because it can cause fetal hydantoin syndrome.

Slide 69: The hydantoins Pharmacodynamics: Adverse effects of the Hydantoins CNS effects- depression, confusion, drowsiness, lethargy, fatigue GIT- GI upset, constipation, dry mouth, GINGIVAL HYPERPLASIA , severe liver toxicity which are all related to cellular toxicity. SKIN- hirsutism and coarsening of the facial skin Bone Marrow depression

Slide 70: The hydantoins Implementation Administer the drug with food to alleviate GI irritation Discontinue the drug at any sign of hypersensitivity reaction, severe liver dysfunction and severe skin rashes. Provide meticulous mouth oral care Rule out pregnancy and advise women to use contraceptive measures to prevent pregnancy.

Slide 72: Drugs affecting GI secretions There are five types of drugs that affect gastric acid secretions and are useful for the treatment of peptic ulcer. 2. Histamine (H2) receptor antagonist/blockers 3. Antacids 4. Proton pump inhibitors 5. Mucosal protectants 6. Prostaglandin analogs

Slide 73: Drugs affecting secretions: anti ulcer Anti-ulcer drugs Prototype Cimetidine Histamine (H2) receptor antagonist/blockers AlOH and MgOH Antacids Omeprazole Proton pump inhibitors Sucralfate Mucosal protectants Misoprostol Prostaglandin analog

Slide 74: General indication of the drugs affecting gastric acid secretion ► Peptic ulcer ► Gastritis ► Patient on NPO to prevent stress ulcer

Slide 75: General time of administration of the drugs affecting gastric acid secretion Anti-ulcer drugs Prototype Best time to give Histamine (H2) Cimetidine With FOOD or ONE receptor hour after ANTACID antagonist/blockers Antacids AlOH and MgOH Usually after meals Proton pump Omeprazole BEFORE MEALS inhibitors Mucosal Sucralfate BEFORE MEALS protectants Prostaglandin Misoprostol WITH MEALS analog

Slide 76: Pharmacology of Anti-ulcer drugs Drug Mechanism of Action Antacids- AlOH, MgOH Neutralize Gastric ACIDITY H2-Blockers- “tidine” Block Histamine receptor causing decreased secretion and Cimetidine, Ranitidine acidity Proton pump inhibitors- Inhibit Proton Pump in parietal “Prazoles” cell decreasing secretion and acidity Omeprazole, pantoprazole

Slide 77: Pharmacology of Anti-ulcer drugs Drug Mechanism of Action Anti-cholinergic- Prophanteline Blocks VAGUS nerve, decreases Bromide secretion Sucralfate (Carafate) Coats the mucosal lining Misoprostol (Cytotec) Prostaglandin Analogue, causes secretion of MUCUS

Slide 78: Pharmacodynamics Histamine (H2) receptor blockers ►These drugs BLOCK the release of hydrochloric acid in the stomach in response to gastrin

Slide 79: Drugs affecting GI secretions Antacids ►These drugs interact with the gastric acids at the chemical level to neutralize them

Slide 80: Drugs affecting GI secretions Proton pump inhibitors ►These drugs suppress the secretion of hydrochloric acid into the lumen of the stomach

Slide 81: Drugs affecting GI secretions Mucosal protectants ►These are agents that coat any injured area in the stomach to prevent further injury from acid

Slide 82: Drugs affecting GI secretions Prostaglandin analogs ►These are agents that inhibit the secretion of gastrin and ►increase the secretion of mucus lining of the stomach, providing a buffer.

Slide 83: The H2 Blockers- “tidines” Prototype: Cimetidine ► 1. Ranitidine ► 2. Famotidine ► 3. Nizatidine

Slide 84: The H2 Blockers- “tidines” Pharmacodynamics: Drug Action ► The H2 blockers are antagonists at the receptors in the parietal cells of the stomach. ► The blockage results to inhibition of the hormone gastrin. ► There will be decreased production of gastric acid from the parietal cells. ► Also, the chief cells will secrete less pepsinogen.

Slide 85: The H2 Blockers- “tidines” Therapeutic use of the H2 blockers ► Short-term treatment of active duodenal ulcer or benign gastric ulcer ► Treatment of hypersecretory conditions like the Zollinger-Ellison syndrome ► Prevention of stress-induced ulcers and acute GI bleeding ► Treatment of erosive GERD (reflux disease) ► Relief of Symptoms of heart burn and acid indigestion

Slide 86: The H2 Blockers- “tidines” Precautions and Contraindications ► Any known allergy is a clear contraindication to the use of the agents. Conditions such as pregnancy, lactation, renal dysfunction and hepatic dysfunction should warrant cautious use. ► Nizatidine can be used in hepatic dysfunction.

Slide 87: The H2 Blockers- “tidines” Pharmocodynamics- Side effects and adverse effects ► GIT= diarrhea or constipation ► CNS= Dizziness, headache, drowsiness, confusion and hallucinations ► Cardio= arrhythmias, HYPOTENSION (related to H2 receptor blockage in the heart) ► Cimetidine= TREMORS, Gynecomastia and impotence in males

Slide 88: The H2 Blockers- “tidines” Drug-drug Interactions ► Cimetidine, Famotidine, Ranitidine are metabolized in the liver- they can cause slowing of excretion of other drugs leading to their increased concentration.

Slide 89: The H2 Blockers- “tidines” Drug-drug Interactions ► These drugs can interact with CIMETIDINE anticoagulants, phenytoin, alcohol, antidepressants.

Slide 90: The H2 Blockers- “tidines” Nursing considerations: ►Administer the drug WITH meals at BEDTIME to ensure therapeutic level ►One hour after Antacids ►Stress the importance of the continued use for the length of time prescribed

Slide 91: The H2 Blockers- “tidines” Nursing considerations: ►Monitor the cardiovascular status especially if the drugs are given IV ►Warn patient of the potential problems of increased drug concentration if the H2 blockers are used with other drugs or OTC drugs. Advise consultation first!

Slide 92: The H2 Blockers- “tidines” Nursing considerations: ► Provide comfort measures like analgesics for headache, assistance with ambulation and safety measures ► Warn the patients taking cimetidine that drowsiness may pose a hazard if driving or operating delicate machines.

Slide 93: The H2 Blockers- “tidines” Nursing considerations: ► Provide health teaching as to the dose, frequency, comfort measures to initiate when side-effects are intolerable Evaluate the effectiveness: ► Relief of symptoms of ulcer, heart burn and GERD

Slide 94: The Antacids ► These are drugs or inorganic chemicals that have been used for years to neutralize acid in the stomach. The following are the common antacids that can be bought OTC: ► Aluminum salts (hydroxide) ► Calcium salts (carbonate) ► Magnesium salts (milk of magnesia) ► Sodium bicarbonate ► Magaldrate (aluminum and magnesium combination)

Slide 95: The Antacids Pharmacodynamics: drug action ► These agents act to neutralize the acidic pH in the stomach. ► They do not affect the rate of gastric acid secretion.

Slide 96: The Antacids Pharmacodynamics: drug action ► The administration of antacid may cause an acid rebound. ► Neutralizing the stomach content to an alkaline level stimulates gastrin production to cause an increase in acid production and return the stomach to its normal acidic state.

Slide 97: The Antacids Therapeutic Indications ► Symptomatic relief of upset stomach associated with hyperacidity ► Hyperacidic conditions like peptic ulcer, gastritis, esophagitis and hiatal hernia ► Special use of AMPHOGEL (aluminum hydroxide): to BIND phosphate

Slide 98: The Antacids Precautions of Antacid Use ► Known allergy is a clear contraindication. Caution should be instituted if used in electrolyte imbalances, GI obstruction and renal dysfunction. ► Sodium bicarbonate is rarely used because of potential systemic absorption

Slide 99: The Antacids Pharmacokinetics ► These agents are taken orally and act locally in the stomach

Slide 100: The Antacids Pharmacodynamics: Effects of drugs 2. GIT= rebound acidity; alkalosis may occur. ► Calcium salts may lead to hypercalcemia ► Magnesium salts can cause DIARRHEA ► Aluminum salts may cause CONSTIPATION and hypophosphatemia by binding with phosphates in the GIT. 2. Fluid retention due to the high sodium content of the antacids.

Slide 101: The Antacids Nursing Considerations: ► Administer the antacids apart from any other medications by ONE hour before or TWO hours after- to ensure adequate absorption of the other medications ► Tell the patient to CHEW the tablet thoroughly before swallowing. Follow it with one glass of water ► Regularly monitor for manifestations of acid-base imbalances as well as electrolyte imbalances

Slide 102: The Antacids Nursing Considerations: ► Provide comfort measures to alleviate constipation associated with aluminum and diarrhea associated with magnesium salts. ► Monitor for the side-effects, effectiveness of the comfort measures, patient’s response to the medication and the effectiveness of the health teachings

Slide 103: The Antacids Nursing Considerations: ► Evaluate for effectiveness: Decreased symptoms of ulcer and pyrosis Decreased Phosphate level (amphogel)

Slide 104: The PPI These are the newer agents for ulcer treatment ► The “prazoles” Prototype: Omeprazole ► Lanisoprazole ► Esomeprazole ► Pantoprazole

Slide 105: The PPI Pharmacodynamics: drug action ► They act at specific secretory surface receptors to prevent the final step of acid production and thus decrease the level of acid in the stomach. “pump” in the parietal cell is the H-K ► The ATPase enzyme system on the secretory surface of the gastric parietal cells

Slide 106: The PPI Clinical use of the PPIs ► Short-term treatment of active duodenal ulcers, GERD, erosive esophagitis and benign gastric ulcer. ► Long-term- maintenance therapy for healing of erosive disorders.

Slide 107: The PPI Clinical use of the PPIs. Precautions with the use of the PPIs ► Known allergy is a clear contraindication. Caution if patient is pregnant

Slide 108: The PPI Pharmacodynamics: Adverse effects ► CNS- dizziness, headache, asthenia (loss of strength), vertigo, insomnia, apathy ► GIT- diarrhea, abdominal pain, nausea, vomiting, dry mouth and tongue atrophy ► Respi- cough, stuffy nose, hoarseness and epistaxis.

Slide 109: The PPI Nursing considerations: ► Administer the drug BEFORE meals. Ensure that patient does not open, chew or crush the drug. ► Provide safety measures if CNS dysfunction happens. ► Arrange for a medical follow-up if symptoms are NOT resolved after 4-8 weeks of therapy.

Slide 110: The PPI Nursing considerations: ► Provide health teaching as to drug name, dosages and frequency, safety measures to handle common problems. ► Monitor patient response to the drug, the effectiveness of the teaching plan and the measures to employ

Slide 111: The PPI Nursing considerations: Evaluate for effectiveness of the drug ► Healing of peptic ulcer ► Decreased symptoms of ulcer

Slide 112: The Mucosal Protectant Sucralfate ► This is given to protect the eroded ulcer sites in the GIT from further damage by acid and digestive enzymes

Slide 113: Sucralfate Pharmacodynamics: Action of drug ► It forms an ulcer-adherent complex at duodenal ulcer sites, protecting the sites against acid, pepsin and bile. ► This action prevents further breakdown of proteins in the area and promotes healing.

Slide 114: Sucralfate Clinical use of sucralfate ► Short and long term management of duodenal ulcer. ► NSAIDs induced gastritis ► Prevention of stress ulcer ► Treatment of oral and esophageal ulcers due to radiation, chemotherapy or sclerotherapy.

Slide 115: Sucralfate Precautions on the use of Sucralfate ► This agent should NOT be given to any person with known allergy to the drug, and to those patients with renal failure/dialysis because of build-up of aluminum may occur if used with aluminum containing products.

Slide 116: The Mucosal Protectant Pharmacodynamics: Side-effects & adverse reactions ► Primarily GIT= CONSTIPATION, occasionally diarrhea, nausea, indigestion, gastric discomfort, and dry mouth may also occur ► CNS= dizziness, drowsiness, vertigo ► Others= rash and back pain

Slide 117: The Mucosal Protectant Drug-drug interactions ► If used with aluminum salts= high risk of accumulation of aluminum and toxicity. ► If used with phenytoin, fluoroquinolones and penicillamines- decreased levels of these drugs when taken with sucralfate

Slide 118: The Mucosal Protectant Nursing Considerations ► Administer drug ON AN EMPTY stomach, 1 hour before meals , or 2 hour after meals and at BEDTIME ► Monitor for side-effects like constipation and GI upset ► Encourage intake of high-fiber foods and increased fluid intake ► Administer antacids BETWEEN doses of sucralfate, NOT WITHIN 30 minutes of sucralfate dose

Slide 119: The Mucosal Protectant Nursing Considerations ► Provide comfort measures if CNS effects occur ► Provide health teaching as to drug name, dosages and frequency, safety measures to handle common problems. ► Monitor patient response to the drug, the effectiveness of the teaching plan and the measures employed

Slide 120: The Mucosal Protectant Nursing Considerations ► Evaluate effectiveness of therapy Healing of ulcer No formation of ulcer

Slide 121: Prostaglandin analogue Misoprostol ► This agent is a synthetic prostaglandin E1 analog that is employed to protect the lining of the mucosa of the stomach

Slide 122: Prostaglandin analogue Misoprostol: Pharmacodynamics ► Being a prostaglandin analog, it inhibits gastric acid secretion to some degree ► It INCREASES mucus production in the stomach lining.

Slide 123: Prostaglandin analogue Misoprostol: Clinical use ► NSAIDs-induced gastric ulcers ► Duodenal ulcers unresponsive to H2 antagonists.

Slide 124: Prostaglandin analogue Precautions of Misoprostol Use ► This drug is CONTRAINDICATED during pregnancy because it is an abortifacient. ► Women should be advised to have a negative pregnancy test within 2 weeks of beginning therapy and should begin the drug on the second or third day of the next menstrual cycle. ► They should be instructed in the use of contraceptives during therapy.

Slide 125: Prostaglandin analogue Pharmacodynamic effects: drug reactions ► GIT= Nausea, diarrhea, abdominal pain, flatulence, vomiting, dyspepsia ► GU effects= miscarriages, excessive uterine CRAMPING and bleeding, spotting, hypermenorrhea and menstrual disorders.

Slide 126: Prostaglandin analogue Nursing Considerations ► Administer to patients at risk for NSAIDs-induced ulcers during the full course of NSAIDs therapy ► Administer four times daily with meals and at bedtime ► Obtain pregnancy test within 2 weeks of beginning therapy. Begin the therapy on second or third day of menstrual period to ensure that the woman is not pregnant

Slide 127: Prostaglandin analogue Nursing Considerations ► Provide patient with both written and oral information regarding the associated risks of pregnancy ► Provide health teaching as to drug name, dosages and frequency, safety measures to handle common problems. ► Monitor patient response to the drug, the effectiveness of the teaching plan and the measures to employ

Slide 129: Laxatives Type Prototype Action Chemical Bisacodyl (Dulcolax) Direct stimulation of the stimulants GIT nerves Irritant laxatives Mechanical (bulk) Lactulose Increased fluid content of stimulants the fecal material causing stimulation of the local reflex Lubricants Docusate Lubricating the intestinal material to promote passage through the GIT

Slide 130: Laxatives ► Generally used to INCREASE the passage of the colonic contents ► The general classifications is as follows: 1. Chemical stimulants 2. Mechanical stimulants 3. Lubricants

Slide 131: Therapeutic Indications of the Laxatives term relief of Constipation ► SHORT ► Prevention of straining in conditions like CHF, post-MI, post partum, post-op ► Preparation for diagnostic examination ► Removal of poison or toxins ► Adjunct in anti-helminthic therapy

Slide 132: Contraindications in Laxative use ► ACUTE abdominal disorders Appendicitis  Diverticulitis  Ulcerative colitis 

Slide 133: Chemical Stimulant Cathartics Prototype: Bisacodyl Irritant laxatives: ► 1. Castor oil ► 2. Senna ► 3. Cascara ► 4. Phenolphthalein

Slide 134: Chemical Stimulant Cathartics Pharmacodynamics ► These agents DIRECTLY stimulate the nerve plexus in the intestinal wall ► The result is INCREASED movement or motility of the colon

Slide 135: Mechanical Stimulant Cathartics ► Prototype: LACTULOSE (Cephulac) Bulk-forming laxatives ► 1. Magnesium (citrate, hydroxide, sulfate) ► 2. Psyllium ► 3. Polycarbophil

Slide 136: Mechanical Stimulant Cathartics Pharmacodynamics ► These agents are rapid-acting laxatives that INCREASE the GI motility by Increasing the fluids in the colonic material  Stimulating the local stretch receptors  Activating local defection reflex 

Slide 137: Lubricants ► Prototype: Docusate ► 1. Glycerin ► 2. Mineral oil

Slide 138: Lubricants Pharmacodynamics ► Docusate increases the admixture of fat and water producing a softer stool ► Glycerin ► Mineral oil forms a slippery coat on the colonic contents

Slide 139: Pharmacokinetics: Common Side-effects of the Laxatives ► Diarrhea ► Abdominal cramping ► Nausea ► Fluid and electrolyte imbalance ► Sympathetic reactions- sweating, palpitations, flushing and fainting ► CATHARTIC dependence

Slide 140: The Nursing Process and Laxative ASSESSMENT ► Nursing History- elicit allergy to any laxatives, elicit history of conditions like diverticulitis and ulcerative colitis ► Physical Examination- abdominal assessment ► Laboratory Test: fecalysis, electrolyte levels

Slide 141: The Nursing Process and Laxative NURSING DIAGNOSIS ► Alteration in bowel pattern ► Alteration in comfort: pain ► Knowledge deficit

Slide 142: The Nursing Process and Laxative IMPLEMENTATION 2. Emphasize that it is use on a SHORT term basis 3. Provide comfort and safety measures like ready access to the bathroom, side-rails 4. Administer with a full glass of water

Slide 143: The Nursing Process and Laxative IMPLEMENTATION 4. Encourage fluid intake, high fiber diet and daily exercise 5. DO NOT administer if acute abdominal condition like appendicitis is present 6. Advise to change position slowly an avoid hazardous activities because of potential dizziness

Slide 144: The Nursing Process and Laxative EVALUATION of drug effectiveness 2. Evaluate relief of GI symptoms, absence of staining and increased evacuation of GI tract 3. For Lactulose: decreased ammonia

Slide 145: The Anti-diarrheals ► These are agents used to calm the irritation of the GIT for the symptomatic relief of diarrhea ► General Classifications 1. Local anti-motility 2. Local reflex inhibition 3. Central action on the CNS

Slide 146: The Anti-diarrheals Type Prototype Action Local reflex inhibitor Bismuth subsalicylate Locally coats the lining of the GIT to soothe irritation that may stimulate the reflex Local anti-motility Loperamide Directly inhibits the intestinal muscle activity to SLOW peristalsis Central acting agent Opium derivatives Stops GIT spasm by (paregoric) CNS action

Slide 147: Clinical Indications of drug use ► Relief of symptoms of acute and chronic diarrhea ► Reduction of fecal volume discharges from ileostomies ► Prevention and treatment of traveler's diarrhea

Slide 148: Contraindications of anti-diarrheal Use ► Poisoning ► Drug allergy ► GI obstruction ► Acute abdominal conditions

Slide 149: Pharmacokinetics: Side effects ► Constipation ► Nausea,vomiting ► Abdominal distention and discomfort ► TOXIC MEGACOLON

Slide 150: Nursing process and anti-diarrheals ASSESSMENT ► Nursing History – Elicit history of drug allergy, conditions like poisoning, GI obstruction and acute abdominal conditions ► Physical Examination- Abdominal examination ► Laboratory test- electrolyte levels

Slide 151: Nursing process and anti-diarrheals NURSING DIAGNOSIS ► Alteration in bowel pattern ► Alteration in comfort: pain

Slide 152: Nursing process and anti-diarrheals IMPLEMENTATION 2. Monitor patient response within 48 hours. Discontinue drug use if no effect 3. Provide comfort measures for pain 4. Provide teaching

Slide 153: Nursing process and anti-diarrheals EVALUATION 2. Monitor effectiveness of drug- RELIEF of diarrhea 3. Monitor adverse effects, effectiveness of pain measures and effectiveness of teaching plan

Slide 154: Emetics and Anti-emetics Emetic Agent ► Syrup of Ipecac Anti-emetics ► 1. Phenothiazines ► 2. Non-phenothiazines ► 3. Anticholinergics/Antihistamines ► 4. Serotonin receptor Blockers ► 5. Miscellaneous

Slide 155: EMETIC ► Prototype: Ipecac Syrup

Slide 156: EMETIC Pharmacodynamics ► Ipecac syrup irritates the GI mucosa locally, resulting to stimulation of the vomiting center ► It acts within 20 minutes

Slide 157: EMETIC Clinical Use of ipecac ► To induce vomiting as a treatment for drug overdose and certain poisonings

Slide 158: EMETIC Contraindications of Ipecac use ► Ingestion of CORROSIVE chemicals ► Ingestion of petroleum products ► Unconscious and convulsing patient

Slide 159: EMETIC Pharmacokinetics: side effects of Ipecac ► Nausea ► Diarrhea ► GI upset ► Mild CNS depression ► CARDIOTOXICITY if large amounts are absorbed in the body

Slide 160: Nursing process and the EMETIC ASSESSMENT ► Nursing History- elicit the exact nature of poisoning ► Physical Examination- CNS status and abdominal exam

Slide 161: Nursing process and the EMETIC IMPLEMENTATION 2. Administer to conscious patient only 3. Administer ipecac as soon as possible 4. Administer with a large amount of water 5. Vomiting should occur within 20 minutes of the first dose. Repeat the dose and expect vomiting to occur with 20 minutes

Slide 162: Nursing process and the EMETIC IMPLEMENTATION 5. Provide comfort measures like ready access to bathroom, assistance with ambulation 6. Offer support

Slide 163: Nursing process and the EMETIC EVALUATION 2. Evaluate patient response within 20 minutes of drug ingestion 3. Monitor for adverse effects 4. Evaluate effectiveness of comfort measures and teaching plan

Slide 164: ANTI-EMETICS ► These are agents used to manage nausea and vomiting ► They act either locally or centrally

Slide 165: ANTIEMETICS Anti-emetic types Common examples Phenothiazines Prochlorperazine, promethazine Non-phenothiazines Metoclopramide Anticholinergics and Antihistaminics Meclizine, buclizine Serotonin Receptor blockers “setron”- dolasetron Miscellaneous Dronabinol, hydroxyzine

Slide 166: ANTIEMETICS Types Pharmacodynamics Phenothiazines Centrally block the vomiting center in the medulla Non-phenothiazine Reduces the responsiveness of the nerve cell in the medulla Anticholinergics Block the transmission of the impulses to the medulla Serotonin receptor blockers Centrally and locally inhibits the serotonin receptors Miscellaneous Act in the CNS , either in the medulla or in the cortex

Slide 167: ANTIEMETICS Types Clinical Use Phenothiazines N/V associated with anesthesia, intractable hiccups Non-phenothiazine N/V associated with chemical stimulation Anticholinergics N/V associated with motion sickness Serotonin-receptor Blockers N/V associated with chemotherapy Miscellaneous N/V associated with chemotherapy

Slide 168: ANTIEMETICS Contraindications ► 1. Severe CNS depression ► 2. Severe liver dysfunction

Slide 169: ANTIEMETICS Pharmacokinetics: Side-effects 1. PHOTHOSENSITIVITY 2. Drowsiness, dizziness, weakness and tremors and DEHYDRATON 3. Phenothiazines= autonomic anti- cholinergic effects like dry mouth, nasal congestion and urinary retention

Slide 170: Nursing Process and the ANTIEMETICS ASSESSMENT ► Nursing History- elicit allergy, impaired hepatic function and CNS depression ► Physical Examination- CNS status and abdominal examination ► Laboratory test- Liver function studies

Slide 171: Nursing Process and the ANTIEMETICS NURSING DIAGNOSIS 2. Alteration in comfort: pain 3. High risk for injury 4. Knowledge deficit

Slide 172: Nursing Process and the ANTIEMETICS IMPLEMENTATION 2. Assess patient’s intake of other drugs that may cause dangerous drug interaction 3. Emphasize that this is given on a short term basis

Slide 173: Nursing Process and the ANTIEMETICS IMPLEMENTATION 3. Provide comfort and safety measures Advise to change position slowly  Avoid hazardous activities  Provide mouth care and ice chips  Monitor for dehydration and offer fluids if  it occurs

Slide 174: Nursing Process and the ANTIEMETICS IMPLEMENTATION 4. Protect from sun exposure Sunscreens  Protective covering  5. Provide health teaching

Slide 175: Nursing Process and the ANTIEMETICS EVALUATION 1. Monitor for the drug effectiveness • Relief of nausea and vomiting 2. Monitor for adverse effects 3. Evaluate effectiveness of comfort measures and teaching plan

Slide 176: Pharmacology of the Selected Endocrine Drugs Nursing Review

Slide 177: Endocrine Medications Anti-diuretic hormones Enhance re-absorption of water in the kidneys Used in DI 1. Desmopressin and Lypressin intranasally 2. Pitressin IM

Slide 178: Endocrine Medications Anti-diuretic hormones SIDE-effects Flushing and headache Water intoxication

Slide 179: Thyroid Medications Thyroid hormones These products are used to treat the manifestations of hypothyroidism Replace hormonal deficit in the treatment of HYPOTHYROIDSM

Slide 180: Thyroid Medications Thyroid hormones Levothyroxine (Synthroid) Liothyroxine (Cytomel) Thyroid dessicated Liotrix (Thyrolar)

Slide 181: Thyroid Medications Thyroid hormones: Actions Increase the metabolic rate Increase O2 consumption Increase HR, RR, BP

Slide 182: Thyroid Medications Thyroid hormones Side-effects • Nausea and Vomiting • Signs of increased metabolism= tachycardia, hypertension, cardiac arrhythmias, anxiety, headache

Slide 183: Thyroid Medications Thyroid hormones : Nursing responsibility 1. Monitor weight, VS 2. Instruct client to take daily medication the same time each morning WITHOUT FOOD Monitor blood tests to check the activity of thyroid

Slide 184: Thyroid Medications Thyroid hormones: Nursing responsibility 3. Advise to report palpitation, tachycardia, and chest pain 4. Instruct to avoid foods that inhibit thyroid secretions like cabbage, spinach and radishes

Slide 185: ANTI-Thyroid Medications ANTI-THYROID medications The thyroid becomes oversaturated with iodine and stop producing thyroid hormone

Slide 186: ANTI-Thyroid Medications ANTI-THYROID medications Drugs used to BLOCK the thyroid hormones and treat hyperthyroidism Inhibit the synthesis of thyroid hormones

Slide 187: ANTI-Thyroid Medications ANTI-THYROID medications 1. Methimazole (Tapazole) 2. PTU (prophylthiouracil) 3. Iodine solution- SSKI and Lugol’s solution

Slide 188: ANTI-Thyroid Medications ANTI-THYROID medications Side-effects of thionamides N/V, drowsiness, lethargy,  bradycardia, skin rash  GI complaints  AGRANULOCYTOSIS Most important to monitor

Slide 189: ANTI-Thyroid Medications ANTI-THYROID medications Side-effects of Iodine solutions Most common adverse effects is  HYPOTHYROIDISM  Iodism= metallic taste, burning in the mouth, sore teeth and gums, diarrhea, stomach upset

Slide 190: ANTI-Thyroid Medications ANTI-THYROID medications Nursing responsibilities 1. Monitor VS, T3 and T4, weight 2. The medications WITH MEALS to avoid gastric upset

Slide 191: ANTI-Thyroid Medications ANTI-THYROID medications Nursing responsibilities 3. Instruct to report SORE THROAT or unexplained FEVER 4. Monitor for signs of hypothyroidism. Instruct not to stop abrupt  medication

Slide 192: ANTI-Thyroid Medications ANTI-THYROID medications Lugol’s Solution Used to decrease the vascularity of the thyroid (in preparation for thyroid surgery) T3 and T4 production diminishes Given per orem, can be diluted with juice Use straw to decrease staining Monitor iodism (metallic taste, burning in mouth)

Slide 193: STEROIDS Replaces the steroids in the body Interfere with the release of inflammatory factors and immune responses

Slide 194: STEROIDS Cortisol, cortisone, betamethasone, and hydrocortisone Dexamethasone= long acting

Slide 195: STEROIDS These drugs enter the cells and bind to receptors They inhibit the enzyme phospholipase

Slide 196: STEROIDS Corticosteroids are used topically and locally to achieve the desired anti-inflammatory effects at a particular site

Slide 197: STEROIDS Steroid Clinical use Dexamethasone Use to induce the formation of lung surfactant Other steroids Use for the treatment of immune-related diseases, control of asthma and allergic symptoms

Slide 198: STEROIDS Side-effects  HYPERglycemia  Increased susceptibility to infection (immunosuppression)  Hypokalemia  Edema and Hypertension  Peptic ulceration

Slide 199: STEROIDS Side-effects  If high doses- osteoporosis, growth retardation, peptic ulcer, hypertension, cataract, mood changes, hirsutism, and fragile skin

Slide 200: STEROIDS Nursing responsibilities 1. Monitor VS, electrolytes, glucose 2. Monitor weight edema and I/O. Encourage Potassium supplements

Slide 201: STEROIDS Nursing responsibilities 3. Protect patient from infection 4. Handle patient gently 5. Instruct to take meds WITH MEALS to prevent gastric ulcer formation

Slide 202: STEROIDS Nursing responsibilities 6. Caution the patient NOT to abruptly stop the drug 7. Drug is tapered to allow the adrenal gland to secrete endogenous hormones

Slide 203: STEROIDS Evaluation: The drugs are effective if there is: • Relief of signs and symptoms of inflammation • Return of adrenal function to normal

Slide 205: The cardiac glycosides  These are agents extracted from the foxglove plant. They are available in oral and parenteral preparations. The following are the cardiac glycosides:  Digoxin (Lanoxin)  Digitoxin (Crystodigin)  Ouabain

Slide 206: The cardiac glycosides Pharmacodynamics: the Mechanism of action  They increase the level of CALCIUM inside the cell by inhibiting the Sodium-Potassium pump.  More calcium will accumulate inside the cell during cellular depolarization.

Slide 207: The cardiac glycosides Positive inotropic Effect- the  myocardium will contract forcefully – Increased cardiac output – Increased blood flow to the body organs like the kidney and liver Negative chronotropic effect- the heart  rate is slowed due to decreased rate of cellular repolarization – Bradycardia Decreased conduction velocity through  the AV node

Slide 208: The cardiac glycosides Clinical Use of the cardiac glycosides  Treatment of congestive heart failure  Treatment of dysrhythmias like atrial flutter, atrial fibrillation and paroxysmal atrial tachycardia

Slide 209: The cardiac glycosides Contraindications and Precautions  Contraindicated in the presence of allergy to any cardiac glycoside.  They are NOT given to patients with ventricular dysrhythmias, heart block or sick sinus syndrome, aortic stenosis, acute MI, electrolyte imbalances (HYPOKALEMIA, HYPOMAGNESEMIA and HYPERCALCEMIA) and renal failure (may cause accumulation of drug)

Slide 210: The cardiac glycosides Pharmacodynamics: the Adverse Effects of the Cardiac glycosides  CNS- Headache, weakness , seizures and drowsiness  CVS- arrhythmias  If digitalis toxicity is developing- the nurse must assess the following adverse effects: Anorexia, nausea and vomiting, visual changes- YELLOW halo around an object, and palpitations or very slow heart rate

Slide 211: The cardiac glycosides Remember= NAVDA and hypokalemia

Slide 212: The cardiac glycosides Drug-Drug Interactions  If taken with potassium-losing diuretics like furosemide- can INCREASE the risk of toxicity and arrhythmias. Potassium replacement must be given.

Slide 213: The cardiac glycosides Implementation  Administer the initial rapid digitalization and loading dose as ordered intravenously  Monitor the APICAL pulse rate for ONE full minute before administering the drug. Withhold the drug if – Less than 60 in adults – Less than 90 in infants – More than 110 in adults Retake pulse in one hour, if pulses remain  abnormal, refer!

Slide 214: The cardiac glycosides Implementation  Check the spelling of the drug- DIGOXIN is different from DIGITOXIN!  Check the dosage preparation and the level of digitalis in the blood. (Therapeutic level is 0.5 to 2.0 nanograms/mL)  Administer intravenous drug VERY slow IV over 5 minutes to avoid arrhythmias. Do NOT administer intramuscularly because it can cause severe pain

Slide 215: The cardiac glycosides Implementation  Administer the drug without food if possible to avoid delayed absorption. Weight patient daily to determine fluid retention  Maintain emergency equipment and drugs= Potassium salts, Lidocaine for arrhythmias, phenytoin for seizures, atropine for bradycardia.  Provide comfort measures- small, frequent meals, adequate lighting, comfortable position, rest periods and safety precautions

Slide 216: The cardiac glycosides Implementation Provide health teaching- drug name, action,  dosage and side effects. Advise the patient to report any of the following: Visual changes, rapid weight gain, unusually low heart rate, persistent nausea, vomiting and anorexia Monitor serum potassium level 

Slide 217: The cardiac glycosides Evaluation Evaluate effectiveness of the drug: Increased urine output Normal heart rate in arrhythmia

Slide 218: The Antianginal drugs In the treatment of angina, three agents  are commonly employed- – Organic nitrates – Beta-blockers and – Calcium-channel blockers. The benefits of the drugs lie in their  different mode of action.

Slide 219: The Antianginal drugs The nitrates can cause vasodilatation  of the veins and to some extent, coronary artery

Slide 220: The Antianginal drugs  Beta-blockers will decrease the heart rate

Slide 221: The Antianginal drugs  Calcium-channel blockers will decrease force of contraction leading to a decreased myocardial workload and demand.  They can also produce vasodilation

Slide 222: The Organic nitrates These agents are simple nitric and nitrous  acid esters of alcohols. Being alcohol, they differ in their volatility. The following are the nitrates commonly used:  Nitroglycerin- A moderately volatile nitrate  Isosorbide Dinitrate (Isordil) or mononitrate  Amyl nitrate- an extremely volatile nitrate

Slide 223: The Organic nitrates Nitroglycerin  This agent is supplied in oral, spray, transdermal and ointment preparations.

Slide 224: The Organic nitrates Pharmacodynamics: the mechanism of action  Nitroglycerin relaxes the smooth muscles in the vascular system by its conversion to nitric oxide, a chemical mediator in the body that relaxes smooth muscles.

Slide 225: The Organic nitrates Administered nitrates Increased nitrates in the blood increased formation of nitric oxide increased cGMP formation increased dephosphorylation of myosin Vascular smooth muscle relaxation vasodilatation

Slide 226: The Organic nitrates Pharmacokinetics- absorption to excretion  It can be given orally, parenterally and topically.  The onset of action of nitroglycerin is more than 1 hour.  Because significant first-pass hepatic effect, Nitroglycerin is given SUBLINGUALY.

Slide 227: The Organic nitrates Pharmacodynamics: Side effects and adverse effects  HEADACHE is the most common effect of nitroglycerin.  CVS- postural Hypotension, facial flushing, tachycardia  TOLERANCE- the tolerance to the actions of nitrates develop rapidly. This can be managed by providing a day of abstinence.

Slide 228: The Nitrates Implementation  Monitor vital signs, especially watchful for hypotensive episodes  Advise patient to remain supine or sit on a chair when taking the nitroglycerin for the first time. Emphasize that he should change his position slowly or rise from bed slowly to avoid orthostatic Hypotension  Offer sips of water before giving sublingual nitroglycerin because dryness may inhibit drug absorption

Slide 229: The Nitrates Implementation  Apply nitroglycerin ointment to the designated mark on paper.  The nurse should remove any excess ointment on the skin from the previous dose.  She should NEVER USE her bare fingers because the drug can be absorbed, utilize gloves or tongue blades instead.

Slide 230: The Nitrates Implementation  Apply nitroglycerin patch to an area with few hairs. Never touch the medication portion.  The patch and the ointment should NOT be applied near the area for defibrillation because explosion and skin burns may result

Slide 231: The Nitrates IMPLEMENTATION  Emphasize that tolerance to the nitroglycerin can occur.  If the medication cannot relieve the pain, report to the hospital immediately.

Slide 232: The Nitrates IMPLEMENTATION  Provide client health teaching- the sublingual nitroglycerin tablet is USED if chest pain occurs  The dose may be repeated if pain is unrelieved within 5 minutes.  Repeat the medication administration if the pain has not yet subsided.  DO NOT give more than 3 tablets!!! If chest pain persists for more than 15 minutes, hospital consult should be done immediately.

Slide 233: The Nitrates IMPLEMENTATION  Instruct the client to avoid alcohol while taking nitroglycerin to avoid potentiating the hypotensive effect of the medication  If beta blockers and calcium-channel blockers are given, instruct the patients to consult the physician before discontinuing the medication

Slide 234: The Nitrates IMPLEMENTATION  Other components of health teaching for home self-administration: – If taking Sublingual Nitroglycerin, the patient should be instructed to place the tablet under the tongue for quick absorption. – A burning sensation/biting/stinging sensation may indicate that the tablet is FRESH! – Store the tablet in a dark container, keep it away from heat and direct sunlight to avoid lessening the potency

Slide 235: The Nitrates IMPLEMENTATION  Other components of health teaching for home self-administration: – HEADACHES are common in the initial period of nitroglycerin therapy. Advise patient to take PARACETAMOL for relief – The nitroglycerin patch is applied once a day, usually in the morning. The sites should be rotated, in the chest, arms and thighs avoiding hairy areas.

Slide 236: The Nitrates IMPLEMENTATION  Other components of health teaching for home self-administration: – Position supine with elevated legs to manage Hypotension. – Nitroglycerin tablet can be taken prophylactically in situations where chest pain is anticipated- Sex, exercise, etc.. – If patient is taking beta blockers, instruct how to obtain heart rate in a minute

Slide 237: Drugs for Shock Dopamine  This is a sympathomimetic drug often used to treat Hypotension in shock states that are not caused by Hypovolemia.  This drug is an immediate precursor of nor-epinephrine, occurs naturally in the CNS basal ganglia where it functions as a neurotransmitter.

Slide 238: Drugs for Shock Dopamine  Pharmacodynamics: It can activate the alpha and beta adrenergic receptor depending upon the concentration. It stimulates receptors to cause cardiac stimulation and renal vasodilation.  The dose range is 1-20 micrograms/kg/min

Slide 239: Drugs for Shock Dopamine  Pharmacokinetics: Dopamine is administered IV, excreted in the urine.  At low dose (1-2 micrograms), dopamine DILATES the renal and mesenteric blood vessels producing an increase output (dopaminergic effect)

Slide 240: Drugs for Shock Dopamine  At moderate dose of 2-10 micrograms, dopamine enhance cardiac output by increasing heart rate (beta 1-adrenergic effect) and elevates blood pressure through peripheral vasoconstriction (alpha adrenergic effect)

Slide 241: Drugs for Shock Dopamine  At higher doses of more than 10 micrograms- vasoconstriction of all vessels will predominate that can lead to diminished tissue perfusion

Slide 242: Drugs for Shock Dopamine  Dopamine is indicated to treat Hypotension, to increase heart rate and to increase urine output (given less than 5 mg/kg/min)  The nurse typically prepares the dopamine drip- dopamine (at a concentration of 400-800 mg) is mixed in 250 mL D5W and administered as drip via an infusion pump for precise dosage administration.  Sodium bicarbonate will inactivate the dopamine

Slide 243: Drugs for Shock Dopamine  Pharmacodynamics: side effects- Tachycardia hypertension ectopic beats, angina, dysrhythmias, myocardial ischemia, nausea and vomiting.

Slide 244: Drugs for Shock Dopamine: Nursing consideration – Check the IV site hourly for signs of drug infiltration of dopamine, which can cause tissue necrosis. – Phentolamine should be infiltrated in multiple areas to reduce tissue damage. – Drug is effective if Urine output is increased and BP is increased

Slide 245: Antihypertensive drugs The Drugs employed to control hypertension can be classified as:  Diuretics  Beta-blockers  Alpha adrenergic blockers  Calcium channel blockers  Angiotensin-converting enzyme inhibitors  Angiotensin II receptor blockers  Peripheral vasodilators

Slide 246: Common Drugs in HPN IN Evaluating the effectiveness of these drugs is simply to monitor the BP if it becomes NORMAL

Slide 247: Anti-hypertensive drugs Class Prototype MOA Side effects Diuretics Furosemide Decreases blood Hypokalemia volume Beta-blocker Propranolol Blocks B1 receptor Bradycardia, in the heart hypoglycemia ACE Captopril Prevents A1 to AII Headache, Cough, Inhibitors conversion flushing Ca channel Nifedipine Blocks Ca entry Headache, flushing, blockers into cell reflex tachycardia Vasodilator Nitroglycerin Dilates veins and HEADACHE arteries Alpha Prazozin Blocks alpha Urination blockers receptor in BV causing vasodilatation Central alpha Clonidine Stimulates CNS Depression agonist alpha 2 receptor

Slide 248: Anticoagulants HEPARIN WARFARIN Parenteral (SQ and IV) Oral Action is to enhance natural Action is to INHIBIT Vitamin-K dependent clotting factors anti-thrombin III in the blood (10,9,7,2) Acts within minutes Acts within days Monitor for aPTT Monitor for PT and INR Large molecule, can be given to Small molecule CANNOT be pregnant given to pregnant Antidote: Protamine Antidote: Vit. K sulfate SE: bleeding, decreased SE: Bleeding platelets

Slide 249: The antianemics: Iron preparations and Epoetin Iron preparations  Iron is important for hemoglobin formation. The iron preparations are:  Ferrous sulfate  Ferrous fumarate  Ferrous gluconate

Slide 250: The antianemics: Iron preparations and Epoetin Side-effects: GIT- constipation (usually), diarrhea, vomiting, epigastric pain, gastric ulceration and darkening of stools.  Liquid preparation can stain the teeth, and injectable iron can cause tissue discoloration  Other- dizziness

Slide 251: The antianemics: Iron preparations and Epoetin Drug-Drug interaction  Tetracyclines combine with iron preparations and render the iron unabsorbable.  Antacids and cimetidine- decrease iron absorption and effects  Foods can impair iron absorption but they should be taken with iron to reduce GI discomfort.  Milk containing foods, coffee, tea and eggs are NOT given with iron because they delay iron absorption.

Slide 252: The antianemics: Iron preparations and Epoetin Implementation  Encourage the patient to eat iron-rich foods like liver, lean meat, egg yolk, dried beans, green leafy vegetables.  Administer iron preparations orally with foods to decrease GI discomfort.  If increased absorption is necessary, administer IN BETWEEN meals with full glass of water or juice.  It is best to offer citrus juices because the vitamin C content can increase iron absorption.  Instruct the patient to swallow the whole tablet and remain upright for 30 minutes to prevent esophageal corrosion from reflux.  DO NOT administer iron together with or within 1 hour of ingesting tetracyclines, antacids, milk and milk-containing products.  Advise clients to increase fluid intake and consume fiber rich foods if constipation becomes a problem.

Slide 253: The antianemics: Iron preparations and Epoetin Implementation  Emphasize that the therapeutic effect of iron therapy may not be apparent until several weeks.  If injecting a parenteral iron preparation, inject DEEP IM utilizing the Z-track method to avoid leakage into the subcutaneous tissues and skin.  Offer straw if giving liquid iron preparation to avoid staining the teeth.  To prevent undue alarm, instruct the patient that the stools may turn black or dark green. This is a harmless occurrence.

Slide 254: The antianemics: Iron preparations and Epoetin Evaluation  The nurse evaluates the effectiveness of the drug therapy by determining that the client is not fatigued, with absence of pallor, and with hemoglobin results within desired range.

Slide 255: Erythropoietin The mechanism of action of epoetin alfa (Epogen)  This drug acts like the natural glycoprotein erythropoietin to stimulate the production of RBC in the bone marrow.

Slide 256: Erythropoietin Clinical indications  It is given SUBCUTANEOUSLY or INTRAVENOUSLY for the treatment of anemia associated with renal failure or for patients on dialysis.  It is also used in patients for blood transfusion to decrease the need for blood in surgical patients.

Slide 257: Erythropoietin Pharmacodynamics: the adverse effects of epoetin alfa  CNS- headache, fatigue, asthenia, dizziness and seizures- these are due to the cellular response to the glycoprotein.  GIT- nausea, vomiting and diarrhea  CVS- hypertension, edema and chest pain due to increase RBC number

Slide 258: Erythropoietin Implementation  Administer the drug SC or IV usually 3 times per week.  Monitor the IV access line if given IV. Do not mix with other solutions  Determine periodically the level of hematocrit and iron stores during therapy. If patient does not respond to the drug, reevaluate the cause of anemia.  Maintain seizure precaution on stand by as seizure can occur.  Provide comfort measures like small frequent feedings and pain medications for headache.  Provide thorough health teaching: need for lifetime injection

Slide 259: Erythropoietin Evaluation  Monitor patient response to the drug= increased hemoglobin

Slide 261: Psychotrophic drugs • Drugs that can: 2. Stimulate the release of neurotransmitters 3. Block the receptor/activity of the neurotransmitter= like dopamine 4. Stimulate the receptors in the CNS 5. Prevents the breakdown of the neurotransmitters or the re-uptake mechanism

Slide 262: Anti-Psychotics/Neuroleptics • Drugs used to treat PSYCHOSES • MAIN ACTION: Blockage of the DOPAMINE receptor in the CNS

Slide 263: Anti-Psychotics/Neuroleptics Class Prototype Others Phenothiazines Chlorpromazine Thioridazine, Fluphenazine, Perphenazine Butyrophenones Haloperidol droperidol Thioxanthines Chlorprothixene thirothixene Dibenzoxapine Molindone Diphenylbutlypiperidine Pimozide Atypical drugs Clozapine Olanzapine Risperidone quetiapine

Slide 264: Anti-Psychotics/Neuroleptics Desired Effects 1 Reduced hallucination and illusions 2 CNS sedation and emotional slowing 3 Decreased ambivalence, reduced delusion 4 Reduced agitation resulting to calmness 5 Relief of emotional turmoil 6 Reduced flattening of affect

Slide 265: Anti-Psychotics/Neuroleptics Nursing Interventions Common SE Sugarless gum, bed rest Anticholinergic effects Sunglasses, sunscreen, avoid Photosensitivity sun Change position slowly, lie Postural hypotension prone for 1 hour after drug intake, monitor BP Instruct to report sore throat Agranulocytosis and fever, monitor WBC Monitor EEG Seizure Safety, no machine operation Sedation

Slide 266: Anti-Psychotics/Neuroleptics Extra-Pyramidal Syndrome Nursing Intervention Parkinsonism-Tremor, rigidity, Avoid abrupt withdrawal, give anti- bradikinesia EPS drugs like Cogentin Dystonia- torticollis, contraction Remain with client, administer anti- of face and tongue EPS Akathisia= motor restlessness Verbalize understanding of the condition, administer anti-EPS Tardive Dyskinesia= irreversible No treatment except discontinue drooling, tongue movement and drug shuffling gait Neuroleptic Malignant Notify physician, prepare to syndrome= elevated temp, administer dantrolene treme muscle rigidity

Slide 267: Review Outline Adrenergic Agonists  Adrenergic Antagonists  Cholinergic Agonists  Cholinergic Antagonists 

Slide 268: Comparison of the Sympathetic and Parasympathetic Nervous system Characteristics Sympathetic Parasympathetic CNS origin Thoraco-lumbar spinal Cranio-Sacral spinal cord cord Pre-ganglionic neuron Short axon Long axon Pre-ganglionic NTA Acetylcholine Acetylcholine Ganglia location Next to spinal cord Near target organ Post-ganglionic neuron Long axon Short axon Post-ganglionic NTA Epi and NE Acetylcholine Enzyme for NTA MAO, COMT Acetylcholine- ESTERASE General response Fight or flight Rest and Digest

Slide 269: The autonomic drugs Pharmacologic use depends on their  EFFECTS on the body They can STIMULATE= agonists OR  mimetics They can DECREASE THE RESPONSE=  antagonists OR blockers

Slide 270: The autonomic drugs They can STIMULATE= agonists OR mimetics  DIRECT STIMULATION by binding with receptors INDIRECT STIMULATION by blocking  the enzymes that degrade the neurotransmitters or increasing the release of neurotransmitters

Slide 271: The autonomic drugs They can DECREASE THE RESPONSE= antagonists OR blockers DIRECT blockage by removing the  neurotransmitter or competing with the neurotransmitter Binding with the receptor and NO  RESPONSE will happen

Slide 272: The autonomic drugs They can be NON-SELECTIVE when they stimulate or block many receptors SELECTIVE when they stimulate or block specific receptors SPECIFIC when only ONE type of receptor is stimulated or blocked

Slide 273: The autonomic drugs: Pharmacologic use depends on their EFFECTS on the body Effect on the body Therapeutic use Increases BP Used for SHOCK where there is LOW BP Decreases BP and heart rate Used for HYPERTENSION and Tachycardia

Slide 274: The Adrenergic AGONISTS Also called SYMPATHOMIMETIC agents  These drugs MIMIC the effects of the  sympathetic nervous system

Slide 275: The Adrenergic AGONISTS They usually stimulate DIRECTLY the  receptors of the adrenergic system

Slide 276: The Adrenergic AGONISTS Alpha and Beta agonists (non-selective)  Prototype: Epinephrine  Alpha Agonists (Selective)  Prototype: Phenylephrine  Beta Agonists (Selective)  Prototype: Isoproterenol 

Slide 277: The Adrenergic AGONISTS Alpha and Beta agonists (non-selective)  Pharmacodynamics: These agents stimulate ALL types of adrenergic receptors in the body by direct interaction or by releasing neurotransmitters from the nerve cells

Slide 278: The Adrenergic AGONISTS Alpha and Beta agonists  Prototype: Epinephrine  1. Ephedrine 2. Epinephrine 3. Metaraminol 4. Norepinephrine 5. Dobutamine (sometimes a B1 specific) 6. Dopamine

Slide 279: The Adrenergic AGONISTS Alpha and Beta agonists: Clinical Use  1. Dopamine- used in shock  2. Epinephrine- drug of choice of anaphylaxis, Status asthmaticus  3. Norepinephrine- used in shock  4. Dobutamine- used in CHF  5. Ephedrine- used in shock, asthma and rhinitis

Slide 280: The Adrenergic AGONISTS Alpha and Beta agonists: Desirable effects  Increased myocardial contractility  Bronchial DILATATION  Vasoconstriction  Increased blood pressure  Decreased intraocular pressure  Pupillary dilatation 

Slide 281: The Adrenergic AGONISTS Alpha and Beta agonists:  Contraindications Pheochromocytoma  Tachyarrhythmias  With halogenated anesthesia- increased  sensitivity to adrenergic drugs

Slide 282: The Adrenergic AGONISTS Alpha and Beta agonists: Adverse effects  Sympathetic stimulation effects  CVS- hypertension, tachycardia, palpitations Respi- tachypnea GI- nausea, vomiting Others- sweating, headache, piloerection

Slide 283: The Adrenergic AGONISTS Alpha and Beta agonists: Nursing considerations 2. Monitor patient response to the drug 3. Emphasize to avoid the use with MAOIs and TCA 4. Maintain phentolamine (alpha blocker) to manage extravasation of IV drug 5. Usually given IV

Slide 284: The Adrenergic AGONISTS Alpha and Beta agonists: Nursing considerations Determine effectiveness of the drug: Increased BP in shock Relief of anaphylaxis and asthma attack Relief of nasal congestion

Slide 285: The Adrenergic AGONISTS Alpha Agonists (selective) Prototype: phenylephrine clonidine (alpha-2 specific)

Slide 286: The Adrenergic AGONISTS Alpha Agonists Pharmacodynamics: These agents bind primarily to the alpha receptors in the body Clonidine Stimulating the ALPHA-2 receptor causes decreased sympathetic outflow from the CNS/ decreased release of NE

Slide 287: The Adrenergic AGONISTS Alpha Agonists: Clinical use Phenylephrine- vasoconstricting drug, 3. used topically to decrease the symptoms of rhinitis Clonidine- for hypertension 4.

Slide 288: The Adrenergic AGONISTS Alpha Agonists: Contraindication 2. Allergy to drug 3. Caution in the following conditions: Hyperthyroidism-aggravation of symptoms • Diabetes- increased glucose levels • Tachyarrhythmias- possible additive effect •

Slide 289: The Adrenergic AGONISTS Alpha Agonists: Adverse effects CNS- anxiety, depression, fatigue CVS- palpitations GI- nausea, vomiting and anorexia GU- oliguria, dysuria

Slide 290: The Adrenergic AGONISTS Alpha Agonists: Nursing considerations 1. DO NOT discontinue drug abruptly to prevent rebound effect 2. Maintain phentolamine if giving IV drug 3. Provide comfort measures- rest, quiet environment, analgesics

Slide 291: The Adrenergic AGONISTS Alpha Agonists: Nursing considerations Evaluate effectiveness: Decreased BP Decreased Nasal congestion

Slide 292: The Adrenergic AGONISTS Beta Agonists (Selective): ANTI-ASTHMA DRUGS Prototype: isoproterenol (B1 and B2) salbutamol (Ventolin)= B2 specific 5. Ritodrine (B2 specific) 6. “terol”- albuterol, salmeterol, bitolterol 7. Terbutaline (B2)

Slide 293: The Adrenergic AGONISTS Beta Agonists Pharmacodynamics These agents bind to the BETA receptors causing the sympathetic manifestations and effects

Slide 294: The Adrenergic AGONISTS Beta Agonists Clinical use 2. Asthma- due to the bronchodilation! 3. Preterm labor- ritodrine is given to relax the uterine muscles 4. Shock= To increase BP

Slide 295: The Adrenergic AGONISTS Beta Agonists Adverse effects CNS- restlessness, headache, anxiety , tremors CVS- tachycardia, angina, palpitations GI- nausea, vomiting and anorexia Others- pupilary dilation, rash, sweating, pulmonary edema

Slide 296: The Adrenergic AGONISTS Beta Agonists Nursing considerations 2. Monitor VS when giving the drug 3. Remind mothers to lie on the left side during ritodrine administration 4. Maintain a beta blocker on stand by 5. Provide comfort- quiet environment, rest, analgesics. 6. Prevent over-hydration to avoid pulmonary edema

Slide 297: The Adrenergic AGONISTS Beta Agonists Nursing considerations  These are given usually inhalational for asthma attack  Instruct on how to use inhalers and nebulizers Evaluate effectiveness: Normal RR Clear breath sounds

Slide 298: The Adrenergic ANTAGONISTS These are called adrenergic blockers  They can be Alpha Blockers (selective)  Beta Blockers (selective) Both Alpha & Beta Blockers (non-selective)

Slide 299: The Adrenergic ANTAGONISTS The alpha blockers (selective) Prototype: Phentolamine Phenoxybenzamine “zosin”- prazosin, doxazosin, terazosin- these are alpha 1 blockers

Slide 300: The Adrenergic ANTAGONISTS The alpha blockers: Pharmacodynamics These agents have affinity for the ALPHA receptors Blocking the alpha receptors will cause: Vasodilation Sphincter relaxation in the bladder

Slide 301: The Adrenergic ANTAGONISTS The alpha blockers: Clinical use 2. Phenoxybenzamine- used in pheochromocytoma 3. Phentolamine- also used in pheochomocytoma 4. “zosin” drugs- are used to decrease blood pressure and to relax the urinary sphincter in BPH!

Slide 302: The Adrenergic ANTAGONISTS The alpha blockers: Contraindications Myocardial infarction 3. Allergy 4.

Slide 303: The Adrenergic ANTAGONISTS The alpha blockers: Adverse Effects CVS- hypotension, reflex tachycardia, flushing CNS- dizziness, weakness, fatigue, drowsiness Others- nasal congestion, reddened eyes, priapism

Slide 304: The Adrenergic ANTAGONISTS The alpha blockers: nursing consideration 2. Monitor heart rate and BP 3. Caution to change position slowly 4. Advise to avoid hazardous activities 5. Provide supportive measures like quiet environment, rest and analgesics 6. Monitor response to the drug- improvement of blood pressure readings and urination

Slide 305: The Adrenergic ANTAGONISTS The Beta blockers These are agents used to treat cardiovascular problems- Hypertension, CHF, angina Blocking beta receptor will cause decreased heart rate decreased BP

Slide 306: The Adrenergic ANTAGONISTS The Beta blocker or The “olol”s They can be beta 1 blockers, beta 2 blockers or Both Prototype of non-selective: propranOLOL (beta 1 and 2) carteOLOL nadOLOL penbutOLOL sotaLOL

Slide 307: The Adrenergic ANTAGONISTS The Beta blocker or The “olol”s They can be beta 1 blockers, beta 2 blockers or Both Prototype of B1 selective: atenOLOL acebutOLOL betaxOLOL esmOLOL metoprOLOL

Slide 308: The Adrenergic ANTAGONISTS The Beta blockers: pharmacodynamics These agents block the beta receptors of the sympathetic system. The selective B1 antagonists block the B1 receptors, especially in the heart and the kidney

Slide 309: The Adrenergic ANTAGONISTS The Beta blockers: Clinical use 2. Hypertension 3. Angina and MI 4. Cardiac arrhythmias 5. Migraine headache 6. HYPERTHYROIDISM

Slide 310: The Adrenergic ANTAGONISTS The Beta blockers: Clinical use to decrease BP Hypertension to decrease cardiac workload Angina and MI to terminate arrhythmias Cardiac tachyarrhythmias to cause vasoconstriction in Migraine headache the cranial vessels to decrease the tachycardia HYPERTHYROIDISM

Slide 311: The Adrenergic ANTAGONISTS The Beta blockers: contraindications 2. Allergy 3. Heart blocks 4. Bradycardia 5. COPD 6. Precaution in DM

Slide 312: The Adrenergic ANTAGONISTS The Beta blockers: Adverse effects CVS- bradycardia, hypotension, heart block CNS- fatigue, dizziness, depression Respi- bronchospasm, pulmonary edema GI- nausea, vomiting, diarrhea, hypoglycemia GU- decreased libido, impotence, dysuria

Slide 313: The Adrenergic ANTAGONISTS The Beta blockers: nursing considerations 2. Emphasize NOT to stop abruptly the drug intake 3. Give with FOODS to improve absorption 4. Provide comfort measures Adequate rest periods  Avoidance of hazardous activities  Change position slowly 

Slide 314: The Adrenergic ANTAGONISTS The Beta blockers: nursing considerations Evaluate effectiveness: Decreased BP in hypertension Decreased HR in hyperthyroidism Decreased PAIN angina

Slide 316: The Cholinergic Agonists These are also called  parasympathomimetic agents Their action mimics the parasympathetic  nervous system

Slide 317: The Cholinergic Agonists These agents INCREASE the activity of  acetylcholine in the acetylcholine receptors DIRECTLY by occupying the receptor  INDIRECTLY by blocking the enzyme  that degrades the acetylcholine, preventing it from breakdown - the enzyme: acetylcholinESTERASE

Slide 318: The Cholinergic Agonists Direct acting cholinergic agonists  Prototype: BetaneCHOL CarbaCHOL Pilocarpine Indirect acting cholinergics  Prototype: Pyridostigmine Neostigmine Endrophonium (Tensilon)

Slide 319: The Cholinergic Agonists Direct acting cholinergic agonists Pharmacodynamics  They are similar to acetylcholine and directly act on the acetylcholine receptors

Slide 320: The Cholinergic Agonists Direct acting cholinergic agonists Parasympathetic stimulation will cause: DUMBELS urination miosis (pupil constriction)

Slide 321: The Cholinergic Agonists Direct acting cholinergic agonists: Clinical use 2. Post operative and post partum urinary retention and to treat neurogenic bladder 3. Relief of increased intraocular pressure of glaucoma by inducing miosis

Slide 322: The Cholinergic Agonists Direct acting cholinergic agonists: Clinical use 2. The drugs INCREASE the bladder tone, RELAX the GI and urinary sphincters 3. The topical agent (pilocarpine) topically causes pupilary constriction to reduce IOP

Slide 323: The Cholinergic Agonists Direct acting cholinergic agonists: Contraindications 2. Bradycardia 3. Hypotension 4. Asthma

Slide 324: The Cholinergic Agonists Direct acting cholinergic agonists: Adverse effects (DUMBELS) CVS- bradycardia, heart block, hypotension GIT- nausea, vomiting, diarrhea, increased salivation, lacrimation GUT- sense of urgency, sphincter relaxation Others- increased sweating, headache, miosis

Slide 325: The Cholinergic Agonists Direct acting cholinergic agonists: nursing considerations 2. Assure proper administration of ophthalmic preparations 3. Administer on EMPTY stomach 4. Provide safety precautions- because of poor visual acuity 5. Promote cool environment, maintain access to the bathroom (urination)

Slide 326: The Cholinergic Agonists: evaluate effectiveness Drug effectiveness Pilocarpine Decreased IOP in glaucoma Betanechol/Carbachol Urination/ relief of bladder distention

Slide 327: The Cholinergic Agonists Indirect acting cholinergic agonists Pharmacodynamics These agents DO NOT react directly with the receptors but REACT chemically with the enzyme= acetylcholinesterase

Slide 328: The Cholinergic Agonists Indirect acting cholinergic agonists Pharmacodynamics The acetylcholine breakdown is prevented so that the effect of acetylcholine is prolonged!= increased muscle contraction They are used IN myasthenia gravis

Slide 329: The Cholinergic Agonists Indirect acting cholinergic agonists Clinical use 3. Myasthenia gravis Physostigmine, pyridostigmine, Neostigmine,  and endrophonium 2. Alzheimer's disease Tacrine and Donepezil 

Slide 330: The Cholinergic Agonists Indirect acting cholinergic agonists Adverse effects GI- nausea, vomiting, cramps, diarrhea, increased salivation, involuntary defection CVS- bradycardia, heart block, hypotension GU- urinary urgency Others- blurred vision, miosis, headache, dizziness

Slide 331: The Cholinergic Agonists Indirect acting cholinergic agonists Nursing considerations 3. Administer IV drug slowly 4. Administer with foods BUT better BEFORE meals 5. Maintain atropine sulfate as antidote 6. Discontinue the drug if excessive salivation, diarrhea, vomiting become problematic

Slide 332: The Cholinergic Agonists Indirect acting cholinergic agonists Nursing considerations Evaluate effectiveness Decreased muscle weakness Decreased dysphagia, ptosis Increased muscular activity

Slide 333: The ANTI-cholinergics These are drugs that BLOCK the effect of  acetylcholine They are also called parasympatholytic  agents In effect, the sympathetic system becomes  unopposed!!!

Slide 334: The ANTI-cholinergics Anticholinergics:  Prototype: Atropine dicyclomine glycopyrrolate propantheline scopolamine

Slide 335: The ANTI-cholinergics Anticholinergics: pharmacodynamics These agents work by BLOCKING or COMPETING with acetylcholine for the acetylcholine receptors BEST taken BEFORE MEALS

Slide 336: Atropine Depresses salivation  Decreases bronchial secretions  Mydriasis  Cyclopedia  Inhibits vagal response in the heart  Reverses cholinergic toxicity 

Slide 337: Atropine effects Clinical use Depresses salivation Used as pre-op med Decreases bronchial Used as pre-op med secretions Mydriasis Used in cataract surgery Cyclopledia Used in cataract surgery Inhibits vagal response in Used in BRADYCARDIA the heart and heart block Used in partly to control diarrhea Constipation (in Lomotil) Used in Cholinergic and Reverses cholinergic Organophosphate poisoning toxicity

Slide 338: Scopolamine Decreases nausea and vomiting associated  with motion sickness

Slide 339: Anticholinergic Contraindications of anticholinergic  Known allergy 3. Glaucoma 4. Bladder obstruction (like PBH) 5.

Slide 340: Anticholinergic Adverse effects: anticholinergic effects CNS- blurred vision, pupil DILATION, photophobia, cycloplegia and increased Intraocular pressure GI- dry mouth, constipation, bloatedness CVS- tachycardia, palpitations GU- urinary retention Others- decreased sweating, flushing

Slide 341: Anticholinergic Nursing considerations 2. Provide comfort measures Frequent mouth care  Provide increased fluids  Protect eyes form lights  Advise to avoid hazardous activities  Provide high-fiber diet and laxative  Avoid extremes of temperature  Instruct to void before administering the drug 

Slide 342: Anticholinergic Nursing considerations 2. Monitor for toxicity: 3. Ensure adequate hydration to prevent hyperpyrexia Evaluate effectiveness of drug: Increased HR in heart block Decreased secretions in pre-op patients Relief of motion sickness (scopolamine)




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