Pharmacology Handout  Diuretic effect is achieved by the sodium loss to offset

Arellano Course Audit potassium retention

Pharmacokinetics: Side effects
 HYPERkalemia!
DRUGS Affecting the KIDNEY  Avoid high potassium foods:
 Bananas, Potatoes, Spinach
Diuretic class Major site of action Special Side effect  Broccoli, Nuts, Prunes, Tomatoes, Oranges
Diuretic class Special Uses (s)
Peaches
1. Carbonic Proximal tubule Acidosis
1. Carbonic
anhydrase Mountain sickness
Osmotic Diuretics
anhydrase
inhibitor Meniere’s disease
Prototype: Mannitol
2. inhibitor
Thiazide and Proximal tubule Hyperuricemia 1. Glycerin
2. Thiazide
thiazide like and Nephrolithiasis due to calcium
Hypokalemia 2. Isosorbide
thiazide like stones 3. Urea
3. Loop diuretics Loop of Henle Hypokalemia
Hypocalcemia Osmotic Diuretics
Ototoxicity
3. Loop diuretics Hypercalcemia Pharmacodynamics
4. Potassium Distal tubule Hyperkalemia
sparing  Mannitol is a sugar not well absorbed in the nephron
4. Potassium CHF taking digoxin osmotic pull of water diuresis
5. sparing
Osmotic Glomerulus Hypovolemia &
Pharmacokinetics: side effects
diuretic
5. Osmotic Increased ICP hypotension  Sudden hypovolemia
diuretic LITHIUM TOXICITY  Important for the nurse to warm the solution to allow
the crystals to DISSOLVE in the bottle!
Thiazides
Prototype: Hydrochlorothiazide Carbonic Anhydrase Inhibitors
1. Bendroflumethiazide Prototype: Acetazolamide
2. Benthiazide 1. Methazolamide
3. Chlorothiazide (Diuril) Carbonic Anhydrase Inhibitors
4. Hydroflumethiazide Pharmacodynamics
5. Methylclothiazide  Carbonic Anhydrase forms sodium bicarbonate
6. Trichlormethiazide  BLOCK of the enzyme results to slow movement of
hydrogen and bicarbonate into the tubules
Thiazide-like
 plus sodium is lost in the urine
1. Indapamide
Pharmacokinetics: side effects
2. Quinethazone
 Metabolic ACIDOSIS happens when bicarbonate is
3. Metolazone
lost
4. Chlorthalidone
 Hypokalemia
Pharmacodynamics
The Nursing Process and the diuretics
 These drugs BLOCK the chloride pump
ASSESSMENT
 This will keep the Chloride and Sodium in the distal
 The nurse must elicit history of allergy to the drugs
tubule to be excreted into the urine
 Allergy to sulfonamides may contraindicate the
 Potassium is also flushed out!!
use of thiazides
Thiazide
 Assess fluid and electrolyte balance
 Special Pharmacodynamics: Side effects
 Assess other conditions like gout, diabetes, pregnancy
 Hypokalemia
and lactation
 DECREASED calcium excretion hypercalcemia
Physical assessment
 DECREASED uric acid secretion hyperuricemia
 Vital signs
 Hyperglycemia
 Special electrolyte and laboratory examination
 Assess symptom of body weakness which may
Loop Diuretics
indicate hypokalemia
Prototype: Furosemide
Nursing Diagnosis
1. Bumetanide
2. Ethacrynic acid  Fluid volume deficit related to diuretic effect
3. Torsemide  Alteration in urinary pattern
Loop Diuretics  Potential for injury (ototoxocity, hypotension)
Pharmacodynamics  Knowledge deficit
 High-ceiling diuretics IMPLEMENTATION
 BLOCK the chloride pump in the ascending loop of  Administer IV drug slowly
Henle  Safety precaution for dizziness/hypotension
 SODIUM and CHLORIDE reabsorption is prevented  Provide potassium RICH foods for most diuretics, with
 Potassium is also excreted together with Na and Cl the exception of spironolactone
 Provide skin care, oral care and urinary care

Loop Diuretics
 Special Pharmacodynamics: side-effects
 Hypokalemia The Nursing Process and the diuretics
 Bicarbonate is lost in the urine IMPLEMENTATION
 INCREASED calcium excretion Hypocalcemia  Monitor DAILY WEIGHT- to evaluate the effectiveness
 Ototoxicity- due to the electrolyte imbalances of the therapy
 Monitor urine output, cardiac rhythm. Serum
Potassium sparing diuretics electrolytes
Prototype: Spironolactone  ADMINISTER in the MORNING!
1. Amiloride
2. Triamterene  Administer with FOOD!
EVALUATION: for effectiveness of therapy
Pharmacodynamics Weight loss
Increased urine output
 Spironolactone is an ALDOSTERONE antagonist
Resolution of edema
 Triamterene and Amiloride BLOCK the potassium
Decreased congestion
secretion in the distal tubule
Normal BP
CNS DRUGS: Drugs affecting the CNS CVS= Hypotension or hypertension, arrhythmias,
The ANXIOLYTICS AND HYPNOTICS palpitations, and respiratory difficulties.
 These drugs are used to change the individual’s Hematologic= blood dyscrasias and anemia
responses to the environment. GU= urinary retention, hesitancy, loss of libido and sexual
 The medications that can prevent the feelings of functions changes.
tension and fear are called ANXIOLYTICS. Nursing Considerations:
 Anti-anxiety drugs Maintain patients on bed for at least 3 hours after drug
 The drugs that can calm individuals making them administration.
unaware of the environment are called SEDATIVES. Instruct to avoid hazardous activities like driving and
 The drugs that can induce sleep are called machine operation.
HYPNOTICS. Instruct to avoid consuming ALCOHOL while taking the
drug.
The ANXIOLYTICS AND HYPNOTICS Provide comfort measures to help patients tolerate drug
The drugs in this class are the effects-
 BENZODIAZEPINES  instruct to urinate before taking drug
 BARBITURATES  give high fiber foods
Clinical indications for the use of the anxiolytics, sedatives and  use side-rails and assistance with ambulation.
hypnotics Have available FLUMAZENIL as an antidote for
1. Prevention of anxiety benzodiazepine overdose.
2. Formation of sedative state
3. Induction of sleep The BARBITURATES
These are also anxiolytics and hypnotics with a greater
The BENZODIAZEPINES likelihood of producing sedation, with increase risk of addiction
The benzodiazepines are the most frequently used anxiolytic and dependence.
drugs. The following are the barbiturates
These agents prevent anxiety states without causing much  amobarbital
sedation, with less physical dependence than other agents.  aprobarbital
The following are the benzodiazepines  butabarbital
Alprazolam (Xanax)  mephobarbital
Chlordiazepoxide (Librium)  pentobarbital
clonazepam  Phenobarbital
clorazepate  Secobarbital
Diazepam (Valium)
estazolam The BARBITURATES
flurazepam The Mechanism of Action of the Barbiturates
lorazepam  They depress the motor output from the brain.
midazolam  The results of their MOA are sedation, hypnosis and
oxazepam anesthesia, and if extreme, coma.
quazepam Clinical indications of the Barbiturates
temazepam Relief of anxiety manifestations
triazolam For sedation
The BENZODIAZEPINES For patients with insomnia
Special uses For pre-anesthesia
Diazepam Status epilepticus seizures/epilepsy
(Valium) • The rapid acting barbiturates are also used for the
treatment of acute manic reactions and status epilepticus
Chlordiazepoxide (Librium) Alcohol withdrawal Pharmacodynamics: The Adverse effects
• CNS= CNS depression, somnolence, vertigo,
lethargy, ataxia, paradoxical excitement, anxiety and
Alprazolam (Xanax) Panic attack
hallucinations.
• GIT= nausea, vomiting, constipation/diarrhea and
epigastric pain
The Mechanism of Action of the Benzodiazepines • CVS= bradycardia, Hypotension and syncope.
These agents act on the Limbic system and the RAS (reticular
activating system) to make the GABA ( Gamma-aminobutyric • Respi= serious hypoventilation, respiratory
acid) more effective causing interference with neuron firing. depression and laryngospasms
• Others= hypersensitivity and Stevens-Johnson
syndrome.

The GABA is an inhibitory neurotransmitter.

This will result to an anxiolytic effect at lower doses than
required for sedation/hypnosis.
Nursing Considerations
These agents are indicated for the treatment of
Provide stand-by life support facilities in cases of severe
anxiety disorders
respiratory depression or hypersensitivity reaction.
alcohol withdrawal
Taper the drug gradually after long-term therapy to avoid
hyperexcitability, and agitation
withdrawal syndrome.
pre-operative relief of anxiety and tension and in induction
Provide comfort measures including small frequent meals,
of balanced anesthesia.
access to bathroom facilities, high-fiber foods,
environmental control, safety precaution and skin care.
The BENZODIAZEPINES
Pharmacodynamics: The adverse effects
The CNS stimulants
CNS effects= sedation, drowsiness, depression, lethargy,
These are drugs used to treat certain disorders
blurred vision
GIT= dry mouth, constipation, nausea, vomiting • exogenous obesity
 2. Valproic Acid
• attention-deficit
3. Zosinamide
hyperactivity disorders (ADHD) Anti-epileptics
• narcolepsy Agents for treating Partial FOCAL SEIZURES
What is unusual is the ability of the CNS stimulants to 1. Carbamazepine
CALM hyperactive children, which allows them to focus on 2. Gabapentin
one activity for a longer period. 3.Lamotrigine
4. Tiagabine
The following are the CNS stimulants: 5. Topiramate
1. Methylphenidate (Ritalin)= most commonly used for The hydantoins
ADHD These agents are utilized for general seizures because they
2. Dextroamphetamine= a CNS stimulant that is used for can depress the central nervous system.
short tem therapy for obesity. They affect the entire brain and reduce the chance of
3. Modafinil= used for narcolepsy sudden electrical outburst that causes seizures.
4. Pemoline= used for ADHD These agents generally are less sedating than other anti-
epileptics.
The Mechanism of Action The hydantoins
These agents act as to stimulate the cortical and reticular Mechanism of Action of the Hydantoins
activating system (RAS) of the brain. These agents STABILIZE the nerve cell membrane
This is by releasing neurotransmitters from the nerve cells throughout the brain reducing and limiting the excitability
leading to increased stimulation of the post-synaptic and conduction through nerve pathways.
neurons. The hydantoins
Clinical Indications of the hydantoins
The CNS stimulants o Tonic-clonic seizures
o Status epilepticus
• The paradoxical effect of calming hyperexcitability o For the prevention of seizures in neurosurgery
through CNS stimulation seen in ADHD is believed to be o For muscle relaxation.
related to the increased stimulation of an IMMATURE
The hydantoins
Reticular Activating System leading to the ability to be
Contraindications and Precautions
more selective in response to incoming stimuli.
Hydantoins are NOT given to pregnant patient because it
Pharmacodynamics: Adverse effects of the CNS stimulants
can cause fetal hydantoin syndrome.
o CNS= nervousness, insomnia, dizziness,
Pharmacodynamics: Adverse effects of the Hydantoins
headache, and blurred vision
o GIT= anorexia, nausea and weight loss  CNS effects- depression, confusion, drowsiness,
o CVS= hypertension, tachycardia arrhythmias, lethargy, fatigue
and angina  GIT- GI upset, constipation, dry mouth, GINGIVAL
o Others= rashes, physical/psychological HYPERPLASIA , severe liver toxicity which are all related to
dependence. cellular toxicity.
o The CNS stimulants
o Implementation  SKIN- hirsutism and coarsening of the facial skin
o The nurse must ensure that the drug is only  Bone Marrow depression
given to the indicated conditions Implementation
o Administer the drug before 6 pm to reduce Administer the drug with food to alleviate GI irritation
the effect of insomnia Discontinue the drug at any sign of hypersensitivity
o BEST given AFTER meals to prevent the reaction, severe liver dysfunction and severe skin rashes.
effect of anorexia Provide meticulous mouth oral care
o Consult with school personnel to monitor the Rule out pregnancy and advise women to use
patient under therapy contraceptive measures to prevent pregnancy.
o Provide safety measures such as side-rails
and assisted ambulation Drugs affecting GI secretions
Evaluation There are five types of drugs that affect gastric acid
Evaluate the effectiveness of the drug: secretions and are useful for the treatment of peptic ulcer
• Calming effect in the patient with ADHD
Anti-ulcer drugs Prototype
• Alertness for patients with narcolepsy
Histamine (H2) receptor Cimetidine
The Anti-epileptics antagonist/blockers
 These agents, also called anticonvulsants, are used to Antacids AlOH and MgOH
treat epileptic conditions.
Proton pump inhibitors Omeprazole
 Hydantoins, Barbiturates, benzodiazepines,
Succinimides and many others are given to a specific type of Mucosal protectants Sucralfate
seizure.
Anti-epileptics
Agents for treating TONIC-CLONIC SEIZURES
1. Hydantoins Prostaglandin analog Misoprostol
Phenytoin
Ethotoin
Fosphenytoin
Mephenytoin
2. Benzodiazepines
Diazepam
Clonazepam
Clorazepate
3. Barbiturates
Phenobarbital
Anti-epileptics
Agents for treating ABSENCE SEIZURES
1. Succinimides
a. Ethosuximide
b. Methsuximide
c. Phensuximide
  Treatment of erosive GERD (reflux disease)
Drug Mechanism of Action  Relief of Symptoms of heart burn and acid indigestion
Anti-ulcer drugs Prototype Best time to Precautions and Contraindications
Antacids- AlOH, MgOH
give Neutralize Gastric ACIDITY
Any known allergy is a clear contraindication to the use of the
Histamine (H2) Cimetidine With FOOD or agents. Conditions such as pregnancy, lactation, renal
receptor ONE Block Histamine receptor
H2-Blockers- “tidine” dysfunction and hepatic dysfunction should warrant cautious
antagonist/blockers
Cimetidine, Ranitidine causing decreasedhour after use.
ANTACIDsecretion and acidity Nizatidine can be used in hepatic dysfunction.
Antacids AlOH and MgOH Usually after
Proton pump inhibitors- Inhibit Proton Pump in
meals Pharmocodynamics- Side effects and adverse effects
“Prazoles” parietal cell decreasing
Proton pump pantoprazole
Omeprazole, Omeprazole BEFORE
secretion and acidity  GIT= diarrhea or constipation
inhibitors MEALS  CNS= Dizziness, headache, drowsiness, confusion and
Drug Mechanism of Action hallucinations
Mucosal Sucralfate BEFORE
 Cardio= arrhythmias, HYPOTENSION (related to H2
protectants MEALS
receptor blockage in the heart)
Prostaglandin Misoprostol WITH MEALS  Cimetidine= TREMORS, Gynecomastia and impotence
Anti-cholinergic-
analog Blocks VAGUS nerve,
in males
Prophanteline Bromide decreases secretion
Drug-drug Interactions
Sucralfate (Carafate) Coats the mucosal lining Cimetidine, Famotidine, Ranitidine are metabolized in the
liver- they can cause slowing of excretion of other drugs
leading to their increased concentration.
The H2 Blockers- “tidines”
Misoprostol (Cytotec) Prostaglandin Analogue, Drug-drug Interactions
causes secretion of These drugs can interact with CIMETIDINE anticoagulants,
MUCUS phenytoin, alcohol, antidepressants.
The H2 Blockers- “tidines”
Drugs affecting secretions: anti ulcer Nursing considerations:
General indication of the drugs affecting gastric acid secretion  Administer the drug WITH meals at BEDTIME to
Peptic ulcer ensure therapeutic level
Gastritis
 One hour after Antacids
Patient on NPO to prevent stress ulcer
 Stress the importance of the continued use for the
General time of administration of the drugs affecting gastric acid
length of time prescribed
secretion
Pharmacology of Anti-ulcer drugs  The H2 Blockers- “tidines”
Pharmacology of Anti-ulcer drugs  Nursing considerations:
Pharmacodynamics  Monitor the cardiovascular status especially if the
Histamine (H2) receptor blockers drugs are given IV
 These drugs BLOCK the release of hydrochloric  Warn patient of the potential problems of increased
acid in the stomach in response to gastrin drug concentration if the H2 blockers are used with
Drugs affecting GI secretions other drugs or OTC drugs. Advise consultation
 Antacids first!
 These drugs interact with the gastric acids at the Nursing considerations:
chemical level to neutralize them Provide comfort measures like analgesics for headache,
Drugs affecting GI secretions assistance with ambulation and safety measures
Warn the patients taking cimetidine that drowsiness may
 Proton pump inhibitors
pose a hazard if driving or operating delicate machines.
 These drugs suppress the secretion of
Provide health teaching as to the dose, frequency, comfort
hydrochloric acid into the lumen of the stomach
measures to initiate when side-effects are intolerable
Drugs affecting GI secretions
Evaluate the effectiveness:
 Mucosal protectants Relief of symptoms of ulcer, heart burn and GERD
 These are agents that coat any injured area in the
stomach to prevent further injury from acid
 Drugs affecting GI secretions
 Prostaglandin analogs
 These are agents that inhibit the secretion of
gastrin and
 increase the secretion of mucus lining of the
stomach, providing a buffer.

The H2 Blockers- “tidines” The Antacids

Prototype: Cimetidine These are drugs or inorganic chemicals that have been
1. Ranitidine used for years to neutralize acid in the stomach. The
2. Famotidine following are the common antacids that can be bought
3. Nizatidine OTC:
The H2 Blockers- “tidines”  Aluminum salts (hydroxide)
Pharmacodynamics: Drug Action  Calcium salts (carbonate)
 The H2 blockers are antagonists at the receptors in  Magnesium salts (milk of magnesia)
the parietal cells of the stomach.  Sodium bicarbonate
 The blockage results to inhibition of the hormone  Magaldrate (aluminum and magnesium combination)
gastrin.
 There will be decreased production of gastric acid Pharmacodynamics: drug action
from the parietal cells. These agents act to neutralize the acidic pH in the stomach.
 Also, the chief cells will secrete less pepsinogen. They do not affect the rate of gastric acid secretion.
The H2 Blockers- “tidines” The administration of antacid may cause an acid rebound.
Therapeutic use of the H2 blockers Neutralizing the stomach content to an alkaline level stimulates
 Short-term treatment of active duodenal ulcer or benign gastrin production to cause an increase in acid production and
gastric ulcer return the stomach to its normal acidic state.
 Treatment of hypersecretory conditions like the Zollinger-
Ellison syndrome Therapeutic Indications
 Prevention of stress-induced ulcers and acute GI bleeding
Symptomatic relief of upset stomach associated with
hyperacidity
Hyperacidic conditions like peptic ulcer, gastritis, esophagitis
and hiatal hernia
Special use of AMPHOGEL (aluminum hydroxide): to BIND
phosphate
Precautions of Antacid Use
Known allergy is a clear contraindication. Caution should be
instituted if used in electrolyte imbalances, GI obstruction and
renal dysfunction.
Sodium bicarbonate is rarely used because of potential
systemic absorption
Pharmacokinetics
These agents are taken orally and act locally in the stomach
Pharmacodynamics: Effects of drugs
 GIT= rebound acidity; alkalosis may occur.
 Calcium salts may lead to hypercalcemia
 Magnesium salts can cause DIARRHEA
 Aluminum salts may cause CONSTIPATION and
hypophosphatemia by binding with phosphates in
the GIT.
 Fluid retention due to the high sodium content of the
antacids.
Nursing Considerations:
Administer the antacids apart from any other medications by
ONE hour before or TWO hours after- to ensure adequate
absorption of the other medications
Tell the patient to CHEW the tablet thoroughly before
swallowing. Follow it with one glass of water
Regularly monitor for manifestations of acid-base imbalances as
well as electrolyte imbalances
Provide comfort measures to alleviate constipation
associated with aluminum and diarrhea associated with
magnesium salts.
Monitor for the side-effects, effectiveness of the comfort
measures, patient’s response to the medication and the
effectiveness of the health teachings
Evaluate for effectiveness:
Decreased symptoms of ulcer and pyrosis
Decreased Phosphate level (amphogel)
The PPI
 These are the newer agents for ulcer treatment
The “prazoles”
 Prototype: Omeprazole
 Lanisoprazole
 Esomeprazole
 Pantoprazole
Pharmacodynamics: drug action
They act at specific secretory surface receptors to prevent the
final step of acid production and thus decrease the level of acid
in the stomach.
The “pump” in the parietal cell is the H-K ATPase enzyme
system on the secretory surface of the gastric parietal cells
Provide safety measures if CNS dysfunction happens.
Arrange for a medical follow-up if symptoms are NOT resolved
after 4-8 weeks of therapy.
Provide health teaching as to drug name, dosages and
frequency, safety measures to handle common problems.
Monitor patient response to the drug, the effectiveness of the
teaching plan and the measures to employ
Evaluate for effectiveness of the drug
Healing of peptic ulcer
Decreased symptoms of ulcer
The Mucosal Protectant
Sucralfate
This is given to protect the eroded ulcer sites in the GIT from
further damage by acid and digestive enzymes
Pharmacodynamics: Action of drug
It forms an ulcer-adherent complex at duodenal ulcer sites,
protecting the sites against acid, pepsin and bile.
This action prevents further breakdown of proteins in the area
and promotes healing.
Clinical use of sucralfate
Short and long term management of duodenal ulcer.
NSAIDs induced gastritis
Prevention of stress ulcer
Treatment of oral and esophageal ulcers due to radiation,
chemotherapy or sclerotherapy.
Precautions on the use of Sucralfate
This agent should NOT be given to any person with known
allergy to the drug, and to those patients with renal
failure/dialysis because of build-up of aluminum may occur if
used with aluminum containing products.
Pharmacodynamics: Side-effects & adverse reactions
Primarily GIT= CONSTIPATION, occasionally diarrhea,
nausea, indigestion, gastric discomfort, and dry mouth
may also occur
CNS= dizziness, drowsiness, vertigo
Others= rash and back pain
Drug-drug interactions
If used with aluminum salts= high risk of accumulation of
aluminum and toxicity.
If used with phenytoin, fluoroquinolones and penicillamines-
decreased levels of these drugs when taken with sucralfate
Nursing Considerations
Administer drug ON AN EMPTY stomach, 1 hour before
meals , or 2 hour after meals and at BEDTIME
Monitor for side-effects like constipation and GI upset
Encourage intake of high-fiber foods and increased fluid intake
Administer antacids BETWEEN doses of sucralfate, NOT
WITHIN 30 minutes of sucralfate dose
Provide comfort measures if CNS effects occur
Provide health teaching as to drug name, dosages and
frequency, safety measures to handle common problems.
Monitor patient response to the drug, the effectiveness of the
teaching plan and the measures employed

Clinical use of the PPIs Evaluate effectiveness of therapy

Short-term treatment of active duodenal ulcers, GERD, erosive
esophagitis and benign gastric ulcer. Type Prototype Action
Long-term- maintenance therapy for healing of erosive
disorders
Chemical Bisacodyl Direct stimulation of the
Clinical use of the PPIs. stimulants (Dulcolax) GIT nerves
Precautions with the use of the PPIs Irritant laxatives
Known allergy is a clear contraindication. Caution if patient is
pregnant Mechanical Lactulose Increased fluid content
Pharmacodynamics: Adverse effects (bulk) of the fecal material
CNS- dizziness, headache, asthenia (loss of strength), vertigo, stimulants causing stimulation of
insomnia, apathy the local reflex
GIT- diarrhea, abdominal pain, nausea, vomiting, dry mouth Lubricants Docusate Lubricating the
and tongue atrophy intestinal material to
Respi- cough, stuffy nose, hoarseness and epistaxis. promote passage
through the GIT
Nursing considerations: Healing of ulcer
Administer the drug BEFORE meals. Ensure that patient does No formation of ulcer
not open, chew or crush the drug. Prostaglandin analogue
Misoprostol
This agent is a synthetic prostaglandin E1 analog that is Mechanical Stimulant Cathartics
employed to protect the lining of the mucosa of the stomach Prototype: LACTULOSE (Cephulac)
Prostaglandin analogue Bulk-forming laxatives
1. Magnesium (citrate, hydroxide, sulfate)
Being a prostaglandin analog, it inhibits gastric acid secretion 2. Psyllium
to some degree 3. Polycarbophil
It INCREASES mucus production in the stomach lining.
Mechanical Stimulant Cathartics
Misoprostol: Clinical use Pharmacodynamics
NSAIDs-induced gastric ulcers These agents are rapid-acting laxatives that INCREASE the GI
Duodenal ulcers unresponsive to H2 antagonists. motility by
Prostaglandin analogue  Increasing the fluids in the colonic material
Precautions of Misoprostol Use  Stimulating the local stretch receptors
This drug is CONTRAINDICATED during pregnancy  Activating local defection reflex
because it is an abortifacient.
Women should be advised to have a negative pregnancy Lubricants
test within 2 weeks of beginning therapy and Prototype: Docusate
should begin the drug on the second or third day
of the next menstrual cycle. 1. Glycerin
They should be instructed in the use of contraceptives 2. Mineral oil
during therapy. Lubricants
Pharmacodynamic effects: drug reactions Pharmacodynamics
GIT= Nausea, diarrhea, abdominal pain, flatulence, vomiting, Docusate increases the admixture of fat and water producing a
dyspepsia softer stool
GU effects= miscarriages, excessive uterine CRAMPING and Glycerin
bleeding, spotting, hypermenorrhea and menstrual disorders. Mineral oil forms a slippery coat on the colonic contents

Prostaglandin analogue Pharmacokinetics:

Nursing Considerations Common Side-effects of the Laxatives
Administer to patients at risk for NSAIDs-induced ulcers Diarrhea
during the full course of NSAIDs therapy Abdominal cramping
Administer four times daily with meals and at bedtime Nausea
Obtain pregnancy test within 2 weeks of beginning therapy. Fluid and electrolyte imbalance
Begin the therapy on second or third day of menstrual Sympathetic reactions- sweating, palpitations, flushing and
period to ensure that the woman is not pregnant fainting
Prostaglandin analogue CATHARTIC dependence
Nursing Considerations The Nursing Process and Laxative
Provide patient with both written and oral information ASSESSMENT
regarding the associated risks of pregnancy Nursing History- elicit allergy to any laxatives, elicit history of
Provide health teaching as to drug name, dosages and conditions like diverticulitis and ulcerative colitis
frequency, safety measures to handle common Physical Examination- abdominal assessment
problems. Laboratory Test: fecalysis, electrolyte levels
Monitor patient response to the drug, the effectiveness of
the teaching plan and the measures to employ The Nursing Process and Laxative
NURSING DIAGNOSIS
Laxatives Alteration in bowel pattern
Generally used to INCREASE the passage of the colonic Alteration in comfort: pain
contents Knowledge deficit
The general classifications is as follows: The Nursing Process and Laxative
1. Chemical stimulants IMPLEMENTATION
2. Mechanical stimulants
3. Lubricants • Emphasize that it is use on a SHORT term basis
Therapeutic Indications of the Laxatives • Provide comfort and safety measures like ready
SHORT term relief of Constipation access to the bathroom, side-rails
Prevention of straining in conditions like CHF, post-MI, post
partum, post-op • Administer with a full glass of water
Preparation for diagnostic examination The Nursing Process and Laxative
Removal of poison or toxins IMPLEMENTATION
Adjunct in anti-helminthic therapy 4. Encourage fluid intake, high fiber diet and daily exercise
5. DO NOT administer if acute abdominal condition like
Contraindications in Laxative use appendicitis is present
ACUTE abdominal disorders 6. Advise to change position slowly an avoid hazardous
 Appendicitis activities because of potential dizziness
 Diverticulitis The Nursing Process and Laxative
EVALUATION of drug effectiveness
 Ulcerative colitis
Chemical Stimulant Cathartics • Evaluate relief of GI symptoms, absence of staining
Prototype: Bisacodyl and increased evacuation of GI tract
Irritant laxatives:
1. Castor oil
• For Lactulose: decreased ammonia
2. Senna The Anti-diarrheals
3. Cascara These are agents used to calm the irritation of the GIT for the
4. Phenolphthalein symptomatic relief of diarrhea
General Classifications
1. Local anti-motility
2. Local reflex inhibition
3. Central action on the CNS
The Anti-diarrheals
Clinical Indications of drug use
Pharmacodynamics Relief of symptoms of acute and chronic diarrhea
These agents DIRECTLY stimulate the nerve plexus in the Reduction of fecal volume discharges from ileostomies
intestinal wall Prevention and treatment of traveler's diarrhea
The result is INCREASED movement or motility of the colon Contraindications of anti-diarrheal Use
Poisoning
Drug allergy
• Vomiting should occur within 20 minutes of the first
dose. Repeat the dose and expect vomiting to occur with 20
GI obstruction
minutes
Acute abdominal conditions
Nursing process and the EMETIC
Pharmacokinetics: Side effects
IMPLEMENTATION
Constipation
5. Provide comfort measures like ready access to bathroom,
Nausea, vomiting
assistance with ambulation
Abdominal distention and discomfort
6. Offer support
TOXIC MEGACOLON
Nursing process and the EMETIC
EVALUATION
Nursing process and anti-diarrheals
ASSESSMENT • Evaluate patient response within 20 minutes of drug
Nursing History – Elicit history of drug allergy, conditions like ingestion
poisoning, GI obstruction and acute abdominal conditions
Physical Examination- Abdominal examination
• Monitor for adverse effects
Laboratory test- electrolyte levels • Evaluate effectiveness of comfort measures and
teaching plan
Nursing process and anti-diarrheals
NURSING DIAGNOSIS ANTI-EMETICS
Alteration in bowel pattern These are agents used to manage nausea and vomiting
Alteration in comfort: pain They act either locally or centrally
Nursing process and anti-diarrheals
IMPLEMENTATION Anti-emetic types Common examples
• Monitor patient response within 48 hours. Discontinue
drug use if no effect Phenothiazines Prochlorperazine, promethazine

• Provide comfort measures for pain

Non-phenothiazines Metoclopramide
• Provide teaching
Nursing process and anti-diarrheals Anticholinergics and Meclizine, buclizine
EVALUATION Antihistaminics
• Monitor effectiveness of drug- RELIEF of diarrhea Serotonin Receptor blockers “setron”- dolasetron

• Monitor adverse effects, effectiveness of pain Miscellaneous Dronabinol, hydroxyzine

measures and effectiveness of teaching plan

Emetics and Anti-emetics Contraindications

Emetic Agent 1. Severe CNS depression
► Syrup of Ipecac Types Pharmacodynamics
Anti-emetics Phenothiazines Centrally block the vomiting
center in the medulla
► 1. Phenothiazines
Non-phenothiazine Reduces the responsiveness of
► 2. Non-phenothiazines the nerve cell in the medulla
► 3. Anticholinergics/Antihistamines
Anticholinergics Block the transmission of the
► 4. Serotonin receptor Blockers impulses to the medulla
► 5. Miscellaneous Serotonin receptor blockers Centrally and locally inhibits the
serotonin receptors
EMETIC Miscellaneous Act in the CNS , either in the
Prototype: Ipecac Syrup medulla or in the cortex
Pharmacodynamics 2. Severe liver dysfunction
Ipecac syrup irritates the GI mucosa locally, resulting to ANTIEMETICS
stimulation of the vomiting center Pharmacokinetics: Side-effects
It acts within 20 minutes 1. PHOTHOSENSITIVITY
Clinical Use of ipecac 2. Drowsiness, dizziness, weakness and tremors and
To induce vomiting as a treatment for drug overdose and certain DEHYDRATON
poisonings 3. Phenothiazines= autonomic anti-cholinergic effects like dry
Contraindications of Ipecac use mouth, nasal congestion and urinary retention
Ingestion of CORROSIVE chemicals
Ingestion of petroleum products Nursing Process and the ANTIEMETICS
Unconscious and convulsing patient ASSESSMENT
Pharmacokinetics: side effects of Ipecac Nursing History- elicit allergy, impaired hepatic function and
Nausea CNS depression
Diarrhea Physical Examination- CNS status and abdominal examination
GI upset Laboratory test- Liver function studies
Mild CNS depression Nursing Process and the ANTIEMETICS
CARDIOTOXICITY if large amounts are absorbed in the NURSING DIAGNOSIS
body
Nursing process and the EMETIC
• Alteration in comfort: pain
ASSESSMENT • High risk for injury
Nursing History- elicit the exact nature of poisoning
Physical Examination- CNS status and abdominal exam • Knowledge deficit
Nursing Process and the ANTIEMETICS
Nursing process and the EMETIC IMPLEMENTATION
IMPLEMENTATION • Assess patient’s intake of other drugs that may cause
• Administer to conscious patient only dangerous drug interaction

• Administer ipecac as soon as possible • Emphasize that this is given on a short term basis

• Administer with a large amount of water Nursing Process and the ANTIEMETICS
IMPLEMENTATION
3. Provide comfort and safety measures
 Advise to change position slowly 4. Instruct to avoid foods that inhibit thyroid secretions like
cabbage, spinach and radishes
 Avoid hazardous activities ANTI-Thyroid Medications
 Provide mouth care and ice chips ANTI-THYROID medications

 Monitor for dehydration and offer fluids if it occurs  The thyroid becomes oversaturated with iodine
Nursing Process and the ANTIEMETICS and stop producing thyroid hormone
IMPLEMENTATION ANTI-Thyroid Medications
4. Protect from sun exposure ANTI-THYROID medications
 Sunscreens
 Drugs used to BLOCK the thyroid hormones and
 Protective covering treat hyperthyroidism
5. Provide health teaching
Nursing Process and the ANTIEMETICS
EVALUATION
 Inhibit the synthesis of thyroid hormones
ANTI-Thyroid Medications
1. Monitor for the drug effectiveness ANTI-THYROID medications
• Relief of nausea and vomiting 1. Methimazole (Tapazole)
2. Monitor for adverse effects 2. PTU (prophylthiouracil)
3. Evaluate effectiveness of comfort measures and teaching 3. Iodine solution- SSKI and Lugol’s solution
plan ANTI-Thyroid Medications
Pharmacology of the Selected Endocrine Drugs ANTI-THYROID medications
Nursing Review Side-effects of thionamides
Endocrine Medications  N/V, drowsiness, lethargy, bradycardia, skin rash
Anti-diuretic hormones  GI complaints
Enhance re-absorption of water in the kidneys  AGRANULOCYTOSIS
 Most important to monitor
Used in DI ANTI-Thyroid Medications
1. Desmopressin and Lypressin intranasally ANTI-THYROID medications
2. Pitressin IM Side-effects of Iodine solutions
Endocrine Medications  Most common adverse effects is
Anti-diuretic hormones HYPOTHYROIDISM
SIDE-effects  Iodism= metallic taste, burning in the mouth, sore
 Flushing and headache teeth and gums, diarrhea, stomach upset

 Water intoxication
ANTI-Thyroid Medications
ANTI-THYROID medications
Nursing responsibilities
Thyroid Medications
Thyroid hormones  1. Monitor VS, T3 and T4, weight
 These products are used to treat the
 2. The medications WITH MEALS to avoid gastric
manifestations of hypothyroidism
upset
 Replace hormonal deficit in the treatment of ANTI-Thyroid Medications
ANTI-THYROID medications Nursing responsibilities
HYPOTHYROIDSM

Thyroid Medications
 3. Instruct to report SORE THROAT or unexplained
Thyroid hormones FEVER

 Levothyroxine (Synthroid)  4. Monitor for signs of hypothyroidism.

 Instruct not to stop abrupt medication
 Liothyroxine (Cytomel) ANTI-Thyroid Medications
ANTI-THYROID medications
 Thyroid dessicated Lugol’s Solution

 Liotrix (Thyrolar)
 Used to decrease the vascularity of the thyroid (in
preparation for thyroid surgery)
Thyroid Medications
Thyroid hormones: Actions  T3 and T4 production diminishes

 Increase the metabolic rate

 Given per orem, can be diluted with juice
 Use straw to decrease staining
 Increase O2 consumption
 Monitor iodism (metallic taste, burning in mouth)
 Increase HR, RR, BP
STEROIDS
Thyroid Medications
Thyroid hormones
 Replaces the steroids in the body
Side-effects

• Nausea and Vomiting

 Interfere with the release of inflammatory factors
and immune responses
• Signs of increased metabolism= tachycardia,
STEROIDS

hypertension, cardiac arrhythmias, anxiety, headache

Thyroid Medications
 Cortisol, cortisone, betamethasone, and
Thyroid hormones : Nursing responsibility hydrocortisone
1. Monitor weight, VS
2. Instruct client to take daily medication the same time  Dexamethasone= long acting
each morning WITHOUT FOOD STEROIDS


Monitor blood tests to check the activity of thyroid
Thyroid Medications These drugs enter the cells and bind to receptors
Thyroid hormones: Nursing responsibility
3. Advise to report palpitation, tachycardia, and chest pain
 They inhibit the enzyme phospholipase
STEROIDS
Corticosteroids are used topically and locally to achieve
 Treatment of dysrhythmias like atrial flutter, atrial
fibrillation and paroxysmal atrial tachycardia
the desired anti-inflammatory effects at a particular site
The cardiac glycosides
STEROIDS
Contraindications and Precautions
STEROIDS
Side-effects  Contraindicated in the presence of allergy to any
 HYPERglycemia cardiac glycoside.
 Increased susceptibility to infection  They are NOT given to patients with ventricular
(immunosuppression) dysrhythmias, heart block or sick sinus syndrome, aortic
 Hypokalemia stenosis, acute MI, electrolyte imbalances (HYPOKALEMIA,
 Edema and Hypertension HYPOMAGNESEMIA and HYPERCALCEMIA) and renal
 Peptic ulceration failure (may cause accumulation of drug)
STEROIDS The cardiac glycosides
Side-effects Pharmacodynamics: the Adverse Effects of the Cardiac
 If high doses- osteoporosis, growth retardation, glycosides
peptic ulcer, hypertension, cataract, mood changes,  CNS- Headache, weakness , seizures and drowsiness
hirsutism, and fragile skin  CVS- arrhythmias
STEROIDS  If digitalis toxicity is developing- the nurse must assess

 Nursing responsibilities
the following adverse effects: Anorexia, nausea and vomiting,
visual changes- YELLOW halo around an object, and
1. Monitor VS, electrolytes, glucose palpitations or very slow heart rate
2. Monitor weight edema and I/O. Encourage The cardiac glycosides
Potassium supplements Remember= NAVDA and hypokalemia
The cardiac glycosides
STEROIDS Drug-Drug Interactions

 Nursing responsibilities
3. Protect patient from infection
4. Handle patient gently
5. Instruct to take meds WITH MEALS to prevent
gastric ulcer formation
STEROIDS
 Nursing responsibilities
6. Caution the patient NOT to abruptly stop the
drug
7. Drug is tapered to allow the adrenal gland to secrete
endogenous hormones
STEROIDS
Evaluation:
The drugs are effective if there is:
• Relief of signs and symptoms of inflammation
• Return of adrenal function to normal
The cardiac glycosides
 These are agents extracted from the foxglove plant.
They are available in oral and parenteral preparations. The
following are the cardiac glycosides:
 Digoxin (Lanoxin)
 Digitoxin (Crystodigin)
 Ouabain
The cardiac glycosides
Pharmacodynamics: the Mechanism of action
 They increase the level of CALCIUM inside the cell
by inhibiting the Sodium-Potassium pump.
 More calcium will accumulate inside the cell during
cellular depolarization.
The cardiac glycosides
 Positive inotropic Effect- the myocardium will contract
forcefully
– Increased cardiac output
 If taken with potassium-losing diuretics like
furosemide- can INCREASE the risk of toxicity and
arrhythmias. Potassium replacement must be given.
The cardiac glycosides
Implementation
 Administer the initial rapid digitalization and loading
dose as ordered intravenously

Monitor the APICAL pulse rate for ONE full minute
before administering the drug. Withhold the drug if
– Less than 60 in adults
– Less than 90 in infants
– More than 110 in adults
 Retake pulse in one hour, if pulses remain abnormal,
refer!
The cardiac glycosides
Implementation
 Check the spelling of the drug- DIGOXIN is different
from DIGITOXIN!
 Check the dosage preparation and the level of digitalis
in the blood. (Therapeutic level is 0.5 to 2.0 nanograms/mL)
 Administer intravenous drug VERY slow IV over 5
minutes to avoid arrhythmias. Do NOT administer
intramuscularly because it can cause severe pain
The cardiac glycosides
Implementation
 Administer the drug without food if possible to avoid
delayed absorption. Weight patient daily to determine fluid
retention
 Maintain emergency equipment and drugs= Potassium
salts, Lidocaine for arrhythmias, phenytoin for seizures, atropine
for bradycardia.
 Provide comfort measures- small, frequent meals,
adequate lighting, comfortable position, rest periods and safety
precautions
The cardiac glycosides
Implementation
 Provide health teaching- drug name, action, dosage
and side effects. Advise the patient to report any of the
following: Visual changes, rapid weight gain, unusually low
heart rate, persistent nausea, vomiting and anorexia

– Increased blood flow to the body organs like the kidney

 Monitor serum potassium level
The cardiac glycosides
and liver Evaluation
 Negative chronotropic effect- the heart rate is slowed Evaluate effectiveness of the drug:
due to decreased rate of cellular repolarization Increased urine output
– Bradycardia
Normal heart rate in arrhythmia

 Decreased conduction velocity through the AV node

The cardiac glycosides
Clinical Use of the cardiac glycosides The Antianginal drugs
 Treatment of congestive heart failure
 In the treatment of angina, three agents are commonly  She should NEVER USE her bare fingers because the
employed- drug can be absorbed, utilize gloves or tongue blades instead.
– Organic nitrates
The Nitrates
Implementation
– Beta-blockers and  Apply nitroglycerin patch to an area with few hairs.
– Calcium-channel blockers. Never touch the medication portion.

 The benefits of the drugs lie in their different mode of

 The patch and the ointment should NOT be applied
near the area for defibrillation because explosion and skin burns
action.
may result
The Antianginal drugs
The Nitrates
IMPLEMENTATION
 The nitrates can cause vasodilatation of the veins and  Emphasize that tolerance to the nitroglycerin can
to some extent, coronary artery occur.
The Antianginal drugs  If the medication cannot relieve the pain, report to the
hospital immediately.
The Nitrates
 Beta-blockers will decrease the heart rate IMPLEMENTATION
The Antianginal drugs  Provide client health teaching- the sublingual
nitroglycerin tablet is USED if chest pain occurs
 The dose may be repeated if pain is unrelieved
 Calcium-channel blockers will decrease force of within 5 minutes.
contraction leading to a decreased myocardial workload and  Repeat the medication administration if the pain
demand. has not yet subsided.
 They can also produce vasodilation  DO NOT give more than 3 tablets!!! If chest pain
The Organic nitrates persists for more than 15 minutes, hospital consult should
be done immediately.
 These agents are simple nitric and nitrous acid esters
The Nitrates
of alcohols. Being alcohol, they differ in their volatility. The IMPLEMENTATION
following are the nitrates commonly used:
 Nitroglycerin- A moderately volatile nitrate
 Instruct the client to avoid alcohol while taking
nitroglycerin to avoid potentiating the hypotensive effect of the
 Isosorbide Dinitrate (Isordil) or mononitrate medication
 Amyl nitrate- an extremely volatile nitrate  If beta blockers and calcium-channel blockers are
The Organic nitrates given, instruct the patients to consult the physician before
Nitroglycerin discontinuing the medication
 This agent is supplied in oral, spray, transdermal and
ointment preparations. The Nitrates
The Organic nitrates IMPLEMENTATION
Pharmacodynamics: the mechanism of action  Other components of health teaching for home self-
 Nitroglycerin relaxes the smooth muscles in the
administration:
vascular system by its conversion to nitric oxide, a – If taking Sublingual Nitroglycerin, the patient should be
chemical mediator in the body that relaxes smooth instructed to place the tablet under the tongue for quick
muscles. absorption.
The Organic nitrates – A burning sensation/biting/stinging sensation may
Pharmacokinetics- absorption to excretion indicate that the tablet is FRESH!
 It can be given orally, parenterally and topically. – Store the tablet in a dark container, keep it away from
 The onset of action of nitroglycerin is more than 1 hour. heat and direct sunlight to avoid lessening the potency
The Nitrates
 Because significant first-pass hepatic effect, IMPLEMENTATION
Nitroglycerin is given SUBLINGUALY.  Other components of health teaching for home self-
The Organic nitrates
administration:
Pharmacodynamics: Side effects and adverse effects
 HEADACHE is the most common effect of
– HEADACHES are common in the initial period of
nitroglycerin therapy. Advise patient to take PARACETAMOL for
nitroglycerin.
relief
 CVS- postural Hypotension, facial flushing, tachycardia
– The nitroglycerin patch is applied once a day, usually in
 TOLERANCE- the tolerance to the actions of nitrates the morning. The sites should be rotated, in the chest, arms and
develop rapidly. This can be managed by providing a day of thighs avoiding hairy areas.
abstinence.
The Nitrates
The Nitrates IMPLEMENTATION
Implementation  Other components of health teaching for home self-
 Monitor vital signs, especially watchful for hypotensive administration:
episodes – Position supine with elevated legs to manage
 Advise patient to remain supine or sit on a chair when Hypotension.
taking the nitroglycerin for the first time. Emphasize that he – Nitroglycerin tablet can be taken prophylactically
should change his position slowly or rise from bed slowly to
in situations where chest pain is anticipated- Sex, exercise,
avoid orthostatic Hypotension
etc..
 Offer sips of water before giving sublingual
– If patient is taking beta blockers, instruct how to obtain
nitroglycerin because dryness may inhibit drug absorption
heart rate in a minute
The Nitrates
Drugs for Shock
Implementation
Dopamine
 Apply nitroglycerin ointment to the designated mark on
 This is a sympathomimetic drug often used to treat
paper.
Hypotension in shock states that are not caused by
 The nurse should remove any excess ointment on the Hypovolemia.
skin from the previous dose.
 This drug is an immediate precursor of nor-
epinephrine, occurs naturally in the CNS basal ganglia where it
functions as a neurotransmitter.

Drugs for Shock

Dopamine
Class Prototype MOA Side effects
 Pharmacodynamics: It can activate the alpha and beta Diuretics Furosemide Decreases Hypokalemia
adrenergic receptor depending upon the concentration. It blood volume
stimulates receptors to cause cardiac stimulation and renal Beta- Propranolol Blocks B1 Bradycardia,
vasodilation. blocker receptor in thehypoglycemia
 The dose range is 1-20 micrograms/kg/min heart
Drugs for Shock ACE Captopril Prevents A1 Headache,
Dopamine Inhibitors to AII Cough,
 Pharmacokinetics: Dopamine is administered IV, conversion flushing
excreted in the urine. Ca channel Nifedipine Blocks Ca Headache,
blockers entry into cell flushing,
 At low dose (1-2 micrograms), dopamine DILATES reflex
the renal and mesenteric blood vessels producing an increase tachycardia
output (dopaminergic effect) Vasodilator Nitroglycerin Dilates veins HEADACHE
Drugs for Shock and arteries
Dopamine Alpha Prazozin Blocks alpha Urination
 At moderate dose of 2-10 micrograms, dopamine blockers receptor in BV
enhance cardiac output by increasing heart rate (beta 1- causing
adrenergic effect) and elevates blood pressure through vasodilatation
peripheral vasoconstriction (alpha adrenergic effect) Central Clonidine Stimulates Depression
Drugs for Shock alpha CNS alpha 2
Dopamine agonist receptor
 At higher doses of more than 10 micrograms- The antianemics: Iron preparations and Epoetin
vasoconstriction of all vessels will predominate that can lead
to diminished tissue perfusion Iron preparations
Drugs for Shock  Iron is important for hemoglobin formation.
Dopamine
 Dopamine is indicated to treat Hypotension, to The iron preparations are:
increase heart rate and to increase urine output (given less than HEPARIN WARFARIN
5 mg/kg/min)
 The nurse typically prepares the dopamine drip- Parenteral (SQ and IV) Oral
dopamine (at a concentration of 400-800 mg) is mixed in 250
mL D5W and administered as drip via an infusion pump for Action is to enhance natural Action is to INHIBIT Vitamin-K
precise dosage administration. anti-thrombin II in the blood dependent clotting factors
 Sodium bicarbonate will inactivate the dopamine (10,9,7,2)
Drugs for Shock
Dopamine Acts within minutes Acts within days
 Pharmacodynamics: side effects- Tachycardia
hypertension Monitor for aPTT Monitor for PT and INR
ectopic beats, angina, dysrhythmias, myocardial ischemia,
nausea and vomiting. Large molecule, can be given Small molecule CANNOT be
Drugs for Shock to pregnant given to pregnant
Dopamine: Nursing consideration
Antidote: Protamine sulfate Antidote: Vit. K
– Check the IV site hourly for signs of drug infiltration of
dopamine, which can cause tissue necrosis.
– Phentolamine should be infiltrated in multiple areas to SE: bleeding, decreased SE: Bleeding
reduce tissue damage. platelets

– Drug is effective if Urine output is increased and BP is

increased  Ferrous sulfate
Antihypertensive drugs  Ferrous fumarate
The Drugs employed to control hypertension can be  Ferrous gluconate
classified as:
 Diuretics The antianemics: Iron preparations and Epoetin
 Beta-blockers Side-effects:
 Alpha adrenergic blockers GIT- constipation (usually), diarrhea, vomiting, epigastric
pain, gastric ulceration and darkening of stools.
 Calcium channel blockers
 Angiotensin-converting enzyme inhibitors  Liquid preparation can stain the teeth, and
 Angiotensin II receptor blockers injectable iron can cause tissue discoloration
 Peripheral vasodilators  Other- dizziness
Common Drugs in HPN
IN Evaluating the effectiveness of these drugs is simply to The antianemics: Iron preparations and Epoetin
monitor the BP if it becomes NORMAL Drug-Drug interaction
 Tetracyclines combine with iron preparations and
Anticoagulants render the iron unabsorbable.
 Antacids and cimetidine- decrease iron absorption and
effects
 Foods can impair iron absorption but they should be
taken with iron to reduce GI discomfort.
 Milk containing foods, coffee, tea and eggs are NOT
given with iron because they delay iron absorption.
The antianemics: Iron preparations and Epoetin
Implementation  Monitor patient response to the drug= increased
 Encourage the patient to eat iron-rich foods like liver, hemoglobin
lean meat, egg yolk, dried beans, green leafy vegetables.
 Administer iron preparations orally with foods to Psychotrophic drugs
decrease GI discomfort.
 If increased absorption is necessary, administer IN • Drugs that can:
BETWEEN meals with full glass of water or juice.
 It is best to offer citrus juices because the vitamin • Stimulate the release of neurotransmitters
C content can increase iron absorption.
 Instruct the patient to swallow the whole tablet and • Block the receptor/activity of the neurotransmitter= like
remain upright for 30 minutes to prevent esophageal corrosion dopamine
from reflux.
 DO NOT administer iron together with or within 1 hour
• Stimulate the receptors in the CNS
of ingesting tetracyclines, antacids, milk and milk-containing Extra-Pyramidal Syndrome Nursing Intervention
products. Parkinsonism-Tremor, Avoid abrupt withdrawal,
 Advise clients to increase fluid intake and consume rigidity, bradikinesia give anti-EPS drugs like
fiber rich foods if constipation becomes a problem. Cogentin
The antianemics: Iron preparations and Epoetin Dystonia- torticollis, Remain with client,
Implementation contraction of face and administer anti-EPS
 Emphasize that the therapeutic effect of iron tongue
therapy may not be apparent until several weeks. Akathisia= motor Verbalize understanding of
 If injecting a parenteral iron preparation, inject restlessness the condition, administer
anti-EPS
DEEP IM utilizing the Z-track method to avoid leakage into
the subcutaneous tissues and skin. Tardive Dyskinesia= No treatment except
irreversible drooling, tongue discontinue drug
 Offer straw if giving liquid iron preparation to avoid
movement and shuffling gait
staining the teeth.
Neuroleptic Malignant Notify physician, prepare to
 To prevent undue alarm, instruct the patient that syndrome= elevated temp, administer dantrolene
the stools may turn black or dark green. This is a harmless treme muscle rigidity
occurrence.
The antianemics: Iron preparations and Epoetin
Evaluation
 The nurse evaluates the effectiveness of the drug
therapy by determining that the client is not fatigued, with
absence of pallor, and with hemoglobin results within desired
range. • • Prevents the breakdown of the
neurotransmitters or the re-uptake mechanism
Anti-Psychotics/Neuroleptics
Erythropoietin
The mechanism of action of epoetin alfa • Drugs used to treat PSYCHOSES
(Epogen)
 This drug acts like the natural glycoprotein Class Prototype Others
erythropoietin to stimulate the production of RBC in the bone
marrow.
Phenothiazines Chlorpromazine Thioridazine,
Erythropoietin Fluphenazine,
Clinical indications Perphenazine
 It is given SUBCUTANEOUSLY or INTRAVENOUSLY
for the treatment of anemia associated with renal failure or for
patients on dialysis. Haloperidol droperidol
 It is also used in patients for blood transfusion to Butyrophenones
decrease the need for blood in surgical patients.
Thioxanthines Chlorprothixene thirothixene
Erythropoietin
Pharmacodynamics: the adverse effects of epoetin alfa
 CNS- headache, fatigue, asthenia, dizziness and Dibenzoxapine Molindone
seizures- these are due to the cellular response to the
glycoprotein.
 GIT- nausea, vomiting and diarrhea Diphenyl Pimozide
butlypiperidine
 CVS- hypertension, edema and chest pain due to
increase RBC number
Atypical drugs Clozapine Olanzapine
Erythropoietin
Implementation
 Administer the drug SC or IV usually 3 times per week. Risperidone quetiapine
 Monitor the IV access line if given IV. Do not mix with
other solutions
 Determine periodically the level of hematocrit and iron
stores during therapy. If patient does not respond to the drug,
reevaluate the cause of anemia. • MAIN ACTION: Blockage of the DOPAMINE receptor
 Maintain seizure precaution on stand by as seizure can in the CNS
occur.
 Provide comfort measures like small frequent feedings Desired Effects
and pain medications for headache.
 Provide thorough health teaching: need for lifetime 1 Reduced hallucination and illusions
injection
2 CNS sedation and emotional slowing
Erythropoietin
3 Decreased ambivalence, reduced delusion
Evaluation
4 Reduced agitation resulting to calmness Acetylcholine

5 Relief of emotional turmoil Acetylcholine-ESTERASE

6 Reduced flattening of affect Rest and Digest

Common SE Nursing Interventions The autonomic drugs

 Pharmacologic use depends on their EFFECTS on
Anticholinergic effects Sugarless gum, bed rest the body

Photosensitivity Sunglasses, sunscreen, avoid  They can STIMULATE= agonists OR mimetics

sun
Postural hypotension Change position slowly, lie
prone for 1 hour after drug
intake, monitor BP
Agranulocytosis Instruct to report sore throat
and fever, monitor WBC
Seizure Monitor EEG
Sedation Safety, no machine operation
 They can DECREASE THE RESPONSE=
antagonists OR blockers
The autonomic drugs
They can STIMULATE= agonists OR mimetics
 DIRECT STIMULATION by binding with receptors
 INDIRECT STIMULATION by blocking the enzymes
that degrade the neurotransmitters or increasing the
release of neurotransmitters
The autonomic drugs
They can DECREASE THE RESPONSE= antagonists OR
blockers

 DIRECT blockage by removing the

neurotransmitter or competing with the neurotransmitter
Review Outline
 Binding with the receptor and NO RESPONSE will
 Adrenergic Agonists
happen
 Adrenergic Antagonists The autonomic drugs
 Cholinergic Agonists They can be
 Cholinergic Antagonists
NON-SELECTIVE when they stimulate or block many
Comparison of the Sympathetic and Parasympathetic Nervous receptors
system
SELECTIVE when they stimulate or block specific receptors

Characteristics Sympathetic SPECIFIC when only ONE type of receptor is stimulated or

blocked
CNS origin Thoraco-lumbar spinal cord
The autonomic drugs: Pharmacologic use depends on
their EFFECTS on the body
Pre-ganglionic neuron Short axon
The Adrenergic AGONISTS
Pre-ganglionic NTA Acetylcholine
 Also called SYMPATHOMIMETIC agents

 These drugs MIMIC the effects of the sympathetic

Ganglia location Next to spinal cord
nervous system
The Adrenergic AGONISTS
Post-ganglionic neuron Long axon  They usually stimulate DIRECTLY the receptors of
the adrenergic system
The Adrenergic AGONISTS
Post-ganglionic NTA Epi and NE  Alpha and Beta agonists (non-selective)
 Prototype: Epinephrine
Enzyme for NTA MAO, COMT
 Alpha Agonists (Selective)
General response Fight or flight
 Prototype: Phenylephrine

 Beta Agonists (Selective)

 Prototype: Isoproterenol
The Adrenergic AGONISTS
 Alpha and Beta agonists (non-selective)
Pharmacodynamics:
These agents stimulate ALL types of adrenergic
receptors in the body by direct interaction or by releasing
neurotransmitters from the nerve cells
The Adrenergic AGONISTS
Parasympathetic  Alpha and Beta agonists
Cranio-Sacral spinal cord  Prototype: Epinephrine
1. Ephedrine
2. Epinephrine
Long axon 3. Metaraminol
4. Norepinephrine
Acetylcholine
5. Dobutamine (sometimes a B1 specific)
Near target organ 6. Dopamine
The Adrenergic AGONISTS
Short axon Alpha and Beta agonists: Clinical Use
 1. Dopamine- used in shock
 2. Epinephrine- drug of choice of anaphylaxis, Alpha Agonists: Nursing considerations
Status asthmaticus 1. DO NOT discontinue drug abruptly to prevent rebound
 3. Norepinephrine- used in shock effect
2. Maintain phentolamine if giving IV drug
 4. Dobutamine- used in CHF
3. Provide comfort measures- rest, quiet environment,
 5. Ephedrine- used in shock, asthma and rhinitis analgesics
The Adrenergic AGONISTS The Adrenergic AGONISTS
 Alpha and Beta agonists: Desirable effects Alpha Agonists: Nursing considerations
 Increased myocardial contractility Evaluate effectiveness:
 Bronchial DILATATION Decreased BP
 Vasoconstriction Decreased Nasal congestion
 Increased blood pressure The Adrenergic AGONISTS
Beta Agonists (Selective): ANTI-ASTHMA DRUGS
 Decreased intraocular pressure
 Pupillary dilatation Prototype: isoproterenol (B1 and B2)
salbutamol (Ventolin)= B2 specific
The Adrenergic AGONISTS
• Ritodrine (B2 specific)
 Alpha and Beta agonists: Contraindications
• “terol”- albuterol, salmeterol, bitolterol
 Pheochromocytoma
 Tachyarrhythmias • Terbutaline (B2)
 With halogenated anesthesia- increased sensitivity
The Adrenergic AGONISTS
to adrenergic drugs
Beta Agonists Pharmacodynamics
The Adrenergic AGONISTS
These agents bind to the BETA receptors causing
 Alpha and Beta agonists: Adverse effects the sympathetic manifestations and effects
 Sympathetic stimulation effects The Adrenergic AGONISTS
CVS- hypertension, tachycardia, palpitations Beta Agonists Clinical use
Respi- tachypnea • Asthma- due to the bronchodilation!
GI- nausea, vomiting
Others- sweating, headache, piloerection
• Preterm labor- ritodrine is given to relax the uterine
The Adrenergic AGONISTS muscles
Alpha and Beta agonists: Nursing considerations • Shock= To increase BP
• Monitor patient response to the drug The Adrenergic AGONISTS
Beta Agonists Adverse effects
• Emphasize to avoid the use with MAOIs and TCA CNS- restlessness, headache, anxiety , tremors
• Maintain phentolamine (alpha blocker) to manage CVS- tachycardia, angina, palpitations
extravasation of IV drug GI- nausea, vomiting and anorexia
• Usually given IV Others- pupilary dilation, rash, sweating, pulmonary edema
The Adrenergic AGONISTS
The Adrenergic AGONISTS Beta Agonists Nursing considerations
Alpha and Beta agonists: Nursing considerations • Monitor VS when giving the drug
Determine effectiveness of the drug: • Remind mothers to lie on the left side during
Increased BP in shock ritodrine administration
Relief of anaphylaxis and asthma attack
Relief of nasal congestion
• Maintain a beta blocker on stand by
The Adrenergic AGONISTS • Provide comfort- quiet environment, rest,
Alpha Agonists (selective) analgesics.
• Prevent over-hydration to avoid pulmonary edema
Prototype: phenylephrine
clonidine (alpha-2 specific)
The Adrenergic AGONISTS
Alpha Agonists Pharmacodynamics: The Adrenergic AGONISTS
Beta Agonists Nursing considerations
These agents bind primarily to the alpha receptors  These are given usually inhalational for asthma
in the body attack
Clonidine  Instruct on how to use inhalers and nebulizers
Stimulating the ALPHA-2 receptor causes Evaluate effectiveness:
decreased sympathetic outflow from the CNS/ decreased Normal RR
release of NE Clear breath sounds
The Adrenergic AGONISTS The Adrenergic ANTAGONISTS
Alpha Agonists: Clinical use
 These are called adrenergic blockers
• Phenylephrine- vasoconstricting drug, used
topically to decrease the symptoms of rhinitis
 They can be Alpha Blockers (selective)
Beta Blockers (selective)
• Clonidine- for hypertension Both Alpha & Beta
The Adrenergic AGONISTS Blockers
Alpha Agonists: Contraindication (non-
• Allergy to drug selective)
• Caution in the following conditions: The Adrenergic ANTAGONISTS
• Hyperthyroidism-aggravation of symptoms The alpha blockers (selective)
• Diabetes- increased glucose levels
• Tachyarrhythmias- possible additive effect

Prototype: Phentolamine
The Adrenergic AGONISTS Phenoxybenzamine
Alpha Agonists: Adverse effects “zosin”- prazosin, doxazosin,
CNS- anxiety, depression, fatigue terazosin- these are alpha blockers
CVS- palpitations The Adrenergic ANTAGONISTS
GI- nausea, vomiting and anorexia The alpha blockers: Pharmacodynamics
GU- oliguria, dysuria These agents have affinity for the ALPHA receptors
The Adrenergic AGONISTS
Blocking the alpha receptors will cause: CVS- bradycardia, hypotension, heart block
Vasodilation CNS- fatigue, dizziness, depression
Sphincter relaxation in the bladder Respi- bronchospasm, pulmonary edema
GI- nausea, vomiting, diarrhea, hypoglycemia
The Adrenergic ANTAGONISTS GU- decreased libido, impotence, dysuria
The alpha blockers: Clinical use The Adrenergic ANTAGONISTS
• Phenoxybenzamine- used in pheochromocytoma The Beta blockers: nursing considerations
• Phentolamine- also used in pheochomocytoma • Emphasize NOT to stop abruptly the drug intake
• “zosin” drugs- are used to decrease blood • Give with FOODS to improve absorption
pressure and to relax the urinary sphincter in BPH! • Provide comfort measures
The Adrenergic ANTAGONISTS  Adequate rest periods
The alpha blockers: Contraindications  Avoidance of hazardous activities
 Change position slowly
• Myocardial infarction The Adrenergic ANTAGONISTS
• Allergy The Beta blockers: nursing considerations
Evaluate effectiveness:
The Adrenergic ANTAGONISTS Decreased BP in hypertension
The alpha blockers: Adverse Effects Decreased HR in hyperthyroidism
CVS- hypotension, reflex tachycardia, flushing Decreased PAIN angina
CNS- dizziness, weakness, fatigue, drowsiness
Others- nasal congestion, reddened eyes, priapism
The Adrenergic ANTAGONISTS The Cholinergic Agonists
The alpha blockers: nursing consideration  These are also called parasympathomimetic agents
• Monitor heart rate and BP
• Caution to change position slowly  Their action mimics the parasympathetic nervous
• Advise to avoid hazardous activities system
• Provide supportive measures like quiet
environment, rest and analgesics The Cholinergic Agonists
• Monitor response to the drug- improvement of  These agents INCREASE the activity of
blood pressure readings and urination acetylcholine in the acetylcholine receptors
The Adrenergic ANTAGONISTS
The Beta blockers
 DIRECTLY by occupying the receptor
These are agents used to treat cardiovascular  INDIRECTLY by blocking the enzyme that degrades
problems- Hypertension, CHF, angina the acetylcholine, preventing it from breakdown - the
Blocking beta receptor will cause enzyme: acetylcholinESTERASE
decreased heart rate The Cholinergic Agonists
decreased BP  Direct acting cholinergic agonists
The Adrenergic ANTAGONISTS Prototype: BetaneCHOL
The Beta blocker or The “olol”s CarbaCHOL
They can be beta 1 blockers, beta 2 blockers or Pilocarpine
Both  Indirect acting cholinergics
Prototype of non-selective: propranOLOL (beta 1 and 2) Prototype: Pyridostigmine
carteOLOL Neostigmine
nadOLOL Endrophonium (Tensilon)
penbutOLOL The Cholinergic Agonists
sotaLOL Direct acting cholinergic agonists
The Adrenergic ANTAGONISTS Pharmacodynamics
The Beta blocker or The “olol”s  They are similar to acetylcholine and directly act
They can be beta 1 blockers, beta 2 blockers or on the acetylcholine receptors
Both
Prototype of B1 selective: atenOLOL The Cholinergic Agonists
acebutOLOL Direct acting cholinergic agonists
betaxOLOL Parasympathetic stimulation will cause:
esmOLOL DUMBELS
metoprOLOL urination
The Adrenergic ANTAGONISTS miosis (pupil constriction)
The Beta blockers: pharmacodynamics The Cholinergic Agonists
These agents block the beta receptors of the Direct acting cholinergic agonists: Clinical use
sympathetic system. The selective B1 antagonists block
the B1 receptors, especially in the heart and the kidney
• Post operative and post partum urinary retention
The Adrenergic ANTAGONISTS and to treat neurogenic bladder
The Beta blockers: Clinical use • Relief of increased intraocular pressure of
• Hypertension glaucoma by inducing miosis
The Cholinergic Agonists
• Angina and MI Direct acting cholinergic agonists: Clinical use
• Cardiac arrhythmias • The drugs INCREASE the bladder tone, RELAX the
• Migraine headache GI and urinary sphincters
• HYPERTHYROIDISM • The topical agent (pilocarpine) topically causes
The Adrenergic ANTAGONISTS pupilary constriction to reduce IOP
The Beta blockers: Clinical use The Cholinergic Agonists
Direct acting cholinergic agonists: Contraindications
The Adrenergic ANTAGONISTS • Bradycardia
The Beta blockers: contraindications
• Hypotension
• Allergy
• Asthma
• Heart blocks The Cholinergic Agonists
• Bradycardia Direct acting cholinergic agonists: Adverse effects
• COPD (DUMBELS)
• Precaution in DM CVS- bradycardia, heart block, hypotension
The Adrenergic ANTAGONISTS GIT- nausea, vomiting, diarrhea, increased salivation,
The Beta blockers: Adverse effects lacrimation
GUT- sense of urgency, sphincter relaxation Atropine
Others- increased sweating, headache, miosis  Depresses salivation
The Cholinergic Agonists  Decreases bronchial secretions
Direct acting cholinergic agonists: nursing considerations
 Mydriasis
• Assure proper administration of ophthalmic
 Cyclopedia
preparations
 Inhibits vagal response in the heart
• Administer on EMPTY stomach
 Reverses cholinergic toxicity
• Provide safety precautions- because of poor visual
acuity Atropine
• Promote cool environment, maintain access to the Scopolamine
bathroom (urination)  Decreases nausea and vomiting associated with
motion sickness
The Cholinergic Agonists: evaluate effectiveness Anticholinergic
The Cholinergic Agonists
Indirect acting cholinergic agonists
 Contraindications of anticholinergic
Pharmacodynamics
These agents DO NOT react directly with the • Known allergy
receptors but REACT chemically with the enzyme= • Glaucoma
acetylcholinesterase • Bladder obstruction (like PBH)

The Cholinergic Agonists Anticholinergic

Indirect acting cholinergic agonists Adverse effects: anticholinergic effects
Pharmacodynamics CNS- blurred vision, pupil DILATION, photophobia,
The acetylcholine breakdown is prevented so that cycloplegia and increased Intraocular pressure
the effect of acetylcholine is prolonged!= increased muscle GI- dry mouth, constipation, bloatedness
contraction CVS- tachycardia, palpitations
GU- urinary retention
They are used IN myasthenia gravis Others- decreased sweating, flushing
The Cholinergic Agonists Anticholinergic
Indirect acting cholinergic agonists Nursing considerations
Clinical use • Provide comfort measures
• Myasthenia gravis  Frequent mouth care
 Physostigmine, pyridostigmine, Neostigmine, and  Provide increased fluids
endrophonium  Protect eyes form lights
2. Alzheimer's disease
 Advise to avoid hazardous activities
 Tacrine and Donepezil
The Cholinergic Agonists
 Provide high-fiber diet and laxative
Indirect acting cholinergic agonists  Avoid extremes of temperature
Adverse effects  Instruct to void before administering the drug
GI- nausea, vomiting, cramps, diarrhea, increased
salivation, involuntary defection
CVS- bradycardia, heart block, hypotension Anticholinergic
GU- urinary urgency Nursing considerations
Others- blurred vision, miosis, headache, dizziness 2. Monitor for toxicity:
The Cholinergic Agonists 3. Ensure adequate hydration to prevent hyperpyrexia
Indirect acting cholinergic agonists Evaluate effectiveness of drug:
Nursing considerations Increased HR in heart block
• Administer IV drug slowly Decreased secretions in pre-op patients
Relief of motion sickness (scopolamine)
• Administer better BEFORE meals
• Maintain atropine sulfate as antidote
• Discontinue the drug if excessive salivation, ANTIBIOTICS
diarrhea, vomiting become problematic
Anti-tubercular Side effects
The Cholinergic Agonists drugs
Indirect acting cholinergic agonists INH Peripheral neuritis
Nursing considerations Give Vitamin B6 (pyridoxine)
Evaluate effectiveness Rifampicin Reddish-orange discoloration of the
Decreased muscle weakness secretion
Decreased dysphagia, ptosis Hepatotoxicity, jaundice
Increased muscular activity Pyrazinamide Hyperuricemia, not given in gout
The ANTI-cholinergics Ethambutol Optic neuritis, color vision disturbance,
 These are drugs that BLOCK the effect of NOT given to children
acetylcholine Streptomycin An aminoglycoside that can cause
 They are also called parasympatholytic agents ototoxicity
 In effect, the sympathetic system becomes Given IM
unopposed!!!
The ANTI-cholinergics
 Anticholinergics:
Prototype: Atropine
dicyclomine
glycopyrrolate
propantheline
scopolamine
The ANTI-cholinergics
Anticholinergics: pharmacodynamics
These agents work by BLOCKING or COMPETING
with acetylcholine for the acetylcholine receptors

BEST taken BEFORE MEALS