PHARMACOLOGY Greek term pharmakon drug or medicine Logos the truth about or rational discussion Clinical pharmacology is the

he study of drugs in humans. A drug is any chemical that can effect living processes. Pharmacology Study of the biological effects of chemicals Pharmacotherapeutics Clinical pharmacology involving drugs use to treat, prevent, or diagnose a disease NURSING PROCESS AND MEDICATION ADMINISTRATION 1. ASSESSMENT Allergies Pattern of health care Understanding of the disease process Financial support 2. Physical Assesment Age and weight Social support at home Chronic condition 3. Diagnostic test, laboratory test 4. Medication History Prescriptions OTCS Herbals Response to medications Nursing Diagnosis Human response to illness Drug therapy may only be a part of the total picture Drug therapy is incorporated in the total picture PLANNING 1. identify possible intractions 2. client and family education 3. gather equipment, review procedures, safety measures, timing and frequency of drugs 4. storage of drugs IMPLEMENTATION 1. Maximising therapeutic effects 2. Minimizing adverse effects 3. SIX rights of medication administration EVALUATION Monitor the patient response to drug therapy expected outcome Unexpected outcome The 5 RIGHTS of Medication Administration Right drug Right dose Right time Right route Right patient WHAT OTHER RIGHTS TO ENSURE SAFETY IN GIVING DRUGS? Right to: Consistent system Analysis A double check The entire system of medication administration Ordering, preparing, dispensing, documenting

RIGHT TO: Proper drug storage Proper documentation Actual dosage preparation Accurate dosage calculation and preparation Careful checking of orders Patients safety SIX ELEMENTS OF A DRUG ORDER 1. Name of the patient 2. Date order is written 3. Name of medication 4. Dosage which includes size, frequency and number of doses 5. Route of delivery 6. Name and signature of the prescriber DRUG NAMES 1. Chemical Name Describe the chemical structure and composition 2. Generic Name Non propriety name given by USANC 3.Brand Name Registered trademark EXAMPLES Chemical Name Propionic acid Generic Name Ibuprofen Brand Name Motrin Pharmacologic Principles DRUG Any chemical that affects the physiologic mechanism of a living organism PHARMACOLOGY The study or science of drugs Pharmacologic Principles 1.PHARMACEUTICS Study of Drug forms Deals with the delivery system The rate at which drug is dissolved and absorbed a.1. Pharmaceutical phase Dose of formulated drug Administration Disintegration and dissolution of the drug in the body a.2. Pharmacokinetic phase drug available for absorption Absorption, distribution, metabolism, excretion a.3. Pharmacodynamic Phase Drug available for action Drug receptor interaction Effect 2. Pharmacokinetics The study of what actually happens to a drug from the time it enters the body until it has left the body A. Absorption - movement of drug from the site of administration

B. Distribution transport of a drug to the bloodstream C. Metabolism alteration of a drug in the body D. Elimination elimination of the drug or its compound in the body PHARMACOKINETICS 1. Absorption the route of administration affects the rate and extent of absorption of that drug A. Enteral B. Parenteral C. Topical The extent of drug is called Bioavailability A. Absorption of oral drugs Varies according to the dosage form and route Status of the absorptive surface portions of the small intesines may be missing or damaged Rate of blood flow to the intestines sepsis ,excersise labor Activity of the stomach food increases gastric acid production leading to decreased Ph . Status of gastric motility fast or slow transmit time due to pathology, conditions which might delay transmission Some drugs are taken with an empty stomach with a full glass of water Other drugs should be taken with a full stomach to avoid gastric irritation or to enhance absorption Drugs that are given by the oral route Mesenteric blood system Liver for biotransformation before travelling into general circulation and this is called FIRST PASS EFFECT FACTORS AFFECTING DRUG ACTION 1. ABSORPTION - refers to the time the drug enters the body to the bloodstream. Factors: A. Dosage Form B. Route of administration a) Parenteral generally rapid b) Intravenous and Intra-arterial most rapid c) Intramuscular and Subcutaneous - Absorption is fast when given in aqueous base -Depends on condition of blood flow -Impaired peripheral circulation and shock will delay absorption

c. Diarrhea can cause drugs not to be absorbed d. Constipation may delay absorption 2. DISTRIBUTION Drugs are distributed first to areas that have extensive blood supplies heart kidney liver brain Areas of slower distributions are: muscles, skin, fats Sites like Bone and Brain might be very difficult for drugs to reach due to barriers or poor blood supply FACTORS THAT AFFECT DISTRIBUTION 1. Protein Binding albumin is the main protein to bind with drugs drugs that are bound to protein are not available for use and called PROTEIN BOUND Drugs not bound to protein are available to act at the intended site of action and excert their effects and this is called: FREE DRUG IF THE PATIENT HAS LOW ALBUMIN More drugs is available and the patient may have increased adverse effects 2. Water soluble VS Fat soluble Water soluble: tend to stay in the blood stream and have a slow absorption in the tissues Fat Soluble: distributed to the tissues more quickly 3. Blood Brain Barrier difficult for drugs to pass thru and will allow some fat soluble drugs to pass thru 4. Placental Barrier Metabolism Also known as BIOTRANSFORMATION It takes place mainly in the liver and produces: A. Inactive metabolite B. More soluble compound C. A more potent metabolite ORGANS RESPONSIBLE FOR METABOLISM LIVER KIDNEYS SKELETAL MUSCLES LUNGS PLASMA INTESTINAL MUCOSA FACTORS AFFECTING METABOLISM 1. Age elderly has decreased hepatic enzymes neonates has immature liver functions 2. Foods grapefruits and other foods 3. Diseases Cardiovascular or renal dysfunction . Illness pathologic condition: shock = decrease peripheral vascular circulation = slow absorption patients who are vomiting nephrotic syndrome or malnutrition = decrease protein (for distribution) kidney failure = decrease dose 5. Psychological aspect Placebo drug dosage form such as tablet or capsule; has no pharmacologic activity; has no active ingredient 6. Tolerance person begins to require higher dose to produce the same effect

d) Intradermal absorption is slow and

confined to area of injection only

e) Oral rate and degree of absorption

-depends on G.I. motility, presence of foods, gastric pH and other drugs taken C. Lipid Solubility affects absorption as it passes the G.I. mucosa D. G.I. Motility a. Stomach empties slowly with food and delay absorption b. Most oral drugs are best absorbed if given before meals or between meals

7. Dependence addiction or habituation withdrawal symptoms 8. Cumulative effect = drug accumulation =drug toxicity -rate of consumption > rate of metabolism and excretion DECREASED METABOLISM RESULTS IN: Accumulation of drugs Prolonged action of drugs Possible toxic effects FACTORS THAT INCREASED METABOLISM Drugs that stimulate the formation of new enzymes Barbiturates Rifampicin Drugs may leave the system more quickly or diminished therapeutic effects. 3. METABOLISM Process of metabolism is a sequence of chemical events that change a drug as it enters the body. Liver is the principal site Oral medications - go directly into the liver via portal before entering systemic circulation - many medications become entirely inactivated by the liver the first time they go through it. Age infants and elderly has reduced ability to metabolized some drugs Nutrition Liver enzymes involved in metabolism rely on adequate amounts of lipids, vitamins etc. Insufficient amounts of hormones such as insulin can affect metabolism of drug in the liver. 4. EXCRETION Kidney is the main organ Liver Bowel MORE PHARMACOKINETIC PRINCIPLES 1. Onset The time the drug takes it therapeutic effect 2. Peak The time the drug takes its full therapeutic response Time to change dressings or do painfull procedures 3. Duration The time the drug concentration is sufficient to elicit a therapeutic response How long it is going to last to anticipate the next dose 4. Trough The lowest blood level of a drug 5. Half life The time it takes for the original amount of the drug in the body to be removed Example: Short life need to be taken frequently Compliance maybe a problem Acyclovir 5x daily Long half life may have adverse effects . It will stay in the body for long Pharmacodynamics The mechanism of drug action in living tissue

How the drug alter the system A. Therapeutic effect positive change Drugs excert their actions in 3 ways: Receptor interactions Enzyme interactions NON SPECIFIC INTERACTIONS 1. Receptor interaction Key in a lock Agonist Drugs that fit well and elicit their own response Exa. Beta 2 drug agonist Antagonist Drugs that attach to the cell and block other drugs from attaching to the cell Benadryl is an antagonist 2. Enzyme interactions Alters the enzyme necessary for a certain body function Ace Inhibitors alters the enzyme pathway 3. Non specific interactions Alters the cell structure after some crucial process Antibiotics Pharmacotherapeutics The use of drugs and its clinical indications to prevent and treat a disease Acute therapy stroke, heart attack Maintainance therapy HPN, lipidemia Supplemental/replacement therapy insulin, iron, thyroid drugs Palliative high dose opioids for cancer Supportive fluids and electrolytes Prophylactic antibiotics during surgery Empiric experience shows it works, no evidence 1.Therapeutic drug monitoring Some drug have a very narrow range oftherapeutic and toxic effects Digoxin and gentamycin are closely monitored 2. Peak level highest blood level 3. trough lowest blood level Blood is drawn at specific times before and after administration to know the amount of drug in the body Factors of Monitoring 1. Therapeutic index Ratio of safety A low therapeutic index indicates a greater chance of adverse reaction 2. Drug concentration Consider pathologic conditions 3. Patients condition Stress and anxiety 4. tolerance A decreasing response to repeated doses 5. Dependence Physiologic and psychologic need for a drug 6. Interactions a. Additive effect smaller doses can be given with the same effect ie. Tylenol and codeine b. Synergestic effect 2 drugs have better effect than given alone HCTZ plus enalapril

c. Antagonistic 2 drugs have lesser effect than with either drug alone Antacids with tetracycline d. incompatibility when given together one deteriorates Furosemide and heparin Hazy color of parenteral drugs can occur when incompatible with i.v tubings 7. Adverse effects 2 broad categories 1. medication errors 2. Adverse reactions a. Hypersensitivity reactions b. Pharmacologic reactions 8. Contraindications Should not be given if contraindicated Aspirin with gastric ulcer Allergic to drug Pregnant Impaired liver or kidney function 5. Psychological aspect Placebo drug dosage form such as tablet or capsule; has no pharmacologic activity; has no active ingredient 6. Tolerance person begins to require higher dose to produce the same effect 7. Dependence addiction or habituation -withdrawal symptoms 8. Cumulative effect = drug accumulation =drug toxicity -rate of consumption > rate of metabolism and excretion Drug Interactions action of one drug is altered by the action of another drug Drug 1 + Drug 2 = increase activity of drug 1 and drug 2. Drug 1 + Drug 2 = decrease activity of drug 1 and drug 2. Ex: Antacids inhibit the dissolution of ketoconazole Aluminum containing antacids inhibit the absorption of tetracycline Only unbound drug is pharmacologically ACTIVE ADDITIVE EFFECT- 2 drugs with similar action are taken for a doubled effect ex: propoxyphene + aspirin=added analgesic effect SYNERGISTIC EFFECT- the combined effect of 2 drugs is greater than the sum of the effect of each drug given alone ex. Aspirin + codeine=increased analgesic effect Examples of drug destroyed by the acidity of the stomach INSULIN and GENTAMYCIN Brownish discoloration of the teeth-Tetracycline GRAY BABY SYNDROME- bone marrow toxicity----Chloramphenicol Drug Administration Principles of drug administration 1. Observe the 7 rights of drug administration: Give the right dose of the right drug to the

right client at the right time by the right route and approach, then record it right. 2. Verify all now or questionable orders with physician or nurse-in-charge. Be knowledgeable about meds you administer 3. i.e. know drugs purpose, action, side effects, etc. 4. Use only medications in clearly labeled containers and check label 3x (from pharmacy/ cabinet, before and after preparation) 5. Check expiry date and look for any changes that may indicate decomposition(color, odor, and clarity) 6. Practice aseptic techniques: wash hands, do not contaminate containers, place caps upside down. 7. Be sure meds are identified for each client. Confirm or ask clients name and counter check with ID bracelet/tag 8. Check for any allergies(skin tenting prior to administration) 9. Inform client of medication, technique and purpose. 10. Stay with client until meds are taken. Do not leave meds at bedside. Dispose all used items in sink or toilet. 11. Assist client as needed. If client vomits, report to physician. 12. Record administration of drug immediately and accurately/ chart any omission, initial it, and give rationale. 13. For errors in administration, report immediately. 14. For safety, give only meds that you personally prepared. Common Dosage Forms Form Caplet Description Solid form for oral use; shaped like a capsule and coated for ease of swallowing Capsule Solid form for oral use; meds in powder, liquid, or oil form encased by gelatin shell Elixir Clear fluid containing water and/or alcohol; designed for oral use; usually has sweetener Enteric Tablet coated with tablet materials that dissolve in intestine, where medication is absorbed Extract Concentrated form made by removing active portion of meds from its other components Glycerite Solution of medication combined with glycerin (at least 50%) external use Intraocula Small, flexible oval when r disk moistened by ocular fluid, releases medication for up to 1 week

Liniment

Lotion

Preparation usually containing alcohol, oil, or soapy emollient that is applied to the skin Medication in liquid suspension applied externally to protect skin

Remember Sit client upright to enhance swallowing When preparing solid meds: only scored tablets may be broken Crush tables only when appropriate( e.g. for children, elderly, dysphagia); otherwise consider a liquid preparation For enteric-coated tablets: dont crush or give with antacids, milk When preparing liquid meds: Shake suspensions & pour away from label to prevent dirtying it Read amount at meniscus & at eye level Wipe lip and neck of bottle before recapping it Evaluate clients response to meds after 30 min. if client vomits after taking meds, inform physician. Do not give again. Major Routes of Administration ORAL ADMINISTRATION OF MEDICATIONS Advantages Convenient Inexpensive to administer Disadvantages: Absorption varies from person to person Oral meds may irritate GI tract Client must cooperate Absorption: two gates of absorption Gastrointestinal tract Capillary walls Most of an oral dose is absorbed in the small intestine Rate and degree of absorption depends on pH of stomach contents Food in stomach Gastric emptying time Coating on medication preparation Topical medications(skin, nose, eye, ear, vagina, rectum) Via skin Use gloves, gauze or sterile applicators Cleanse skin with soap & warm water to remove encrustation that blocks contact and absorption of new meds. Remember Lotion and creams: applied lightly, not rubbed Liniment: rubbed into skin gently but firmly Powder: dusted lightly to cover affected area thinly Transdermal patches: remove backing and place patch in area with little hair; use gloves to avoid drug absorption Nitroglycerin patch: take blood pressure before and after application Via nose Have client blow nose, lie supine and breath thru mouth

Pill

Solid form containing 1 or more meds, shaped into globules, ovoid, or oblong shapes Solution Liquid that may be used orally, parenterally, or externally; can also be instilled into body Supposito Pellet-shaped solid with ry gelatin, for insertion into body cavity(rectum or vagina) Suspensio Fine drug particles n dispersed in liquid medium which settles on standing, so shake before using Syrup Medication dissolved in concentrated sugar solution; may contain flavoring for palatability Tablet Powder form pressed into hard disks or cylinders; also contains binders(adhesive), disintegrators(for tablet dissolution), lubricants, and fillers(for convenient tablet size) Tincture Alcohol or water-alcohol medication solution Transder Meds in semipermeable mal patch membrane disk or patch absorbed thru skin slowly over long period Troche/ Flat & round form lozenge dissolved in mouth to release meds; contains flavoring, sugar, and mucilage Routes of administration Via the mouth Oral Take with 50-100 ml of cold fluid unless contraindicated Contraindications: GI dysfxn(vomiting), unconscious or unable to swallow, NPO preor post-op Disadvantages: gastric irritation, inactivation by gastric acid, unpleasant taste or odor, teeth discoloration.

Position head as follows for 5 min (to ensure absorption) Remember Posterior pharynx: head tilted or extended backward Ethmoid and sphenoid sinus: head hyper extended or tilted over edge of bed (Parkinsons position) Frontal & maxillary sinus: hyper extended and side wards (Proetzs) - Place dropper or atomizer 1 cm above nares &squeeze quickly, being careful not to touch nose with applicator - Client may wipe but not blow nose. - Meds may produce unpleasant taste or coughing - Contraindications to decongestants (most common nasal med): Heart dse, DM, and hypertension Via eye Recall: O.D.= right eye, O.S.=left eye, O.U.= both eyes Gently clean eyelid of crusts or discharge using gauze in saline. Always wipe from inner to outer canthus. For eye drops - While client looks up, use thumb/ forefinger to pull down cheekbone and pull up lid exposing lower conjunctiva - Drop prescribed meds and ask client to blink or close eyes - Repeat if client closes eyes prematurely For eye ointment Squeeze thin stream along inner edge of lover conjunctiva from inner to outer canthus. Dont touch eye with container; twist tube to break stream. Client closes eyes, then lightly rub lid in circular motion Via ear - Recall: A.D. = right ear, A.S.= left ear; A.U.= both ears - With client side-lying, straighten ear canal by pulling ear up and backward(adult & older children); down and backward (infants) - Assess eardrum perforation( contraindication to irrigation) or discharge (clean if present) - Warm meds in hands (to avoid vertigo). Hold dropper 1 cm above the ear & instill meds. Maintain for 2-3 min. - For irrigation: place towel under clients head and have client hold basin under ear. Slowly irrigate with 50ml of fluid & allow all fluid to drain out Via vagina -Decrease client anxiety: explain procedure, may prefer self administration, provide privacy, have her void prior -Position: dorsal recumbent, over bedpan if for irrigation -Use gloves; then retract labia with nondominant hand.

For suppositories: - With dominant hand, apply water-based lubricant on rounded end of suppository & insert 3-4 inches down along posterior wall of the vaginal canal - Store suppositories in the ref to avoid melting For creams, foams, jelly or irrigating solutions (douche) Insert applicator 2-3 inches down and deposit meds. Client remains in position for 1520minutes Via rectum - Provide privacy. Use gloves. Explain procedure - Ask client to lie on side& breathe slowly thru the mouth - Apply lubricant, insert tapered end past internal anal sphincter (kids 2 in; adults 4 in) and hold buttocks together as client may expel suppository. Inhalant medications (Metered-dose Inhalers, MDI) These clients depend on meds for adequate control of airway obstruction & must learn selfadministration. Position: upright (sitting or standing) Shake inhaler then have client inhale & exhale deeply -3 point or lateral hand position: client holds inhaler, thumb at bottom of mouthpiece & index & middle finger at the top. -Place inhaler in mouth or 1-2 in away with spacer (ensures drug is inhaled & not just deposited on tongue or throat) -Simultaneously, client inhales deeply & presses canister. -Hold breath for 10 sec then exhale thru pursed lips. PARENTERAL MEDICATIONS AMPULE PREPARATION Tap neck to move fluid down ampule then snap off neck towards self. Hold ampule upside down, quickly draw meds without needle touching rim Also, keep tip of needle under fluid to avoid aspirating bubbles. If aspirated, do not expel air in ampule To expel bubbles, tap syringe to move bubbles up & draw back plunger slightly then push to expel air VIAL PREPARATION (SOLUTION) Multi-dose vials: Wipe off rubber stopper with alcohol pledget Without contaminating plunger, draw up air equal to amount of meds needed & inject air into vial. This prevents negative pressure buildup & aids in drawing up meds. Insert needle thru center (thinnest part) of rubber seal. Keep tip below fluid level & allow pressure in vial to fill syringe. Before injecting into client, change dulled needle Vial Preparation (Powder for Reconstitution)

Prepare diluent & inject into vial. Remove needle & roll vial in palms. Do not shake. Use a filter needle when drawing up reconstituted meds

Advantages: readily accessible; in the event of hypersensitivity reaction, medication absorption can be delayed by tourniquet Disadvantages: small muscle mass; limited to small volume doses; close to nerves; requires accurate technique VASTUS LATERALIS Position: sitting, supine Advantages: good site for infants; size acceptable for multiple injections; free of major nerves Disadvantages: special attention required to avoid sciatic nerve or femoral structures if long needle is used INTRAVENOUS THERAPY use - replace fluid, electrolytes and other nutrients for clients who cannot eat or drink adequately types of IV therapy solutions osmotic pressure similar to that of plasma examples: normal saline 0.9%; lactated Ringer's solution; 5% dextrose in water hypotonic exerts less osmotic pressure than plasma examples: 2.5% dextrose in water; half strength normal saline 0.45% hypertonic exerts higher osmotic pressure than plasma (draws water out of the cells) examples: 5% dextrose in normal saline 0.9%; 5% dextrose in lactated Ringer's solution INTRAVENOUS ADMINISTRATION Venipuncture Prepare infusion set. Place roller clamp 1-2 inches below drip chamber & move to off position. Insert spike to fluid bag. Prime or fill drip chamber & tubing with solution Remove any air bubbles by tapping tubing. Apply tourniquet & select a vein large enough for the catheter Use the most distal site in the non-dominant arm. Dilate vein: Open / close clients fist or milk arm towards site Cleanse site then anchor vein using the thumb and stretch skin opposite the direction of insertion For both butterfly needle and over-the-needle catheter: Insert at 20-30 degree angle, bevel up, slightly distal to the site. Look for blood return then fully lower needle or catheter ( remove stylet if ONC before lowering) Stabilize catheter, connect to infusion set & secure with tape IV PUSH VIA HEPARIN LOCK Use SASH method S: flush with 2 ml saline A: administer meds S: flush with 2 ml saline H: flush with 10-100 units heparin IV PUSH VIA EXISTING LINE Occlude primary IV line by pinching tubing just above injection port closest to patient, give meds & release tubing.

Mixing Medications 2 Vials: Inject air into vial A & withdraw needle (tip must not touch the solution) Inject air into vial B & withdraw meds. Change needle. Inject new needle into vial A & withdraw meds Vial to Ampule: Draw meds from vial first then from ampule Administering Injections Select Appropriate site, avoiding bruised or tender areas & rotating sites as much as possible for repeated injections. Clean site with alcohol swab, let dry. Always use gloves to prevent contact with client blood. Insert needle quickly, bevel up, then release hold to decrease pain Aspirate for blood. Re-insert if with blood Inject slowly. Press swab over site before removing needle. Massage area except for Z-track or heparin injection Most common site for heparin injection is the abdomen INTRAMUSCULAR INJECTION SITES Absorbed across capillary wall Rate of absorption depends on How water soluble is the medication? How much blood flows to site of injection? Adverse effects: discomfort, possible local tissue injury INTRAMUSCULAR INJECTION SITE VENTROGLUTEAL Position: Supine lateral Advantages: Anatomic landmarks well defined; muscle mass suited for deep IM or Z-track injections; free of major nerves Disadvantages: in the event of hypersensitivity reaction, medication absorption cannot be delayed by tourniquet DORSOGLUTEAL Position: Prone Advantages: muscle mass suited for deep IM or Ztrack injections Disadvantages: Requires correct/accurate site and technique to avoid injury to major nerves and vascular structures; in the event of hypersensitivity reaction, medication absorption cannot be delayed by tourniquet DELTOID Position: lateral, prone, sitting, supine

IV INFUSION Inject meds thru port in IV bag with rubber stopper not thru air vent or port for IV tubing. Label rate and time

PIGGYBACK Add med solution bag to an existing line Connect IV tubing to medication bag. Hang med bag higher than primary fluid bag if piggyback, same height if tandem. SUBCUTANEOUS ADMINISTRATION Absorbed across capillary wall Rate of absorption depends on How water soluble is the medication? How much blood flows to site of injection? Adverse effects: discomfort, possible local tissue injury SUCCESS IS TAKEN ONE STEP AT A TIME I CAN Did is a word of achievement, Wont is a word of bereavement, Cant is a word of defeat, Ought is a word of duty, I CAN Try is a word each hour, Will is a word of beauty Can is a word of power MEDICATION CALCULATIONS Metric System To convert within the metric system, simply divide or multiply multiples of 10 1000mg= 1 g, 1= 1000ml, 0.45L= 450 ml Apothecary System System rarely used; basic unit is grain Uses small Roman numerals (gr xvi= 16 grains); Fractions (1/3 gr) Weight 60 grains= 1 dram 8 grains= 1 ounce 12 grains= 1 pound Volume 60 minims= 1 fluidram 16 fluidram= 2 fluidounce= 1 pint 1 gallon= 4 quarts= 8 pints Household System Familiar to most people but not as accurate as metric system

Househol d 1 drop 15 drops 1 tsp 1 tbsp 1 ounce 1 glass= 1 measurin g cup 2 measurin g cups 1 quart 1 gallon 2.2 pounds 1 inch

Metric 0.06 ml 1ml 5 ml 15 ml 30 ml 240 ml 480 ml= 500 ml 960 ml= 1 L 3840 ml= 4 L 1 kg 2.54 cm 60 mg

Apothecary 1 minim 15 minims 1 fluidram= 60 min 4 fluidram 1 fluidounce 8 fluid ounce 1 pint 1 quart 1 gallon 1 grain

CALCULATIONS Drug Dosage Remember to convert the same unit before calculating Basic formula for unknown volume (ml) of drug needed(x): X(ml)= D/S X known quantity For drugs that need to be diluted, use the following diluents: IM= use 2cc IV=/<500mg= use 5 cc IV> 500mg= use 10 cc Parenteral Injection

Site

syringe

needle method

remarks

Pediatric Drug Dosage 1. Based on Body Surface Area (BSA)- most accurate 2. Based on kg Body Weight (BW) 3. Based on Age: Frieds Rule (birth to 12 months): Infants dose= age in months/150 x adult dose Youngs rule (1- 12 years): Childs dose= age in years/age in yrs + 12 x adult dose Clarks Rule: Childs dose= wt of child in lbs/150 lb x adult dose BSA (m2)= square root of weight (kg) x height (cm) 3600 Childs dose= childs BSA x adult dose adult BSA (average is 1.73 m2) Example: 3 year old child weighs 15 kg with a height of 92 cm is to be given Demerol; adult dose for Demerol is 100 mg/ dose Solution: Childs BSA= square root of (15 kg x 92 =1380/ 3600 =0.619.1392 or 0.62 m2 Childs dose = 0.62 m2 x 100 mg Demerol= 62/1.73 = 35.8 0r 36mg 1.73 m2 Answer: 36 mg Based on kg Body Weight (BW) X (ml)= mg/kg/dose x wt in kg x known quantity stock dose Example: Paracetamol 15 mg/kg/dose for child weighing 20 kg. Stock dose: 250/ 5 ml Solution: Childs dose= 15 mg x 20 kg x 5 ml = 1500 kg/dose / 250 mg= 6mg Answer: 6 ml/ dose Example: Amoxicillin 30 mg/kg/day for a child weighing 20 kg. Preparation is 250 mg/ 5 ml; to be given 3x a day Solution: 30 mg/kg/day x 20 kg x 5 ml/250 mg= 12 ml/day 12 ml/ 3= 4ml/ dose Answer: 4 ml/ dose Example: Cefalexin 50 mg/ kg/ day for a child weighing 30 kg. Preparation is 250 mg/ 5 ml; to be given every 6 hours Solution: 50 mg/kg/day x 30 kg x 5 ml/ 250 mg = 30 ml/ day 30 ml/ 4= 7.5 ml/ dose Answer: 7.5 ml/ dose

ID Ventral forearm, scapula, chest

0.1- 1 ml G: 26 Stretch dont (max) L: 3/8, skin, insert massage. tuberculin 5/8 needle Encircle bevel up, at the site 5- 15 degrees 2-3 mm deep to form a wheal
Kids: 0.5- 1 ml Adults: 1- 3 ml G: 25- 27 L: 3/8, 5/8, Pinch skin to Dont form SC fold aspirate or (needle massage should be heparin or width of insulin fold). Hold injections syringe like a dart, palm down. Insert at 45 deg for ext & thin client, 90 deg for abdomen, obese and emaciated

SC Lateral upper arm, ant thigh, abdomen ( 1 inch from umbilicus), scapula

IM Gluteus, anterior & medial thigh

Kids: 0.5- G: 211 ml 23 Adult: 2- 3 L: 1 ml (kids); 1- (adult)

Hold like Z-track: dart, palm used to down. decrease Insert at 90 irritation deg. Aspirate. If no back flow, inject slowly, wait 10- 20 secs, remove needle and release

Example: Salbutamol 0.15 mg/kg/ dose for a child weighing 20 kg. Stock dose is 2 mg/5 ml Solution: 0.15 mg/kg/dose x 20 kg x 5 ml/ 2mg = 7.5 ml/ dose Answer: 7.5 ml/ dose IV Fluid Flow Rate/ Regulation Basic formula: Macrodrip Gtts/min= amount of solution in ml/min x drop factor Drop factor ( 10, 15, 20 gtts/ml) depends on manufacturer Unless specified, use drop factor 15 gtts/ml (most common) Example: LRS 1L to consume in 8 hours; drop factor 15 gtts/ml Solution: 1 L/ 8 hrs x 1000 ml/ 1L x 1 hour/60 mins x 15 gtts/ ml= 31 gtts/ min Answer: 31 gtts/ min Short Cut Formula: Microdrip Ugtts/min= ml/ hr since drop factor is always 60 ugtts/min & 1 hr= 60 mins Drop conversion: 1 gtt= 4 ugtts Example: LRS 1 L in 24 hours Answer: 42 ugtts/ min Solution: 1 L/ 24 hours x 1ooo ml/ 1 L x 1 hour/ 60 mins x 60 ugtts/ ml= 42 ugtts/ min or

1000 ml/ 24 hrs= 42 ugtts/ min therefore, ml/ hr= ugtts/min Titration: Desired mg/volume in gtts= delivery rate/regulation 1 cc= 15 gtts Example: 1 gram Lidocaine in 500 cc D5 water at 2 mg/ min Solution: 1 gm = 2mg/min 500 cc X 1000 mg = 2mg/min (1 cc= 15 gtts ) 7500 gtts X 1000 mgX= 2mg/min (7500 gtts) X= 2mg/min (7500 gtts) 1000 mg X= 15 gtts/min = 60 ugtts/ min ( 1 gtt= 4 ugtts) Answer: 15 gtts/ min SOLUTIONS Electrolyte Solutions: Hypertonic: D5 LRS, D5 0.9% NaCl, D5 0.45% NaCl, D5 NM, D5 NR Isotonic: 0.9 NaCl, LRS Hypotonic: D5 water, D10 water Nutrient Solutions/ TPN hyperalimentation- provides high calorie IV nutrition; 1 kcal/ ml with amino acids, dextrose, electrolytes, vitamins and minerals PARENTERAL NUTRITION For clients who are unable to digest or absorb enteral nutrition ( GI obstruction, ileus, surgery, trauma) If less than 10% dextrose solution Catheter inserted in peripheral vein & threated into subclavian/ SVC If more than 10% dextrose central venous catheter direct to SVC TPN Requires monitoring of glucose, electrolytes, lipids, proteins Dont increase rate if infusion lags behind NARCOTIC ANALGESICS Case Study Mrs. Linda Boyd, age 48, is admitted to the local hospital for an abdominal hysterectomy. PostoperatiVely she is placed on meperidine (Demerol) 100 mg IM every 4 hours prn. PROTOTYPE-MORPHINE SULFATE Action. Acts on opioid receptors in CNS and induces sedation, analgesia, and euphoria. Use. Relief of moderate to severe pain, preoperative medication, pain relief in Ml, relief of dyspnea occurring in pulmonary edema or acute left ventricular failure. Adverse Effect. respiratory depression Nursing Implications Assess client's pain before giving medication.. The first sign of tolerance is usually a decreased duration of effect of the analgesic.

Monitor respiratory rate and depth before giving drug, and periodically thereafter. . CNS Agents 6 Ds: D- depressed respirations D- dizzy D- drowsy D- decreased GI peristalsis and urine output D- decreased BP D- drug dependence Narcotic Antagonist: Naloxone hydrochloride ( Narcan ) action : Occupies receptor sites and reverse effects of agonist drugs Use : Postoperative respiratory depression Adverse effects: hypertension, tremors, reversal of analgesia Nursing implications: Rescucitative equipments readily available monitor clients for bleeding Narcotic Antagonists -reverses narcotic induced respiratory depression: Naloxone (Narcan) 5 Ps P- perspiration increased P- pulse increased P- puke increased P- pressure increased P- pain increased NEUROLOGICAL (INCLUDING ANESTHETICS) - Anticonvulsives - Antiparkinson Agents - Cholinesterase Inhibitors - Antidepressants - Antimanic Agents - Antipsychotic - Hypnotics - Antianxiety (Anxiolytic) - General Anesthetics - Local Anesthetics ANTICONVULSANTS action - modifies bioelectric activity at subcortical and cortical areas examples diazepam (Valium) magnesium sulfate phenytoin (Dilantin) phenobarbital (Luminal) use: prevents seizures adverse effects blood dyscrasias gastric effects - nausea, vomiting CNS depression - dizziness, drowsiness phenytoin: ataxia, hirsutism, hypotension nursing interventions give medication with food

wiith phenytoin: monitor condition of oral mucosa, don't mix with other IV fluids, monitor blood lab results, monitor urine renal, liver, and blood studies teach clients avoid alcohol notify physician of unusual symptoms carry medical alert information take medication on schedule; do not discontinue avoid driving and other potentially hazardous activities phenytoin: good oral hygiene, frequent dental visits Phenytoin: adverse effects: PHENYTOIN: P-450 interactions Hirsutism Enlarged gums Nystagmus Yellow-browning of skin Teratogenicity Osteomalacia Interference with B12 metabolism (hence anemia) Neuropathies: vertigo, ataxia, headache Anticonvulsant Agents Phenytoin (Dilantin) G- gingival hyperplasia U- use alternate birth control M- mouth care- preventive dental check-up S- soft tooth brush, dont use abruptly ANTIPARKINSON AGENTS action anticholinergics: block or compete at central acetylcholine receptors dopamine agonists: activation of dopamine receptors Parkinsonism: drugs SALAD: Selegiline Anticholinenergics (trihexyphenidyl, benzhexol, ophenadrine) L-Dopa + peripheral decarboxylase inhibitor (carbidopa, benserazide) Amantadine Dopamine postsynaptic receptor agonists (bromocriptine, lisuride, pergolide)

- do not stop taking antiparkinsonian meds suddenly: may precipitate parkinsonian crisis - take with meals - caution with hazardous activities - levodopa - minimize Vitamin B6 in diet, because it hinders drug's effectiveness - sweat and urine may be dark colored - toxicity: personality changes, increased twitching, grimacing, tongue protrusion CHOLINESTERASE INHIBITORS action prevents breakdown of acetylcholine at nerve endings facilitates transmission of impulses across myoneural junction strengthens muscle contractions including respiratory muscles examples edrophonium chloride (Tensilon) for diagnostic purposes neostigmine bromide (Prostigmin) ambenonium chloride (Mytelase) use: treat myasthenia gravis Adverse effects gastric irritation: nausea, vomiting, diarrhea hypersalivation CNS disturbances orthostatic hypotension toxicity: pulmonary edema, respiratory failure, bronchospasm Contraindications intestinal obstruction, renal obstruction peritonitis nursing interventions - monitor client response to medication; may need to adjust dosage - monitor vital signs during period of dosage adjustment - keep atropine sulfate available for overdosage - administer medication with food - administer medication as per schedule - teach client - wear medic alert jewelry and ID - change position cautiously; sit at first feeling of faintness. ANTIDEPRESSANTS action: increase norephinephrine at subcortical neuroeffector sites examples norepinephrine blockers (tricyclic, TCAs): amitriptyline (Elavil), imipramine (Tofranil) monoamine oxidase inhibitors (MAOIs): isocarboxazid (Marplan), phenelzine sulfate (Nardil) selective serotonin reuptake inhibitors: fluoxetine (Prozac), sertraline (Zoloft) use: treat melancholia, depression adverse effects norepinephrine blockers potentiate anticholinergics and CNS depressants orthostatic hypotension drowsiness, dizziness, confusion CNS stimulation

Nursing responsibilities - reinforce client education

MAOIs potentiate alcohol, barbiturates, antihistamines hypertensive crisis with ingestion of foods high in tyramine (pickled herring, beer, wine, cheese, chocolate) orthostatic hypotension SELECTIVE SEROTONIN REUPTAKE INHIBITORS may interact with tryptophan insomnia headache sexual dysfunction gastric irritation contraindications acute schizophrenia mixed mania and depression suicidal tendencies narrow angle glaucoma nursing interventions monitor effect of medication maintain suicide precautions especially as depression lifts give SSRIs in morning; TCAs at bedtime teach client do not take OTC medication without physician approval avoid hazardous activities effect of medication may take up to four weeks MAOIs: teach client to avoid food containing tyramine; monitor client for hypertensive crisis SSRIs and MAOIs should not be given concurrently or close together

ANTIMANIC AGENTS action: reduces adrenergic neurotransmitter levels in cerebral tissue examples antimanic agents: lithium carbonate (Lithane) alternative antimanic agents: carbamazepine (Tegretol), clonazepam (Klonopin) use: control of manic phase of mood disorders; bipolar disorder adverse effects - metallic taste - hand tremors - excess voiding and extreme thirst - slurred speech - disorientation - cogwheel rigidity - renal failure - respiratory depression nursing interventions monitor blood levels avoid concurrent administration of adrenergic drugs evaluate client's response to medication teach client effect of medication may take several weeks high intake of fluids and normal sodium toxicity signs: diarrhea, vomiting, weak muscles, confusion etc. take medication with meals L- level- therapeutic (0.6- 1.2 meq/ml) I- increased urination T- thirst increased H- headache & tremors I- increase fluids U- unsteady M- monitor salt ( decrease lithium level with excess sodium) ANTIPSYCHOTICS action blocks dopamine hydrochloride receptors in the CNS and sympathetic nervous system examples phenothiazines: chlorpromazine (Thorazine), thioridazine (Mellaril) can cause skin irritation or contact dermatitis benzisoxazole: risperidone (Risperdal) thioxanthenes: chlorprothixene (Taractan) butyrophenones: haloperidol (Haldol) adverse effects excessive sedation jaundice orthostatic hypotension urinary retention anorexia dry mouth hypersensitivity reactions (such as photoallergic reaction, impotence, cardiac toxicity) blood dyscrasias - agranulocytosis extrapyramidal side effects: dystonia, pseudoparkinsonism, akathisia, akinesia, tardive dyskinesia

General Concepts for Antidepressants: D- driving is out until response to drug is determined E- effect has a delayed onset of 7- 21 days P- planning pregnancy- consult physician R- relieves symptoms, not a cure! E- evaluate vital signs S- stopping drug abruptly is out! S- safety measures I- instruct client to report undesirable effects O- observe for suicidal tendencies N- no alcohol or CNS depressants Psychiatric Agents Antidepressants: SSRI, TCA, MAOI 1. SSRIs: Paxil, Celexa, Prozac, Luvox, Zoloft CNS- side effect C- CNS stimulation N- nausea S- Sexual/ changes in libido; Skin: photosensitivity 3. MAOIs : Mar Par Nar: Marplan, Parnate, Nardil Avoid Tyramine rich foods: may cause hypertensive crisis -aged cheese, beer, ale, red wine, pickled foods, smoked fish, beef, liver, avocado

neuroleptic malignant syndrome: fever, muscle rigidity, agitation, confusion, deliruim, respiratory failure Antipsychotics S- sedation & sunlight sensitivity T- tardive dyskinesia, tachycardia, tremors A- anticholinergic,agranulocytosis, addiction N- neuroleptic malignant syndrome C- cardiac arrhythmias, orthostatic hypotension E- extrapyramidal (akathisia), endocrine (libido) A nurse is preparing a plan regarding home care instructions for the parents of a child with generalized tonic-clonic seizures who is being treated with oral phenytoin (Dilantin). The nurse instructions in the plan regarding: a) Monitoring the childs intake and output daily b) Checking the childs blood pressure before the administration of the medication c) Providing oral hygiene, especially care of the gums d) Administering the medication one hour before food intake ANTIANXIETY (ANXIOLYTIC) action: depress CNS examples benzodiazepines: alprazolam (Xanax), chlordiazepoxide (Librium):physical dependency and withdrawl finsings after long term use azapirones: buspirone (Buspar) uses: anxiety, sleep disorders, alcohol withdrawl adverse reactions CNS disturbances: dizziness drowsiness, lethargy, orthostatic hypotension skin rash blood dyscrasias contraindications hypersensitivity acute narrow angle glaucoma liver disease

examples inhalation anesthetics: cyclopropane, enflurane (Ethrane), ether, nitrous oxide IV barbiturates: thiopental sodium (Pentothal), methohexital sodium (Brevital) IV and IM nonbarbiturates: midazolam HCL (Versed), ketamine HCL (Ketaject) use: used in combination for surgical anesthesia adverse effects inhalation anesthetics: excitement and restlessness, nausea and vomiting, respiratory distress IV barbiturates: respiratory depression, hypotension, tachycardia, laryngospasm IV and IM nonbarbiturates: respiratory failure, hyper/hypotension, rigidity, psychiatric disturbances contraindications - CVA - increased intracranial pressure - severe hypertension - cardiac decompensation nursing interventions have oxygen and emergency treatment available monitor vital signs use precautions if agent flammable use safety precautions when client induced Helium brown O2- green Co2 gray Air- yellow Nitrogen black Nitrous oxide blue Abbocath: White 27g 25- yellow 21 blue 19 pink 18 green LOCAL ANESTHETICS action: decreases nerve membrane permeability to sodium ion influx examples topical: benzocaine, cocaine, lidocaine HCL (Xylocaine) spinal: dibucaine (Nupercaine), procaine HCL (Novocaine) nerve block: bupivacaine HCL (Marcaine), mepivacaine HCL (Carbocaine) use: pain control while client is conscious adverse effects - allergic reactions - respiratory arrest - arrhythmias, cardiac arrest - convulsions

A- avoid abrupt discontinuation after prolonged use N- not given if w/HPN, renal/liver dysfxn, drug abuse X- xanax, ativan, serax, diazepam, librium, midazolam I- increase in 3Ds: drowsiness, dizziness, dec BP E- enhances axn of GABA T- teach to rise slowly from supine Y- yes, alcohol shld be avoided GENERAL ANESTHETICS action: depresses the CNS through a progressive sequence PROGRESSIVE SEQUENCE OF GENERAL ANESTHESIA

hypotension

nursing interventions - have oxygen and emergency equipment available - monitor vital signs during local anesthesia - if spinal anesthesia, keep client flat for 6-12 hours to prevent headaches WOMENS HEALTH RELATED AGENTS OXYTOCIN ( PITOCIN) P- pressure is elevated I- intoxication with water T- tetanic contractions O- oxygen decrease in fetus C- cardiac arrhythmia I- irregularity in fetal heart rate N- nausea and vomiting Magnesium Sulfate- for control of convulsion in preeclampsia or eclampsia Mg SO4 Toxicity: decreased BURP B- BP decreased U- urine output decreased R- respiratory rate decreased P- patellar reflex decreased NSAIDs N- no alcohol S- S.E. BIRTH bone marrow depression, inc. GI distress, renal toxicity, tinnitus, hepatotoxicity aspirin sensitivity- do not give inhibits prostaglandin D- do take with food S- stop 5- 7 days before surgery Antineoplastic Agents C- CBC, platelets- monitor A- antiemetics before drug N- nephrotoxicity- undesirable effect C- couselling regarding reproductive issues E- encourage handwashing, avoid crowds R- recommend a wig for alopecia

Mucolytics Antitussives Antituberculosis agents Antihistamines Anti-inflammatory BRONCHODILATORS action: dilate air passages in the lungs, specific action dependent on type of drug. increase heart rate act on the autonomic nervous system examples beta-adrenergic: abuterol (Proventil, Ventolin), metaproterenol (Alupent) xanthines: aminophylline, theophylline (TheoDur) acts on bronchial smooth muscle epinephrine HCL (Adrenalin) - increases the rate and strength of cardiac contraction through the sympathetic nervous system isoproterenol HCL (Isuprel) - increases the heart rate by stimulating the beta-adrenergic blocking agent of the sympathetic nervous system use: bronchospasms, asthma adverse effects - dizziness - tremors - anxiety - palpitations - gastric disturbances - headache - tachycardia - dysrhythmias contraindications - hypersensitivity - narrow angle glaucoma - tachydysrhythmias - severe cardiac disease nursing interventions - monitor theophylline levels (normal ten to 20 mcg/dl) - monitor intake and output, and vital signs - monitor EKG, vital signs during therapy - teach clients - take medication as prescribed only - report adverse effects - stop smoking during therapy - take with meals - avoid OTC drugs

A 40-year-old patient whos receiving chemotherapy for breast cancer develops nausea and vomiting. For this patient, the nurse should give the highest priority to which action in the care plan? a) Serve small portions of bland food. b) Encourage rhythmic breathing exercises. c) Administer metoclopramide (Reglan) and dexamethasone (Decadron), as prescribed. d) Withhold fluids for the first 4 to 6 hours after chemotherapy administration. Respiratory Drugs Bronchodilators

MUCOLYTICS/EXPECTORANTS action mucolytics: disrupt molecular bonds and thins mucus expectorants: stimulate a gastric mucosal reflex to increase production of lung mucous examples mucolytic: acetylcysteine (Mucomyst) expectorant: guaifenesin (Robitussin) uses: asthma acute or chronic bronchopulmonary disease cystic fibrosis mucomyst: acetaminophen toxicity

adverse side effects - oropharyngeal irritation - bronchospasm - gastric effects contraindications increased intracranial pressure status asthmaticus nursing interventions - monitor respiratory status - teach client - take no fluids directly after oral administration - do take plenty of fluids - encourage coughing and deep breathing, especially before treatment ANTITUSSIVES action: to supress coughs through medullary cough center or indirect action on sensory nerves examples narcotic: codeine, hydrocodone bitartrate (Hycoda) nonnarcotic - dextromethorphan (Robitussin) use: colds, respiratory congestion, pneumonia, bronchitis, TB, cystic fibrosis, emphysema adverse effects - drowsiness - nausea - dry mouth - dizziness contraindications hypothyroidism iodine sensitivity nursing interventions - monitor blood counts with long term therapy - increase fluid intake - humidify client's room - teach client - increase fluid intake if not contraindicated - do not to take fluids immediately after medication - avoid driving and other hazardous activity especially if taking narcotic type - antitussives add to the effects of alcohol

first line ethambutol (Myambutol) decreases mycobacterial RNA synthesis isoniazid (INH) - suppresses mycobacterial cell-wall synthesis second line capreomycin (Capastat) pyrazinamide (PZA)

adverse effects - gastric irritation - CNS disturbances - liver disturbances - blood dyscrasias - streptomycin - ototoxicity - ethambutol - visual disturbances - isoniazid - suppressed absorption of fat and vitamin B complex contraindications severe renal disease hypersensitivity nursing interventions - monitor client response to therapy - monitor blood work during therapy - if CNS disturbances are evident, take safety precautions - teach client - to take medication as ordered - to eat foods rich in B-complex vitamins - avoid use of alcohol - report if become pregnant - ethambutol: report eye problems, have regular eye exams Just know your R.I.P.E.S Managing gastrointestinal conditions Antacids action neutralizes gastric acid coats stomach lining examples aluminum hydroxide gel (Amphojel) aluminum and magnesium hydroxides (Maalox) magaldrate (Riopan) use: peptic ulcers, reflux esophagitis, hiatal hernia adverse reactions aluminum compounds - constipation, intestinal obstruction magnesium compounds - diarrhea reduced absorption of calcium and iron nursing interventions shake oral suspension well monitor client's response to treatment administer with 8 oz glass of water teach client avoid overuse of antacids dietary restrictions for ulcers need for diet high in calcium and iron for clients on low sodium diets: antacids contain sodium may color stools whitish Antiulcers

Respiratory Agents B- breathing and coughing techniques R- relaxation techniques E- evaluate heart rate and blood pressure A- arm identification (asthma) T- tremors H- have 8 or more glasses of fluids E- emphasize no smoking ANTITUBERCULOSIS AGENTS action: appears to inhibit RNA synthesis, so stops tubercle bacilli from multiplying (first line) or functioning (second line) examples

actions decrease acetylcholine release block release of histamines inhibit secretion of pepsin inhibit proton pump examples anticholinergics; belladonna tincture, chlorodiazepoxide (Librax) h2 blockers - cimetidine (Tagamat), ranitidine (Zantac) pepsin inhibitor - sucralfate (Carafate) proton pump inhibitor - lansoprazole (Prevacid), omeprazole (Prilosec) uses: management of peptic ulcer disease, gastroesophageal reflux disease(GERD), protects gastric mucosa from hydrochloric acid production adverse reactions - dry mouth, decreased secretions, constipation, tachycardia, & urinary retention - headaches, dizziness, constipation, skin reash, pruritis, impotence - sucralfate is nonabsorbable, occasional constipation contraindications anticholinergics - narrow- angle glaucoma renal failure liver disease nursing interventions - administer on empty stomach - avoid antacids within 30 minutes of sucralfate - avoid antacids within one to two hours of other antiulcer drugs - administer other drugs one to two hours after sucralfate - teach clients - avoid alcohol, spicy food, and caffeinated beverages - eliminate smoking - increase fluid intake - medication can take up to two weeks for full effect - report increasing abdominal pain, vomiting of blood, or passage of bloody stools Gastrointestinal Agents Anti-ulcer: H2 receptor antagonists: tidine drugs: NO WINE JUST DINE D- dont take with antacids I- inform physician of bleeding N- no smoking, alcohol or NSAIDs E- elevate head of bed A patient with peptic ulcer is about to begin a therapeutic regiment that includes a bland diet, antacids, and ranitidine (Zantac). Which instruction should the nurse provide before this patient is discharged? a) Eat three balanced meals every day. b) Stop taking the drugs when the symptoms subside. c) Avoid aspirin and products that contain aspirin. d) Increase the intake of fluids containing caffeine. Cardiovascular Drugs Cardiac glycosides Antihypertensives

Thrombolytics Lipid-lowering agents Antianginals Hypotension and shock Anticoagulants Antidysrhythmics Cardiac Glycosides CARDIAC GLYCOSIDES action: makes heart beat slower but stronger improves pumping ability of heart increases force of heart's contraction decreases rate of contraction increases cardiac output examples digitoxin (Crystodigin) digoxin (Lanoxin) Use congestive heart failure atrial flutter atrial fibrillation Contraindications ventricular tachycardia ventricular fibrillation second and third degree heart block Adverse Side Effects gastrointestinal effects such as nausea and vomiting, diarrhea, and anorexia bradycardia xanthopsia muscle weakness dysrhythmia Nursing Interventions before giving glycoside, check apical pulse and heart rhythm. Report if < 60 bpm Report for toxicity in children - cardiac arrhythmias in adults - visual disturbances, nausea and vomiting, anorexia older clients more prone to toxicity monitor drug levels therapeutic range 0.8 to 2.0 mg/ml toxic range > 2 mg/ml diuretics may increase chance of toxicity monitor intake and output Client teaching - identify and report signs of toxicity - for atrial fibrillation: take pulse and report if below 60 or above 100 or changes in rhythm - daily weights: report two pound increase ANTIHYPERTENSIVES action: dilates peripheral blood vessels examples hydralazine HCL (Apresoline) enalapril maleate (Vasotec) reserpine (Serpasil) prazosin HCL (Minipress) methyldopa (Aldomet) clonidine (Catapres) contraindications heart block children

adverse side effects - orthostatic hypotension - dizziness - bradycardia - tachycardia - sexual dysfunction - deterioration in renal function - agranulosis Nursing interventions - monitor vital signs and blood pressure, sitting and standing - monitor for hearing changes, renal functioning - if hypotension, closely monitor client - encourage intake of foods high in vitamin B teach client low sodium diet change positions slowly take medication as instructed avoid hazardous activities protect medication from heat and light

hypersensitivity pregnancy/lactation active liver disease adverse side effects skin flushing gastric upset niacin: temporary, intense flushing of face, neck and ears reduced absorption of fat-soluble vitamins disruption of liver function muscle tenderness or weakness (rhabdomyolysis) nursing interventions - monitor cholesterol levels - monitor liver function tests - teach client - blood work and eye exams will be necessary during treatment - to report blurred vision, severe GI symptoms, or headache - about low-cholesterol high-fiber diet - to report muscle weakness or tenderness - with cholestyramine, colestipol: Give other medications (e.g., such as thiazide diuretics, digoxin, warfarin, and certain antibiotics) one hour before or four hours after administration of cholestryramine and colestipol, so that they will not react with bile-acid-binding resins ANTIANGINALS: NITRATES examples: nitroglycerin, isosorbide dinitrate (Isordil) action: dilate arterioles which lowers peripheral vascular resistance (afterload) uses: treatment and prevention of acute chest pain caused by myocardial ischemia adverse effects: postural hypotension, headache, flushing, dizziness contraindications hypersensitivity severe anemia hypotension hypovolemia nursing Interventions monitor for orthostatic hypotension monitor for tolerance with long term use administer every five minutes but not more than three tablets in 15 minutes if pain not relieved after 15 minutes and three tablets, notify physician immediately instruct client -take pulse before taking medication -take oral preparations without food -when to seek medical attention -not to chew or swallow sublingual tabs -make position changes slowly -carry drug so that it is always within reach but avoid exposure to body heat and light -replace drug approximately every six months -avoid alcohol ingestion -With nitroglycerin patch, never go near the microave ANTIANGINALS: BETA ADRENERGIC AGENTS

THROMBOLYTICS action: binds with plasminogen to dissolve thrombi (clots) in coronary arteries within four to six hours of myocardial infarction. Activates conversion of plasminogen to plasmin. Plasmin is able to break down clots (fibrin). examples streptokinase (Streptase) urokinase (Abbokinase) uses: myocardial infarction deep venous thrombosis, pulmonary emboli contraindications active bleeding cerebral embolism/thrombosis/hemorrhage recent intraarterial diagnostic procedure or surgery recent major surgery neoplasms of the CNS severe hypertension nursing interventions - monitor for bleeding - monitor coagulation studies - monitor for allergic reactions - keep available: aminocaproic acid (fibrinolysis inhibitor)

LIPID-LOWERING AGENTS (ANTILIPEMIC) action and use: lower LDL levels by reducing the synthesis of cholesterol and/or triglycerides. Use: primary hypercholesterolemia examples cholestyramine (Questran) atorvastatin (Lipitor) colestipol (Colestid) nicotinic acid (Niacin) contraindications:

examples: propranolol (Inderal), metoprolol (Lopressor) action: inhibit sympathetic stimulation of beta receptors in the heart decreases heart rate and force of myocardial contraction thus decreasing myocardial oxygen consumption uses: reduces frequency and severity of acute anginal attacks, dysrhythmias side effects: blood dyscrasias, hypotension, GI disturbances, flushing of the skin contraindications - hypersensitivity - cardiogenic shock - cardiac failure nursing interventions - weigh daily. Report weight gain of five pounds or greater - monitor ECG if using for dysrhythmia - administer on an empty stomach - protect injectable solution from light Beta-blockers: main contraindications ABCDE: Asthma Block (heart block) COPD Diabetes mellitus Electrolyte (hyperkalemia contraindications - hypersensitivity - cardiogenic shock - cardiac failure nursing interventions - weigh daily. Report weight gain of five pounds or greater - monitor ECG if using for dysrhythmia - administer on an empty stomach - protect injectable solution from light ANTIANGINALS: CALCIUM CHANNEL BLOCKERS examples: verapamil (Isoptin), nifedipine (Adalat), diltiazem (Cardizem) action: prevent the movement of extracellular calcium into the cell resulting in coronary and peripheral artery dilation uses: stable angina, dysrhythmias, hypertension side effects: headache, drowsiness, dizziness, GI disturbances, flushing of the skin contraindications: hypersensitivity nursing interventions - monitor chest pain - monitor ECG if used for dysrhythmia - administer with food - instruct client - increase fluids to counteract constipation - take pulse before taking drug - avoid hazardous activities until stabilized on drug

- limit caffeine consumption - avoid alcohol - change position slowly ACE INHIBITORS Captopril (an ACE inhibitor): side effects CAPTOPRIL: Cough Angioedema/ Agranulocystosis Proteinuria/ Potassium excess Taste changes Orthostatic hypotension Pregnancy contraindication/ Pancreatitis/ Pressure drop (first dose hypertension) Renal failure (and renal artery stenosis contraindication)/ Rash Indomethacin inhibition Leukopenia/ Liver toxicity Hypotension and shock NATURAL AND SYNTHETIC CATECHOLAMINES examples: epinephrine, dopamine (Intropin), dobutamine (Dobutrex) actions: increase cardiac output, (+) inotrope, (+) chronotrope uses: dopamine and dobutamine: hypovolemic and cardiogenic shock, epinephrine: anaphylactic shock Hypotension and shock adverse effects: dysrhythmias, hypotension, tissue necrosis if extravasation occurs. Tremors, anxiety, dizziness with epinephrine contraindications - hypersensitivity - ventricular fibrillation - tachydysrhythmias - safety in children not known - Hypotension and shock nursing interventions - correct hypokalemia before administering - monitor vital signs frequently - monitor ECG continuously during administration - administer with infusion pump - start drug slowly and increase according to health care provider's orders - monitor injection site for extravasation - protect solution from light - do not use discolored solution - stop the drug gradually Anticoagulants action: disrupt the blood coagulation process, thereby suppressing the production of fibrin examples heparin: parenteral administration coumadin (Warfarin): oral administration use pulmonary embolism deep vein thrombosis myocardial infarction atrial fibrillation

adverse side effects - allergic responses such as chills, fever and urticaria - use cautiously if client tends to bleed (hemophilia, peptic ulcer) - GI disturbances- nausea and vomiting, diarrhea, abdominal cramps contraindications hemophilia leukemia peptic ulcer blood dyscrasias nursing interventions - heparin: monitor APTT (activated partial thromboplastin time) - normal 40 seconds - at therapeutic levels, APTT increases by a factor of 1.5 to 2 - coumadin - monitor PT (prothrombin time) - normal 12 seconds - INR (International normalized ratio) two to three - do baseline blood studies before therapy - have antidote ready - heparin: protamine sulfate - coumadin: vitamin K - monitor client for symptoms of hemorrhage such as increased pulse, decreased BP - avoid salicylates (such as aspirin) - avoid IM injections teach client - take medication at same time every day - wear medical alert jewelry: wearer takes anticoagulants - use a soft toothbrush - do not use a straight razor; use an electric razor - avoid alcohol and smoking - report any signs of bleeding, red or black bowel movements, headaches, rashes, red or pink-tinged urine, sputum - avoid trauma - blood levels of the anticoagulant may be monitored - do not take over-the-counter (OTC) medications without health care provider's approval ANTIDYSRHYTHMICS Action : prevent abnormal heart rhythms action depends on type of antidysrhythmics drug examples class I:sodium channel blockers quinidine (Quinidex), lidocaine; decreases myocardial excitability and contractility class II: beta blockers propranolol (Inderal); stabilizes cell membrane class III: conduction delayers bretylium (Bretylol); decreases conduction and excitability of myocardial cells class IV: calcium channel blockers - verapamil (Isoptin);inhibits influx of calcium ions across cell membrane during cardiac contraction;

reduces cardiac excitability and dilates main coronary arteries others - digoxin (Lanoxin), adenosine (Adenocard); slows heart rate, improves pumping ability of the heart CARDIOVASCULAR AGENTS P- pressure (blood) monitor R- rise slowly E- eating must be considered S- stay on medications S- skipping or stopping is a n0- n0 U- undesirable responses: drowsiness, dizziness R- remind to exercise, dec alcohol E- eliminate smoking Medical surgical planning, the nurse is discussing the medication regime with a patient who takes nitroglycerin (Nitrostat) for angina, as needed. Which statement from the patient indicates that further teaching is necessary? a) I store the tablets in a dark bottle. b) I take the tablet with a full glass of water. c) I wait for my tongue to tingle when I take a tablet. d) Ill go to the hospital if three tablets, minutes apart, dont relieve the pain. A nurse has completed diet teaching for a client on a low-sodium diet for the treatment of hypertension. The nurse determines that further teaching is necessary if the client makes which statement? a) This diet will help lower my blood pressure. b) The reason I need to lower my salt intake is to reduce fluid retention. c) This diet is not a replacement for my antihypertensive medications. d) Frozen foods are lowest in sodium. A patient with an arteriovenous malformation has been admitted with a hemorrhagic stroke. The physician prescribes several drugs for this patient. Which drug order should the nurse question? a) Heparin b) Dexamethasone (Decadron) c) Methyldopa (Aldomet) d) Phenytoin (Dilantin) A patient with heart failure has been receiving an I.V. infusion at 125 ml/hour. Now the patient is short of breath, and the nurse notes bilateral crackles, jugular vein distention, and tachycardia. What should the nurse do first? a) Notify the physician. b) Discontinue the I.V. access device. c) Administer the prescribed diuretic. d) Slow the infusion and notify the physician. ANTIBIOTICS M- monitor superinfections E- evaluate renal/ liver dysfxn D- diarrhea- take yogurt I- inform provider prior to taking other meds C- cultures prior to initial dose A- alcohol is out; ask about allergy T- take full course E- evaluate cultures, WBC, temperature

A patient with a urinary tract infection (UTI) receives a prescription for cotrimoxazole (Septra) 2 tablets by mouth daily for 10 days. Which observation best demonstrates that the patient followed the prescribed regimen? a) Increased urine output to 2,000 ml in 24 hours b) Decreased flank and abdominal discomfort c) Absence of bacteria on urine culture d) Normal red blood cell (RBC) output TERATOGENS 1.Androgen- masculinization of female infants 2. Thalidomide- phocomelia, cardiac and lung defect 3. Anticonvulsant (Dilantin)- cleft lip and palate, cogenital heart defects 4. Lithium- congenital heart defects 5. Tetracycline- yellow staining of teeth, inhibit bone growth, not given to children below 7 6. Vitamin K- hyperbilirubinemia 7. Salicylates(aspirin)- neonatal bleeding, decreased intrauterine growth 8. Sodium bicarbonate- fetal metabolic alkalosis 9. Streptomycin- nerve deafness 10.Vitamin A- CNS defects 11. Iodides- goiter, mental retardation 12. Steroids, cortisone- cleft lip and palate 13. Barbiturates- bleeding disorder ENDOCRINE AGENTS CORTICOSTEROIDS (end in one: prednisone, dexamethasone, betamethasone, hydrocortisone) C- cushing- like symptoms b U- ffalo hump S- sodium increase, sweating H- headache, hyperglycemia increase in BP, HR, appetite N- not healing quickly G- GI upset CORTICOSTEROIDS Some People Get Cold S- Sodium increased P- Potassium decreased G- Glucose increased C- Calcium decreased The nurse is preparing a care plan for a 35-yearold patient with Addisons disease. Which nursing diagnosis is most appropriate for this client? a) Risk for infection b) Excess fluid volume c) Urinary retention d) Hypothermia

The nurse should expect to administer which of these drugs to a patient with diabetes insipidus? a) Desmopressin (DDAVP) b) Furosemide (Lasix) c) Regular insulin d) 10% dextrose A 55-year-old female with Addisons disease has been admitted to the nursing unit with dehydration. Your initial assessment confirms a nursing diagnosis of deficient fluid volume. Which of the following etiologic factors establishes this nursing diagnosis? a) Glucocorticoid excess. b) Mineralocorticoid deficiency c) Melanocyte-stimulating hormone excess d) Melanocyte-stimulating hormone deficit Thyroid Preparations For Hypothyroidism: Levothyroxine T4 (synthroid), Liothyronine T3 (Cytomel) T- TSH, T3, T4- monitor H- Hypo/hyperthyroidism- monitor R- review how to take a pulse O- observe clinical improvement in 3-4 days I- increase metabolic rate- action D- do not change brands of drugs A patient with hypothyroidism is receiving levothyroxine (Levothroid), 50 mcg by mouth daily. Which of these findings should the nurse recognize as an adverse drug effect? a) Dysuria b) Leg cramps c) Tachycardia d) Blurred vision ANTITHYROID PREPARATIONS For hyperthyroidism: methimazole (tapazole), propylthiouracil (PTU) B- bleeding I- Infection G- give with food When assessing the ear canal of a 1-year-old client, which direction should the pinna be pulled to straighten the ear canal? a) Up and back b) Down and back c) Laterally d) The pinna should never be pulled. ANTINEOPLASTICS (CYTOTOXIC, ANTIPROLIFERATIVE AGENTS) Action Highly toxic agents that attack all rapidly dividing cells, both normal and malignant Represents a systemic approach that bases its action on disruption of the cell life cycle Most agents modify or interfere with DNA synthesis Examples Alkalyting agents: mechlorethamine HCl (Nitrogen Mustard), cyclophosphamide (Cytoxan): produce breaks in DNA molecule and cross-linking of strands thus interfering with DNA replication; most effective in hematologic malignancies

A patient with diabetes insipidus has been receiving intranasal administration of a synthetic vasopressin. Which outcome indicates that treatment has been effective? a) Fluid intake of less than 85 oz (2,500 ml) in 24 hours. b) Urine output of more than 200 ml/hour. c) Blood pressure of 90/50 mm Hg. d) Pulse rate of 126 beats/minute.

Antitumor antibiotics: Biomycin; bind directly with DNA changing its configuration and inhibiting replication Antimetabolites: methotrexate, 5-fluorouracil, floxuridine, cytosine arabinoside, 6mercaptopurine, 6-thioguanine: inhibit DNA synthesis; most effective against rapidly growing tumors enzymes necessary for cell function and replication Plant alkaloids: Vinblastine, Vincristine, Etoposide: Bind to substances needed to form mitotic spindle, thus preventing cell division Hormones and hormone inhibitors: Tamoxifen alters the endocrine environment to make it less conducive to cell growth; used in cancers of the breast, prostate, and other reproductive organs Routes of administration Intravenous (peripheral or central venous access) Oral Intraarterial Intraperitoneal Intrapleural Intrathecal Via ventricular reservoir Use: To cure, control or palliate results of neoplasm May be used as an adjunct to surgery and radiation Adverse effects: result from the damage to normal cells Nausea/ vomiting, stomatitis, alterations in taste, anorexia Diarrhea, constipation Alopecia, dermatitis, pruritus, paresthesia, rash, bruising Hemorrhagic cystitis Cardiomyopathy Fatigue, dyspnea, fever, chills Sterility, amenorrhea Depression, anxiety Myelosuppression Nursing interventions Monitor lab studies as ordered Monitor IV administration site for extravasation Maintain strict asepsis Administer antiemetic agents as ordered and prophylactically before chemotherapy. Give antihistamines as ordered Withhold food and fluids for four to six hours before treatment Between treatments, give small, frequent, bland meals Give antidiarrheals as ordered Monitor for signs of dehydration and encourage fluids as tolerated Provide frequent oral hygiene, lubricate lips as indicated For stomatitis, use topical anesthetics before eating and as indicated

Apply lotion to skin as indicated; avoid harsh, drying soaps Provide a restful environment, emotional support and anxiolytics as ordered Teach client medications and side effects alopecia is temporary avoid bruising, aspirin products, and persons with infections conserve energy recognize signs of bleeding; anemia, infection use a soft-bristle toothbrush avoid use of razors Guidlines for reducing risks when handling cytotoxic antineoplastic drugs wear a mask to avoid inhaling powder when handling a powder form of a drug. do not prepare drugs in eating places Wear gloves, eye protectors and protective clothing when in contact with injectable solutions. dispose of contaminated materials in puncture-proof containers labeled as hazardous material. wear gloves when handling linens contaminated with drugs for at least 48 hours after contamination. wash hands thoroughly before and after exposure to drugs. follow organizational procedure to clean-up after chemical spill.