PHARMACOLOGY

Definition of Terms
 Pharmacology
 Pharmacodynamics
 Pharmacokinetics
-absorption
-distribution
-metabolism
-elimination
 Pharmacotherapeutics
 Pharmacognosy
 Toxicology
 Half Life, Peak Plasma Level
 Adverse Effects
 Efficacy and Potency
 MTC and MEC

Drug concentration in plasma after a single oral administration of drug

Drug concentration in plasma after multiple oral administrations of drugs

Drug concentration in plasma after a single intravenous (bolus) administration of drug

Drug Uses
 Palliative treatment
 Preventive treatment
 Diagnostic drugs
 Curative treatment
 Health maintenance drugs
 Contraceptive drugs
Dosage Forms
 Tablets
-is the most popular dosage form and usually the easiest to administer
-mostly contains a disintegrating agent in their formulation (cornstarch)
-some are scored
-some are enteric-coated
>should never be crushed or chewed
>should never be administered with antacids, milk or other alkaline substances
*Timed or Sustained Release Tablets
-for permitting drugs to be released from tablets in controlled fashion
-forms:
>crystals of the active ingredient embedded in a wax
>microencapsulated with varying degrees of thickness of the polymer coating
>osmotic pumps

 Capsules
-is a dosage form in which a drug is enclosed in either a hard or soft soluble shell, usually made up of gelatin.
-the shell generally dissolves in the stomach in 10-20 minutes
-hard gelatin capsules or soft gelatin capsules

 Troches
-also called lozenges
-are solid dosage forms that are generally disc shaped and dissolved slowly in the mouth

 Suppositories
-a dosage form that is to be inserted into one of the external body orifices, usually in the rectum, vagina or urethra
-may exert a localized or systemic effect
-cocoa butter is the most popular vehicle or base
>is waxy solid at room or refrigerator temperatures, but melts at body temperature

 Solutions
-is a clear liquid preparation that contains one or more solvents and one or more dissolved components, or solutes.
-often colored and flavored
-easy to administer particularly for the pediatric and geriatric age groups
*Syrups
-are sweetened solutions that are often used to mask the unpleasant taste of certain drugs
-has soothing effect
*Elixirs
-contain a solvent mixture of alcohol and water as well as other components
*Tinctures
-contain alcohol as the primary solvent but which may contain water as well
-are available for internal or external use
*Douche
-is intended to be used in cleansing a body part or cavity, usually the vagina
-prepared by diluting a liquid concentrate or powder with water to make an appropriate strength
 Suspensions
-are liquid dosage forms that contain solid drug particles that are suspended in a suitable liquid medium
-should never be administered intravenously

 Emulsions
-are dispersions of fine droplets of an oil in water or water in oil
-those which contain an oil dispersed in water are primarily used orally
-those which contain water dispersed in oil are used primarily for topical applications
*must be shaken thoroughly prior to use

 Topical
 Implants
 Parenteral products

Pharmacodynamics
 Drugs usually act in one of four ways:
1. To replace or act as substitutes for missing chemicals
2. To increase or stimulate certain cellular activities
3. To depress or slow cellular activities
4. To interfere with the functioning of the foreign cells such as invading microorganisms or neoplasm
  Receptor Sites
-specific areas in a cell where many drugs are thought to act
-reacts with certain chemicals to cause an effect within the cell (enzyme system activation or inhibition)
-agonism, antagonism (competitive and non competitive)
 Drug-Enzyme Interactions
 Selective Toxicity

Drug-receptor interaction

Protein-bound drug molecules

Pharmacokinetics
 Critical Concentration/Therapeutic Index
 Loading dose/Maintenance dose
 Dynamic Equilibrium
-absorption, distribution, metabolism and excretion
A. Absorption
>passive diffusion
>active transport
>filtration
*First pass effect

Factors that affect absorption of drugs:

 Intravenous
-none (direct entry into the venous system)
 Intramuscular
-Perfusion or blood flow to the muscle
-Fat content of the muscle
-Temperature of the muscle
 Subcutaneous
-Perfusion or blood flow to the tissues
-Fat content to the tissues
-temperature of the tissue
 Oral
-Acidity of the stomach
-length of time in the stomach
-blood flow to the GIT
-presence of interacting foods and drugs
 Rectum
-Perfusion or blood flow to the rectum
-lesions to the rectum
-length of time retained in the rectum for absorption
 Mucous membranes (sublingual, buccal)
-perfusion or blood flow to the area
 -integrity to the mucous membranes
-presence of food or smoking
-length of time retained in the area
 Topical
-perfusion or blood flow to the area
-integrity of the skin
 Inhalation
-perfusion to the area
-integrity of lung lining
-ability to administer drug properly

B. Distribution
-significant factors:
*ionization
*lipid solubility
*perfusion of reactive tissues
-affected by protein binding
-affected by the blood brain barrier
-affected by pregnancy and lactation

C. Biotransformation (metabolism)
-needed in the maintenance of homeostasis
-the liver enzyme systems serve as the single most important site of drug metabolism
-the liver enzymes as the hepatic microsomal system
-types:
1. Phase I Biotransformation
>oxidation, reduction or hydrolysis
>involves the hepatic cytochrome P450 enzyme systems
2. Phase II Biotransformation
>conjugation reaction
-drugs that increase or induce the hepatic enzyme systems:
*Nicotine
*Alcohol
*Glucocorticoids
-drugs that inhibit or decrease hepatic enzyme system activity
*Ketoconazole
*Mexiletine
*Quinidine

D. Excretion
-removal of the drug from the body
-kidneys, skin, saliva, lungs, bile and feces
-water soluble drugs > glomerular filtration
-affected by the pH of the urine
Factors influencing drug effects:
1. weight- adult dosages based on a 150 pound person
2. age- extremes of ages (very young and very old)
3. gender- more adipose in women
4. physiological factors
-nervous and endocrine balance, acid-base balance, hydration and electrolyte balance
5. pathological factors
-diseases that can affect absorption,
-distribution, metabolism and excretion of the drug
6. Genetic factors
-predictable differences in the pharmacodynamic and pharmacokinetic processes based on the hepatic enzyme
systems
7. Immunological factors
-hypersensitivity
8. Psychological factors
-placebo effect
-health seeking behavior affects compliance to drug therapy
9. Environmental factors
-environmental temperature to affect antihypertensive agents
-sedatives affected by environmental noises
10. Tolerance
11. Cumulation
-occurs with shorter frequency and a relatively larger dosage than recommended
12. Drug to drug interaction
A. absorption- aspirin and antacids
B. distribution- methotrexate and aspirin
C. metabolism- phenobarbital and warfarin
D. Excretion- Quinidine and Digoxin
13. Drug-Food Interactions
-tetracycline and iron
-tetracycline and calcium
14. Drug-Laboratory Test Interactions
-Dalteparin and Liver Function Test

Adverse Effects
>are undesired effects that may be unpleasant or even dangerous.
>can be of several types:
1. Primary Actions
2. Secondary Actions
3. Hypersensitivity
1. Primary Actions
-the development of adverse reactions from simple overdosage
-the patient suffers from the extension of the desired effects
-can be due to oversensitivity to the recommended dose
2. Secondary Actions
-undesirable secondary drug effect.
3. Hypersensitivity
-due to excessive responsiveness to either the primary or secondary effects of the drug

Drug Allergy
Four main classifications:
A. Anaphylactic Reactions
-this allergy involves an antibody that reacts with specific sites in the body to cause the release of chemicals, including
histamine, that produce an immediate reaction (mucous membrane swelling and constricting bronchi) that can lead to
respiratory distress and even respiratory arrest.
-signs/symptoms:
>rashes
>diaphoresis
>increased BP
>Panic feeling
>dilated pupils
>increased HR
>difficulty of breathing
>respiratory arrest
-interventions:
>Epinephrine
*massage the site to speed up the absorption process

B. Cytotoxic Reactions
-this allergy involves antibodies that circulate in the blood and attack antigens (the drug) on cell sites causing death of that
cell. This reaction is not immediate but may occur over a few days.
-signs/symptoms:
>decreased RBC, WBC and platelets
>elevated liver enzymes
>decreased renal function
-intervention:
>notify the prescriber
>discontinue the drug
>prevent infection
>conserve energy

C. Serum Sickness Reaction

-involves antibodies that circulate in the blood and cause damage to various tissues by depositing in blood vessels. This
reaction may occur up to a week or more after exposure to the drug.
-signs/symptoms:
>itchy rash
 >edema of the face and limbs
>high fever
>swollen lymph nodes
>swollen and painful joints
-interventions:
>notify the prescriber
>discontinue the drug
>supportive and symptomatic treatment

D. Delayed Allergic Reaction

-occurs several hours after exposure and involves antibodies that are bound to specific WBC
-signs/symptoms:
>rashes
>swollen joints
-interventions:
>notify the prescriber and discontinue the med

Drug Induced Tissue Damage

1. Dermatological Reactions
-may range from a simple rash to potentially fatal exfoliative dermatitis
A. Rashes
>Procainamide (antiarrythmic)
-frequent skin care
-avoid rubbing, tight or rough clothing, harsh soaps
-administer antihistamine
-steroids, antihistamine

B. Stomatitis
-due to direct reaction to the drug or due to drug deposits in the end capillaries in the mucus membranes leading to
inflammation
>Fluorouracil (antineoplastic)
-swollen gums and tongue
-difficulty swallowing
-halitosis
-pain in the mouth and throat
-interventions
-mouth care
-frequent small meals
-arrange for dental consultation
-antifungal or local anesthetic agents

C. Superinfections
-due to the usage of broad spectrum antibiotics
-signs/symptoms:
>variable (constitutional and nonconstitutional)
-interventions:
>supportive care
>antifungal
>discontinue the drug

2. Blood Dyscrasia
-bone marrow suppression due to drug effects
-caused by chemotherapeutic drugs
-signs/symptoms:
>nonspecific
>low platelets
>low RBC
>low WBC
-interventions:
>monitor blood counts
>supportive measures
>discontinue the drug until the recovery of the bone marrow

3. Toxicity
A. Liver Injury
-due to the extensive first pass effect
-signs/symptoms:
>fever, malaise, nausea, vomiting
>jaundice, change in the color of the urine
>elevated liver enzymes
*aspartate aminotransferase
*alanine aminotransferase
>alterations of clotting factors
>alterations in the bilirubin levels
-interventions:
>discontinue the drug
>notify the prescriber
>supportive care

B. Renal Injury
-due to plugging of the glomerular capillary network by an unchanged drug
-aminoglycosides (Garamycin)
-signs/symptoms:
>elevated results of renal function test (BUN and creatinine)
>decreased hematocrit
>electrolyte imbalances, edema
>fatigue, malaise, rashes
>irritability
-interventions:
>notify the prescriber
>discontinue the drug
>supportive measures
>dialysis

C. Poisoning
-occurs when an overdose of a drug damages multiple body systems which could be fatal
-assessment parameters and treatment varies depending on the drug

4. Alterations in Glucose Metabolism

A. Hypoglycemia
-due to antidiabetic drugs (oral hypoglycemic agents)
*Glypizide, Glyburide
-signs/symptoms:
>fatigue, drowsiness, hunger, anxiety, headache, cold clammy skin, shaking and
lack of coordination, increased HR, BP, numbness, tingling sensation of the mouth, tongue and/or
lips, confusion, rapid, shallow breathing, coma
-interventions:
>glucose (oral or IV)
>supportive measures
>safety measures
>reassurance
B. Hyperglycemia
-due to the stimulation of the breakdown of glycogen or alter metabolism in such a way as to cause a high serum
glucose level
-signs/symptoms:
>fatigue
>polydipsia&polyphagia
>polyuria
>Kussmaul’s respiration
>restlessness
>flushed skin
>nausea
>fruity odor of breath
-intervention:
>insulin therapy
>supportive measures
5. Electrolyte Imbalances
A. Hypokalemia
-due to drugs affecting renal function like the loop diuretics (Furosemide)
-signs/symptoms:
>potassium concentration <3.5 mEqs /L
>weakness, numbness, tingling of the extremities, muscle cramps, nausea, diarrhea, decreased bowel sounds,
irregular and weak pulse, orthostatic hypotension and disorientation.
>in severe cases, abdominal distention and acute abdomen
-interventions:
>replace serum potassium
>monitor patients response
>supportive care
B. Hyperkalemia
-due potassium sparing diuretics (Spironolactone)
-due to drugs that cause cell injury (antineoplastic drugs)
-signs/symptoms:
>serum potassium level higher than 5mEqs/L
>weakness, muscle cramps
>slow heart rate
>low BP, decreased urine output
>difficulty of breathing
-interventions:
>sodium polystyrene sulfonate
>supportive measures
>safety measures
>monitor cardiac effects and be prepared for cardiac emergency
>dialysis

6. Sensory Effects
A. Ocular Toxicity
-due to Chloroquine
-due to blockage of end arteries to the retina
-signs/symptoms:
>blurring of vision
>color blindness
>blindness
-interventions
>monitor for untoward s/sx
>notify the prescriber
>discontinue the drug
>supportive measures
B. Auditory Damage
-sensorineural type of deafness
-due to Macrolides (erythromycin) or Aspirin
-signs/symptoms:
>dizziness, tinnitus, loss of balance and deafness
-interventions:
>monitor for hearing changes
>protect from injury
>notify the prescriber

7. Neurologic Effects
A. General CNS Effects
B. Anticholinergic Effects
C. Parkinson-like syndrome
D. Neuroleptic Malignant Syndrome

Drug Dosage Calculation

Systems of Measurement:
1.Metric System
-the most widely used
-gram as the basic unit of solid measurement
-liter as the basic unit of liquid measurement

2. Apothecary System
-the very old system of measurement developed for use by pharmacists
-minim as the basic unit of liquid measure
-grain as the basic unit of solid measure
-it uses Roman Numerals placed after the unit of measure to denote amount

3. Household System
-the least accurate system of measurement
-teaspoon as the basic unit of fluid measurement
-pound as the basic unit of solid measurement

4. Avoirdupois System
-an older system of measurement routinely used by pharmacists to compound medications
-uses ounces and grains but measurement is different from the apothecary and household system

5. Other Systems of Measurement

-Units
>reflects the biological activity of the drug in 1mL of a solution
-Milliequivalents
> used to measure electrolytes

Drug Dosage Calculations

Formula for Oral and Parenteral Drugs:
volume in mL = prescribed dose X volume
stock dose
Formula for Intravenous Flow Rate Calculation:
drops/minute=volume of the solution in mL x drop or drip factor
number of hours x 60 min/hour

Pediatric Drug Dosage Calculation

Fried’s Rule
child’s dose (age < 1 yr)= infants age in mos
150 mos
x average adult dose
Young’s Rule
child’s dose = child’s age in years
(1 -12years) child’s age in yrs + 12
x average adult dose

Clark’s Rule
child’s dose= weight of the child in pounds
150 lbs x average adult dose
Surface Area Calculation
child’s dose= surface area in square meters
1.73

Classification of Drugs
 Prescription Drugs
 Nonprescription Drugs
 Illicit Drugs

Drug Names
 Generic Name (nonproprietary name)
 Brand Name (trade name)

Parts of a Prescription
1. Descriptive client’s information
2. The date on which the prescription was written by the prescriber
3. The Rx symbol
4. Name and dosage strength of the prescribed medication
5. Dispensing instruction for the pharmacist
6. Directions for the client or the signa
 7. Refill and/or specialized labeling instructions
8. The prescriber’s signature, address and tel #

Factors contributing to individual variation of drug response:

 Age
 Gender
 Body weight
 Body surface area
 BMR
 Genetics
 Placebo effect

Drug Interactions
 Additive effect
 Synergistic Effect
 Antagonistic effect

Nursing Process and drug Administration

 Assessment
 Diagnosis and Planning
 Implementation
 Evaluation

Rights of Medication Administration

 The right drug
 The right dose
 The right client
 Right time
 Right route
 Right documentation
 Right to refuse

Routes of Administration
 Oral
 Parenteral
-intradermal
-subcutaneous
-intramuscular
-intravenous
-intracardiac

Complications of Intravenous Administration

 Infiltration
 Extravasation
 Thrombophlebitis
 Pain
 Fluid overload
 Pyrogenic reactions
 Tissue necrosis
Sites of Intramuscular Injection
 Deltoid muscles
 Vastus lateralis
 Ventrogluteal and dorsogluteal muscles

Sites of Subcutaneous Injection

 Upper arm(lateral part)
 Thigh
 Buttocks
 Abdomen(lower part)

Antimicrobials
 Antibacterial
  Antiviral
 Antifungal
 Antiparasitic

Susceptibility of the body to infection

 Age
 Exposure to pathogenic organisms
 Disruption of the body’s normal barriers to infection
 Inadequate immunological defenses
 Impaired circulation
 Poor nutritional status

Selection of antimicrobial agents

 Location of infecting organism
 Status of the client’s organ function
 Age of the client
 Pregnancy and lactation
 Risk of drug resacistance

Mechanisms of Action
1. Interference with the biosynthesis of the cell wall.
2. Prevention of the cells of the invading microorganisms from using substances essential to their growth and
development.
3. Interference with the steps involved in protein synthesis, a necessary function to maintain the cell and allow for cell
division.
4. Interference with the DNA synthesis.
5. Alteration of the cell membrane permeability to
allow essential cellular components to leak out causing cell death.

Anti-infective Activity
1. Broad spectrum
2. Narrow spectrum
--
1. Bacteriostatic
2. Bactericidal

Role of Human Immune Response

Resistance
1. Natural or Intrinsic Resistance
2. Acquired Resistance
-could develop in a number of ways:
*by producing an enzyme that deactivates the antimicrobial drug
*by changing permeability to prevent the drug from entering the cell or altering the transport systems to exclude the
drug from active transport into the cell
*by altering binding sites on the membrane or ribosomes, which then no longer accepts the drug
*by producing a chemical antagonist to the drug
Preventing Resistance
1. High doses
2. Long duration of treatment
3. Around the clock dosing

Treatment of Systemic Infection

1. Identification of the pathogens
2. Sensitivity of the pathogens
3. Combination Therapy
reasons:
*may allow the use of smaller dosage of each drug > fewer adverse effects
*synergism
*infection caused by more than one organism
*delay in the emergence of bacterial drug resistance

1. Antibacterial agents
 Penicillin
  Cephalosporins
 Tetracyclines
 Macrolides
 Aminoglycosides
 Flouroquinolones
 Sulfonamides

a. Penicillin
 Mode of action
- exert their antimicrobial activity by inhibiting cell wall synthesis resulting in the destruction of the microorganism.

Penicillins differ in their:

 Chemical stability in the stomach acid
 Susceptibility to penicillinase
 Spectrum of action
 Route of administration
 Duration of action
 Site of action

Narrow spectrum Penicillins

 Penicillin G
 Penicillin V
 Penicillinase resistant
-nafcillin, oxacillin, cloxacillin, methicillin, dicloxacillin

Aminopenicillins
 Ampicillin
 Bacampicilin
 Amoxicillin

Extended spectrum Penicillins

 Mezlocillin
 Piperacillin
 Ticarcillin
 Penicillin-Clavulanic Acid combination
 Penicillin-Sulbactam combination
 Penicillin-Tazobactam combination

Things to consider:
 Monitor all patients with signs of hypersensitivity. Discontinue therapy at the first sign of hypersensitivity reaction.
Observe clients receiving penicillin in an emergency room
 Ticarcillin, Mezlocilllin or Piperacillin
may cause bleeding abnormalities. Closely monitor clients with renal impairment.
 Administration with bacteriostatic antibiotics (Erythromycin and Tetracycline) may diminish effectiveness.
 Probenecid blocks renal tubular excretion of Penicillin and may cause higher blood levels and longer duration of
action of Penicillin.
 High intravenous doses of sodium or potassium salts of Penicillin may cause electrolyte disturbances.
 Although not always essential, it is advisable to administer oral Penicillin on an empty stomach with a full glass of
water.
 To prevent peripheral IV site irritation, avoid infusing the medication rapidly.

b. Cephalosporins
 Mode of action
- Interfere with bacterial cell wall synthesis, thereby altering the osmotic stability of the actively growing
bacterial cell and resulting in in its death.
 Can be bactericidal or bacteriostatic
 Metabolized in the liver, excreted in the kidney

Cephalosporins: bactericidal or bacteriostatic

 Depends upon:
1. The susceptibility of the organism
2. The dose of the drug used
 3. The tissue concentration of the drug
4. The rate of bacterial multiplication

First Generation Cephalosporins

 Tends to have greatest activity against several gram positive as well gram negative organisms and are generally
quite susceptible to beta lactamase produced by some bacteria.
 Cephalexin, Cephadroxil, Cephadrin,
Cefazolin, Cephalothin, Cephapirin

Second Generation Cephalosporins

 Have a broader spectrum of activity against gram negative organisms and a somewhat diminished activity against
gram positive organisms.
 Tends to become resistant to inactivation by beta lactamases
 Cefaclor, Cefrozil, Loracarbef, Cefuroxime, Cefoxitin, Cefotetan, Cefonicid, Cefmetazole

Third Generation Cephalosporins

 Have even broader gram negative activity and less gram positive activity than do second generation agents.
 Tends to become resistant to inactivation by beta lactamases
 Cefdinir, Cefpodoxime, Ceftibuten, Cefoperazone, Cefotaxime, Ceftazidime, Ceftizoxime, Ceftriaxone

Fourth Generation Cephalosporins

 Have the greatest action against gram negative organisms among the four generations and minimal action against
the gram positive organisms
*in the transition from the first generation to the fourth generation, there has been an increasing cost of the drug
 Cefepime, Ceftidoren

Things to consider:
 Monitor clients for hypersensitivity
 Use with caution in patients with renal impairment
 Make IM injections deep to prevent or reduce inflammatory reactions
 IV administration for prolonged periods or in high doses may cause thrombophlebitis.
 Bacteriostatic antimicrobial agents may interfere with Cephalosporins’ bactericidal action.
 Probenecid administered with Cephalosporins may increase and prolong their plasma levels by interfering with their
renal tubular secretion.
 Use of potentially nephrotoxic drugs with Cephalosporins may increase the likelihood of renal toxicity.
 Avoid consuming alcoholic beverages while receiving cephalosporins and for at least 72 hours after completing the
dose after completing the drug course.
 Monitor for gastrointestinal distress, renal impairment and hematological changes.

c. Tetracyclines
 Inhibits protein synthesis in the cell wall of bacteria, thereby slowing its growth and reproductive rate so that it
becomes more susceptible to the body’s immune defense.
 Bacteriostatic at doses usually employed.
 Broad spectrum

The primary drawback in its use is the toxicity:

 Effect on the bone and enamel of tooth
 Photosensitivity
 Likelihood of superinfection with the repeated or prolonged administration of Tetracyclines

Things to consider:
 Avoid use in children under 8 because of possible interference with the development of teeth and bones and
staining of teeth
 Clients must avoid unprotected exposure to direct sunlight of UV light to reduce risk of phototoxicity
 IV therapy in excess of 2g/day may produce hepatotoxicity.
 Should not be used during pregnancy
 Monitor clients for fungal or bacterial superinfection, particularly involving the GI tract or vagina.
 Avoid use with calcium supplements, antacids, iron or dairy products as they may reduce the drug absorption.
 Should be given on an empty stomach 1 hour before or 2-3 hours after any meal or other medication
 Demeclocycline, Minocycline, Doxycycline, Oxytetracycline

Known Drug Interactions with Tetracycline:

 1. Penicillin
2. Oral contraceptives
3. Methoxyflurane
4. Digoxin
5. Calcium salts, Zinc salts, Aluminum salts, Bismuth salts, Iron, Urinary alkalinizers and Charcoal
d. Macrolides
 Inhibits protein synthesis in the bacterial cell wall.
 Used primarily for the oral therapy of infections caused by gram positive and gram negative organisms.
 Primarily metabolized in the liver with excretion in the kidneys
 Can be excreted also in the bile and feces
 Teratogenic and can be excreted in the breast milk
 Azithromycin, Clarithromycin, Erythromycin and Dirithromycin

Things to consider:
 Monitor clients for signs of hepatoxicity and nephrotoxicity
 Hypersensitivity reactions may occur.
 Oral doses should be taken 1 hour before or 2 hours after meals. Administer with food if GI upsets occur.
 Safety precautions (changing positions slowly and avoidance of driving)
 Maintenance of nutrition and hydration

Drug Interactions with Macrolides

1. Digoxin- at risk of digoxin toxicity
2. Oral anticoagulants, theophyllines, carbamazapine and corticosteroids
3. Cycloserine

e. Aminoglycosides
 Act by inhibiting protein synthesis in the bacterial cell wall and may exert their bactericidal or bacteriostatic action,
depending on the drug dosage employed.

Things to consider:
 Monitor clients for signs of nephrotoxicity.
 Neuromuscular blockade and respiratory paralysis may occur when administered with or shortly after anesthetics or
,muscle relaxants.
 Provide good hydration to reduce the likelihood of hepatoxicity and nephrotoxicity.
 Avoid use of other drugs that produce ototoxicity and nephrotoxicity.
 To prevent IV site irritation, avoid infusing the medication rapidly.
 Amikacin, Gentamycin, Kanamycin, Neomycin, Netilmicin, Streptomycin, Tobramycin, Paromomycin

Other Antibacterial Agents:

 Report evidence of allergic reaction
 Report symptomatic improvement
 Review administration and storage instructions that accompany the product.
 To prevent peripheral IV site irritation, avoid using the medication rapidly.
 Astreonam, Bacitracin, Chloramphenicol, Clindamycin, Enoxacin, Imipenem, Lincomycin, Metronidazole,
Ciprofloxacin. Ofloxacin, Norfloxacin, Vancomycin, Spectinomycin, Sulfonamides

Urinary tract Anti- infectives

 Nalidixic Acid
 Cinoxacin
 Nitrofurantoin
 Methenamine Products
- Methenamine mandelate
- Methenamine hippurate
 Trimethoprim

Adverse effects of Antibacterials:

 Hypersensitivity reactions
 Organ toxicity
 Hematological disorders

Classification of Antimicrobials
 Bactericidal or bacteriostatic
  Narrow or Extended (broad) spectrum

Other Agents Used in the Treatment of UTI

 Phenazopyridine HCl (Pyridium)
 Neomycin and Polymyxin B

Drugs Used in TB
 Two forms:
1. Prophylaxis
- aimed at reducing the number of organisms to prevent s/sx
2. Treatment of active infection

Antitubercular Drugs
First Line Anti TB Drugs
 Isoniazid
- inhibits mycolic acid synthesis
 Rifampicin
- inhibits DNA polymerase
 Pyrazinamide
 Ethambutol
 Streptomycin
Other Anti TB drugs
 Second line anti TB drugs
1. Capreomycin
2.Aminosalicylate
3. Cycloserine

Things to consider:
 Determine prior drug use of anti TB drugs
 Note color and nature of the sputum
 Teach client appropriate hygiene to ensure safety of others
 Stress the importance of completing the course of treatment.

2. Anti-Fungal Drugs
 Fungal infections:
1. superficial
2. localized skin infection
3. life-threatening systemic infections
 Nystatin (Mycostatin)
 Flucytosine (Ancobon)

 Ketoconazole (Nizoral)

 Amphotericin B (Fungizone Intravenous)

 Griseofulvin (Fulvicin)
 Fluconazole (Diflucan)
 Itraconazole (Sporanox)

3. Anti-Viral Drugs
 Amantadine HCl (Symmetrel) and Rimantadine HCl (Flumadine)
 Vidarabine (Vira A)
 Rivabirin (Virazole)
 Interferon Alfa
 Zidovudine (AZT)
 Didanosine (Videx)
 Zalcitabine

Other anti-viral drugs

 Ganciclovir and Foscarnet

Miscellaneous anti-infective:
  Pentamidine isethionate
 Furazolidone

Leprostatic Agents
 Rifampicin
 Dapsone
 Clofazimine (Lamprene)

Anti-Malarial Drugs
 Chloroquine
 Primaquine phosphate
 Halofantrine
 Quinine
 Mefloquine
 Hydroxychloroquine

Anti-Protozoal Drugs
 Metronidazole
 Paromomycin
 Emetine
 Atovaquone

4. Anti-Parasitic Drugs
Round worm (ascariasis) Pyrantel Pamoate
or Mebendazole
Pinworm (Enterobiasis) Pyrantel Pamoate
or Mebendazole
Threadworm (Strongyloidiasis) Thiabendazole
Beef tape worm (Taeniasis) Praziquantel

Whipworm (Trichuriasis) Mebendazole

Hookworm (Uncinariasis) Mebendazole of
Pyrantel Pamoate
Tapeworm (Dipylidium Albendazole
caninum)

Dermatological Parasitic Disorder

 Lindane- scabicide/pediculocide
 Crotamiton- scabicide
 Malathion- pediculocide
 Pyrethrins and piperonyl butoxide
Analgesics and Antipyretics
 Types:
1. Opioid Analgesics
2. Non opioid analgesics
A. Opioids
1. Morphine SO4
2. Oxycodone
3. Codeine
Opioid antagonists:
1. Naloxone
2. Naltrexone
B. Non Opioid
1. Nalbuphine
2. Pentazocine HCl

Analgesics Used to treat Headaches

 For Vascular Headaches
1. Ergotamine Tartrate
Dihydroergotamine Mesylate
Methysergide maleate
 2. Sumatriptan succinate

Analgesic/Antipyretic
 Acetylsalicylic Acid
 Acetaminophen
 Phenacetin
 Ibuprofen
 Ketoprofen
 Mefenamic Acid

Anti-hypertensive Drugs
Hypertension Risk Groups
Risk Groups Number of Risk Factors

Risk Group A No cardiovascular risk factors or conditions

Risk Group B One cardiovascular risk factor but no diabetes or other risk
conditions
Risk Group C Diabetes and/or any of the other risk conditions

A. Diuretics
-attributed to the ability of this group to reduce the plasma volume
1. Thiazides
Hydrochlorothiazide
2. Loop Diuretics
Furosemide, Ethacrynic Acid, Bumetanide, Torsemide
-more potent than thiazide diuretics
-with comparable effects with thiazides in normal renal function
-superior to thiazides in renal insufficiency
3. Potassium Sparing Diuretics
Spironolactone (Aldactone)
Triamterene (Dyrenium)
Amiloride (Midamor)
-not as effective as thiazides and loop diuretics
-may be used alone
-may be used in combination (prevention of hypokalemia)

B. Beta Blockers if diuretic therapy

C. Calcium Channel Blockers fails
D. ACE Inhibitors

E. Centrally Acting Antiadrenergic Agents

-sedation as a major side effects
1. Methyldopa
>>metabolized to alpha methylnorepinephrine
(false neurotransmitter)

replace epinephrine on the adrenergic storage sites

>>stimulation of alpha 2 adrenergic receptors

vasodilation of arteries

2. Clonidine (Catapres)
>>stimulates the alpha 2 adrenergic receptors in the CNS
-action is apparent 30 – 60 minutes after administration oral dose
-maximum effect is 3 – 5 hours after administration
-may cause rebound hypertension (should be gradually discontinued over a period of 2 to 4 days)

Clonidine-TTS
>releases the drug very slowly over 7 days
*administered 2 – 4 times a day
3. Guanfacine
-with similar mechanism of action and secondary effects to Methyldopa and Clonidine

4. Guanabenz
-similar to Guanfacine

F. Peripherally Acting Anti-Adrenergic Agents

1. Rauwolfia Derivatives
-depletes the neurotransmitter norepinephrine at peripheral sympathetic nerve junctions
-with low daily dose
-once a day administration
Reserpine Rescinnamine
Deserpidine Rauwolfia serpentina
-AR:
-depression
-exacerbation of PUD
-nasal congestion

2. Guanethidine Monosulfate (Ismelin Sulfate)

-depletion of catecholamines to peripheral adrenergic neurons
-AR:
>postural hypotension
>impairment of sexual function in males
>diarrhea
*all are dose dependent

3. Guanadrel sulfate (Hylorel)

-similar effects with Guanethidine

4. Prazocin (Minipress), Terazosin (Hytrin) and Doxazosin (Cardura)

-selective blockers of post synaptic alpha adrenergic receptors
*Terazosin and Doxazosin
-also used for BPH

G. Vasodilators
Hydralazine (Apresoline), Minoxidil (Loniten), Nitroglycerin IV

Cardiotonic Drugs

1. Cardiac Glycosides (digoxin, digitoxin)

-originally derived from a foxglove or a digitalis plant
-available for oral and parenteral use
-excreted unchanged in the urine
-has a narrow margin of safety
-indicated in the treatment of CHF
-antidote of digoxin toxicity (Digoxin Immune Fab)
-Mechanisms of action:
*positive inotropic effect
*increased cardiac output and renal perfusion
*negative chronotropic effect
* decreased conduction velocity through the AV node
Nursing Considerations:
1. Need for a loading dose
2. Apical pulse monitoring (rate and rhythm)- may suggest digoxin toxicity
3. Narrow margin of safety
4. Easily degraded by the environmental conditions
5. Avoid IM injection (slow IV push)
6. Orally administered with an empty stomach
7. Weight monitoring
8. Maintain emergency equipment on standby
9. Therapeutic digoxin level: .5 to 2 ng/ml
10. Comfort measures as regards to the adverse effects:
*headache
*GI upsets & anorexia
*weakness
*risk of arrhythmia
*drowsiness
*vision changes
11. Drug Interactions
Drugs that decrease digoxin effects:
a. thyroid hormones
b. metoclopramide
c. penicillamine

Drugs that increase digoxin effects:

a. verapamil e. erythromycin
b. amiodarone f. tetracycline
c. quinidine g. cyclosporine
d. quinine

2. Phosphodiesterase Inhibitors
-Inamrinone (Inocor):
*for IV use as alternative drug for CHF
-Milrinone (Primacor):
*for IV use for short term treatment of CHF
-mechanism of action:
*blocks the enzyme phosphodiesterase – increase in cAMP – increase in intracellular calcium
- positive inotropic effect
Nursing considerations:
1. Easily degraded by environmental conditions
2. Monitoring of HR and BP
3. Painful upon infusion
4. Maintain emergency equipments
5. Patient education as regards to the drug therapy
6. Responsibilities as regards to the adverse effects:
*arrhythmias, hypotension and chest pain
*nausea, vomiting, anorexia and abdominal pain
*thrombocytopenia
*hypersensitivity reactions
-contraindications:
*acute MI
*fluid volume deficit
*severe aortic and pulmonary valvular stenosis
-drug interaction:
*precipitates if mixed with Furosemide

Antiarrhythmic Drugs
-proarrhythmic drugs

Classes of Antiarrhythmic drugs:

1. Class 1
-blockers of Na channels
A. Class 1a
-Quinidine, Dysopyramide, Procainamide and Moricizine
B. Class 1b
-Lidocaine, Mexiletine
C. Class 1c
-Flecainide and Propafenone
Mechanisms of action
-stabilize the cell membrane by binding to sodium channels
-have a local anesthetic effect
-for the treatment of life-threatening ventricular arrhythmias
-Quinidine, Flecainide and Propafenone are also indicated in atrial arrhythmias
Nursing Considerations:
1. Hepatic metabolism and renal excretion
2. Crosses the placenta and enters the breast milk
3. Cardiac rhythm monitoring
4. Maintain emergency equipment on standby
 5. IV if cannot tolerate oral route
6. Dosage titration
7. Establish safety precautions (CNS effects)
8. Responsibilities in relation to CI and AR
CI- hypersensitivity, bradycardia or heart block,
CHF, hypotension and shock, renal or hepatic dysfunction, pregnancy and lactation
AR- CNS effects, GI effects, CVS effects and respiratory depression

2. Class II
-are beta blockers
*acebutolol- PVC
*esmolol- short term management of supraventricular tachycardia
*propranolol- antihypertensive, antianginal and antimigraine
- supraventricular tachycardia caused by digoxin and catecholamines
Mechanism of Action:
-blocks beta receptors in the heart and the kidneys --- decreased HR, cardiac excitability and cardiac output,
slowing conduction through the AV node and decreasing the release of renin
Nursing considerations:
1. Hepatic metabolism and renal excretion
2. Teratogenic and excreted in the breast milk
3. CI in sinus bradycardia and AV block, cardiogenic shock, asthma or respiratory depression, diabetes, thyroid dysfunction
4. AR- CNS effects (dizziness, insomnia, dreams and fatigue), CVS effects (hypotension, bradycardia, AV block, arrhythmias
and alterations in the peripheral perfusion), respiratory effects (bronchospasm and dyspnea), GI problems, loss of libido,
decreased exercise tolerance and alterations in the blood glucose levels
5. Drug Interactions
-drug effect increases with:
*verapamil
*insulin

3. Class III
-block potassium channels
Amiodarone- IV or oral, for life threatening arrhythmias only
Bretylium- IV or IM, for short term use
Ibutilide-atrial arrhythmias of less than 90 days
Sotalol
Mechanism of Action:
-Blocks the potassium channels and slows the outward movement of potassium
-For the treatment of atrial and ventricular arrhythmias
Nursing considerations
1. Hepatic metabolism and renal excretion
2. Potentially teratogenic and excreted in the breast milk
3. Ibutilide and Dofetilide should not be used in patients with AV block
4. Use with caution in shock, hypotension and respiratory depression
5. AR involve the CNS (dizziness), GI (nausea,
vomiting), muscular (weakness), CVS (hypotension, CHF, arrhythmia)
Amiodarone- liver toxicity, ocular abnormalities, arrhythmia
6. Drug Interactions
a. quinidine
b. digoxin

4. Class IV
-calcium channel blockers
Verapamil, Diltiazem
-paroxysmal supraventricular tachycardia
Verapamil
-for the treatment of rapid ventricular response to atrial flutter and fibrillation
Nursing considerations
1. IV administration
2. Hepatic metabolism and renal excretion
3. Teratogenic and excreted in the breast milk
4. CI in patients with previous hx of hypersensitivity reaction, sick sinus syndrome and heart block
5. AR include dizziness, headache, depression, fatigue and weakness
Other AR include GI upset, hypotension, shock,
arrhythmias and edema.
 6. Drug Interactions
a. beta blockers- more cardiac depression
b. digoxin, carbamazepine, prazocin and quinidine- more AV slowing
c. atracurium, pancuronium, rurocuronium, tubocurarine, gallamine, metocurine and vecuronium- increased
respiratory depression
d. cyclosporine- more toxic if combined with diltiazem

Other Antiarrhythmic Drugs

A. Adenosine- DOC usually for supraventricular tachycardia
-short duration of action (15 seconds)
-very few AR (headache, flushing and dyspnea of short duration)
-slows the conduction at the AV node, increase the refractory period, decreases the automaticity at the AV node
Nursing consideration
1. Continuous monitoring while on drug therapy
B. Digoxin
-slows down calcium outflow from the cell
-also effective in atrial arrhythmias

Antianginal Agents

1. Nitrates
Amyl Nitrate, Isosorbide Mono/Dinitrate, Nitroglycerin
-are drugs that act directly on smooth muscles to cause relaxation and depress the muscle tone
-with fast onset of action
Nursing consideration:
 Hepatic metabolism and renal excretion
 Teratogenic and excreted in the breast milk
 CI in patients with previous allergy, severe anemia, head trauma or brain injury and pregnancy and lactation
 AR- related to profound vasodilatation
Drug Interactions
a. ergot derivatives
b. heparin
2. Beta Blockers
3. Calcium Channel Blockers

Hypolipidemic Agents

1. Bile Acid Sequestrants

Cholestyramine, Colestipol and Colesevelam
Mechanism of Action
-binds with bile acids, leading to their excretion in the feces --- low bile acids in the hepatic circulation --- more
hepatic bile acid production --- utilization of more LDL --- lower plasma cholesterol level
>indicated in primary hypercholesterolemia
>Cholestyramine can be used in pruritus secondary to partial biliary obstruction
Nursing Considerations
1. CI include previous hypersensitivity reaction, complete biliary obstruction, abnormal intestinal function, pregnancy
and lactation
2. AR are related to the changes of serum cholesterol (anxiety, fatigue, headache and drowsiness), GI (constipation,
fecal impaction, hemorrhoid), bleeding, fat soluble vitamin deficiencies
3. Before administration, these drugs must be mixed with fluids to be effective. (Colestipol must be mixed with
carbonated beverages to be effective)
4. Tablets should not be crushed
5. To be given before meals
6. Administer oral meds 1 hour before or 4-6 hours after meals
7. Bowel program
8. Comfort measures
9. Patient education

2. HMG CoA Reductase Inhibitors

Mechanism of Action
-inhibits the early rate limiting step in the synthesis of cellular cholesterol.
-LDL decrease, HDL increase
Atorvastatin- associated with severe liver disease
 -can be used in children at 10-17 years of age
Fluvastatin- hypersensitivity reaction
Lovastatin- oldest, very long acting
- can cause rhabdomyolysis
Pravastatin- is the only statin with the outcome data to show that it is effective in decreasing CAD and the incidence of MI.
Rosuvastatin- newest statin
- better than the older statins in increasing the HDL and decreasing the LDL
- increased risk of rhabdomyolysis in Asians
Simvastatin- lowers cholesterol and prevent MI in patients known to have hypercholesterolemia and CAD
Mechanism of Action
-block the formation of cellular cholesterol, leading to a decrease in the serum cholesterol and decrease in the
serum LDLs with a slight or no increase in HDLs
-with marked first pass effect
Nursing Consideration
1. Hepatic metabolism, renal and fecal excretion
2. All statins are potentially nephrotoxic except
Atorvastatin
3. Pregnancy category X and excreted in the breast milk
4. Long term drug therapy
5. CI in pregnancy, lactation, severe liver disease, previous hypersensitivity and impaired endocrine function
6. AR include CNS effects (dizziness, headache, blurred vision, insomnia, fatigue, cataract devt) and GI effects
*Rhabdomyolysis in Lovastatin, Atorvastatin, Fluvastatin and Rosuvastatin
7. Administer the drug at bedtime except Atorvastatin
8. Monitor serum cholesterol and LDL
9. Periodic ophthalmoscopic exam
10. Diet and exercise for 3-6 months before beginning drug therapy
11. Withhold in any condition suggesting myopathy
12. Use of contraceptive
Drug to Drug Interactions
Erythromycin, Cyclosporine, Gemfibrozil, Niacin or antifungal drugs ---- RHABDOMYOLYSIS
Digoxin and Warfarin- increased toxicity
Oral contraceptives- increased estrogen levels
Grapefruit juice- increased drug concentration and toxicity

3. Cholesterol Absorption Inhibitors

-recently approved for its therapeutic use
-localizes in the brush border of the small intestines
--- increased clearance of cholesterol from the serum
Ezetimibe
-as an adjunct to diet and exercise
-as a drug to be combined with other hypolipidemic agents
-absorbed from the GIT (peak after 4-6 hours), 22 hours half life
-metabolized in the liver and small intestines, excreted in the urine and feces
-no data yet on its risks during pregnancy and lactation
Nursing considerations
1. Monitor serum cholesterol, triglyceride and LDL levels before and after therapy
2. Monitor liver function test
3. Should have attempted first to diet and exercise
4. Use of contraceptives
5. CI in patients with previous hypersensitivity reaction, pregnancy, lactation, severe liver disease
6. AR include GI (mild abdominal pain and diarrhea), CNS (headache and dizziness), URTI, muscle aches
Drug Interactions
Bile Acid Sequestrants and Fibrates
-bloating and flatulence
Cholestyramine, Fenofibrate, Gemfibrozil or antacids
-increased serum levels of Ezetimibe
-2 hours before or 4 hours after taking these drugs
Cyclosporine
-ototoxicity
Fibrate
-cholelithiasis
Warfarin- increased levels

DRUGS AFFECTING BLOOD COAGULATION

Anticoagulants vs. Thrombolytics

1. Antiplatelets
Abciximab- PTCA, angina and non Q wave MI
Anagrelide- essential thrombocytopenia
Aspirin- prevention of TIA, strokes and MI
Cilostazol- claudication
Clopidogrel- prevention of MI, peripheral artery disease, ischemic stroke and acute coronary
syndrome
Dipyridamole- Prevention of thromboembolism
Eptifibatide- acute coronary syndrome
Sulfinpyrazone- Prevent reinfarction in MI, thromboembolism, also an antigout
Ticlopidine- alternative to aspirin
Tirofiban- used in combination with Heparin in PTCA

Mechanism of Action
-inhibits platelet adhesion and aggregation by blocking receptor sites on the platelet membrane, preventing platelet
to platelet interaction
*Anagrelide- blocks the production of platelets in the bone marrow
Nursing Considerations
1. Hepatic metabolism and renal excretion
2. Avoidance in pregnancy and lactation
3. Provide small, frequent meals if with GI irritation
4. Comfort measures and analgesia for headache
5. Safety measures- increased risk of bleeding
6. Precautionary measures during invasive procedures
7. Proper documentation
8. Patient education
9. Support and encouragement

2. Anticoagulants
Mechanism of Action
-interferes with the clotting cascade and thrombin formation
Warfarin
-oral drug that interferes with the production of vit K dependent clotting factors
-metabolized in the liver and excreted in the urine and feces
-onset of action is 3 days, duration is 4-5 days
-used in patients with atrial fibrillation, artificial heart valves or valvular damage, MI
-avoid in pregnancy and lactation
Heparin- inhibits the conversion of prothrombin to thrombin, thus blocking the conversion of fibrinogen to fibrin.
-IV or SC
-excreted in the urine
-avoid in pregnancy but can be used during lactation
-can be used in DIC (Disseminated Intravascular Coagulation), stroke and MI.
Antithrombin III- antithrombin III deficiency
-safe during pregnancy and lactation
Argatroban- thrombin inhibiting drug
Bivalirudin- thrombin inhibiting drug vc
Desirudin- thrombin inhibiting drug in DVT
Nursing Considerations
1. Evaluate for the therapeutic effectiveness of Warfarin (PT 1.5 to 2.5 times the control value or INR of 2-3)
2. Evaluate for the therapeutic effects of Heparin (WBCT- 2.5 to 3 times the control or PTT 1.5 to 3 the control value)
3. Evaluate for any sign of untoward bleeding
4. Safety precautions
5. Proper documentation
6. Maintain antidotes on standby
7. Monitor the patient for any reaction to added or withdrawn drug associated with anticoagulants
8. Patient education
9. Support and encouragement
Low Molecular Weight Heparins
-inhibits thrombus and clot formation by blocking Xa and IIa
-fewer adverse effects (do not greatly affect thrombin, clotting or prothrombin time)
-block angiogenesis
3. Thrombolytic Agents
Mechanism of Action
-works by activating the natural anti-clotting system, conversion of plasminogen to plasmin
Alteplase- used in MI, Acute pulmonary embolism and stroke
Reteplase- MI
Tenecteplase- MI
Streptokinase- CA thrombosis, pulmonary embolism, DVT, arterial thrombosis and embolism
Urokinase
Nursing Considerations
1. Hepatic metabolism
2. Avoid in pregnancy and lactation
3. Evaluate for any sign of bleeding
4. Monitor coagulation studies regularly
5. Administer within the golden period.
6. Prepare for possible blood transfusion
7. Monitor cardiac rhythm and have emergency equipments on standby
8. Precautionary measures during invasive procedures
9. Proper documentation
10. Support and encouragement
Drug Interactions
Anticoagulants and antiplatelets
Antihemophilic Agents
1. Antihemophilic Factor VIII
2. Coagulation Factor VIIa
3. Factor IX Complex
Mechanism of Action
-replacement of the deficient or absent clotting factor/s
Nursing Considerations
1. Relatively contraindicated during pregnancy and absolutely contraindicated during lactation.
2. IV route of administration to ensure effectiveness
3. Monitor clinical response and clotting factor levels regularly
4. Monitor for any sign of thrombosis
5. Decrease the infusion if adverse effects occur (Headache, chills, fever and tingling sensation)
6. Prepare for a possible blood transfusion
7. Proper documentation
8. Patient education

Systemic Hemostatic Agents

Aprotinin
-from a bovine lung tissue
-form complexes with clot dissolving factors
-IV route of administration
-excreted by the kidneys (half life of 150 minutes)
-relatively contraindicated during pregnancy and lactation

Aminocaproic Acid
-inhibits plasminogen activating substance and has an antiplasmin activity
Nursing Considerations
1. Monitor clinical response and clotting factor levels regularly
2. Monitor for signs of thrombosis
3. Support and safety measures if hallucinations occur
4. Comfort measures
5. Patient education
6. Support and encouragement
7. CI in the presence of hypersensitivity to this drug and DIC.
8. Caution in cardiac disease, renal or hepatic dysfunction, pregnancy and lactation
9. AR- excessive clotting (most common), CNS effects (hallucinations, drowsiness, dizziness, headache and psychotic
states), GI effects (nausea, cramps and diarrhea), muscular (weakness, fatigue, malaise and muscle pain), renal (intrarenal
obstruction and dysfunction)
Aprotinin- arrhythmia, MI, CHF and hypotension

Drug Interactions
1. Heparin- increased risk of bleeding
2. OCP or estrogens- hypercoagulation states
Topical Hemostatic Agents
1. Absorbable gelatin (Gelfoam)
2. Microfibrillar collagen (Avitene)
-increased risk of infection on the site
3. Thrombin (Thrombinar, Thrombostat)
-derived from bovine sources
-may precipitate an allergic response

Drugs Used to Treat Anemias

1. Erythropoeitin
-Epoetin alfa, Darbopoetin alfa
Nursing considerations
1. No adequate study in pregnancy and lactation (Darbopoetin) crosses the breast milk
2. Confirm the chronic renal nature of the patient’s anemia
3. Epoetin- 2-3x a week, Darbopoetin- once a week
4. Do not mix with other drugs- incompatibilities
5. Monitor access lines for clotting
6. Arrange for hematocrit reading before drug administration (if no response within 8 weeks--- reevaluation)
7. Evaluate iron stores
8. Maintain seizure precaution on standby
9. Comfort measures in relation to adverse effects
CNS effects, GI effects, CVS effects

2. Iron Preparations
-Ferrous Fumarate, Ferrous Sulfate, Ferrous Gluconate, Iron Dextran, Iron Sucrose and Sodium Ferric
Mechanism Of Action
-incorporated into the hemoglobin
-trapped into the RES for storage
Nursing Considerations
1. Confirm iron deficiency anemia
2. Collaborate with the physician
3. Administer with meals (avoid eggs, milk, coffee and tea). Use a straw
4. IM injection should apply the z track technique
5. Hgb and Hct monitoring before and during the therapy
6. Comfort measures as regards to AR
-GI irritation is the most common (GI upset, nausea, vomiting, anorexia, dark stools
and constipation)
-CNS effects (toxicity- coma and death)
-anaphylaxis, local irritation, staining of the tissues and phlebitis

Drug Interactions
1. Antacids, H2 blockers, tetracycline
-decreases absorption (should be spaced 2 hours apart)
2. Ciprofloxacin, norfloxacin and Ofloxacin
-decreases anti-infective activity because of inefficient absorption (2 hours apart)
3. Chloramphenicol
-increased iron level
4. Levodopa
-may decrease its effect

3. Folic Acid Derivatives

and Vitamin B12
Leucovorin- folic acid preparation
-used in chemotherapy in patients receiving methotrexate
-oral, IM and IV
Folic Acid (Folvite)
-oral, sc, IM, IV
Hydroxocobalamin
-traditional treatment of pernicious anemia and vit B12 deficiency
-IM everyday for 5-10 days then once a month for life
Cyanocobolamin
-relatively shorter duration of action
-can be given as intranasal gel
 (Nascobal) intranasal spray in one nostril given once a week
Nursing Considerations
1. Liver metabolism and renal excretion
2. To be used with caution in pregnant and lactating women
3. Caution in patients with nasal erosions and ulcers
4. AR- pain and discomfort on the injection sites
-nasal irritation

Drugs Affecting the Respiratory System

Anatomy and Physiology of the Respiratory System
Upper Respiratory Tract Conditions
-common colds
-seasonal rhinitis
-sinusitis
-pharyngitis and laryngitis
Lower Respiratory Tract
-atelectasis -bronchitis
-pneumonia -bronchiectasis
-obstructive pulmonary diseases
*asthma
*COPD (emphysema and chronic bronchitis)
-cystic fibrosis
-respiratory distress syndrome

1. Antitussives
Codeine, Hydocodone, Dextromethorphan, Benzonatate
-drugs that suppress the cough reflex
-metabolized in the liver, excreted in the kidneys
-cross the placenta and excreted in the breastmilk
Nursing Considerations
1. Collaborate with the physician
2. Non pharmacologic management of cough
3. Patient education
4. AR- sedation and drowsiness
-can cause drug dependence
-drying effect on the mucous membranes and increased viscosity of respiratory tract
secretions
-drying effect can lead to nausea, constipation and dry mouth

2. Decongestants
A. Topical Nasal Decongestants
Ephedrine, Oxymetazoline, Phenylephrine, Tetrahydrozoline, Xylometazoline
Mechanism of Action
-sympathomimetics
Nursing Considerations
1. Metabolized in the liver and excreted in the kidneys
2. Caution during pregnancy and lactation
3. Patient education on the proper administration of the drug
4. Not to be used for more than 5 days
5. Can be found in the OTC preparations---- prevent overdosage
6. Safety measures- dizziness and sedation
7. Institute non pharmacologic management of pain
8. Support and encouragement
B. Oral Decongestants
Pseudoephedrine
-systemic effect (sympathomimetic)
Nursing Considerations
1. metabolized in the liver, excreted in the urine
2. caution in pregnancy and lactation
3. check OTC preparations to prevent overdosage
4. safety measures
5. not to use for more than a week
6. patient teaching
 7. support and encouragement
8. CI in glaucoma, hypertension, diabetes, thyroid disease, coronary disease, and prostate
problems
9. AR- rebound congestion, anxiety, tenseness, restlessness, tremors, hypertension,
arrhythmias, sweating and pallor
C. Topical Nasal Steroid Decongestants
Beclomethasone, Budesonide, Dexamethasone, Flunisolide, Fluticasone, Triamcinolone
-treatment of allergic rhinitis unresponsive to other decongestants
Mechanism of Action
-the exact mechanism is unknown
Nursing Considerations
1. generally not absorbed systemically
2. patient education as to the proper use of the different drug preparations
3. clear the nasal passages before administering the drug
4. benefits may take 2-3 weeks to appear
5. monitor for the development of acute infection
6. support and encouragement
7. CI in acute bacterial, viral and fungal infections
8. AR- local burning, irritation, stinging, dryness of the mucosa and headache

3. Antihistamines
First Generation
-Brompheniramine, Cetirizine, Chlorpheniramine, Diphenhydramine, Hydroxyzine, Clemastine
Second Generation
-Dexloratadine, Fexofenadine, Loratadine
Mechanism of Action
-blocks the effects of histamine at histamine 1 receptor, bringing relief to patients suffering from itchy eyes, swelling,
congestion and drippy nose
-relieve respiratory symptoms and treat allergies
-also have anticholinergic and anti-pruritic effect
Nursing Considerations
1. Metabolized in the liver, excretion in the urine and feces
2. Cross the placenta and excreted in the breast milk
3. Administer with an empty stomach (1 hour before or 2 hours after meals)
4. Provide safety measures
5. Increase humidity and push fluids
6. Have the patient void before administration to prevent urinary retention
7. Skin care (dryness)
8. Check OTC preparations
9. Avoid alcohol or other CNS depressant
10. CI in pregnancy and lactation, cardiac arrhythmias, renal or hepatic impairment
11. AR- drowsiness and sedation
-anticholinergic affects (dryness of the GI and respiratory mucosa, nausea, arrhythmia,
dysuria, urinary hesitancy and itching associated with dryness)

4. Expectorants
Guaifenesin
-liquefy the lower respiratory tract secretions, reduce the viscosity of these secretions and making it easier to cough
up phlegm

5. Mucolytics
Acetylcysteine
Dornase Alfa
Mechanism of Action
-break down mucus in order to aid the high risk respiratory patient in coughing up thick tenacious secretions.

Drugs Used to Treat Obstructive Disorders

1. Bronchodilators
A. Xanthines
Aminophylline, Dyphylline, Caffeine and Theophylline
-were once the first line drugs used in asthma
-narrow margin of safety
Mechanism of Action
-direct effect on the smooth muscle of the bronchi and blood vessels by affecting the mobilization of intracellular
calcium (theory)
 -stimulates the release of two prostaglandins--- smooth muscle relaxation
-inhibits the slow reacting substance of anaphylaxis and histamine
Indications
-bronchial asthma and COPD
-additional uses: apnea, Cheyne-Stokes respiration, bradycardia in premature infants

Nursing Considerations
1. Hepatic metabolism and renal excretion
2. Crosses the placenta and enters the breast milk
3. Monitor the patient’s response to the drug
4. Frequent monitoring of blood levels
5. Patient teaching
6. Comfort measures in relation to AR
GI upset, nausea, irritability, tachycardia, seizures, brain damage and even death
7. CI in patients with GI problems, respiratory problems, CAD, renal or hepatic disease, alcoholism,
hyperthyroidism
Drug Interactions
-Nicotine: increases xanthine metabolism

2. Sympathomimetics
Albuterol- older than 2 years of age
Bitolterol- older than 12 years of age
Ephedrine and Epinephrine- acute bronchospasm
Formoterol- older than 12 years of age
Isoetharine
Isoproterenol- bronchospasm in anesthesia
-more cardiac side effects
Levabuterol- older than 6 years of age
Metaproterenol- older than 6 years of age
Salmeterol- exercise induced asthma
-older than 4 years of age
Terbutaline- older than 12 years of age
-oral, parenteral or inhalation
Mechanism of Action
beta 2 selective adrenergic agonists
Nursing Considerations
1. Hepatic metabolism and renal excretion
2. Relatively contraindicated in pregnancy and lactation
3. To prevent exercise induced asthma-- 30-60 minutes before exercise
4. Safety measures
5. Patient education
6. Use minimal amount effective for the shortest period to prevent or minimize AR
-sympathomimetic stimulation
7. CI- conditions that would be aggravated by sympathetic stimulation (cardiac disease, vascular disease, arrhythmias,
diabetes, hyperthyroidism, pregnancy and lactation
Drug Interactions
Cyclopropane and halogenated hydrocarbons
-will sensitize the myocardium to catecholamines and cause serious cardiac complications
3. Anticholinergic Bronchodilators
Ipratropium, Triotropium
-not as effective as the sympathomimetic agents
Mechanism of Action
-affects the vagus nerve to block parasympathetic impulses
Nursing Considerations
1. Adequate hydration and provide environmental controls
2. Encourage to void to prevent urinary retention
3. Safety measures
4. Small frequent meals and sugarless lozenges
5. Caution with the use of inhalator- not to exceed 12 times a day
6. Patient education
7. Support and encouragement
8. AR- anticholinergic effects (dizziness, headache, fatigue, nervousness, dry mouth, sore throat, palpitations and urinary
retention)
9. CI- Narrow angle glaucoma, bladder neck obstruction, prostatic hypertrophy, conditions aggravated by dry mouth and
throat
4. Inhaled Steroids
Beclomethasone, Budesonide, Flunisolide, Fluticasone, Triamcinolone
-inhalation decreases the systemic effects
Nursing Considerations
1. Hepatic metabolism and renal excretion
2. Avoid n pregnancy and lactation
3. Not to be administered in acute asthma or status asthmaticus
4. Taper systemic steroids
5. Topical decongestant first before the steroid
6. Advise to rinse the mouth after use
7. Monitor for signs of respiratory infection
8. Patient education
9. Support and encouragement
10. AR- sore throat, hoarseness, coughing, dry mouth, pharyngeal and laryngeal fungal infections
-systemic adverse effects
11. CI- emergency, pregnancy and lactation, active infection of the respiratory tract

5. Leukotriene Receptor Antagonist

Zafirlukast, Montelukast and Zileuton

6. Mast Cell Stabilizers

Cromolyn, Nedocromil

Drugs Affecting the Gastrointestinal Tract

Drugs Used to Treat Peptic Ulcer Disease

1. H2 Blockers
Cimetidine, Ranitidine, Famotidine and Nizatidine
Mechanism of Action and Indications
-block H2 receptors---reduced HCl and pepsin production---healing of PUD
-active duodenal ulcer and benign gastric ulcer
-Zollinger-Ellison Syndrome
-Prophylaxis of stress-induced ulcer and acute upper GI bleeding
Nursing Consideration
1. Administer oral drug with or before meals and at bedtime
2. Decrease the dosage in hepatic or renal dysfunction
3. Monitor continuously for AR especially if given through IV
-GI (diarrhea and constipation), CNS (dizziness, headache, somnolence, confusion, hallucinations), CVS
(arrhythmias and hypotension), gynecomastia and impotence
4. Arrange for regular follow up
5. Patient education
6. Support and encouragement
7. Drug Interactions
-warfarin, anticoagulants, phenytoin, beta blockers, alcohol, quinidine, lidocaine, theophylline, chloroquine,
benzodiazepines
2. Antacids
Aluminum salts, Calcium salts, Megaldrate, Magnesium salts, Sodium bicarbonate
Mechanism of Action
-neutralize stomach acid by direct chemical reaction
Indications
-hyperacidity
-gastric hyperacidity
-peptic ulcer
-hiatal hernia
-peptic esophagitis
Nursing considerations:
1. Administer the drug apart from other oral medications
2. Periodically monitor serum electrolytes
3. Periodically monitor acid base balance
4. Patient education
5. Support and encouragement
 6. AR- rebound hyperacidity, alkalosis (nausea, vomiting, neuromuscular changes, headache, irritability, muscle
twitching and even coma), hypercalcemia, milk alkali syndrome, constipation, diarrhea, hypophosphatemia, fluid
retention and CHF
7. CI- allergy, any condition that can be aggravated by acid base imbalance (GI obstruction, renal dysfunction and
pregnancy and lactation)
8. Drug Interaction
Tetracycline, Phenothiazines, Ketoconazole
-absorption affected
Quinidine
-increased blood level
Aspirin
-decreased blood level

3. Proton Pump Inhibitors

Esomeprazole, Omeprazole, Lanzoprazole, Pantoprazole, Rabeprazole
Mechanism of Action
-prevent the final step in HCl production and thereby decrease the acid level in the stomach
Indications
-duodenal ulcers -benign active gastric
-GERD ulcer
-erosive esophagitis
Nursing Considerations
1. Administer before meals
2. Safety and comfort measures
3. Medical follow-up check up if s/sx persist beyond 4-8 weeks of therapy
4. Patient education

4. Antipeptic Agents (Cytoprotectives)

Sucralfate

5. Prostaglandin
Misoprostol

Digestive Enzymes
2 Digestive Enzymes for Replacement:
1. Saliva Substitute
-for dry mouth due to stroke, radiation therapy, chemotherapy
2. Pancrelipase
-cystic fibrosis and pancreatic dysfunction

Laxatives and Antidiarrheal Agents

1. Laxatives
-chemical stimulants
Cascara, Senna, Castor Oil, Bisacodyl
-bulk stimulants
Magnesium sulfate, Magnesium citrate, Magnesium hydroxide, Lactulose, Polycarbophil, Psyllium
-lubricating laxative
Docusate, Glycerin and mineral oil
Indications
-short term relief of constipation
-to prevent straining
-for diagnostic procedures
-for poisoning
-as an adjunct for antihelminthic therapy

2. Gastrointestinal Stimulants
Dexpanthenol, Metoclopramide

3. Antidiarrheal Drugs
Bismuth subsalicylate, Loperamide, Opium derivative

Antipsychotic Drugs
-reduce excessive dopamine activity, by blocking post synaptic dopamine receptors in the cerebral cortex, basal
ganglia, hypothalamus, limbic system, brainstem and medulla
 Phenothiazines
 Chlorpromazine Perphenazine
Prochlorperazine Trifluoperazine
Thioridazine Triflupromazine
 Non Phenothiazines
Clozapine Pimozide
Haloperidol Thiothixine
Risperidone Loxapine
-indications:
a. schizophrenia
b. organic psychosis
c. manic phase of bipolar affective disorder
-also referred to as “Major Tranquilizers” or “Neuroleptics”
-nursing considerations:
a. impairment of physical and mental activities
b. avoidance of activities requiring mental alertness
c. avoidance of the use of alcohol and other CNS depressants
d. monitor for the presence of EPS, anticholinergic effects and orthostatic
hypotension
e. monitor for the occurrence of tardive dyskinesia

EPS/ Pseudoparkinsonism/ Parkinson-like Disease

a. tremors and other involuntary movements
b. akathisia
-differentiate from increased agitation
-give propranolol or lorazepam
-reduce the dosage of anti-psychotic agent
c. dystonias, dyskinesias
-give anticholinergic agents

Tardive Dyskinesia
-an EPS that does not usually appear until 2 or more years of antipsychotic drug therapy
-result of dopamine receptor hypersensitivity due to prolonged blockage
-mild:
>rhythmic involuntary movement of facial muscles
*fly catching movement of the tongue
*lip smacking and chewing movt.
-severe:
>dyskinetic movements of the extremities
*jerks of the limbs, fingers and toes
>reversible upon the discontinuation of the drug during the first two years