Pharmacology Bullet Review


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Pharmacology Bullet Review

  1. 1. Pharmacology Bullet Review
  2. 2. Drug classification Nursing process applied to pharmacology Pharmacokinetics Pharmacodynamics
  3. 4. Diuretics Comparison Hypokalemia Ototoxicity Loop of Henle 3. Loop diuretics Hypovolemia & hypotension Glomerulus 5. Osmotic diuretic Hyperkalemia Distal tubule 4. Potassium sparing Hyperuricemia Hypokalemia Proximal tubule 2. Thiazide and thiazide like Acidosis Proximal tubule 1. Carbonic anhydrase inhibitor Special Side effect (s) Major site of action Diuretic class
  4. 5. Diuretics Comparison Hypercalcemia 3. Loop diuretics Increased ICP LITHIUM TOXICITY 5. Osmotic diuretic CHF taking digoxin 4. Potassium sparing Nephrolithiasis due to calcium stones Hypocalcemia 2. Thiazide and thiazide like Mountain sickness Meniere’s disease 1. Carbonic anhydrase inhibitor Special Uses Diuretic class
  5. 6. Thiazides <ul><li>Prototype: Hydrochloro thiazide </li></ul><ul><li>1. Bendroflume thiazide </li></ul><ul><li>2. Ben thiazide </li></ul><ul><li>3. Chloro thiazide (Diuril) </li></ul><ul><li>4. Hydroflume thiazide </li></ul><ul><li>5. Methylclo thiazide </li></ul><ul><li>6. Trichlorme thiazide </li></ul>
  6. 7. Thiazide-like <ul><li>1. Indapamide </li></ul><ul><li>2. Quinethazone </li></ul><ul><li>3. Metolazone </li></ul><ul><li>4. Chlorthalidone </li></ul>
  7. 8. Thiazides <ul><li>Pharmacodynamics </li></ul><ul><li>These drugs BLOCK the chloride pump </li></ul><ul><li>This will keep the Chloride and Sodium in the distal tubule to be excreted into the urine </li></ul><ul><li>Potassium is also </li></ul><ul><li>flushed out!! </li></ul>
  8. 9. Thiazide <ul><li>Special Pharmacodynamics: Side effects </li></ul><ul><ul><li>Hypokalemia </li></ul></ul><ul><ul><li>DECREASED calcium excretion  hypercalcemia </li></ul></ul><ul><ul><li>DECREASED uric acid secretion  hyperuricemia </li></ul></ul><ul><ul><li>Hyperglycemia </li></ul></ul>
  9. 10. Loop Diuretics <ul><li>Prototype: Furosemide </li></ul><ul><li>1. Bumetanide </li></ul><ul><li>2. Ethacrynic acid </li></ul><ul><li>3. Torsemide </li></ul>
  10. 11. Loop Diuretics <ul><li>Pharmacodynamics </li></ul><ul><li>High-ceiling diuretics </li></ul><ul><li>BLOCK the chloride pump in the ascending loop of Henle </li></ul><ul><li>SODIUM and CHLORIDE reabsorption is prevented </li></ul><ul><li>Potassium is also excreted together with Na and Cl </li></ul>
  11. 12. Loop Diuretics
  12. 13. Loop Diuretics <ul><li>Special Pharmacodynamics: side-effects </li></ul><ul><ul><li>Hypokalemia </li></ul></ul><ul><ul><li>Bicarbonate is lost in the urine </li></ul></ul><ul><ul><li>INCREASED calcium excretion  Hypocalcemia </li></ul></ul><ul><ul><li>Ototoxicity- due to the electrolyte imbalances </li></ul></ul>
  13. 14. Potassium sparing diuretics <ul><li>Prototype: Spironolactone </li></ul><ul><li>1. Amiloride </li></ul><ul><li>2. Triamterene </li></ul>
  14. 15. Potassium sparing diuretics <ul><li>Pharmacodynamics </li></ul><ul><li>Spironolactone is an ALDOSTERONE antagonist </li></ul><ul><li>Triamterene and Amiloride BLOCK the potassium secretion in the distal tubule </li></ul><ul><li>Diuretic effect is achieved by the sodium loss to offset potassium retention </li></ul>
  15. 16. Potassium sparing diuretics
  16. 17. Potassium sparing diuretics <ul><li>Pharmacokinetics: Side effects </li></ul><ul><ul><li>HYPERkalemia! </li></ul></ul><ul><ul><li>Avoid high potassium foods: </li></ul></ul><ul><ul><ul><li>Bananas </li></ul></ul></ul><ul><ul><ul><li>Potatoes </li></ul></ul></ul><ul><ul><ul><li>Spinach </li></ul></ul></ul><ul><ul><ul><li>Broccoli </li></ul></ul></ul><ul><ul><ul><li>Nuts </li></ul></ul></ul><ul><ul><ul><li>Prunes </li></ul></ul></ul><ul><ul><ul><li>Tomatoes </li></ul></ul></ul><ul><ul><ul><li>Oranges </li></ul></ul></ul><ul><ul><ul><li>Peaches </li></ul></ul></ul>
  17. 18. Osmotic Diuretics <ul><li>Prototype: Mannitol </li></ul><ul><li>1. Glycerin </li></ul><ul><li>2. Isosorbide </li></ul><ul><li>3. Urea </li></ul>
  18. 19. Osmotic Diuretics <ul><li>Pharmacodynamics </li></ul><ul><li>Mannitol is a sugar not well absorbed in the nephron  osmotic pull of water  diuresis </li></ul>
  19. 20. Osmotic Diuretics <ul><li>Pharmacokinetics: side effects </li></ul><ul><ul><li>Sudden hypovolemia </li></ul></ul><ul><li>Important for the nurse to warm the solution to allow the crystals to DISSOLVE in the bottle! </li></ul>
  20. 21. Carbonic Anhydrase Inhibitors <ul><li>Prototype: Acetazolamide </li></ul><ul><li>1. Methazolamide </li></ul>
  21. 22. Carbonic Anhydrase Inhibitors <ul><li>Pharmacodynamics </li></ul><ul><li>Carbonic Anhydrase forms sodium bicarbonate </li></ul><ul><li>BLOCK of the enzyme results to slow movement of hydrogen and bicarbonate into the tubules </li></ul><ul><li>plus sodium is lost in the urine </li></ul>
  22. 23. Carbonic Anhydrase Inhibitors <ul><li>Pharmacokinetics: side effects </li></ul><ul><ul><li>Metabolic ACIDOSIS happens when bicarbonate is lost </li></ul></ul><ul><ul><li>Hypokalemia </li></ul></ul>
  23. 24. The Nursing Process and the diuretics <ul><li>ASSESSMENT </li></ul><ul><li>Assess the REASON why the drug is given: </li></ul><ul><li>______ </li></ul><ul><li>______ </li></ul><ul><li>______ </li></ul><ul><li>______ </li></ul>
  24. 25. The Nursing Process and the diuretics <ul><li>ASSESSMENT </li></ul><ul><li>The nurse must elicit history of allergy to the drugs </li></ul><ul><ul><li>Allergy to sulfonamides may contraindicate the use of thiazides </li></ul></ul><ul><li>Assess fluid and electrolyte balance </li></ul><ul><li>Assess other conditions like gout, diabetes, pregnancy and lactation </li></ul>
  25. 26. The Nursing Process and the diuretics <ul><li>ASSESSMENT </li></ul><ul><li>Physical assessment </li></ul><ul><ul><li>Vital signs </li></ul></ul><ul><ul><li>Special electrolyte and laboratory examination </li></ul></ul><ul><li>Assess symptom of body weakness which may indicate hypokalemia </li></ul>
  26. 27. The Nursing Process and the diuretics <ul><li>Nursing Diagnosis </li></ul><ul><ul><li>Fluid volume deficit related to diuretic effect </li></ul></ul><ul><ul><li>Alteration in urinary pattern </li></ul></ul><ul><ul><li>Potential for injury (ototoxocity, hypotension) </li></ul></ul><ul><ul><li>Knowledge deficit </li></ul></ul>
  27. 28. The Nursing Process and the diuretics <ul><li>IMPLEMENTATION </li></ul><ul><li>Administer IV drug slowly </li></ul><ul><li>Safety precaution for dizziness/hypotension </li></ul><ul><li>Provide potassium RICH foods for most diuretics, with the exception of spironolactone </li></ul><ul><li>Provide skin care, oral care and urinary care </li></ul>
  28. 29. The Nursing Process and the diuretics <ul><li>IMPLEMENTATION </li></ul><ul><li>Monitor DAILY WEIGHT- to evaluate the effectiveness of the therapy </li></ul><ul><li>Monitor urine output, cardiac rhythm. Serum electrolytes </li></ul><ul><li>ADMINISTER in the MORNING! </li></ul><ul><li>Administer with FOOD! </li></ul>
  29. 30. The Nursing Process and the diuretics <ul><li>EVALUATION: for effectiveness of therapy </li></ul><ul><li>Weight loss </li></ul><ul><li>Increased urine output </li></ul><ul><li>Resolution of edema </li></ul><ul><li>Decreased congestion </li></ul><ul><li>Normal BP </li></ul>
  30. 31. CNS DRUGS
  31. 32. The ANXIOLYTICS AND HYPNOTICS <ul><li>These drugs are used to change the individual’s responses to the environment. </li></ul>
  32. 33. The ANXIOLYTICS AND HYPNOTICS <ul><li>The medications that can prevent the feelings of tension and fear are called ANXIOLYTICS. </li></ul><ul><ul><li>Anti-anxiety drugs </li></ul></ul>
  33. 34. The ANXIOLYTICS AND HYPNOTICS <ul><li>The drugs that can calm individuals making them unaware of the environment are called SEDATIVES. </li></ul>
  34. 35. The ANXIOLYTICS AND HYPNOTICS <ul><li>The drugs that can induce sleep are called HYPNOTICS. </li></ul>
  35. 36. The ANXIOLYTICS AND HYPNOTICS <ul><li>The drugs in this class are the </li></ul><ul><ul><li>BENZODIAZEPINES </li></ul></ul><ul><ul><li>BARBITURATES </li></ul></ul>
  36. 37. Use of The Drugs <ul><li>Clinical indications for the use of the </li></ul><ul><li>anxiolytics, sedatives and hypnotics </li></ul><ul><li>1. Prevention of anxiety </li></ul><ul><li>2. Formation of sedative state </li></ul><ul><li>3. Induction of sleep </li></ul>
  37. 38. The BENZODIAZEPINES <ul><li>The benzodiazepines are the most frequently used anxiolytic drugs. </li></ul><ul><li>These agents prevent anxiety states without causing much sedation, with less physical dependence than other agents. </li></ul>
  38. 39. The BENZODIAZEPINES <ul><li>The following are the benzodiazepines </li></ul><ul><li>Alprazolam (Xanax) </li></ul><ul><li>Chlordiazepoxide (Librium ) </li></ul><ul><li>clonazepam </li></ul><ul><li>clorazepate </li></ul><ul><li>Diazepam (Valium) </li></ul><ul><li>estazolam </li></ul><ul><li>flurazepam </li></ul><ul><li>lorazepam </li></ul><ul><li>midazolam </li></ul><ul><li>oxazepam </li></ul><ul><li>quazepam </li></ul><ul><li>temazepam </li></ul><ul><li>triazolam </li></ul>
  39. 40. The BENZODIAZEPINES Special uses Panic attack Alprazolam (Xanax) Alcohol withdrawal Chlordiazepoxide (Librium) Status epilepticus Diazepam (Valium)
  40. 41. The BENZODIAZEPINES <ul><li>The Mechanism of Action of the Benzodiazepines </li></ul><ul><li>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. </li></ul>
  41. 42. The BENZODIAZEPINES <ul><li>The Mechanism of Action of the Benzodiazepines </li></ul><ul><li>The GABA is an inhibitory neurotransmitter. </li></ul><ul><li>This will result to an anxiolytic effect at lower doses than required for sedation/hypnosis. </li></ul>
  42. 43. The BENZODIAZEPINES <ul><li>These agents are indicated for the treatment of </li></ul><ul><li>anxiety disorders </li></ul><ul><li>alcohol withdrawal </li></ul><ul><li>hyperexcitability, and agitation </li></ul><ul><li>pre-operative relief of anxiety and tension and in induction of balanced anesthesia. </li></ul>
  43. 44. The BENZODIAZEPINES <ul><li>Pharmacodynamics: The adverse effects </li></ul><ul><li>CNS effects= sedation, drowsiness, depression, lethargy, blurred vision </li></ul><ul><li>GIT= dry mouth, constipation , nausea, vomiting </li></ul><ul><li>CVS= Hypotension or hypertension, arrhythmias, palpitations, and respiratory difficulties. </li></ul><ul><li>Hematologic= blood dyscrasias and anemia </li></ul><ul><li>GU= urinary retention, hesitancy, loss of libido and sexual functions changes. </li></ul>
  44. 45. The BENZODIAZEPINES <ul><li>Nursing Considerations: </li></ul><ul><li>Maintain patients on bed for at least 3 hours after drug administration. </li></ul><ul><li>Instruct to avoid hazardous activities like driving and machine operation. </li></ul><ul><li>Instruct to avoid consuming ALCOHOL while taking the drug . </li></ul>
  45. 46. The BENZODIAZEPINES <ul><li>Nursing Considerations: </li></ul><ul><li>Provide comfort measures to help patients tolerate drug effects- </li></ul><ul><ul><li>instruct to urinate before taking drug </li></ul></ul><ul><ul><li>give high fiber foods </li></ul></ul><ul><ul><li>use side-rails and assistance with ambulation. </li></ul></ul><ul><li>Have available FLUMAZENIL as an antidote for benzodiazepine overdose. </li></ul>
  46. 47. The BARBITURATES <ul><li>These are also anxiolytics and hypnotics with a greater likelihood of producing sedation, with increase risk of addiction and dependence. </li></ul>
  47. 48. The BARBITURATES <ul><li>The following are the barbiturates </li></ul><ul><li>amobarbital </li></ul><ul><li>aprobarbital </li></ul><ul><li>butabarbital </li></ul><ul><li>mephobarbital </li></ul><ul><li>pentobarbital </li></ul><ul><li>Phenobarbital </li></ul><ul><li>secobarbital </li></ul>
  48. 49. The BARBITURATES <ul><li>The Mechanism of Action of the Barbiturates </li></ul><ul><li>They depress the motor output from the brain. </li></ul><ul><li>The results of their MOA are sedation, hypnosis and anesthesia, and if extreme, coma. </li></ul>
  49. 50. The BARBITURATES <ul><li>Clinical indications of the Barbiturates </li></ul><ul><li>Relief of anxiety manifestations </li></ul><ul><li>For sedation </li></ul><ul><li>For patients with insomnia </li></ul><ul><li>For pre-anesthesia </li></ul><ul><li>seizures/epilepsy </li></ul><ul><li>The rapid acting barbiturates are also used for the treatment of acute manic reactions and status epilepticus </li></ul>
  50. 51. The BARBITURATES <ul><li>Pharmacodynamics: The Adverse effects </li></ul><ul><li>CNS= CNS depression , somnolence , vertigo, lethargy, ataxia, paradoxical excitement, anxiety and hallucinations. </li></ul><ul><li>GIT= nausea, vomiting, constipation/diarrhea and epigastric pain </li></ul><ul><li>CVS= bradycardia, Hypotension and syncope. </li></ul><ul><li>Respi= serious hypoventilation, respiratory depression and laryngospasms </li></ul><ul><li>Others= hypersensitivity and Stevens-Johnson syndrome. </li></ul>
  51. 52. The BARBITURATES <ul><li>Nursing Considerations </li></ul><ul><li>Provide stand-by life support facilities in cases of severe respiratory depression or hypersensitivity reaction. </li></ul><ul><li>Taper the drug gradually after long-term therapy to avoid withdrawal syndrome. </li></ul><ul><li>Provide comfort measures including small frequent meals, access to bathroom facilities, high-fiber foods, environmental control, safety precaution and skin care. </li></ul>
  52. 53. The CNS stimulants <ul><li>These are drugs used to treat certain disorders </li></ul><ul><li>exogenous obesity </li></ul><ul><li>attention-deficit hyperactivity disorders (ADHD) </li></ul><ul><li>narcolepsy </li></ul>
  53. 54. The CNS stimulants <ul><li>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. </li></ul>
  54. 55. The CNS stimulants <ul><li>The following are the CNS stimulants: </li></ul><ul><li>1. Methylphenidate (Ritalin)= most commonly used for ADHD </li></ul><ul><li>2. Dextroamphetamine= a CNS stimulant that is used for short tem therapy for obesity. </li></ul><ul><li>3. Modafinil= used for narcolepsy </li></ul><ul><li>4. Pemoline= used for ADHD </li></ul>
  55. 56. The CNS stimulants <ul><li>The Mechanism of Action </li></ul><ul><li>These agents act as to stimulate the cortical and reticular activating system (RAS) of the brain. </li></ul><ul><li>This is by releasing neurotransmitters from the nerve cells leading to increased stimulation of the post-synaptic neurons. </li></ul>
  56. 57. The CNS stimulants <ul><li>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. </li></ul>
  57. 58. The CNS stimulants <ul><li>Pharmacodynamics: Adverse effects of the CNS stimulants </li></ul><ul><li>CNS= nervousness, insomnia , dizziness, headache, and blurred vision </li></ul><ul><li>GIT= anorexia , nausea and weight loss </li></ul><ul><li>CVS= hypertension, tachycardia arrhythmias, and angina </li></ul><ul><li>Others= rashes, physical/psychological dependence. </li></ul>
  58. 59. The CNS stimulants <ul><li>Implementation </li></ul><ul><li>The nurse must ensure that the drug is only given to the indicated conditions </li></ul><ul><li>Administer the drug before 6 pm to reduce the effect of insomnia </li></ul><ul><li>BEST given AFTER meals to prevent the effect of anorexia </li></ul><ul><li>Consult with school personnel to monitor the patient under therapy </li></ul><ul><li>Provide safety measures such as side-rails and assisted ambulation </li></ul>
  59. 60. The CNS stimulants <ul><li>Evaluation </li></ul><ul><li>Evaluate the effectiveness of the drug: </li></ul><ul><li>Calming effect in the patient with ADHD </li></ul><ul><li>Alertness for patients with narcolepsy </li></ul>
  60. 61. The Anti-epileptics <ul><li>These agents, also called anticonvulsants, are used to treat epileptic conditions. </li></ul><ul><li>Hydantoins, Barbiturates, benzodiazepines, Succinimides and many others are given to a specific type of seizure. </li></ul>
  61. 62. Anti-epileptics <ul><li>Agents for treating TONIC-CLONIC SEIZURES </li></ul><ul><li>1. Hydantoins </li></ul><ul><ul><li>Phenytoin </li></ul></ul><ul><ul><li>Ethotoin </li></ul></ul><ul><ul><li>Fosphenytoin </li></ul></ul><ul><ul><li>Mephenytoin </li></ul></ul><ul><li>2. Benzodiazepines </li></ul><ul><ul><li>Diazepam </li></ul></ul><ul><ul><li>Clonazepam </li></ul></ul><ul><ul><li>Clorazepate </li></ul></ul><ul><li>3. Barbiturates </li></ul><ul><ul><li>Phenobarbital </li></ul></ul>
  62. 63. Anti-epileptics <ul><li>Agents for treating ABSENCE SEIZURES </li></ul><ul><li>1. Succinimides </li></ul><ul><ul><li>a. Ethosuximide </li></ul></ul><ul><ul><li>b. Methsuximide </li></ul></ul><ul><ul><li>c. Phensuximide </li></ul></ul><ul><li>2. Valproic Acid </li></ul><ul><li>3. Zosinamide </li></ul>
  63. 64. Anti-epileptics <ul><li>Agents for treating Partial FOCAL SEIZURES </li></ul><ul><li>1. Carbamazepine </li></ul><ul><li>2. Gabapentin </li></ul><ul><li>3.Lamotrigine </li></ul><ul><li>4. Tiagabine </li></ul><ul><li>5. Topiramate </li></ul>
  64. 65. The hydantoins <ul><li>These agents are utilized for general seizures because they can depress the central nervous system. </li></ul><ul><li>They affect the entire brain and reduce the chance of sudden electrical outburst that causes seizures. </li></ul><ul><li>These agents generally are less sedating than other anti-epileptics . </li></ul>
  65. 66. The hydantoins <ul><li>Mechanism of Action of the Hydantoins </li></ul><ul><li>These agents STABILIZE the nerve cell membrane throughout the brain reducing and limiting the excitability and conduction through nerve pathways. </li></ul>
  66. 67. The hydantoins <ul><li>Clinical Indications of the hydantoins </li></ul><ul><li>Tonic-clonic seizures </li></ul><ul><li>Status epilepticus </li></ul><ul><li>For the prevention of seizures in neurosurgery </li></ul><ul><li>For muscle relaxation. </li></ul>
  67. 68. The hydantoins <ul><li>Contraindications and Precautions </li></ul><ul><li>Hydantoins are NOT given to pregnant patient because it can cause fetal hydantoin syndrome . </li></ul>
  68. 69. The hydantoins <ul><li>Pharmacodynamics: Adverse effects of the Hydantoins </li></ul><ul><li>CNS effects- depression, confusion, drowsiness, lethargy, fatigue </li></ul><ul><li>GIT- GI upset, constipation, dry mouth , GINGIVAL HYPERPLASIA , severe liver toxicity which are all related to cellular toxicity. </li></ul><ul><li>SKIN- hirsutism and coarsening of the facial skin </li></ul><ul><li>Bone Marrow depression </li></ul>
  69. 70. The hydantoins <ul><li>Implementation </li></ul><ul><li>Administer the drug with food to alleviate GI irritation </li></ul><ul><li>Discontinue the drug at any sign of hypersensitivity reaction, severe liver dysfunction and severe skin rashes. </li></ul><ul><li>Provide meticulous mouth oral care </li></ul><ul><li>Rule out pregnancy and advise women to use contraceptive measures to prevent pregnancy. </li></ul>
  70. 71. GIT DRUGS
  71. 72. Drugs affecting GI secretions <ul><li>There are five types of drugs that affect gastric acid secretions and are useful for the treatment of peptic ulcer. </li></ul><ul><li>Histamine (H2) receptor antagonist/blockers </li></ul><ul><li>Antacids </li></ul><ul><li>Proton pump inhibitors </li></ul><ul><li>Mucosal protectants </li></ul><ul><li>Prostaglandin analogs </li></ul>
  72. 73. Drugs affecting secretions: anti ulcer Misoprostol Prostaglandin analog Sucralfate Mucosal protectants Omeprazole Proton pump inhibitors AlOH and MgOH Antacids Cimetidine Histamine (H2) receptor antagonist/blockers Prototype Anti-ulcer drugs
  73. 74. General indication of the drugs affecting gastric acid secretion <ul><li>Peptic ulcer </li></ul><ul><li>Gastritis </li></ul><ul><li>Patient on NPO to prevent stress ulcer </li></ul>
  74. 75. General time of administration of the drugs affecting gastric acid secretion Misoprostol WITH MEALS Prostaglandin analog Sucralfate BEFORE MEALS Mucosal protectants Omeprazole BEFORE MEALS Proton pump inhibitors AlOH and MgOH Usually after meals Antacids Cimetidine With FOOD or ONE hour after ANTACID Histamine (H2) receptor antagonist/blockers Prototype Best time to give Anti-ulcer drugs
  75. 76. Pharmacology of Anti-ulcer drugs Inhibit Proton Pump in parietal cell decreasing secretion and acidity Proton pump inhibitors- “ Prazoles” Omeprazole, pantoprazole Block Histamine receptor causing decreased secretion and acidity H2-Blockers- “ tidine ” Cimetidine , Ranitidine Neutralize Gastric ACIDITY Antacids- AlOH, MgOH Mechanism of Action Drug
  76. 77. Pharmacology of Anti-ulcer drugs Prostaglandin Analogue, causes secretion of MUCUS Misoprostol (Cytotec) Coats the mucosal lining Sucralfate (Carafate) Blocks VAGUS nerve, decreases secretion Anti-cholinergic- Prophanteline Bromide Mechanism of Action Drug
  77. 78. Pharmacodynamics <ul><li>Histamine (H2) receptor blockers </li></ul><ul><li>These drugs BLOCK the release of hydrochloric acid in the stomach in response to gastrin </li></ul>
  78. 79. Drugs affecting GI secretions <ul><li>Antacids </li></ul><ul><li>These drugs interact with the gastric acids at the chemical level to neutralize them </li></ul>
  79. 80. Drugs affecting GI secretions <ul><li>Proton pump inhibitors </li></ul><ul><li>These drugs suppress the secretion of hydrochloric acid into the lumen of the stomach </li></ul>
  80. 81. Drugs affecting GI secretions <ul><li>Mucosal protectants </li></ul><ul><li>These are agents that coat any injured area in the stomach to prevent further injury from acid </li></ul>
  81. 82. Drugs affecting GI secretions <ul><li>Prostaglandin analogs </li></ul><ul><li>These are agents that inhibit the secretion of gastrin and </li></ul><ul><li>increase the secretion of mucus lining of the stomach, providing a buffer. </li></ul>
  82. 83. The H2 Blockers- “tidines” <ul><li>Prototype: Cimetidine </li></ul><ul><li>1. Ranitidine </li></ul><ul><li>2. Famotidine </li></ul><ul><li>3. Nizatidine </li></ul>
  83. 84. The H2 Blockers- “tidines” <ul><li>Pharmacodynamics: Drug Action </li></ul><ul><li>The H2 blockers are antagonists at the receptors in the parietal cells of the stomach. </li></ul><ul><li>The blockage results to inhibition of the hormone gastrin. </li></ul><ul><li>There will be decreased production of gastric acid from the parietal cells. </li></ul><ul><li>Also, the chief cells will secrete less pepsinogen. </li></ul>
  84. 85. The H2 Blockers- “tidines” <ul><li>Therapeutic use of the H2 blockers </li></ul><ul><li>Short-term treatment of active duodenal ulcer or benign gastric ulcer </li></ul><ul><li>Treatment of hypersecretory conditions like the Zollinger-Ellison syndrome </li></ul><ul><li>Prevention of stress-induced ulcers and acute GI bleeding </li></ul><ul><li>Treatment of erosive GERD (reflux disease) </li></ul><ul><li>Relief of Symptoms of heart burn and acid indigestion </li></ul>
  85. 86. The H2 Blockers- “tidines” <ul><li>Precautions and Contraindications </li></ul><ul><li>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. </li></ul><ul><li>Nizatidine can be used in hepatic dysfunction. </li></ul>
  86. 87. The H2 Blockers- “tidines” <ul><li>Pharmocodynamics- Side effects and adverse effects </li></ul><ul><li>GIT= diarrhea or constipation </li></ul><ul><li>CNS= Dizziness, headache, drowsiness, confusion and hallucinations </li></ul><ul><li>Cardio= arrhythmias, HYPOTENSION (related to H2 receptor blockage in the heart) </li></ul><ul><li>Cimetidine= TREMORS, Gynecomastia and impotence in males </li></ul>
  87. 88. The H2 Blockers- “tidines” <ul><li>Drug-drug Interactions </li></ul><ul><li>Cimetidine, Famotidine, Ranitidine are metabolized in the liver- they can cause slowing of excretion of other drugs leading to their increased concentration. </li></ul>
  88. 89. The H2 Blockers- “tidines” <ul><li>Drug-drug Interactions </li></ul><ul><li>These drugs can interact with CIMETIDINE anticoagulants, phenytoin, alcohol, antidepressants. </li></ul>
  89. 90. The H2 Blockers- “tidines” <ul><li>Nursing considerations: </li></ul><ul><li>Administer the drug WITH meals at BEDTIME to ensure therapeutic level </li></ul><ul><li>One hour after Antacids </li></ul><ul><li>Stress the importance of the continued use for the length of time prescribed </li></ul>
  90. 91. The H2 Blockers- “tidines” <ul><li>Nursing considerations: </li></ul><ul><li>Monitor the cardiovascular status especially if the drugs are given IV </li></ul><ul><li>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! </li></ul>
  91. 92. The H2 Blockers- “tidines” <ul><li>Nursing considerations: </li></ul><ul><li>Provide comfort measures like analgesics for headache, assistance with ambulation and safety measures </li></ul><ul><li>Warn the patients taking cimetidine that drowsiness may pose a hazard if driving or operating delicate machines. </li></ul>
  92. 93. The H2 Blockers- “tidines” <ul><li>Nursing considerations: </li></ul><ul><li>Provide health teaching as to the dose, frequency, comfort measures to initiate when side-effects are intolerable </li></ul><ul><li>Evaluate the effectiveness: </li></ul><ul><li>Relief of symptoms of ulcer, heart burn and GERD </li></ul>
  93. 94. The Antacids <ul><li>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: </li></ul><ul><li>Aluminum salts (hydroxide) </li></ul><ul><li>Calcium salts (carbonate) </li></ul><ul><li>Magnesium salts (milk of magnesia) </li></ul><ul><li>Sodium bicarbonate </li></ul><ul><li>Magaldrate (aluminum and magnesium combination) </li></ul>
  94. 95. The Antacids <ul><li>Pharmacodynamics: drug action </li></ul><ul><li>These agents act to neutralize the acidic pH in the stomach. </li></ul><ul><li>They do not affect the rate of gastric acid secretion. </li></ul>
  95. 96. The Antacids <ul><li>Pharmacodynamics: drug action </li></ul><ul><li>The administration of antacid may cause an acid rebound. </li></ul><ul><li>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. </li></ul>
  96. 97. The Antacids <ul><li>Therapeutic Indications </li></ul><ul><li>Symptomatic relief of upset stomach associated with hyperacidity </li></ul><ul><li>Hyperacidic conditions like peptic ulcer, gastritis, esophagitis and hiatal hernia </li></ul><ul><li>Special use of AMPHOGEL (aluminum hydroxide): to BIND phosphate </li></ul>
  97. 98. The Antacids <ul><li>Precautions of Antacid Use </li></ul><ul><li>Known allergy is a clear contraindication. Caution should be instituted if used in electrolyte imbalances, GI obstruction and renal dysfunction. </li></ul><ul><li>Sodium bicarbonate is rarely used because of potential systemic absorption </li></ul>
  98. 99. The Antacids <ul><li>Pharmacokinetics </li></ul><ul><li>These agents are taken orally and act locally in the stomach </li></ul>
  99. 100. The Antacids <ul><li>Pharmacodynamics: Effects of drugs </li></ul><ul><li>GIT= rebound acidity; alkalosis may occur. </li></ul><ul><li>Calcium salts may lead to hypercalcemia </li></ul><ul><li>Magnesium salts can cause DIARRHEA </li></ul><ul><li>Aluminum salts may cause CONSTIPATION and hypophosphatemia by binding with phosphates in the GIT. </li></ul><ul><li>2. Fluid retention due to the high sodium content of the antacids. </li></ul>
  100. 101. The Antacids <ul><li>Nursing Considerations: </li></ul><ul><li>Administer the antacids apart from any other medications by ONE hour before or TWO hours after- to ensure adequate absorption of the other medications </li></ul><ul><li>Tell the patient to CHEW the tablet thoroughly before swallowing. Follow it with one glass of water </li></ul><ul><li>Regularly monitor for manifestations of acid-base imbalances as well as electrolyte imbalances </li></ul>
  101. 102. The Antacids <ul><li>Nursing Considerations: </li></ul><ul><li>Provide comfort measures to alleviate constipation associated with aluminum and diarrhea associated with magnesium salts. </li></ul><ul><li>Monitor for the side-effects, effectiveness of the comfort measures, patient’s response to the medication and the effectiveness of the health teachings </li></ul>
  102. 103. The Antacids <ul><li>Nursing Considerations: </li></ul><ul><li>Evaluate for effectiveness: </li></ul><ul><li>Decreased symptoms of ulcer and pyrosis </li></ul><ul><li>Decreased Phosphate level (amphogel) </li></ul>
  103. 104. The PPI <ul><li>These are the newer agents for ulcer treatment </li></ul><ul><li>The “prazoles” </li></ul><ul><li>Prototype: Ome prazole </li></ul><ul><li>Laniso prazole </li></ul><ul><li>Esome prazole </li></ul><ul><li>Panto prazole </li></ul>
  104. 105. The PPI <ul><li>Pharmacodynamics: drug action </li></ul><ul><li>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. </li></ul><ul><li>The “pump” in the parietal cell is the H-K ATPase enzyme system on the secretory surface of the gastric parietal cells </li></ul>
  105. 106. The PPI <ul><li>Clinical use of the PPIs </li></ul><ul><li>Short-term treatment of active duodenal ulcers, GERD, erosive esophagitis and benign gastric ulcer. </li></ul><ul><li>Long-term- maintenance therapy for healing of erosive disorders. </li></ul>
  106. 107. The PPI <ul><li>Clinical use of the PPIs. </li></ul><ul><li>Precautions with the use of the PPIs </li></ul><ul><li>Known allergy is a clear contraindication. Caution if patient is pregnant </li></ul>
  107. 108. The PPI <ul><li>Pharmacodynamics: Adverse effects </li></ul><ul><li>CNS- dizziness , headache, asthenia (loss of strength), vertigo , insomnia, apathy </li></ul><ul><li>GIT- diarrhea, abdominal pain, nausea, vomiting, dry mouth and tongue atrophy </li></ul><ul><li>Respi- cough, stuffy nose, hoarseness and epistaxis. </li></ul>
  108. 109. The PPI <ul><li>Nursing considerations: </li></ul><ul><li>Administer the drug BEFORE meals. Ensure that patient does not open, chew or crush the drug. </li></ul><ul><li>Provide safety measures if CNS dysfunction happens. </li></ul><ul><li>Arrange for a medical follow-up if symptoms are NOT resolved after 4-8 weeks of therapy. </li></ul>
  109. 110. The PPI <ul><li>Nursing considerations: </li></ul><ul><li>Provide health teaching as to drug name, dosages and frequency, safety measures to handle common problems. </li></ul><ul><li>Monitor patient response to the drug, the effectiveness of the teaching plan and the measures to employ </li></ul>
  110. 111. The PPI <ul><li>Nursing considerations: </li></ul><ul><li>Evaluate for effectiveness of the drug </li></ul><ul><li>Healing of peptic ulcer </li></ul><ul><li>Decreased symptoms of ulcer </li></ul>
  111. 112. The Mucosal Protectant <ul><li>Sucralfate </li></ul><ul><li>This is given to protect the eroded ulcer sites in the GIT from further damage by acid and digestive enzymes </li></ul>
  112. 113. Sucralfate <ul><li>Pharmacodynamics: Action of drug </li></ul><ul><li>It forms an ulcer-adherent complex at duodenal ulcer sites, protecting the sites against acid, pepsin and bile. </li></ul><ul><li>This action prevents further breakdown of proteins in the area and promotes healing. </li></ul>
  113. 114. Sucralfate <ul><li>Clinical use of sucralfate </li></ul><ul><li>Short and long term management of duodenal ulcer. </li></ul><ul><li>NSAIDs induced gastritis </li></ul><ul><li>Prevention of stress ulcer </li></ul><ul><li>Treatment of oral and esophageal ulcers due to radiation, chemotherapy or sclerotherapy. </li></ul>
  114. 115. Sucralfate <ul><li>Precautions on the use of Sucralfate </li></ul><ul><li>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. </li></ul>
  115. 116. The Mucosal Protectant <ul><li>Pharmacodynamics: Side-effects & adverse reactions </li></ul><ul><li>Primarily GIT= CONSTIPATION, occasionally diarrhea, nausea, indigestion, gastric discomfort, and dry mouth may also occur </li></ul><ul><li>CNS= dizziness, drowsiness, vertigo </li></ul><ul><li>Others= rash and back pain </li></ul>
  116. 117. The Mucosal Protectant <ul><li>Drug-drug interactions </li></ul><ul><li>If used with aluminum salts= high risk of accumulation of aluminum and toxicity . </li></ul><ul><li>If used with phenytoin, fluoroquinolones and penicillamines- decreased levels of these drugs when taken with sucralfate </li></ul>
  117. 118. The Mucosal Protectant <ul><li>Nursing Considerations </li></ul><ul><li>Administer drug ON AN EMPTY stomach , 1 hour before meals , or 2 hour after meals and at BEDTIME </li></ul><ul><li>Monitor for side-effects like constipation and GI upset </li></ul><ul><li>Encourage intake of high-fiber foods and increased fluid intake </li></ul><ul><li>Administer antacids BETWEEN doses of sucralfate, NOT WITHIN 30 minutes of sucralfate dose </li></ul>
  118. 119. The Mucosal Protectant <ul><li>Nursing Considerations </li></ul><ul><li>Provide comfort measures if CNS effects occur </li></ul><ul><li>Provide health teaching as to drug name, dosages and frequency, safety measures to handle common problems. </li></ul><ul><li>Monitor patient response to the drug, the effectiveness of the teaching plan and the measures employed </li></ul>
  119. 120. The Mucosal Protectant <ul><li>Nursing Considerations </li></ul><ul><li>Evaluate effectiveness of therapy </li></ul><ul><li>Healing of ulcer </li></ul><ul><li>No formation of ulcer </li></ul>
  120. 121. Prostaglandin analogue <ul><li>Misoprostol </li></ul><ul><li>This agent is a synthetic prostaglandin E1 analog that is employed to protect the lining of the mucosa of the stomach </li></ul>
  121. 122. Prostaglandin analogue <ul><li>Misoprostol: Pharmacodynamics </li></ul><ul><li>Being a prostaglandin analog, it inhibits gastric acid secretion to some degree </li></ul><ul><li>It INCREASES mucus production in the stomach lining. </li></ul>
  122. 123. Prostaglandin analogue <ul><li>Misoprostol: Clinical use </li></ul><ul><li>NSAIDs-induced gastric ulcers </li></ul><ul><li>Duodenal ulcers unresponsive to H2 antagonists. </li></ul>
  123. 124. Prostaglandin analogue <ul><li>Precautions of Misoprostol Use </li></ul><ul><li>This drug is CONTRAINDICATED during pregnancy because it is an abortifacient. </li></ul><ul><li>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. </li></ul><ul><li>They should be instructed in the use of contraceptives during therapy. </li></ul>
  124. 125. Prostaglandin analogue <ul><li>Pharmacodynamic effects: drug reactions </li></ul><ul><li>GIT= Nausea, diarrhea, abdominal pain, flatulence, vomiting, dyspepsia </li></ul><ul><li>GU effects= miscarriages, excessive uterine CRAMPING and bleeding , spotting, hypermenorrhea and menstrual disorders. </li></ul>
  125. 126. Prostaglandin analogue <ul><li>Nursing Considerations </li></ul><ul><li>Administer to patients at risk for NSAIDs-induced ulcers during the full course of NSAIDs therapy </li></ul><ul><li>Administer four times daily with meals and at bedtime </li></ul><ul><li>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 </li></ul>
  126. 127. Prostaglandin analogue <ul><li>Nursing Considerations </li></ul><ul><li>Provide patient with both written and oral information regarding the associated risks of pregnancy </li></ul><ul><li>Provide health teaching as to drug name, dosages and frequency, safety measures to handle common problems. </li></ul><ul><li>Monitor patient response to the drug, the effectiveness of the teaching plan and the measures to employ </li></ul>
  127. 128. laxatives
  128. 129. Laxatives Lubricating the intestinal material to promote passage through the GIT Docusate Lubricants Increased fluid content of the fecal material causing stimulation of the local reflex Lactulose Mechanical (bulk) stimulants Direct stimulation of the GIT nerves Irritant laxatives Bisacodyl (Dulcolax) Chemical stimulants Action Prototype Type
  129. 130. Laxatives <ul><li>Generally used to INCREASE the passage of the colonic contents </li></ul><ul><li>The general classifications is as follows: </li></ul><ul><li>1. Chemical stimulants </li></ul><ul><li>2. Mechanical stimulants </li></ul><ul><li>3. Lubricants </li></ul>
  130. 131. Therapeutic Indications of the Laxatives <ul><li>SHORT term relief of Constipation </li></ul><ul><li>Prevention of straining in conditions like CHF, post-MI, post partum, post-op </li></ul><ul><li>Preparation for diagnostic examination </li></ul><ul><li>Removal of poison or toxins </li></ul><ul><li>Adjunct in anti-helminthic therapy </li></ul>
  131. 132. Contraindications in Laxative use <ul><li>ACUTE abdominal disorders </li></ul><ul><ul><li>Appendicitis </li></ul></ul><ul><ul><li>Diverticulitis </li></ul></ul><ul><ul><li>Ulcerative colitis </li></ul></ul>
  132. 133. Chemical Stimulant Cathartics <ul><li>Prototype: Bisacodyl </li></ul><ul><li>Irritant laxatives: </li></ul><ul><li>1. Castor oil </li></ul><ul><li>2. Senna </li></ul><ul><li>3. Cascara </li></ul><ul><li>4. Phenolphthalein </li></ul>
  133. 134. Chemical Stimulant Cathartics <ul><li>Pharmacodynamics </li></ul><ul><li>These agents DIRECTLY stimulate the nerve plexus in the intestinal wall </li></ul><ul><li>The result is INCREASED movement or motility of the colon </li></ul>
  134. 135. Mechanical Stimulant Cathartics <ul><li>Prototype: LACTULOSE (Cephulac) </li></ul><ul><li>Bulk-forming laxatives </li></ul><ul><li>1. Magnesium (citrate, hydroxide, sulfate) </li></ul><ul><li>2. Psyllium </li></ul><ul><li>3. Polycarbophil </li></ul>
  135. 136. Mechanical Stimulant Cathartics <ul><li>Pharmacodynamics </li></ul><ul><li>These agents are rapid-acting laxatives that INCREASE the GI motility by </li></ul><ul><ul><li>Increasing the fluids in the colonic material </li></ul></ul><ul><ul><li>Stimulating the local stretch receptors </li></ul></ul><ul><ul><li>Activating local defection reflex </li></ul></ul>
  136. 137. Lubricants <ul><li>Prototype: Docusate </li></ul><ul><li>1. Glycerin </li></ul><ul><li>2. Mineral oil </li></ul>
  137. 138. Lubricants <ul><li>Pharmacodynamics </li></ul><ul><li>Docusate increases the admixture of fat and water producing a softer stool </li></ul><ul><li>Glycerin </li></ul><ul><li>Mineral oil forms a slippery coat on the colonic contents </li></ul>
  138. 139. Pharmacokinetics: Common Side-effects of the Laxatives <ul><li>Diarrhea </li></ul><ul><li>Abdominal cramping </li></ul><ul><li>Nausea </li></ul><ul><li>Fluid and electrolyte imbalance </li></ul><ul><li>Sympathetic reactions- sweating, palpitations, flushing and fainting </li></ul><ul><li>CATHARTIC dependence </li></ul>
  139. 140. The Nursing Process and Laxative <ul><li>ASSESSMENT </li></ul><ul><li>Nursing History- elicit allergy to any laxatives, elicit history of conditions like diverticulitis and ulcerative colitis </li></ul><ul><li>Physical Examination- abdominal assessment </li></ul><ul><li>Laboratory Test: fecalysis, electrolyte levels </li></ul>
  140. 141. The Nursing Process and Laxative <ul><li>NURSING DIAGNOSIS </li></ul><ul><li>Alteration in bowel pattern </li></ul><ul><li>Alteration in comfort: pain </li></ul><ul><li>Knowledge deficit </li></ul>
  141. 142. The Nursing Process and Laxative <ul><li>IMPLEMENTATION </li></ul><ul><li>Emphasize that it is use on a SHORT term basis </li></ul><ul><li>Provide comfort and safety measures like ready access to the bathroom, side-rails </li></ul><ul><li>Administer with a full glass of water </li></ul>
  142. 143. The Nursing Process and Laxative <ul><li>IMPLEMENTATION </li></ul><ul><li>4. Encourage fluid intake, high fiber diet and daily exercise </li></ul><ul><li>5. DO NOT administer if acute abdominal condition like appendicitis is present </li></ul><ul><li>6. Advise to change position slowly an avoid hazardous activities because of potential dizziness </li></ul>
  143. 144. The Nursing Process and Laxative <ul><li>EVALUATION of drug effectiveness </li></ul><ul><li>Evaluate relief of GI symptoms, absence of staining and increased evacuation of GI tract </li></ul><ul><li>For Lactulose: decreased ammonia </li></ul>
  144. 145. The Anti-diarrheals <ul><li>These are agents used to calm the irritation of the GIT for the symptomatic relief of diarrhea </li></ul><ul><li>General Classifications </li></ul><ul><li>1. Local anti-motility </li></ul><ul><li>2. Local reflex inhibition </li></ul><ul><li>3. Central action on the CNS </li></ul>
  145. 146. The Anti-diarrheals Stops GIT spasm by CNS action Opium derivatives (paregoric) Central acting agent Directly inhibits the intestinal muscle activity to SLOW peristalsis Loperamide Local anti-motility Locally coats the lining of the GIT to soothe irritation that may stimulate the reflex Bismuth subsalicylate Local reflex inhibitor Action Prototype Type
  146. 147. Clinical Indications of drug use <ul><li>Relief of symptoms of acute and chronic diarrhea </li></ul><ul><li>Reduction of fecal volume discharges from ileostomies </li></ul><ul><li>Prevention and treatment of traveler's diarrhea </li></ul>
  147. 148. Contraindications of anti-diarrheal Use <ul><li>Poisoning </li></ul><ul><li>Drug allergy </li></ul><ul><li>GI obstruction </li></ul><ul><li>Acute abdominal conditions </li></ul>
  148. 149. Pharmacokinetics: Side effects <ul><li>Constipation </li></ul><ul><li>Nausea, vomiting </li></ul><ul><li>Abdominal distention and discomfort </li></ul><ul><li>TOXIC MEGACOLON </li></ul>
  149. 150. Nursing process and anti-diarrheals <ul><li>ASSESSMENT </li></ul><ul><li>Nursing History – Elicit history of drug allergy, conditions like poisoning, GI obstruction and acute abdominal conditions </li></ul><ul><li>Physical Examination- Abdominal examination </li></ul><ul><li>Laboratory test- electrolyte levels </li></ul>
  150. 151. Nursing process and anti-diarrheals <ul><li>NURSING DIAGNOSIS </li></ul><ul><li>Alteration in bowel pattern </li></ul><ul><li>Alteration in comfort: pain </li></ul>
  151. 152. Nursing process and anti-diarrheals <ul><li>IMPLEMENTATION </li></ul><ul><li>Monitor patient response within 48 hours. Discontinue drug use if no effect </li></ul><ul><li>Provide comfort measures for pain </li></ul><ul><li>Provide teaching </li></ul>
  152. 153. Nursing process and anti-diarrheals <ul><li>EVALUATION </li></ul><ul><li>Monitor effectiveness of drug- RELIEF of diarrhea </li></ul><ul><li>Monitor adverse effects, effectiveness of pain measures and effectiveness of teaching plan </li></ul>
  153. 154. Emetics and Anti-emetics <ul><li>Emetic Agent </li></ul><ul><li>Syrup of Ipecac </li></ul><ul><li>Anti-emetics </li></ul><ul><li>1. Phenothiazines </li></ul><ul><li>2. Non-phenothiazines </li></ul><ul><li>3. Anticholinergics/Antihistamines </li></ul><ul><li>4. Serotonin receptor Blockers </li></ul><ul><li>5. Miscellaneous </li></ul>
  154. 155. EMETIC <ul><li>Prototype: Ipecac Syrup </li></ul>
  155. 156. EMETIC <ul><li>Pharmacodynamics </li></ul><ul><li>Ipecac syrup irritates the GI mucosa locally, resulting to stimulation of the vomiting center </li></ul><ul><li>It acts within 20 minutes </li></ul>
  156. 157. EMETIC <ul><li>Clinical Use of ipecac </li></ul><ul><li>To induce vomiting as a treatment for drug overdose and certain poisonings </li></ul>
  157. 158. EMETIC <ul><li>Contraindications of Ipecac use </li></ul><ul><li>Ingestion of CORROSIVE chemicals </li></ul><ul><li>Ingestion of petroleum products </li></ul><ul><li>Unconscious and convulsing patient </li></ul>
  158. 159. EMETIC <ul><li>Pharmacokinetics: side effects of Ipecac </li></ul><ul><li>Nausea </li></ul><ul><li>Diarrhea </li></ul><ul><li>GI upset </li></ul><ul><li>Mild CNS depression </li></ul><ul><li>CARDIOTOXICITY if large amounts are absorbed in the body </li></ul>
  159. 160. Nursing process and the EMETIC <ul><li>ASSESSMENT </li></ul><ul><li>Nursing History- elicit the exact nature of poisoning </li></ul><ul><li>Physical Examination- CNS status and abdominal exam </li></ul>
  160. 161. Nursing process and the EMETIC <ul><li>IMPLEMENTATION </li></ul><ul><li>Administer to conscious patient only </li></ul><ul><li>Administer ipecac as soon as possible </li></ul><ul><li>Administer with a large amount of water </li></ul><ul><li>Vomiting should occur within 20 minutes of the first dose. Repeat the dose and expect vomiting to occur with 20 minutes </li></ul>
  161. 162. Nursing process and the EMETIC <ul><li>IMPLEMENTATION </li></ul><ul><li>5. Provide comfort measures like ready access to bathroom, assistance with ambulation </li></ul><ul><li>6. Offer support </li></ul>
  162. 163. Nursing process and the EMETIC <ul><li>EVALUATION </li></ul><ul><li>Evaluate patient response within 20 minutes of drug ingestion </li></ul><ul><li>Monitor for adverse effects </li></ul><ul><li>Evaluate effectiveness of comfort measures and teaching plan </li></ul>
  163. 164. ANTI-EMETICS <ul><li>These are agents used to manage nausea and vomiting </li></ul><ul><li>They act either locally or centrally </li></ul>
  164. 165. ANTIEMETICS Dronabinol, hydroxyzine Miscellaneous “ setron”- dolasetron Serotonin Receptor blockers Meclizine, buclizine Anticholinergics and Antihistaminics Metoclopramide Non-phenothiazines Prochlorperazine, promethazine Phenothiazines Common examples Anti-emetic types
  165. 166. ANTIEMETICS Act in the CNS , either in the medulla or in the cortex Miscellaneous Centrally and locally inhibits the serotonin receptors Serotonin receptor blockers Block the transmission of the impulses to the medulla Anticholinergics Reduces the responsiveness of the nerve cell in the medulla Non-phenothiazine Centrally block the vomiting center in the medulla Phenothiazines Pharmacodynamics Types
  166. 167. ANTIEMETICS N/V associated with chemotherapy Miscellaneous N/V associated with chemotherapy Serotonin-receptor Blockers N/V associated with motion sickness Anticholinergics N/V associated with chemical stimulation Non-phenothiazine N/V associated with anesthesia, intractable hiccups Phenothiazines Clinical Use Types
  167. 168. ANTIEMETICS <ul><li>Contraindications </li></ul><ul><li>1. Severe CNS depression </li></ul><ul><li>2. Severe liver dysfunction </li></ul>
  168. 169. ANTIEMETICS <ul><li>Pharmacokinetics: Side-effects </li></ul><ul><li>1. PHOTHOSENSITIVITY </li></ul><ul><li>2. Drowsiness, dizziness, weakness and tremors and DEHYDRATON </li></ul><ul><li>3. Phenothiazines= autonomic anti-cholinergic effects like dry mouth, nasal congestion and urinary retention </li></ul>
  169. 170. Nursing Process and the ANTIEMETICS <ul><li>ASSESSMENT </li></ul><ul><li>Nursing History- elicit allergy, impaired hepatic function and CNS depression </li></ul><ul><li>Physical Examination- CNS status and abdominal examination </li></ul><ul><li>Laboratory test- Liver function studies </li></ul>
  170. 171. Nursing Process and the ANTIEMETICS <ul><li>NURSING DIAGNOSIS </li></ul><ul><li>Alteration in comfort: pain </li></ul><ul><li>High risk for injury </li></ul><ul><li>Knowledge deficit </li></ul>
  171. 172. Nursing Process and the ANTIEMETICS <ul><li>IMPLEMENTATION </li></ul><ul><li>Assess patient’s intake of other drugs that may cause dangerous drug interaction </li></ul><ul><li>Emphasize that this is given on a short term basis </li></ul>
  172. 173. Nursing Process and the ANTIEMETICS <ul><li>IMPLEMENTATION </li></ul><ul><li>3. Provide comfort and safety measures </li></ul><ul><ul><li>Advise to change position slowly </li></ul></ul><ul><ul><li>Avoid hazardous activities </li></ul></ul><ul><ul><li>Provide mouth care and ice chips </li></ul></ul><ul><ul><li>Monitor for dehydration and offer fluids if it occurs </li></ul></ul>
  173. 174. Nursing Process and the ANTIEMETICS <ul><li>IMPLEMENTATION </li></ul><ul><li>4. Protect from sun exposure </li></ul><ul><ul><li>Sunscreens </li></ul></ul><ul><ul><li>Protective covering </li></ul></ul><ul><li>5. Provide health teaching </li></ul>
  174. 175. Nursing Process and the ANTIEMETICS <ul><li>EVALUATION </li></ul><ul><li>1. Monitor for the drug effectiveness </li></ul><ul><ul><li>Relief of nausea and vomiting </li></ul></ul><ul><li>2. Monitor for adverse effects </li></ul><ul><li>3. Evaluate effectiveness of comfort measures and teaching plan </li></ul>
  175. 176. Pharmacology of the Selected Endocrine Drugs Nursing Review
  176. 177. Endocrine Medications <ul><li>Anti-diuretic hormones </li></ul><ul><li>Enhance re-absorption of water in the kidneys </li></ul><ul><li>Used in DI </li></ul><ul><li>1. Desmopressin and Lypressin intranasally </li></ul><ul><li>2. Pitressin IM </li></ul>
  177. 178. Endocrine Medications <ul><li>Anti-diuretic hormones </li></ul><ul><li>SIDE-effects </li></ul><ul><li>Flushing and headache </li></ul><ul><li>Water intoxication </li></ul>
  178. 179. Thyroid Medications <ul><li>Thyroid hormones </li></ul><ul><li>These products are used to treat the manifestations of hypothyroidism </li></ul><ul><li>Replace hormonal deficit in the treatment of HYPOTHYROIDSM </li></ul>
  179. 180. Thyroid Medications <ul><li>Thyroid hormones </li></ul><ul><li>Levothyroxine (Synthroid) </li></ul><ul><li>Liothyroxine (Cytomel) </li></ul><ul><li>Thyroid dessicated </li></ul><ul><li>Liotrix (Thyrolar) </li></ul>
  180. 181. Thyroid Medications <ul><li>Thyroid hormones: Actions </li></ul><ul><li>Increase the metabolic rate </li></ul><ul><li>Increase O2 consumption </li></ul><ul><li>Increase HR, RR, BP </li></ul>
  181. 182. Thyroid Medications <ul><li>Thyroid hormones </li></ul><ul><li>Side-effects </li></ul><ul><li>Nausea and Vomiting </li></ul><ul><li>Signs of increased metabolism= tachycardia, hypertension, cardiac arrhythmias, anxiety, headache </li></ul>
  182. 183. Thyroid Medications <ul><li>Thyroid hormones : Nursing responsibility </li></ul><ul><li>1. Monitor weight, VS </li></ul><ul><li>2. Instruct client to take daily medication the same time each morning WITHOUT FOOD </li></ul><ul><li>Monitor blood tests to check the activity of thyroid </li></ul>
  183. 184. Thyroid Medications <ul><li>Thyroid hormones: Nursing responsibility </li></ul><ul><li>3. Advise to report palpitation, tachycardia, and chest pain </li></ul><ul><li>4. Instruct to avoid foods that inhibit thyroid secretions like cabbage, spinach and radishes </li></ul>
  184. 185. ANTI-Thyroid Medications <ul><li>ANTI-THYROID medications </li></ul><ul><li>The thyroid becomes oversaturated with iodine and stop producing thyroid hormone </li></ul>
  185. 186. ANTI-Thyroid Medications <ul><li>ANTI-THYROID medications </li></ul><ul><li>Drugs used to BLOCK the thyroid hormones and treat hyperthyroidism </li></ul><ul><li>Inhibit the synthesis of thyroid hormones </li></ul>
  186. 187. ANTI-Thyroid Medications <ul><li>ANTI-THYROID medications </li></ul><ul><li>1. Methimazole (Tapazole) </li></ul><ul><li>2. PTU (prophylthiouracil) </li></ul><ul><li>3. Iodine solution- SSKI and Lugol’s solution </li></ul>
  187. 188. ANTI-Thyroid Medications <ul><li>ANTI-THYROID medications </li></ul><ul><li>Side-effects of thionamides </li></ul><ul><ul><li>N/V, drowsiness, lethargy, bradycardia, skin rash </li></ul></ul><ul><ul><li>GI complaints </li></ul></ul><ul><ul><li>AGRANULOCYTOSIS </li></ul></ul><ul><ul><ul><li>Most important to monitor </li></ul></ul></ul>
  188. 189. ANTI-Thyroid Medications <ul><li>ANTI-THYROID medications </li></ul><ul><li>Side-effects of Iodine solutions </li></ul><ul><ul><li>Most common adverse effects is HYPOTHYROIDISM </li></ul></ul><ul><ul><li>Iodism= metallic taste, burning in the mouth, sore teeth and gums, diarrhea, stomach upset </li></ul></ul>
  189. 190. ANTI-Thyroid Medications <ul><li>ANTI-THYROID medications </li></ul><ul><li>Nursing responsibilities </li></ul><ul><li>1. Monitor VS, T3 and T4, weight </li></ul><ul><li>2. The medications WITH MEALS to avoid gastric upset </li></ul>
  190. 191. ANTI-Thyroid Medications <ul><li>ANTI-THYROID medications Nursing responsibilities </li></ul><ul><li>3. Instruct to report SORE THROAT or unexplained FEVER </li></ul><ul><li>4. Monitor for signs of hypothyroidism. </li></ul><ul><ul><li>Instruct not to stop abrupt medication </li></ul></ul>
  191. 192. ANTI-Thyroid Medications <ul><li>ANTI-THYROID medications </li></ul><ul><li>Lugol’s Solution </li></ul><ul><li>Used to decrease the vascularity of the thyroid (in preparation for thyroid surgery) </li></ul><ul><li>T3 and T4 production diminishes </li></ul><ul><li>Given per orem, can be diluted with juice </li></ul><ul><li>Use straw to decrease staining </li></ul><ul><li>Monitor iodism (metallic taste, burning in mouth) </li></ul>
  192. 193. STEROIDS <ul><li>Replaces the steroids in the body </li></ul><ul><li>Interfere with the release of inflammatory factors and immune responses </li></ul>
  193. 194. STEROIDS <ul><li>Cortisol, cortisone, betamethasone, and hydrocortisone </li></ul><ul><li>Dexamethasone= long acting </li></ul>
  194. 195. STEROIDS <ul><li>These drugs enter the cells and bind to receptors </li></ul><ul><li>They inhibit the enzyme phospholipase </li></ul>
  195. 196. STEROIDS <ul><li>Corticosteroids are used topically and locally to achieve the desired anti-inflammatory effects at a particular site </li></ul>
  196. 197. STEROIDS Use for the treatment of immune-related diseases, control of asthma and allergic symptoms Other steroids Use to induce the formation of lung surfactant Dexamethasone Clinical use Steroid
  197. 198. STEROIDS <ul><li>Side-effects </li></ul><ul><ul><li>HYPERglycemia </li></ul></ul><ul><ul><li>Increased susceptibility to infection (immunosuppression) </li></ul></ul><ul><ul><li>Hypokalemia </li></ul></ul><ul><ul><li>Edema and Hypertension </li></ul></ul><ul><ul><li>Peptic ulceration </li></ul></ul>
  198. 199. STEROIDS <ul><li>Side-effects </li></ul><ul><ul><li>If high doses- osteoporosis, growth retardation, peptic ulcer, hypertension, cataract , mood changes, hirsutism, and fragile skin </li></ul></ul>
  199. 200. STEROIDS <ul><li>Nursing responsibilities </li></ul><ul><li>1. Monitor VS, electrolytes, glucose </li></ul><ul><li>2. Monitor weight edema and I/O. Encourage Potassium supplements </li></ul>
  200. 201. STEROIDS <ul><li>Nursing responsibilities </li></ul><ul><li>3. Protect patient from infection </li></ul><ul><li>4. Handle patient gently </li></ul><ul><li>5. Instruct to take meds WITH MEALS to prevent gastric ulcer formation </li></ul>
  201. 202. STEROIDS <ul><li>Nursing responsibilities </li></ul><ul><li>6. Caution the patient NOT to abruptly stop the drug </li></ul><ul><li>7. Drug is tapered to allow the adrenal gland to secrete endogenous hormones </li></ul>
  202. 203. STEROIDS <ul><li>Evaluation: </li></ul><ul><li>The drugs are effective if there is: </li></ul><ul><li>Relief of signs and symptoms of inflammation </li></ul><ul><li>Return of adrenal function to normal </li></ul>
  203. 204. Cardiovascular drugs
  204. 205. The cardiac glycosides <ul><li>These are agents extracted from the foxglove plant. They are available in oral and parenteral preparations. The following are the cardiac glycosides: </li></ul><ul><li>Digoxin (Lanoxin) </li></ul><ul><li>Digitoxin (Crystodigin) </li></ul><ul><li>Ouabain </li></ul>
  205. 206. The cardiac glycosides <ul><li>Pharmacodynamics: the Mechanism of action </li></ul><ul><li>They increase the level of CALCIUM inside the cell by inhibiting the Sodium-Potassium pump. </li></ul><ul><li>More calcium will accumulate inside the cell during cellular depolarization. </li></ul>
  206. 207. The cardiac glycosides <ul><li>Positive inotropic Effect- the myocardium will contract forcefully </li></ul><ul><ul><li>Increased cardiac output </li></ul></ul><ul><ul><li>Increased blood flow to the body organs like the kidney and liver </li></ul></ul><ul><li>Negative chronotropic effect- the heart rate is slowed due to decreased rate of cellular repolarization </li></ul><ul><ul><li>Bradycardia </li></ul></ul><ul><li>Decreased conduction velocity through the AV node </li></ul>
  207. 208. The cardiac glycosides <ul><li>Clinical Use of the cardiac glycosides </li></ul><ul><li>Treatment of congestive heart failure </li></ul><ul><li>Treatment of dysrhythmias like atrial flutter, atrial fibrillation and paroxysmal atrial tachycardia </li></ul>
  208. 209. The cardiac glycosides <ul><li>Contraindications and Precautions </li></ul><ul><li>Contraindicated in the presence of allergy to any cardiac glycoside. </li></ul><ul><li>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) </li></ul>
  209. 210. The cardiac glycosides <ul><li>Pharmacodynamics: the Adverse Effects of the Cardiac glycosides </li></ul><ul><li>CNS- Headache, weakness , seizures and drowsiness </li></ul><ul><li>CVS- arrhythmias </li></ul><ul><li>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 </li></ul>
  210. 211. The cardiac glycosides <ul><li>Remember= NAVDA and hypokalemia </li></ul>
  211. 212. The cardiac glycosides <ul><li>Drug-Drug Interactions </li></ul><ul><li>If taken with potassium-losing diuretics like furosemide- can INCREASE the risk of toxicity and arrhythmias. Potassium replacement must be given. </li></ul>
  212. 213. The cardiac glycosides <ul><li>Implementation </li></ul><ul><li>Administer the initial rapid digitalization and loading dose as ordered intravenously </li></ul><ul><li>Monitor the APICAL pulse rate for ONE full minute before administering the drug. Withhold the drug if </li></ul><ul><ul><li>Less than 60 in adults </li></ul></ul><ul><ul><li>Less than 90 in infants </li></ul></ul><ul><ul><li>More than 110 in adults </li></ul></ul><ul><li>Retake pulse in one hour, if pulses remain abnormal, refer! </li></ul>
  213. 214. The cardiac glycosides <ul><li>Implementation </li></ul><ul><li>Check the spelling of the drug- DIGOXIN is different from DIGITOXIN! </li></ul><ul><li>Check the dosage preparation and the level of digitalis in the blood. ( Therapeutic level is 0.5 to 2.0 nanograms/mL ) </li></ul><ul><li>Administer intravenous drug VERY slow IV over 5 minutes to avoid arrhythmias. Do NOT administer intramuscularly because it can cause severe pain </li></ul>
  214. 215. The cardiac glycosides <ul><li>Implementation </li></ul><ul><li>Administer the drug without food if possible to avoid delayed absorption . Weight patient daily to determine fluid retention </li></ul><ul><li>Maintain emergency equipment and drugs= Potassium salts, Lidocaine for arrhythmias, phenytoin for seizures, atropine for bradycardia. </li></ul><ul><li>Provide comfort measures- small, frequent meals, adequate lighting, comfortable position, rest periods and safety precautions </li></ul>
  215. 216. The cardiac glycosides <ul><li>Implementation </li></ul><ul><li>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 </li></ul><ul><li>Monitor serum potassium level </li></ul>
  216. 217. The cardiac glycosides <ul><li>Evaluation </li></ul><ul><li>Evaluate effectiveness of the drug: </li></ul><ul><li>Increased urine output </li></ul><ul><li>Normal heart rate in arrhythmia </li></ul>
  217. 218. The Antianginal drugs <ul><li>In the treatment of angina, three agents are commonly employed- </li></ul><ul><ul><li>Organic nitrates </li></ul></ul><ul><ul><li>Beta-blockers and </li></ul></ul><ul><ul><li>Calcium-channel blockers. </li></ul></ul><ul><li>The benefits of the drugs lie in their different mode of action. </li></ul>
  218. 219. The Antianginal drugs <ul><li>The nitrates can cause vasodilatation of the veins and to some extent, coronary artery </li></ul>
  219. 220. The Antianginal drugs <ul><li>Beta-blockers will decrease the heart rate </li></ul>
  220. 221. The Antianginal drugs <ul><li>Calcium-channel blockers will decrease force of contraction leading to a decreased myocardial workload and demand. </li></ul><ul><li>They can also produce vasodilation </li></ul>
  221. 222. The Organic nitrates <ul><li>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: </li></ul><ul><li>Nitroglycerin- A moderately volatile nitrate </li></ul><ul><li>Isosorbide Dinitrate (Isordil) or mononitrate </li></ul><ul><li>Amyl nitrate- an extremely volatile nitrate </li></ul>
  222. 223. The Organic nitrates <ul><li>Nitroglycerin </li></ul><ul><li>This agent is supplied in oral, spray, transdermal and ointment preparations. </li></ul>
  223. 224. The Organic nitrates <ul><li>Pharmacodynamics: the mechanism of action </li></ul><ul><li>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. </li></ul>
  224. 225. The Organic nitrates <ul><li>Administered nitrates </li></ul><ul><li>Increased nitrates in the blood </li></ul><ul><li>increased formation of nitric oxide </li></ul><ul><li>increased cGMP formation </li></ul><ul><li>increased dephosphorylation of myosin </li></ul><ul><li>Vascular smooth muscle relaxation </li></ul><ul><li>vasodilatation </li></ul>
  225. 226. The Organic nitrates <ul><li>Pharmacokinetics- absorption to excretion </li></ul><ul><li>It can be given orally, parenterally and topically. </li></ul><ul><li>The onset of action of nitroglycerin is more than 1 hour. </li></ul><ul><li>Because significant first-pass hepatic effect, Nitroglycerin is given SUBLINGUALY. </li></ul>
  226. 227. The Organic nitrates <ul><li>Pharmacodynamics: Side effects and adverse effects </li></ul><ul><li>HEADACHE is the most common effect of nitroglycerin . </li></ul><ul><li>CVS- postural Hypotension, facial flushing, tachycardia </li></ul><ul><li>TOLERANCE - the tolerance to the actions of nitrates develop rapidly. This can be managed by providing a day of abstinence. </li></ul>
  227. 228. The Nitrates <ul><li>Implementation </li></ul><ul><li>Monitor vital signs, especially watchful for hypotensive episodes </li></ul><ul><li>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 </li></ul><ul><li>Offer sips of water before giving sublingual nitroglycerin because dryness may inhibit drug absorption </li></ul>
  228. 229. The Nitrates <ul><li>Implementation </li></ul><ul><li>Apply nitroglycerin ointment to the designated mark on paper. </li></ul><ul><li>The nurse should remove any excess ointment on the skin from the previous dose. </li></ul><ul><li>She should NEVER USE her bare fingers because the drug can be absorbed, utilize gloves or tongue blades instead. </li></ul>
  229. 230. The Nitrates <ul><li>Implementation </li></ul><ul><li>Apply nitroglycerin patch to an area with few hairs. Never touch the medication portion. </li></ul><ul><li>The patch and the ointment should NOT be applied near the area for defibrillation because explosion and skin burns may result </li></ul>
  230. 231. The Nitrates <ul><li>IMPLEMENTATION </li></ul><ul><li>Emphasize that tolerance to the nitroglycerin can occur. </li></ul><ul><li>If the medication cannot relieve the pain, report to the hospital immediately. </li></ul>
  231. 232. The Nitrates <ul><li>IMPLEMENTATION </li></ul><ul><li>Provide client health teaching- the sublingual nitroglycerin tablet is USED if chest pain occurs </li></ul><ul><li>The dose may be repeated if pain is unrelieved within 5 minutes. </li></ul><ul><li>Repeat the medication administration if the pain has not yet subsided . </li></ul><ul><li>DO NOT give more than 3 tablets! !! If chest pain persists for more than 15 minutes, hospital consult should be done immediately. </li></ul>
  232. 233. The Nitrates <ul><li>IMPLEMENTATION </li></ul><ul><li>Instruct the client to avoid alcohol while taking nitroglycerin to avoid potentiating the hypotensive effect of the medication </li></ul><ul><li>If beta blockers and calcium-channel blockers are given, instruct the patients to consult the physician before discontinuing the medication </li></ul>
  233. 234. The Nitrates <ul><li>IMPLEMENTATION </li></ul><ul><li>Other components of health teaching for home self-administration: </li></ul><ul><ul><ul><ul><li>If taking Sublingual Nitroglycerin, the patient should be instructed to place the tablet under the tongue for quick absorption. </li></ul></ul></ul></ul><ul><ul><ul><ul><li>A burning sensation/biting/stinging sensation may indicate that the tablet is FRESH! </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Store the tablet in a dark container , keep it away from heat and direct sunlight to avoid lessening the potency </li></ul></ul></ul></ul>
  234. 235. The Nitrates <ul><li>IMPLEMENTATION </li></ul><ul><li>Other components of health teaching for home self-administration: </li></ul><ul><ul><ul><ul><li>HEADACHES are common in the initial period of nitroglycerin therapy. Advise patient to take PARACETAMOL for relief </li></ul></ul></ul></ul><ul><ul><ul><ul><li>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. </li></ul></ul></ul></ul>
  235. 236. The Nitrates <ul><li>IMPLEMENTATION </li></ul><ul><li>Other components of health teaching for home self-administration: </li></ul><ul><ul><ul><ul><li>Position supine with elevated legs to manage Hypotension. </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Nitroglycerin tablet can be taken prophylactically in situations where chest pain is anticipated- Sex, exercise, etc.. </li></ul></ul></ul></ul><ul><ul><ul><ul><li>If patient is taking beta blockers, instruct how to obtain heart rate in a minute </li></ul></ul></ul></ul>
  236. 237. Drugs for Shock <ul><li>Dopamine </li></ul><ul><li>This is a sympathomimetic drug often used to treat Hypotension in shock states that are not caused by Hypovolemia. </li></ul><ul><li>This drug is an immediate precursor of nor-epinephrine, occurs naturally in the CNS basal ganglia where it functions as a neurotransmitter. </li></ul>
  237. 238. Drugs for Shock <ul><li>Dopamine </li></ul><ul><li>Pharmacodynamics: It can activate the alpha and beta adrenergic receptor depending upon the concentration. It stimulates receptors to cause cardiac stimulation and renal vasodilation . </li></ul><ul><li>The dose range is 1-20 micrograms/kg/min </li></ul>
  238. 239. Drugs for Shock <ul><li>Dopamine </li></ul><ul><li>Pharmacokinetics: Dopamine is administered IV, excreted in the urine. </li></ul><ul><li>At low dose ( 1-2 micrograms ), dopamine DILATES the renal and mesenteric blood vessels producing an increase output (dopaminergic effect) </li></ul>
  239. 240. Drugs for Shock <ul><li>Dopamine </li></ul><ul><li>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) </li></ul>
  240. 241. Drugs for Shock <ul><li>Dopamine </li></ul><ul><li>At higher doses of more than 10 micrograms- vasoconstriction of all vessels will predominate that can lead to diminished tissue perfusion </li></ul>
  241. 242. Drugs for Shock <ul><li>Dopamine </li></ul><ul><li>Dopamine is indicated to treat Hypotension, to increase heart rate and to increase urine output (given less than 5 mg/kg/min) </li></ul><ul><li>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. </li></ul><ul><li>Sodium bicarbonate will inactivate the dopamine </li></ul>
  242. 243. Drugs for Shock <ul><li>Dopamine </li></ul><ul><li>Pharmacodynamics: side effects- Tachycardia </li></ul><ul><li>hypertension </li></ul><ul><li>ectopic beats, angina, dysrhythmias, myocardial ischemia, nausea and vomiting. </li></ul>
  243. 244. Drugs for Shock <ul><li>Dopamine: Nursing consideration </li></ul><ul><ul><li>Check the IV site hourly for signs of drug infiltration of dopamine, which can cause tissue necrosis. </li></ul></ul><ul><ul><li>Phentolamine should be infiltrated in multiple areas to reduce tissue damage. </li></ul></ul><ul><ul><li>Drug is effective if Urine output is increased and BP is increased </li></ul></ul>
  244. 245. Antihypertensive drugs <ul><li>The Drugs employed to control hypertension can be classified as: </li></ul><ul><li>Diuretics </li></ul><ul><li>Beta-blockers </li></ul><ul><li>Alpha adrenergic blockers </li></ul><ul><li>Calcium channel blockers </li></ul><ul><li>Angiotensin-converting enzyme inhibitors </li></ul><ul><li>Angiotensin II receptor blockers </li></ul><ul><li>Peripheral vasodilators </li></ul>
  245. 246. Common Drugs in HPN <ul><li>IN Evaluating the effectiveness of these drugs is simply to monitor the BP if it becomes NORMAL </li></ul>
  246. 247. Anti-hypertensive drugs Depression Stimulates CNS alpha 2 receptor Clonidine Central alpha agonist Urination Blocks alpha receptor in BV causing vasodilatation Prazozin Alpha blockers HEADACHE Dilates veins and arteries Nitroglycerin Vasodilator Headache, flushing, reflex tachycardia Blocks Ca entry into cell Nifedipine Ca channel blockers Headache, Cough, flushing Prevents A1 to AII conversion Captopril ACE Inhibitors Bradycardia, hypoglycemia Blocks B1 receptor in the heart Propranolol Beta-blocker Hypokalemia Decreases blood volume Furosemide Diuretics Side effects MOA Prototype Class
  247. 248. Anticoagulants SE: Bleeding SE: bleeding, decreased platelets Antidote: Vit. K Antidote: Protamine sulfate Small molecule CANNOT be given to pregnant Large molecule, can be given to pregnant Monitor for PT and INR Monitor for aPTT Acts within days Acts within minutes Action is to INHIBIT Vitamin-K dependent clotting factors (10,9,7,2) Action is to enhance natural anti-thrombin III in the blood Oral Parenteral (SQ and IV) WARFARIN HEPARIN
  248. 249. The antianemics: Iron preparations and Epoetin <ul><li>Iron preparations </li></ul><ul><li>Iron is important for hemoglobin formation. </li></ul><ul><li>The iron preparations are: </li></ul><ul><li>Ferrous sulfate </li></ul><ul><li>Ferrous fumarate </li></ul><ul><li>Ferrous gluconate </li></ul>
  249. 250. The antianemics: Iron preparations and Epoetin <ul><li>Side-effects: </li></ul><ul><li>GIT- constipation (usually), diarrhea, vomiting, epigastric pain, gastric ulceration and darkening of stools. </li></ul><ul><li>Liquid preparation can stain the teeth, and injectable iron can cause tissue discoloration </li></ul><ul><li>Other- dizziness </li></ul>
  250. 251. The antianemics: Iron preparations and Epoetin <ul><li>Drug-Drug interaction </li></ul><ul><li>Tetracyclines combine with iron preparations and render the iron unabsorbable. </li></ul><ul><li>Antacids and cimetidine- decrease iron absorption and effects </li></ul><ul><li>Foods can impair iron absorption but they should be taken with iron to reduce GI discomfort. </li></ul><ul><li>Milk containing foods, coffee, tea and eggs are NOT given with iron because they delay iron absorption. </li></ul>
  251. 252. The antianemics: Iron preparations and Epoetin <ul><li>Implementation </li></ul><ul><li>Encourage the patient to eat iron-rich foods like liver, lean meat, egg yolk, dried beans, green leafy vegetables. </li></ul><ul><li>Administer iron preparations orally with foods to decrease GI discomfort. </li></ul><ul><li>If increased absorption is necessary, administer IN BETWEEN meals with full glass of water or juice. </li></ul><ul><li>It is best to offer citrus juices because the vitamin C content can increase iron absorption. </li></ul><ul><li>Instruct the patient to swallow the whole tablet and remain upright for 30 minutes to prevent esophageal corrosion from reflux. </li></ul><ul><li>DO NOT administer iron together with or within 1 hour of ingesting tetracyclines, antacids, milk and milk-containing products. </li></ul><ul><li>Advise clients to increase fluid intake and consume fiber rich foods if constipation becomes a problem. </li></ul>
  252. 253. The antianemics: Iron preparations and Epoetin <ul><li>Implementation </li></ul><ul><li>Emphasize that the therapeutic effect of iron therapy may not be apparent until several weeks. </li></ul><ul><li>If injecting a parenteral iron preparation, inject DEEP IM utilizing the Z-track method to avoid leakage into the subcutaneous tissues and skin . </li></ul><ul><li>Offer straw if giving liquid iron preparation to avoid staining the teeth. </li></ul><ul><li>To prevent undue alarm, instruct the patient that the stools may turn black or dark green. This is a harmless occurrence. </li></ul>
  253. 254. The antianemics: Iron preparations and Epoetin <ul><li>Evaluation </li></ul><ul><li>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 . </li></ul>
  254. 255. Erythropoietin <ul><li>The mechanism of action of epoetin alfa </li></ul><ul><li>(Epogen) </li></ul><ul><li>This drug acts like the natural glycoprotein erythropoietin to stimulate the production of RBC in the bone marrow. </li></ul>
  255. 256. Erythropoietin <ul><li>Clinical indications </li></ul><ul><li>It is given SUBCUTANEOUSLY or INTRAVENOUSLY for the treatment of anemia associated with renal failure or for patients on dialysis . </li></ul><ul><li>It is also used in patients for blood transfusion to decrease the need for blood in surgical patients. </li></ul>
  256. 257. Erythropoietin <ul><li>Pharmacodynamics: the adverse effects of epoetin alfa </li></ul><ul><li>CNS- headache, fatigue, asthenia, dizziness and seizures- these are due to the cellular response to the glycoprotein. </li></ul><ul><li>GIT- nausea, vomiting and diarrhea </li></ul><ul><li>CVS- hypertension, edema and chest pain due to increase RBC number </li></ul>
  257. 258. Erythropoietin <ul><li>Implementation </li></ul><ul><li>Administer the drug SC or IV usually 3 times per week. </li></ul><ul><li>Monitor the IV access line if given IV. Do not mix with other solutions </li></ul><ul><li>Determine periodically the level of hematocrit and iron stores during therapy. If patient does not respond to the drug, reevaluate the cause of anemia. </li></ul><ul><li>Maintain seizure precaution on stand by as seizure can occur. </li></ul><ul><li>Provide comfort measures like small frequent feedings and pain medications for headache. </li></ul><ul><li>Provide thorough health teaching: need for lifetime injection </li></ul>
  258. 259. Erythropoietin <ul><li>Evaluation </li></ul><ul><li>Monitor patient response to the drug= increased hemoglobin </li></ul>
  259. 260. Psychiatric Medications
  260. 261. Psychotrophic drugs <ul><li>Drugs that can: </li></ul><ul><li>Stimulate the release of neurotransmitters </li></ul><ul><li>Block the receptor/activity of the neurotransmitter= like dopamine </li></ul><ul><li>Stimulate the receptors in the CNS </li></ul><ul><li>Prevents the breakdown of the neurotransmitters or the re-uptake mechanism </li></ul>
  261. 262. Anti-Psychotics/Neuroleptics <ul><li>Drugs used to treat PSYCHOSES </li></ul><ul><li>MAIN ACTION: Blockage of the DOPAMINE receptor in the CNS </li></ul>
  262. 263. Anti-Psychotics/Neuroleptics quetiapine Risperidone Olanzapine Clozapine Atypical drugs Pimozide Diphenylbutlypiperidine Molindone Dibenzoxapine thirothixene Chlorprothixene Thioxanthines droperidol Haloperidol Butyrophenones Thioridazine, Fluphenazine, Perphenazine Chlorpromazine Phenothiazines Others Prototype Class
  263. 264. Anti-Psychotics/Neuroleptics Reduced flattening of affect 6 Relief of emotional turmoil 5 Reduced agitation resulting to calmness 4 Decreased ambivalence, reduced delusion 3 CNS sedation and emotional slowing 2 Reduced hallucination and illusions 1 Desired Effects
  264. 265. Anti-Psychotics/Neuroleptics Safety, no machine operation Sedation Monitor EEG Seizure Instruct to report sore throat and fever, monitor WBC Agranulocytosis Change position slowly, lie prone for 1 hour after drug intake, monitor BP Postural hypotension Sunglasses, sunscreen, avoid sun Photosensitivity Sugarless gum, bed rest Anticholinergic effects Nursing Interventions Common SE
  265. 266. Anti-Psychotics/Neuroleptics Notify physician, prepare to administer dantrolene Neuroleptic Malignant syndrome= elevated temp, treme muscle rigidity No treatment except discontinue drug Tardive Dyskinesia= irreversible drooling, tongue movement and shuffling gait Verbalize understanding of the condition, administer anti-EPS Akathisia= motor restlessness Remain with client, administer anti-EPS Dystonia- torticollis, contraction of face and tongue Avoid abrupt withdrawal, give anti-EPS drugs like Cogentin Parkinsonism-Tremor, rigidity, bradikinesia Nursing Intervention Extra-Pyramidal Syndrome
  266. 267. Review Outline <ul><ul><li>Adrenergic Agonists </li></ul></ul><ul><ul><li>Adrenergic Antagonists </li></ul></ul><ul><ul><li>Cholinergic Agonists </li></ul></ul><ul><ul><li>Cholinergic Antagonists </li></ul></ul>
  267. 268. Comparison of the Sympathetic and Parasympathetic Nervous system Rest and Digest Fight or flight General response Acetylcholine-ESTERASE MAO, COMT Enzyme for NTA Acetylcholine Epi and NE Post-ganglionic NTA Short axon Long axon Post-ganglionic neuron Near target organ Next to spinal cord Ganglia location Acetylcholine Acetylcholine Pre-ganglionic NTA Long axon Short axon Pre-ganglionic neuron Cranio-Sacral spinal cord Thoraco-lumbar spinal cord CNS origin Parasympathetic Sympathetic Characteristics
  268. 269. The autonomic drugs <ul><li>Pharmacologic use depends on their EFFECTS on the body </li></ul><ul><li>They can STIMULATE= agonists OR mimetics </li></ul><ul><li>They can DECREASE THE RESPONSE= antagonists OR blockers </li></ul>
  269. 270. The autonomic drugs <ul><li>They can STIMULATE= agonists OR mimetics </li></ul><ul><li>DIRECT STIMULATION by binding with receptors </li></ul><ul><li>INDIRECT STIMULATION by blocking the enzymes that degrade the neurotransmitters or increasing the release of neurotransmitters </li></ul>
  270. 271. The autonomic drugs <ul><li>They can DECREASE THE RESPONSE= antagonists OR blockers </li></ul><ul><li>DIRECT blockage by removing the neurotransmitter or competing with the neurotransmitter </li></ul><ul><li>Binding with the receptor and NO RESPONSE will happen </li></ul>
  271. 272. The autonomic drugs <ul><li>They can be </li></ul><ul><li>NON-SELECTIVE when they stimulate or block many receptors </li></ul><ul><li>SELECTIVE when they stimulate or block specific receptors </li></ul><ul><li>SPECIFIC when only ONE type of receptor is stimulated or blocked </li></ul>
  272. 273. The autonomic drugs: Pharmacologic use depends on their EFFECTS on the body Used for HYPERTENSION and Tachycardia Decreases BP and heart rate Used for SHOCK where there is LOW BP Increases BP Therapeutic use Effect on the body
  273. 274. The Adrenergic AGONISTS <ul><li>Also called SYMPATHOMIMETIC agents </li></ul><ul><li>These drugs MIMIC the effects of the sympathetic nervous system </li></ul>
  274. 275. The Adrenergic AGONISTS <ul><li>They usually stimulate DIRECTLY the receptors of the adrenergic system </li></ul>
  275. 276. The Adrenergic AGONISTS <ul><li>Alpha and Beta agonists (non-selective) </li></ul><ul><ul><li>Prototype: Epinephrine </li></ul></ul><ul><li>Alpha Agonists (Selective) </li></ul><ul><ul><li>Prototype: Phenylephrine </li></ul></ul><ul><li>Beta Agonists (Selective) </li></ul><ul><ul><li>Prototype: Isoproterenol </li></ul></ul>
  276. 277. The Adrenergic AGONISTS <ul><li>Alpha and Beta agonists (non-selective) </li></ul><ul><li>Pharmacodynamics: </li></ul><ul><li>These agents stimulate ALL types of adrenergic receptors in the body by direct interaction or by releasing neurotransmitters from the nerve cells </li></ul>
  277. 278. The Adrenergic AGONISTS <ul><li>Alpha and Beta agonists </li></ul><ul><ul><li>Prototype: Epinephrine </li></ul></ul><ul><li>1. Ephedrine </li></ul><ul><li>2. Epinephrine </li></ul><ul><li>3. Metaraminol </li></ul><ul><li>4. Norepinephrine </li></ul><ul><li>5. Dobutamine (sometimes a B1 specific) </li></ul><ul><li>6. Dopamine </li></ul>
  278. 279. The Adrenergic AGONISTS <ul><li>Alpha and Beta agonists: Clinical Use </li></ul><ul><li>1. Dopamine- used in shock </li></ul><ul><li>2. Epinephrine- drug of choice of anaphylaxis, Status asthmaticus </li></ul><ul><li>3. Norepinephrine- used in shock </li></ul><ul><li>4. Dobutamine- used in CHF </li></ul><ul><li>5. Ephedrine- used in shock, asthma and rhinitis </li></ul>
  279. 280. The Adrenergic AGONISTS <ul><li>Alpha and Beta agonists: Desirable effects </li></ul><ul><ul><li>Increased myocardial contractility </li></ul></ul><ul><ul><li>Bronchial DILATATION </li></ul></ul><ul><ul><li>Vaso constriction </li></ul></ul><ul><ul><li>Increased blood pressure </li></ul></ul><ul><ul><li>Decreased intraocular pressure </li></ul></ul><ul><ul><li>Pupillary dilatation </li></ul></ul>
  280. 281. The Adrenergic AGONISTS <ul><li>Alpha and Beta agonists: Contraindications </li></ul><ul><ul><li>Pheochromocytoma </li></ul></ul><ul><ul><li>Tachyarrhythmias </li></ul></ul><ul><ul><li>With halogenated anesthesia- increased sensitivity to adrenergic drugs </li></ul></ul>
  281. 282. The Adrenergic AGONISTS <ul><li>Alpha and Beta agonists: Adverse effects </li></ul><ul><ul><li>Sympathetic stimulation effects </li></ul></ul><ul><li>CVS- hypertension, tachycardia, palpitations </li></ul><ul><li>Respi- tachypnea </li></ul><ul><li>GI- nausea, vomiting </li></ul><ul><li>Others- sweating, headache, piloerection </li></ul>
  282. 283. The Adrenergic AGONISTS <ul><li>Alpha and Beta agonists: Nursing considerations </li></ul><ul><li>Monitor patient response to the drug </li></ul><ul><li>Emphasize to avoid the use with MAOIs and TCA </li></ul><ul><li>Maintain phentolamine (alpha blocker) to manage extravasation of IV drug </li></ul><ul><li>Usually given IV </li></ul>
  283. 284. The Adrenergic AGONISTS <ul><li>Alpha and Beta agonists: Nursing considerations </li></ul><ul><li>Determine effectiveness of the drug: </li></ul><ul><li>Increased BP in shock </li></ul><ul><li>Relief of anaphylaxis and asthma attack </li></ul><ul><li>Relief of nasal congestion </li></ul>
  284. 285. The Adrenergic AGONISTS <ul><li>Alpha Agonists (selective) </li></ul><ul><li>Prototype: phenylephrine </li></ul><ul><li> clonidine (alpha-2 specific) </li></ul>
  285. 286. The Adrenergic AGONISTS <ul><li>Alpha Agonists Pharmacodynamics: </li></ul><ul><li>These agents bind primarily to the alpha receptors in the body </li></ul><ul><li>Clonidine </li></ul><ul><li>Stimulating the ALPHA-2 receptor causes decreased sympathetic outflow from the CNS/ decreased release of NE </li></ul>
  286. 287. The Adrenergic AGONISTS <ul><li>Alpha Agonists: Clinical use </li></ul><ul><li>Phenylephrine- vasoconstricting drug, used topically to decrease the symptoms of rhinitis </li></ul><ul><li>Clonidine- for hypertension </li></ul>
  287. 288. The Adrenergic AGONISTS <ul><li>Alpha Agonists: Contraindication </li></ul><ul><li>Allergy to drug </li></ul><ul><li>Caution in the following conditions: </li></ul><ul><ul><li>Hyperthyroidism-aggravation of symptoms </li></ul></ul><ul><ul><li>Diabetes- increased glucose levels </li></ul></ul><ul><ul><li>Tachyarrhythmias- possible additive effect </li></ul></ul>
  288. 289. The Adrenergic AGONISTS <ul><li>Alpha Agonists: Adverse effects </li></ul><ul><li>CNS- anxiety, depression , fatigue </li></ul><ul><li>CVS- palpitations </li></ul><ul><li>GI- nausea, vomiting and anorexia </li></ul><ul><li>GU- oliguria, dysuria </li></ul>
  289. 290. The Adrenergic AGONISTS <ul><li>Alpha Agonists: Nursing considerations </li></ul><ul><li>1. DO NOT discontinue drug abruptly to prevent rebound effect </li></ul><ul><li>2. Maintain phentolamine if giving IV drug </li></ul><ul><li>3. Provide comfort measures- rest, quiet environment, analgesics </li></ul>
  290. 291. The Adrenergic AGONISTS <ul><li>Alpha Agonists: Nursing considerations </li></ul><ul><li>Evaluate effectiveness: </li></ul><ul><li>Decreased BP </li></ul><ul><li>Decreased Nasal congestion </li></ul>
  291. 292. The Adrenergic AGONISTS <ul><li>Beta Agonists (Selective): ANTI-ASTHMA DRUGS </li></ul><ul><li>Prototype: isoproterenol (B1 and B2) </li></ul><ul><li>salbutamol (Ventolin)= B2 specific </li></ul><ul><li>Ritodrine (B2 specific) </li></ul><ul><li>“ terol”- albuterol, salmeterol, bitolterol </li></ul><ul><li>Terbutaline (B2) </li></ul>
  292. 293. The Adrenergic AGONISTS <ul><li>Beta Agonists Pharmacodynamics </li></ul><ul><li>These agents bind to the BETA receptors causing the sympathetic manifestations and effects </li></ul>
  293. 294. The Adrenergic AGONISTS <ul><li>Beta Agonists Clinical use </li></ul><ul><li>Asthma- due to the bronchodilation ! </li></ul><ul><li>Preterm labor- ritodrine is given to relax the uterine muscles </li></ul><ul><li>Shock= To increase BP </li></ul>
  294. 295. The Adrenergic AGONISTS <ul><li>Beta Agonists Adverse effects </li></ul><ul><li>CNS- restlessness, headache, anxiety , tremors </li></ul><ul><li>CVS- tachycardia , angina, palpitations </li></ul><ul><li>GI- nausea, vomiting and anorexia </li></ul><ul><li>Others- pupilary dilation, rash, sweating, pulmonary edema </li></ul>
  295. 296. The Adrenergic AGONISTS <ul><li>Beta Agonists Nursing considerations </li></ul><ul><li>Monitor VS when giving the drug </li></ul><ul><li>Remind mothers to lie on the left side during ritodrine administration </li></ul><ul><li>Maintain a beta blocker on stand by </li></ul><ul><li>Provide comfort- quiet environment, rest, analgesics. </li></ul><ul><li>Prevent over-hydration to avoid pulmonary edema </li></ul>
  296. 297. The Adrenergic AGONISTS <ul><li>Beta Agonists Nursing considerations </li></ul><ul><li>These are given usually inhalational for asthma attack </li></ul><ul><li>Instruct on how to use inhalers and nebulizers </li></ul><ul><li>Evaluate effectiveness: </li></ul><ul><li>Normal RR </li></ul><ul><li>Clear breath sounds </li></ul>
  297. 298. The Adrenergic ANTAGONISTS <ul><li>These are called adrenergic blockers </li></ul><ul><li>They can be Alpha Blockers (selective) </li></ul><ul><li>Beta Blockers (selective) </li></ul><ul><li>Both Alpha & Beta Blockers </li></ul><ul><li>(non-selective) </li></ul>
  298. 299. The Adrenergic ANTAGONISTS <ul><li>The alpha blockers (selective) </li></ul><ul><li>Prototype: Phentolamine </li></ul><ul><li> Phenoxybenzamine </li></ul><ul><li> “ zosin”- prazosin, doxazosin, terazosin- these are alpha 1 blockers </li></ul>
  299. 300. The Adrenergic ANTAGONISTS <ul><li>The alpha blockers: Pharmacodynamics </li></ul><ul><li>These agents have affinity for the ALPHA receptors </li></ul><ul><li>Blocking the alpha receptors will cause: </li></ul><ul><li>Vasodilation </li></ul><ul><li>Sphincter relaxation in the bladder </li></ul>
  300. 301. The Adrenergic ANTAGONISTS <ul><li>The alpha blockers: Clinical use </li></ul><ul><li>Phenoxybenzamine- used in pheochromocytoma </li></ul><ul><li>Phentolamine- also used in pheochomocytoma </li></ul><ul><li>“ zosin” drugs- are used to decrease blood pressure and to relax the urinary sphincter in BPH! </li></ul>
  301. 302. The Adrenergic ANTAGONISTS <ul><li>The alpha blockers: Contraindications </li></ul><ul><li>Myocardial infarction </li></ul><ul><li>Allergy </li></ul>
  302. 303. The Adrenergic ANTAGONISTS <ul><li>The alpha blockers: Adverse Effects </li></ul><ul><li>CVS- hypotension, reflex tachycardia, flushing </li></ul><ul><li>CNS- dizziness, weakness, fatigue, drowsiness </li></ul><ul><li>Others- nasal congestion, reddened eyes, priapism </li></ul>
  303. 304. The Adrenergic ANTAGONISTS <ul><li>The alpha blockers: nursing consideration </li></ul><ul><li>Monitor heart rate and BP </li></ul><ul><li>Caution to change position slowly </li></ul><ul><li>Advise to avoid hazardous activities </li></ul><ul><li>Provide supportive measures like quiet environment, rest and analgesics </li></ul><ul><li>Monitor response to the drug- improvement of blood pressure readings and urination </li></ul>
  304. 305. The Adrenergic ANTAGONISTS <ul><li>The Beta blockers </li></ul><ul><li>These are agents used to treat cardiovascular problems- Hypertension, CHF, angina </li></ul><ul><li>Blocking beta receptor will cause </li></ul><ul><li>decreased heart rate </li></ul><ul><li>decreased BP </li></ul>
  305. 306. The Adrenergic ANTAGONISTS <ul><li>The Beta blocker or The “olol”s </li></ul><ul><li>They can be beta 1 blockers, beta 2 blockers or Both </li></ul><ul><li>Prototype of non-selective: propranOLOL (beta 1 and 2) </li></ul><ul><li>carteOLOL </li></ul><ul><li>nadOLOL </li></ul><ul><li>penbutOLOL </li></ul><ul><li>sotaLOL </li></ul>
  306. 307. The Adrenergic ANTAGONISTS <ul><li>The Beta blocker or The “olol”s </li></ul><ul><li>They can be beta 1 blockers, beta 2 blockers or Both </li></ul><ul><li>Prototype of B1 selective : atenOLOL </li></ul><ul><li>acebutOLOL </li></ul><ul><li>betaxOLOL </li></ul><ul><li>esmOLOL </li></ul><ul><li>metoprOLOL </li></ul>
  307. 308. The Adrenergic ANTAGONISTS <ul><li>The Beta blockers: pharmacodynamics </li></ul><ul><li>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 </li></ul>
  308. 309. The Adrenergic ANTAGONISTS <ul><li>The Beta blockers: Clinical use </li></ul><ul><li>Hypertension </li></ul><ul><li>Angina and MI </li></ul><ul><li>Cardiac arrhythmias </li></ul><ul><li>Migraine headache </li></ul><ul><li>HYPERTHYROIDISM </li></ul>
  309. 310. The Adrenergic ANTAGONISTS <ul><li>The Beta blockers: Clinical use </li></ul>to decrease the tachycardia HYPERTHYROIDISM to cause vasoconstriction in the cranial vessels Migraine headache to terminate arrhythmias Cardiac tachyarrhythmias to decrease cardiac workload Angina and MI to decrease BP Hypertension
  310. 311. The Adrenergic ANTAGONISTS <ul><li>The Beta blockers: contraindications </li></ul><ul><li>Allergy </li></ul><ul><li>Heart blocks </li></ul><ul><li>Bradycardia </li></ul><ul><li>COPD </li></ul><ul><li>Precaution in DM </li></ul>
  311. 312. The Adrenergic ANTAGONISTS <ul><li>The Beta blockers: Adverse effects </li></ul><ul><li>CVS- bradycardia, hypotension, heart block </li></ul><ul><li>CNS- fatigue, dizziness, depression </li></ul><ul><li>Respi- bronchospasm , pulmonary edema </li></ul><ul><li>GI- nausea, vomiting, diarrhea, hypoglycemia </li></ul><ul><li>GU- decreased libido , impotence, dysuria </li></ul>
  312. 313. The Adrenergic ANTAGONISTS <ul><li>The Beta blockers: nursing considerations </li></ul><ul><li>Emphasize NOT to stop abruptly the drug intake </li></ul><ul><li>Give with FOODS to improve absorption </li></ul><ul><li>Provide comfort measures </li></ul><ul><ul><li>Adequate rest periods </li></ul></ul><ul><ul><li>Avoidance of hazardous activities </li></ul></ul><ul><ul><li>Change position slowly </li></ul></ul>
  313. 314. The Adrenergic ANTAGONISTS <ul><li>The Beta blockers: nursing considerations </li></ul><ul><li>Evaluate effectiveness: </li></ul><ul><li>Decreased BP in hypertension </li></ul><ul><li>Decreased HR in hyperthyroidism </li></ul><ul><li>Decreased PAIN angina </li></ul>
  314. 315. Drugs for the parasympathetic system (cholinergic drugs)
  315. 316. The Cholinergic Agonists <ul><li>These are also called parasympathomimetic agents </li></ul><ul><li>Their action mimics the parasympathetic nervous system </li></ul>
  316. 317. The Cholinergic Agonists <ul><li>These agents INCREASE the activity of acetylcholine in the acetylcholine receptors </li></ul><ul><li>DIRECTLY by occupying the receptor </li></ul><ul><li>INDIRECTLY by blocking the enzyme that degrades the acetylcholine, preventing it from breakdown - the enzyme: acetylcholin ESTERASE </li></ul>
  317. 318. The Cholinergic Agonists <ul><li>Direct acting cholinergic agonists </li></ul><ul><li>Prototype: BetaneCHOL </li></ul><ul><li> CarbaCHOL </li></ul><ul><li> Pilocarpine </li></ul><ul><li>Indirect acting cholinergics </li></ul><ul><ul><li>Prototype: Pyridostigmine </li></ul></ul><ul><ul><li> Neostigmine </li></ul></ul><ul><ul><li> Endrophonium (Tensilon) </li></ul></ul>
  318. 319. The Cholinergic Agonists <ul><li>Direct acting cholinergic agonists </li></ul><ul><li>Pharmacodynamics </li></ul><ul><ul><li>They are similar to acetylcholine and directly act on the acetylcholine receptors </li></ul></ul>
  319. 320. The Cholinergic Agonists <ul><li>Direct acting cholinergic agonists </li></ul><ul><li>Parasympathetic stimulation will cause: </li></ul><ul><li> DUMBELS </li></ul><ul><li>urination </li></ul><ul><li> miosis (pupil constriction) </li></ul>
  320. 321. The Cholinergic Agonists <ul><li>Direct acting cholinergic agonists: Clinical use </li></ul><ul><li>Post operative and post partum urinary retention and to treat neurogenic bladder </li></ul><ul><li>Relief of increased intraocular pressure of glaucoma by inducing miosis </li></ul>
  321. 322. The Cholinergic Agonists <ul><li>Direct acting cholinergic agonists: Clinical use </li></ul><ul><li>The drugs INCREASE the bladder tone, RELAX the GI and urinary sphincters </li></ul><ul><li>The topical agent (pilocarpine) topically causes pupilary constriction to reduce IOP </li></ul>
  322. 323. The Cholinergic Agonists <ul><li>Direct acting cholinergic agonists: Contraindications </li></ul><ul><li>Bradycardia </li></ul><ul><li>Hypotension </li></ul><ul><li>Asthma </li></ul>
  323. 324. The Cholinergic Agonists <ul><li>Direct acting cholinergic agonists: Adverse effects (DUMBELS) </li></ul><ul><li>CVS- bradycardia , heart block, hypotension </li></ul><ul><li>GIT- nausea, vomiting, diarrhea, increased salivation, lacrimation </li></ul><ul><li>GUT- sense of urgency , sphincter relaxation </li></ul><ul><li>Others- increased sweating , headache, miosis </li></ul>
  324. 325. The Cholinergic Agonists <ul><li>Direct acting cholinergic agonists: nursing considerations </li></ul><ul><li>Assure proper administration of ophthalmic preparations </li></ul><ul><li>Administer on EMPTY stomach </li></ul><ul><li>Provide safety precautions- because of poor visual acuity </li></ul><ul><li>Promote cool environment, maintain access to the bathroom (urination) </li></ul>
  325. 326. The Cholinergic Agonists: evaluate effectiveness Urination/ relief of bladder distention Betanechol/Carbachol Decreased IOP in glaucoma Pilocarpine effectiveness Drug
  326. 327. The Cholinergic Agonists <ul><li>Indirect acting cholinergic agonists </li></ul><ul><li>Pharmacodynamics </li></ul><ul><li>These agents DO NOT react directly with the receptors but REACT chemically with the enzyme= acetylcholin esterase </li></ul>
  327. 328. The Cholinergic Agonists <ul><li>Indirect acting cholinergic agonists </li></ul><ul><li>Pharmacodynamics </li></ul><ul><li>The acetylcholine breakdown is prevented so that the effect of acetylcholine is prolonged!= increased muscle contraction </li></ul><ul><li>They are used IN myasthenia gravis </li></ul>
  328. 329. The Cholinergic Agonists <ul><li>Indirect acting cholinergic agonists </li></ul><ul><li>Clinical use </li></ul><ul><li>Myasthenia gravis </li></ul><ul><ul><li>Physostigmine, pyridostigmine , Neostigmine, and endrophonium </li></ul></ul><ul><li>2. Alzheimer's disease </li></ul><ul><ul><li>Tacrine and Donepezil </li></ul></ul>
  329. 330. The Cholinergic Agonists <ul><li>Indirect acting cholinergic agonists </li></ul><ul><li>Adverse effects </li></ul><ul><li>GI- nausea, vomiting, cramps, diarrhea, increased salivation , involuntary defection </li></ul><ul><li>CVS- bradycardia , heart block, hypotension </li></ul><ul><li>GU- urinary urgency </li></ul><ul><li>Others- blurred vision , miosis, headache, dizziness </li></ul>
  330. 331. The Cholinergic Agonists <ul><li>Indirect acting cholinergic agonists </li></ul><ul><li>Nursing considerations </li></ul><ul><li>Administer IV drug slowly </li></ul><ul><li>Administer with foods BUT better BEFORE meals </li></ul><ul><li>Maintain atropine sulfate as antidote </li></ul><ul><li>Discontinue the drug if excessive salivation, diarrhea, vomiting become problematic </li></ul>
  331. 332. The Cholinergic Agonists <ul><li>Indirect acting cholinergic agonists </li></ul><ul><li>Nursing considerations </li></ul><ul><li>Evaluate effectiveness </li></ul><ul><li>Decreased muscle weakness </li></ul><ul><li>Decreased dysphagia, ptosis </li></ul><ul><li>Increased muscular activity </li></ul>
  332. 333. The ANTI-cholinergics <ul><li>These are drugs that BLOCK the effect of acetylcholine </li></ul><ul><li>They are also called parasympatholytic agents </li></ul><ul><li>In effect, the sympathetic system becomes unopposed!!! </li></ul>
  333. 334. The ANTI-cholinergics <ul><li>Anticholinergics: </li></ul><ul><li>Prototype: Atropine </li></ul><ul><li>dicyclomine </li></ul><ul><li>glycopyrrolate </li></ul><ul><li>propantheline </li></ul><ul><li>scopolamine </li></ul>
  334. 335. The ANTI-cholinergics <ul><li>Anticholinergics: pharmacodynamics </li></ul><ul><li>These agents work by BLOCKING or COMPETING with acetylcholine for the acetylcholine receptors </li></ul><ul><li>BEST taken BEFORE MEALS </li></ul>
  335. 336. Atropine <ul><li>Depresses salivation </li></ul><ul><li>Decreases bronchial secretions </li></ul><ul><li>Mydriasis </li></ul><ul><li>Cyclopedia </li></ul><ul><li>Inhibits vagal response in the heart </li></ul><ul><li>Reverses cholinergic toxicity </li></ul>
  336. 337. Atropine Used in partly to control diarrhea (in Lomotil ) Constipation Used in Cholinergic and Organophosphate poisoning Reverses cholinergic toxicity Used in BRADYCARDIA and heart block Inhibits vagal response in the heart Used in cataract surgery Cyclopledia Used in cataract surgery Mydriasis Used as pre-op med Decreases bronchial secretions Used as pre-op med Depresses salivation Clinical use effects
  337. 338. Scopolamine <ul><li>Decreases nausea and vomiting associated with motion sickness </li></ul>
  338. 339. Anticholinergic <ul><li>Contraindications of anticholinergic </li></ul><ul><li>Known allergy </li></ul><ul><li>Glaucoma </li></ul><ul><li>Bladder obstruction (like PBH) </li></ul>
  339. 340. Anticholinergic <ul><li>Adverse effects: anticholinergic effects </li></ul><ul><li>CNS- blurred vision, pupil DILATION, photophobia, cycloplegia and increased Intraocular pressure </li></ul><ul><li>GI- dry mouth , constipation, bloatedness </li></ul><ul><li>CVS- tachycardia, palpitations </li></ul><ul><li>GU- urinary retention </li></ul><ul><li>Others- decreased sweating, flushing </li></ul>
  340. 341. Anticholinergic <ul><li>Nursing considerations </li></ul><ul><li>Provide comfort measures </li></ul><ul><ul><li>Frequent mouth care </li></ul></ul><ul><ul><li>Provide increased fluids </li></ul></ul><ul><ul><li>Protect eyes form lights </li></ul></ul><ul><ul><li>Advise to avoid hazardous activities </li></ul></ul><ul><ul><li>Provide high-fiber diet and laxative </li></ul></ul><ul><ul><li>Avoid extremes of temperature </li></ul></ul><ul><ul><li>Instruct to void before administering the drug </li></ul></ul>
  341. 342. Anticholinergic <ul><li>Nursing considerations </li></ul><ul><li>2. Monitor for toxicity: </li></ul><ul><li>3. Ensure adequate hydration to prevent hyperpyrexia </li></ul><ul><li>Evaluate effectiveness of drug: </li></ul><ul><li>Increased HR in heart block </li></ul><ul><li>Decreased secretions in pre-op patients </li></ul><ul><li>Relief of motion sickness (scopolamine) </li></ul>