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Thursday, November 15, 2007

Pharmacology Git Drugs :: Nursing Pharmacology :: Review For Nursing Licensure Examination

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Pharmacology Git Drugs :: Nursing Pharmacology :: Review For Nursing Licensure Examination Slide Transcript
Slide 1: Pharmacology of the GIT system

Slide 2: LECTURE Outline • REVIEW the Anatomy of the GIT • REVIEW the Physiology of the GIT • Review common GI drugs in the following categories: – 1. Drugs affecting GI secretions – 2. Laxatives – 3. Anti-diarrheals – 4. Emetics and anti-emetics

Slide 3: Fig. 16.1

Slide 4: Fig. 16.10a

Slide 5: Fig. 16.10b

Slide 6: Fig. 16.11a

Slide 7: Fig. 16.11b

Slide 8: Fig. 16.12

Slide 9: 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 10: Drugs affecting secretions: anti ulcer Anti-ulcer drugs Prototype Histamine (H2) receptor Cimetidine antagonist/blockers Antacids AlOH and MgOH Proton pump inhibitors Omeprazole Mucosal protectants Sucralfate Prostaglandin analog Misoprostol

Slide 11: General indication of the drugs affecting gastric acid secretion • Peptic ulcer • Gastritis • Patient on NPO to prevent stress ulcer

Slide 12: 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 13: Pharmacodynamics Histamine (H2) receptor blockers • These drugs BLOCK the release of hydrochloric acid in the stomach in response to gastrin

Slide 14: Drugs affecting GI secretions Antacids • These drugs interact with the gastric acids at the chemical level to neutralize them

Slide 15: Drugs affecting GI secretions Proton pump inhibitors • These drugs suppress the secretion of hydrochloric acid into the lumen of the stomach

Slide 16: Drugs affecting GI secretions Mucosal protectants • These are agents that coat any injured area in the stomach to prevent further injury from acid

Slide 17: 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 19: The H2 Blockers- “tidines” Prototype: Cimetidine • 1. Ranitidine • 2. Famotidine • 3. Nizatidine

Slide 20: 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 21: 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 22: 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 23: The H2 Blockers- “tidines” Dynamics- Side effects/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= Gynecomastia and impotence in males

Slide 24: 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 25: The H2 Blockers- “tidines” Drug-drug Interactions These drugs can interact with CIMETIDINE • Anticoagulants • Phenytoin, • Alcohol • Antidepressants.

Slide 26: 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 27: 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 28: The H2 Blockers- “tidines” Nursing considerations: • Provide comfort measures like analgesics for headache, assistance with ambulation and safety measures because of confusion • Warn the patients taking cimetidine that drowsiness may pose a hazard if driving or operating delicate machines.

Slide 29: 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 31: The Antacids These are drugs or inorganic chemicals that have been used for years to neutralize acid in the stomach

Slide 32: The Antacids 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 33: 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 34: 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 35: 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 36: 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 metabolic alkalosis!!!

Slide 37: The Antacids Pharmacokinetics • These agents are taken orally and act locally in the stomach

Slide 38: 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 39: 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 40: 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 41: The Antacids Nursing Considerations Evaluate for effectiveness: Decreased symptoms of ulcer and pyrosis Decreased Phosphate level (Amphogel) in patients with chronic renal failure

Slide 43: The PPI These are the newer agents for ulcer treatment • The “prazoles” Prototype: Omeprazole • Lanisoprazole • Esomeprazole • Pantoprazole

Slide 44: 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. • The “pump” in the parietal cell is the H- K ATPase enzyme system on the secretory surface of the gastric parietal cells

Slide 45: 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 46: The PPI Precautions with the use of the PPIs • Known allergy is a clear contraindication • Caution if patient is pregnant

Slide 47: 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 48: 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 49: 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 50: The PPI Nursing considerations: Evaluate for effectiveness of the drug • Healing of peptic ulcer • Decreased symptoms of ulcer

Slide 52: The Mucosal Protectant Sucralfate (Caralfate/ Iselpin) • This is given to protect the eroded ulcer sites in the GIT from further damage by acid and digestive enzymes

Slide 53: 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 54: 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 55: 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 56: 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 57: 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 58: 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 59: 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 60: The Mucosal Protectant Nursing Considerations • Evaluate effectiveness of therapy Healing of ulcer No formation of ulcer

Slide 62: 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 63: 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 64: Prostaglandin analogue Misoprostol: Clinical use • NSAIDs-induced gastric ulcers • Duodenal ulcers unresponsive to H2 antagonists

Slide 65: 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 66: Prostaglandin analogue Pharmacodynamic effects: drug reactions • GIT= Nausea, diarrhea, abdominal pain, flatulence, vomiting, dyspepsia • GU effects= miscarriages, excessive uterine CRAMPING and bleeding, spotting, hyper-menorrhea and menstrual disorders.

Slide 67: 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 68: 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 70: Laxatives • Generally used to INCREASE the passage of the colonic contents • The general classifications is as follows: 1. Chemical stimulants- irritants 2. Mechanical stimulants- hyperosmotic agents and saline cathartics 3. Lubricants and stool softeners

Slide 71: Laxatives • They promote bowel evacuation for various purposes • They are classified into their mode of action

Slide 72: Laxatives Type Prototype Action Direct stimulation of the Chemical Bisacodyl GIT nerves stimulants (Dulcolax) Irritant laxatives Increased fluid content Mechanical Lactulose of the fecal material (bulk) causing stimulation of stimulants the local reflex Lubricating the Lubricants Docusate intestinal material to Mineral oil promote passage through the GIT

Slide 73: Therapeutic Indications of the Laxatives • SHORT term relief of Constipation • 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 • To remove AMMONIA by use of lactulose

Slide 74: Contraindications in Laxative use • ACUTE abdominal disorders – Appendicitis – Diverticulitis – Ulcerative colitis

Slide 75: Chemical Stimulant Cathartics Prototype: Bisacodyl Irritant laxatives: • 1. Castor oil • 2. Senna • 3. Cascara • 4. Phenolphthalein

Slide 76: 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 77: Mechanical Stimulant Cathartics Prototype: LACTULOSE (Cephulac) Bulk-forming laxatives • 1. Magnesium (citrate, hydroxide, sulfate)- saline cathatic • 2. Psyllium • 3. Polycarbophil

Slide 78: 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 79: Lubricants-Stool softener Prototype: Docusate • 1. Glycerin • 2. Mineral oil

Slide 80: Lubricants-stool softeners Pharmacodynamics • Docusate increases the admixture of fat and water producing a softer stool • Glycerin and Mineral oil form a slippery coat on the colonic contents

Slide 81: 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 82: 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 83: The Nursing Process and Laxative NURSING DIAGNOSIS • Alteration in bowel pattern • Alteration in comfort: pain • Knowledge deficit

Slide 84: 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 85: 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 and avoid hazardous activities because of potential dizziness

Slide 86: The Nursing Process and Laxative IMPLEMENTATION 7. Record intake and output to assess fluid alteration 8. If possible, observe the character of stools 9. Caution the patient that chronic use may promote dependence and use during pregnancy may cause uterine cramping and Vitamin deficiency

Slide 87: 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 4. Nomal bowel fucntion is restored

Slide 88: 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 89: The Anti-diarrheals Type Prototype Action Locally coats the lining Local reflex Bismuth of the GIT to soothe inhibitor subsalicylate irritation Directly inhibits the Local anti- Loperamide intestinal muscle motility activity to SLOW peristalsis Stops GIT spasm by Central acting Opium CNS action agent derivatives (paregoric)

Slide 90: 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 91: Contraindications of anti-diarrheal Use • Poisoning • Drug allergy • GI obstruction • Acute abdominal conditions

Slide 92: Pharmacokinetics: Side effects • Constipation • Nausea, vomiting • Abdominal distention and discomfort • TOXIC MEGACOLON

Slide 93: 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 94: Nursing process and anti-diarrheals NURSING DIAGNOSIS • Alteration in bowel pattern • Alteration in comfort: pain

Slide 95: 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 regarding its short term use only

Slide 96: 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 98: 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 99: EMETIC • Prototype: Ipecac Syrup

Slide 100: EMETIC Pharmacodynamics • Ipecac syrup irritates the GI mucosa locally, resulting to stimulation of the vomiting center • It acts within 20 minutes

Slide 101: EMETIC Clinical Use of ipecac • To induce vomiting as a treatment for drug overdose and certain poisonings

Slide 102: EMETIC Contraindications of Ipecac use • Ingestion of CORROSIVE chemicals • Ingestion of petroleum products • Unconscious and convulsing patient

Slide 103: EMETIC Pharmacokinetics: side effects of Ipecac • Nausea • Diarrhea • GI upset • Mild CNS depression • CARDIOTOXICITY if large amounts are absorbed in the body

Slide 104: Nursing process and the EMETIC ASSESSMENT • Nursing History- elicit the exact nature of poisoning • Physical Examination- CNS status and abdominal exam

Slide 105: 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 106: Nursing process and the EMETIC IMPLEMENTATION 5. Provide comfort measures like ready access to bathroom, assistance with ambulation 6. Offer support

Slide 107: 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 109: ANTI-EMETICS • These are agents used to manage nausea and vomiting • They act either locally or centrally • In general, they may inhibit the chemoreceptor trigger zone in the medulla by blocking DOPAMINE receptor • Others act by decreasing the sensitivity of the vestibular apparatus

Slide 110: ANTIEMETICS Anti-emetic types Common examples Phenothiazines Prochlorperazine, Promethazine Non-phenothiazines Metoclopramide Anticholinergics and Meclizine, buclizine Antihistaminics Serotonin Receptor “setron”- dolasetron blockers Miscellaneous Dronabinol, hydroxyzine

Slide 111: ANTIEMETICS Types Pharmacodynamics Centrally block the vomiting center in Phenothiazines the medulla Non-phenothiazine Reduces the responsiveness of the nerve cell in the medulla; also blocks the dopamine receptors Block the transmission of the impulses Anticholinergics to the medulla Serotonin receptor Centrally and locally inhibits the serotonin receptors blockers Act in the CNS , either in the medulla or Miscellaneous in the cortex

Slide 112: ANTIEMETICS Types Clinical Use N/V associated with Phenothiazines anesthesia, intractable hiccups N/V associated with chemical Non-phenothiazine stimulation N/V associated with motion Anticholinergics sickness Serotonin-receptor N/V associated with Blockers chemotherapy Miscellaneous N/V associated with chemotherapy

Slide 113: ANTIEMETICS Indications • 1. Prevention and treatment of vomiting • 2. Motion sickness

Slide 114: ANTIEMETICS Contraindications • 1. Severe CNS depression • 2. Severe liver dysfunction

Slide 115: ANTIEMETICS Pharmacokinetics: • Oral absorption is good if vomiting is not present • IV drugs can be given if vomiting is active • Most drugs are metabolized in the liver excreted in the kidneys

Slide 116: 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 Metoclopramide= EPS due to dopamine receptor blockage

Slide 117: 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 118: Nursing Process and the ANTIEMETICS NURSING DIAGNOSIS 2. Alteration in comfort: pain 3. High risk for injury 4. Knowledge deficit

Slide 119: 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 120: 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 121: Nursing Process and the ANTIEMETICS IMPLEMENTATION 4. Protect from sun exposure – Sunscreens – Protective covering 5. Provide health teaching

Slide 122: 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




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