BLUEPRINT FINAL EXAM

RNSG 1301 PHARMACOLOGY

Nursing implications includes assessment, labs to monitor and evaluation of
effectiveness of the medication
# of QUESTIONS
10 Module I
Steps of Nursing Process and what occurs in each
 Assessment- hx/physical exam/ gather info
 Diagnosis- formulate/identify problem
 Plan- prioritize/ intervention planning
 Implement- do the work
o Evaluate serum drug level and results of relevant laboratory tests

o Monitor client for adverse effects, toxicity, and drug interactions; notify physician if any are observed

 Evaluate- outcomes related to Pt goals(time/measurement)

o Verb- pt demonstrates
o Before discharge/q1hr
Return Demonstration
Ex. Will show you (HOW) to draw up own insulin.
Rights of Medication Administration Five additional rights
 Drug  The right assessment
 Dose  The right documentation
 Time  The client’s rights to education
 Route  The right of evaluation
 Patient  The clients right to refuse
o Medication errors: reported to physician, complete incident report, document, and monitor pt!
o Not the NURSES RESPONSIBILITY to change doeses without physician’s order!
 Schedules of Drugs
I- Illegal (heroine-street drugs)
II- Dilaudid/Morphine (shouldn’t really use at home- CNSdepression) RX hard copy
 Written prescription needed, no telephone renewals.

Ex. Pt. receiving morphine triplicate teaching- Dr. wants to see pt. several
days before RX runs out.

III- Combos (hydro+Tylenol) narco Rx 5 refills/6 mo reassess

IV Adavan/Valium
V Cough syrup /antitussive

Variables affecting Drug Absorption

TQ: Low ALUBUMIN (causes drug to get to toxic levels) Need LOWER DOSES
 Age:
 Geriatric traditionally 65 and older, but this is too broad of a group
 Subgroups
o young old 65 - 74
o middle old 75 - 84
o old old 85 and older
o frail elderly age 65 and older who have one or more health problems. Be very alert for adverse
reactions to drugs in this group
 Illness

Half life- TQ: 5 times 1000 100mg Lanoxin/Digoxin- need LOADING doses to reach TE
1200 50mg
200 25mg
400 12.5mg
600 6.25mg
The half-life of the drug is the time it takes for one half-life of the drug concentration to be eliminated.

Drug Excretion- Kidneys/ Feces

Kidneys- disease impacts excretion (will BUILD UP) BUN/Creat labs

First pass effect- Drugs are Metabolized in Liver (LFT labs)

PO doses are Higher due to this
IV doses do not experience this

Effects of aging on Drug Metabolism & Excretion

o Old people take LOWER doses
o Have lower Albumin= high risk of toxicity
o Kidney/Liver function declines= effects metabolism/excretion of drugs
o FAT soluble drugs collect in fat
 o Heart arteries elasticity decreases drug delivery
o BBG increases with age
o Muscoskeletal sys- increased risk for falls

Peak: measured 30 minutes to 2 hours after admin.

Trough: measured 30 minutes before next dose (Vancomycin) TQ
o Trough is generally the 3rd dose.

Agonist: works with

Antagonist: when two drugs have the opposite effect, are administered together, each drug cancel the effect of
the other.

Management of allergic reaction:

o Epinephrine
o Causes:
 Bronchodilation
 Enhances cardiac performance
 Vasoconstriction to increase B/P

8 Module II
Autonomic Nervous System-
Sympathetic(anticholinergics/ cholinergic blocking agents)
EPI/Norepi/Dopamine (fight/flight) 3D
  ↑BP (all blood to
 Broncho DILATION
 ↑HR
 DILATE Pupils
 Digestion stops/ stops overactive bladder- Ditropan
side effects
 Symp- Tachy
 Asthma meds (tremors)
 Urinary retention

Parasympathetic (Cholinergic) Acetylcholine (rest/digest)

Action: interrupts parasympathetic nerve impulses in the CNS and ANS. They compete with
acetylcholine at muscarinic receptor sites.

 Fluids flow
 Muscle contraction (MG pts. need these)
 Sweating/tearing/
Mimetics – acts like
Lytics- acts opposite (acts like other system)
Drugs:
o Probanthine (propantheline)
o Detrol LA (Detropan)
o Atropine: (prototype)

side effects
 Parysym- Pupil constriction (bad for glaucoma pts)
Asthma pts NO (broncho constriction)
Patient teaching
TQ: Check labels (glaucoma pts avoid sympathy stimulant)

Neomonics --- 3D effect , SLUDGE, DUMBELLS

These are s/s of adverse reactions of MG
drugs: Neostigmine, Mestinon, Tensilon.
For SLUDGE: you would give pt. atropine.
For DUMBELLS:
 Assess
respiratory status
and auscultate
breath sounds
 Atropine is
antidote
 s/s of Cholinergic
crisis:
o dysphagia
o resp. weakness
o fasciculation
 Monitor urination
Atropine (parasympatholytics/anticholinergic)- dry up secretion / ↑ HR used in paranesthesia to dry
up secretions and Tx. Bradycardia (atropine will increase
HR)
Toxicity:
o Hot as a hare (temp goes up)
o Blind as a bat
o Dry as a bone (decreased
secretions so you are thirsty)
o Mad as a hatter (confusion/
delirium) (assess mental status)
(watch for s/s of heatstroke/dehydration)
 Blurred vision, dry eyes, constipation, urinary retention, decreased sweating and salivation.
 Don’t give to glaucoma pts, BPH, cardiovascular disease in elderly, hyperthyroidism, and ulcerative
colitis.

Epinephrine/ adrenalin- Extravasation (hard/cold/pain) Tx with REGITINE 5-10ML/NS

 1st s/s of extravasation is pain at infusion site.
 Coldness, hardness, pain @ IV site
 Inject area within 12 hours with 10-15mL of NS w/ 5-10mg of Regitine.

Beta blockers- ↓ HR
Bradycardia/ ↓BP (pots) rise slowly
Atenolol: ↓ workload and ↑ cardiac output
Propanolol: ↓ HR and ↑ exercise intolerance
(hold med if pulse is under 50 and notify HCP)
adverse effects:
 Arrhythmias
 CHF
 Edema
 Cold extremities
 Bronchospasms
 Dyspnea
 Hyper/hypo glycemia: mask s/s of hypoglycemic (s/s of hypoglycemia: sweating, fatigue, and hunger)

Isopto Carpine/ Pilocarpine- eye drop Cholnergic Agnosist

Constricts pupils= better drainage
Is a miotic tx. Glaucoma, you know it is effective if you see meiosis
 Apply pressure to the inner canthus
NeoSynephrine- nasal spray(vasoconstriction) NO for glaucoma pts
Rebound congestion (<4 days)

Urecholine/Bethanechol- Urinary retention

Contract muscle/Relax sphincter
 TQ: from Mod 2: have pt’s urinal ready.
 Report signs of dizziness or HR below 60!
 Miotic agent

Neostigmine/Prostigmine- MG pts: dx and tx MG--muscle contraction-- (aCH) ‘ase’ drug

Antidote for( Anesthesia drugs) Neuromuscular blocker

Edrophonium/Tensilon dx MG – when is this drug used DIAGNOSE only

Short life
 (Drug works if pt. has increased muscle strength, can handle secretions, and no
slurred speech) (antidote: atropine!)
o SLUDGE/ DUMBELLS
 Ex: Testing for MG: They are breathing on their own then you give IV Tensilon
push, they start moving their arm again and squeezing a ball but when the IV
admin. is finished they stop.

Neuromuscular Blockers
(Succs/Vercuron/Percuron) (Succs is given to pt. trying to buck the vent!)
succinylcholine (anectine): drug of choice for short term muscle relaxation.
Pancuronium (pavulon): for intubation and ventilation
 Admin with analgesics because pt. can still feel pain!
 Requires a lower anesthetic dose
Vecuronium (norcuron): used in ICU
 prepare for respiratory arrest
Cant move/breathe
 antidote: prostigmine (anticholinesterase agent which also treats MG)
*Can hear/feel
Give anxiety meds
Adverse effects; APNEA(RESP. support avail)
 #1 thing to assess: Neuro & RR
 Malignant hyperthermia 1:53:48
Dantrolene(DANTRIUM) (prevents Ca ion release)
(Ca: causes muscle contractions): Dantrium stops this)
(Tx. For Malignant Hyperthermia and MS)
TQ on Mod 2 exam: CNS: Muscle relaxant, don’t take with other CNS depressants.
TQ on Mod 2 exam: also used to tx. Malignant hyperthermia!
 s/s of malignant hyperthermia: Temp >105, N/V, confusion, increased RR

Antiparkinson Agents

 Levodopa, Sinemet
How it works- Prevents it from being broken down so it can be converted
to Dopamine in brain ↓tremors

***early sign of over dosage eye winking/twitching***

 TQ on mod 2 exam: don’t eat B6 foods: liver, green veggies, cereal, beans.
 TQ on mod 2: early s/s of overdose: mental disturbances and eye winking

side effects- Urinary retention

Hot
TQ: suck on candy
stay out of heat
confusion
pots

dietary teaching NO b6 foods (liver, beans, green leafy veggies)

Give after meals ↓ GI irritation

Teach Ortho HTN
implications of Vit B6,
Interferes with levodopa= Increased tremors shows it is not working well
B6, ↓ effectiveness of levodopa

Anticonvulsant
Prototype Dilantin –(10-20)
side effects- Gingival Hyperplasia (swollen gums: red/spongy) report bleeding gums
teaching measures, Good oral care soft bristle tooth brush/ mouth wash
SJS-RASH (eye/groin- mucous membrane areas)
Oral BC not working
Electric razor/Soft toothbrush
nursing implications NS ONLY!!!!!!
Check BP could bottom out
 16 Module III
NSAID’s
TX pain & ↓inflammation

ASA=Monitor for bleeding (GI- stool- dasrk tarry contact dr.) Inhibit platelet
aggregation

Salicylism- OTOTOXIC, nv, CONFUSION, DIARRHEA

Reye’s syndrome- In kids <18 NO ASA (liver/brain issues) check

labels: Pepto has ASA in it…. (Kids can’t have aspirin)
adverse effects
 Reye’s syndrome- In kids <18 with flu /varicella
 Pt. Teaching: to read labels (Pepto-Bismol has
ASA)
 TQ: on mod 3 exam: do not take ASA with NSAIDS

Narcotic Agonist & Antagonist

Prototypes: Morphine- heart friendly
 Monitor for CNS depression
 Metabolic Acidosis
TQ: HOLD if RR<10

 Narcotics: sch 2 drug: triplicate order: follow up: call dr.

 Admin: PRN: pain is what the pt. says
o Give drug when pt. requests drug: goal is to keep client comfortable!

Narcan- Reverse Resp depression/ Monitor: RR-O2 sat should go up

Small doses 2-3 min if >10 min no response might not be narcotic
Antidote for Opioids (narcs) if effective: they will wake up and see resp. ↑

When indicated: Antidote for Opioids (narcs)

 Gen Anesthetics (‘ane’)
Nursing Actions after general anesthesia
Monitor RR give (o2)/ Hypothermia
TQ These cause shivering= need for more O2
 Malig/Hyper- give O2 for all of these

TQ on Mod 3:
Adverse effects:
 Decreased B/P: hypotension
 HYPOTHERMIA: shivering
 Increased BMR: which increased 02 demand
o N/I: Apply O2 and monitor O2 saturation
 Resp. Depression

 Ketamine- calm/ quiet area Do not stimulate, no sternal rubs, let them wake up on their own. D/T
↑excitation & hallucinations.

Sedatives & Hypnotics

 Benzodiazepines
ALPRAZOLAM/ Xanax:
admin. IV slowly ↓ risk of phlebitis & cardiovascular collapse
Evaluated effective= less stress

side effects- Toxic (Romazicon-Antidote)TQ on Mod 3 exam

nursing implications- Monitor for RR depression
Drowsy-hangover effects
Do not drive
DO NOT D/C DRUG ABRUPTLY CAN KILL THEM NO ALCOHOL or other CNS depressants

 barbiturates
NO ANTIDOTE!

 Phenobarbital(Luminal) - schedule IV used for sedation, pre-op sedation, anticonvulsant.

- side effects same as pines…RR DECREASED
DO NOT D/C DRUG ABRUPTLY CAN KILL THEM
NO ALCOHOL
expected actions
Is there an antidote for barbiturates? NO
benzodiazepines? Romazicon

Blue Boxes:
 Why we give meds: anxiety
 Evaluate effectiveness: pt. is less anxious
 Antidepressants & Antimanic

 tricyclics (Imipramine/tofranil) DRYING /EPS

 Watch for low grade fever
 Adverse effect: 3D effect, orthostatic hypotension, Extrapyramidal symptoms
o Antidote: Physostigmine (Antilirum)
 Watch for: sedation, orthostatic hypotension, decreased sex drive, dry mouth, urinary
retention, tachycardia

 SSRI ‘s (Sertraline/Zoloft) BETTER TOLERATED less s/e than tri

 Effective: Pt. begins to interact with people (increased social interaction)
 NO GRAPEFRUIT JUICE

 MAOI’snmp-
 AVOID Tyramine foods= can cause Hypertensive crisis TQ
o Aged cheese
o Smoked meats
o Corned beed
o Sour cream
o Yogurt
o Beer/red wine
o Chocolate
o Licorice
o Soy sauce
o Yeast
o Lack suicide tendencies
o S/E Hypersensitive crisis- ^ BP, Severe HA, neck stiffness, fever & palpitations
o NO ALCOHOL
  Lithium (1-1.5)>2 toxic
o why given: MANIA
o teaching implications WATER INTOXICATION*
LOC/CONFUSION
GIVE W/FOOD
WBC-monitor
 Toxic effects if level over 1.5
o Confusion
o Lethargy/slurred speech
o HYPERreflexia
o N/V, tremors/seizures
 N/I:
o Will make you retain Lithium = Toxic!
 LOW SALT DIET
 DIURETICS prevent toxicity
 Diarrhea/Fever
 Fluid Loss

 Keep at a consistent level RANGE: 0.5-1.5 ng

 Lithium toxicity: confusion, lethargy, hyperreflexia, tremors, seizures, diarrhea if toxic stop med and call
HCP.
 Water intoxication- 1st seen is ↓LOC, JVD, edema (only need 1-2 L/day)
 Antipsychotic
 Phenothiazines -
 Chlorpromazine/Thorazine-
o tx schizophrenia & intractable hiccups
 Haloperidol/ Haldol,
o Side effects:
o EPS
 Acute dystonia
 TQ: Akathisia
 Pseudoparkinsonism
 Tardive dyskinesia TQ: on mod 3 exam
 Lip smacking
 Protrusion of tongue
 Fine worm like tongue movements
 Involuntary arm/leg movement

Dystonia-twisting moving limbs, back hump

-Akathisia- pt. is in constant movement- pacing and restless
-tardive dyskinesia-sticking tongue our repeatedly, lip smacking (not curable)
-EPS S/S= Hold Med and call HCP/Monitor Temp.
Give hard candy to help with dry mouth

Why is Benztropine/Cogentin used (ARTANE)- used to control EPS s/s (know these
 Tardive dyskinesias,
 extrapyramidal effects,
 akathisia TQ
 impacts ridgitiy
Clozapine/ Clozaril –
 1st antipsychotic meds (last resort) WBC ct WEEKLY
 positive effects on schizophrenia:
o more effective in controlling negative effects
 flat affect/ Lack of motivation
 For pts. With Tarditive Dyskinesia
 Take pills & weekly WBC checks (5,000-10,000)
 Life Threatening: Agranulocytosis/ Neutropenia
o Flu like symptoms: fever/sore throat/cough/malaise
 Do not admin next dose!
 side effects
o WBC- low grade fever
o NMS- D/C STAT & call MD
o WBC ct WEEKLY

NMS (neuroleptic malignant syndrome): EPS causes it!

 AMS (altered mental status)
 Tachycardia
 Increased RR
 Fever
 Dehydrated
 Sweating
 Muscle ridgity
 Decreased BP/ Cardiovascular Collapse
o Stop med
o Call DR
o Tx w/ Dantrium (ANTIDOTE)

15 Module IV
 Cardiac Glycosides
DIGOXIN/ Lanoxin 0.5-2 >2
 Used to Tx. CHF
o Worsening of CHF
 Wt.gain
 Edema
 SOB TQ on mod 4
 N/V
 Visual disturbances

 dig toxic vision changes (N/V, diarrhea, confusion)

DIGIBIND
- adm. Procedures APICAL <60 HOLD
 S/S of Dig Toxicity
o Anorexia
o Diarrhea TQ answer on mod 4 exam
o N/V
o Bradycardia (below 60: HOLD drug)
o Cardiac dysthrmias
o Headache
o Malaise
o Blurred vision
o Visual illusions (white, green, yellow halos around objects)

Nursing implications: monitor K (if low >dig toxic effect)

Fatigue/gi distress/ muscle weakness

Labs to monitor k: If given with diuretics, can predispose pt to Dig Toxicity- K <3.5
 Monitor BUN (10-20)
 Creatinine (0.5-1.2)
 Hypokalemia (<3.5meq/L)

Antiarrhythmics
Prototypes: Quinidine- COVERTS TO NSR
Toxicity- signs and symptoms
CINNCHOSIHMS- TINNITUS/VERTIGO/ HA/VISUAL DISTUR
3D EFFECT

Beta Blockers: Propranolol/ Inderal

Expected effects: Decreases HR, beats less forceful, decreased O2 demand
Expected effects,
BRADYCARDIA/ ↑CHF/EDEMA/SOB
when contraindicated:
ASTHAMA, COPD, CHF (Bronchoconstricts)
 Lidocaine APICAL <60 HOLD
Toxicity – signs and symptoms
*SAMS* SAMS- SLURRED SPEECH, AMS, MUSCLE TWITCHING, SEIZURES

side effects: DO NOT use Lidocaine w/ EPI if tx for arrhythmias (^ HR)

how they work: Tx Ventricular Arrhythmias, depresses depolarization in myocardial cells
teaching implications: HOLD IF PULSE <50
WATCH FOR S/S OF CHF- (SOB, crackles in lungs) (auscultate lung sounds)
Monitor K levels, arrhythmias, weight daily

Antianginal
Mechanism of action: VASODILATES, AND ^ 02 SUPPLY TO HEART (NOT W/FOOD)

Nitrates:
(Nitroglycerin)
 Action: dilate the arterioles and veins; therefore, they decrease BP and decrease cardiac output and O2
demand.
 Tx Acute angina-Vasodilate, <BP, and <CO
 Adm: AVOID ED (Viagra)
 MEDS, 3 TABS/5 MIN INTERVALS
o Have pt. lying down when taking meds
o After admin; check vital signs: sitting/standing/laying down
o If pain worsens call 911
o Place pt in supine with legs elevated is hypotension results
o Keep nitrates in a dark bottle
o Med is working if pt. experiences a tingling/ burning sensation under their tongue.
o TQ on mod 4 exam: classic angina is relieved by rest
CA channel blockers
(verapamil/Isoptin)
 DILATES /DECREASE CONTRACTION
 AVOID GRAPEFRUIT JUICE TQ on mod 4
 TQ on mod 4: Take pulse, if under 50, HOLD MED: CALL DR
 TQ on mod 4: check pt’s B/P for hypotension

Niphedipine (Proacardia): prevents angina that is unresponsive to other drugs

o Admin: before meals/ no grapefruit juice!

beta blockers
(atenolol)
 (-olols) Long term prevention (Don’t dilate veins)
 Take pulse before med: <50 CALL DR
 TQ on mod 4: adverse effects: orthostatic hypotension

ANTIANGIALS:
CHECK FOR:
o PERIPHERAL EDEMA
o LUNG SOUND FOR CHF/JVD
o WEIGHT GAIN
*****QUESTION!!! PT WANTS TO KNOW WHY TAKING ANTIANGINALS?*****
-TO NORMALIZE MYOCARDIAL O2 SUPPLY/DEMAND & BALANCES
(antianginals are going to dilate which means MORE oxygen, which decreases demand for O2 and pt. is
balanced out.)

Antihypertensives

How they work, nursing implications, side effects

 Beta blockers,
(acebutolol)
 ↓ BP by ↓HR
 Allows ↑ exercise tolerance
 Watch for pots
 <90/60 hold
 TQ: mod 4: don’t stop abruptly will cause rebound hypertension
 TQ on mod 4: Orthostatic hypotension: rise slowly from lying or sitting to standing
position
 TQ on mod 4: Talk with HCP about OTC cold allergies meds!
calcium channel blockers,↓
(verapamil)
 BP by ↓ ♥ contractility
 monitor for CHF signs

ACE inhibitors (captopril, Lisinopril),

 “-prils” prevents conversion in lungs
 Na is excreted in water
 K is retained (hyperkalemia- no a lot of K foods)
 Bananas
 Potatoes
 Angioedema hard to swallow (allergic reaction) s/s: tongue and lips get swollen!
 Cough (switch to ARB (-sartans)
 Muscle pain
 RHABDOMYLOISS- MUSCLE BREAKDOWN
 (Muscle pain)
 Teaching: decrease salt intake/ Get up slowly- Orthostatic hypotension
 DO NOT STOP MED ABRUPTLY
 TQ on mod 4: cannot be given to pregnant pt. or pt. on spirlactone: risk for hyperkalemia.

ARB’s-
(losartan)
 “Sartans” ANGIO BLOCKERS (aldosterone prevents K secretion=↑)
 Block vasodilation/^aldosterone release
 NO COUGH
 MONITOR FOR HYPERKALEMIA(K)

Diuretics

Loop Diuretics:
Furosimide/Lasix-
 push slow over 1-2 min to prevent reaction (heart collapse)
Adverse effects: ringing in the ears and cardiovascular collapse!
 all electrolyes excreted
 Side effects: hypokalemia, hypocalcemia, dehydration, orthostatic hypotension
 Nursing implications: Prevent tinnitus, cardiac collapse, increase K foods
 TQ on mod 4: Monitor: serum potassium: hypokalemia (less than 3.5): muscle weakness/leg
cramps/dysthymias.

Potassium Sparring:
Spiralactone (Aldactone) & Triamterene (HCTZ)
 Side effects HyperK
 Nursing Implications don’t eat high K foods
Confusion/abd pain/diarrhea/muscle weakness

* If you have a pt. receiving oral K and Aldactone/

Triamterene you may want to question order*

Antilipemics

Cholestyramine/Questran
 mix 120-180 ml liquid/powder (reduces absorption of all Fat Soluble vitamins)
A
D
E
K: affect prothrombin time

Statins
(Lovastatin)
(simvastatin)
 take at NIGHT w/meal
 No grapefruit juice
 Teaching implications: Labs drawn before taking meds *Amylase and Lipase*
o Before 1st dose assess labs for baseline
  Side effects billary colic (gallstones) fibric acid
Greasy clay stool
PE
DVT

 Labs to monitor LFT’s cholesterol/trigl baseline

Anticoagulants & Thrombolytics

Heparin-
 PTT IV only
 Only prevents new clots from forming
Normal aPTT= 20-35 secs
Adm: slowly over 1-3 mins.
 Chills low back pain=D/C
 Antidote: Protamine Sulfate
 Chills low back pain=D/C

Coumadin/ Warfarin
 People take warfarin to tx. Thromboembolism after intital tx with heparin, used mainly to prevent
thromboembolic conditions such as thrombophlebitis, PE, and embolism formation by atrial fibrillation
which can lead to stroke.

Normal PT- 12 secs

Normal INR- 1.3-3 (↓ 3 for pt. w/ heart stents)
 Patient teaching: Avoid Vit. K foods
 Antidote: Vitamin K
o Vit K foods: green leafy veggies: cabbage/turnips/broccoli
 TQ on mod 4: tell client to use electric razors and soft-bristle toothbrush to minimize bleeding.

Thrombolytics: (-ASE)
TPA & Streptokinase: bust clot- DISOLVE thrombi
how they work, side effects, nursing implications
 Admin w/ in 4 hrs of AMI and 3 hrs of stroke
 do not initiate bleeding (NO BP cuff, iv sticks)
 Aminocaproic acid(AMICAR)- ANTIDOTE
 Watch for anaphalytic shock(benedryl/epi pen on hand)
 DVT/PE
  Consent form
 Routine labs

Resp Drugs
Theophylline range: 10-20-
facilitates removal of bronchial secretions
toxicity:
 N/V
 Confusion
 Hypotension
 Tachycardia
 Muscle twitching
 Anxiety
nursing implications: If labs high, hold med
TQ: patient teaching: smoking = ↑ dose
Admin: empty stomach full glass of water

Mast Cell inhibitors

Cromolyn Inhaler action- works by blocking release of mast cell mediators
Action: maintanence: decrease inflammation & mucus secretions: prevent acute asthma attacks
side effects: sneezing water eyes dizzy HA, need to pee
teaching implications take for several weeks to see response (1-3wks)

Inhaled steroids: NOT FOR ACUTE ATTACKS

Teaching implications, TACHY IF SYSTEMIC
mechanism of action Use AFTER Bronchodilator/ Rinse Mouth After! (Trush)
N/I: admin brochodialtor 1st; wait 5minutes before steroid inhaler used. When administering multiple
inhalations wait at least two minutes between puffs.

Decongestants (Beconase): topical and systemic, nursing implications RERBOUND CONGESTION

Do not use more than 5 days
Less systemic effects when inhaled, 2 mins between puffs
o Monitor for urinary retention
o ↑BP/HR
o DRYS YOU OUT

18 Module V
Peptic ulcer Agents

 TQ on mod 5: factors that contribute to development of peptic ulcers: smoking, coffee, alcohol,
bacteria, stress, H.pylori, ASA, NSAIDS, corticoid steroids. A: most @risk: pt. on steroids!

TQ: Antacids, (Maalox, Calcium Carbonate, Aluminum Antacids, Na Bicarb)

 EMPTY STOMACH (Ca-Phos relationship)
  1-3 hrs after meals
 Watch for Milk Alkali Syndrome- HA, confusion, N/V, anorexia, abd pain, hypercalcemia

H2 blockers,(tidiens)
Cimetidine (Tagament)
 blocks histamine
 Man boobs/impotence
 Do not drive/dizzy
 Push dilute IV slow(bradycardia)
 Constipation
 Do not admin w/in 1hr of antacids

proton pump inhibitors (-prazoles)

lansoprazole
 decrease acid by blocking proton pump
 TQ on mod 5: irreversibly bind with H/K –atpase

Sulcrafate(Carafate) COATS STOMACHE/ ulcer TQ

admin: before meals and night (give on empty stomach 1 hour ac & hs)

Misoprostol(Cytotec): NSAID induced ulcers/ ripen cervix TQ

Teaching implications: Avoid pregnancy (teratogenic)

Laxatives & Antidiarrheals

Nonpharmacological interventions:

o ↑ fluids

o ↑ Fiber

o ↑ Exercise

How they work:

 increase parastalsis
  increased fluid absorption

teaching measures: Fiber bulk pts need adequate fluid intake (esp elderly) to increase fluids to prevent
obstruction
What classification of meds do laxatives and antidiarrheal interact with?
ANTICHOLINERGICS- DO NOT GIVE TOGETHER!
side effects:

o Laxatives- hypovolemic shock

o Antidiarrheal- observe for hypoperistalsis, hold med
Report tachy/ Sys BP of 10-15 decline

Antidiarrheal:
Diphenoxylate (Lomotil)
 Prototype sch. V drug
 Contains atropine (anticholinergic agent) to discourage abuse
o s/s of atropine toxicity
 dry mouth
 urine retention
 tachycardia
 hyperthermia
o reduce dose if s/s of atropine toxicity! (don’t double dip)
o Assess for hypo-peristalsis
 Anorexia and nausea at early age
 Abd. Distention
 Auscultating of rushes or high pitch sounds over the abdomen
 Eventually a “silent abdomen”-absent of bowel sounds
 Percussion of air or fluid over abd., resonant sound, not dull
 Absence of flatus
 Absence of bowel movements
 Vomiting with resulting fluid and elec. Imbalances.
 If s/s occur: withhold next dose and notify Dr!

Emetics & Antiemetics

Emetics-
Activated Charcoal
 emergency poisoning
 When contraindicated: Do not want to encourage vomiting with petroleum distillates such as
Kerosene
 How to administer: Within 30 mins of poisoning/ Must have gag reflex
Antiemetic
Promethazine (Phenergan)
 Tx motion sickness, block H1, CNS depressant, anticholinergic
 Monitor for urinary retention!
 N/I: dilute Phenergan with NS to prevent infiltration

Scopolamine patch-
 Avoid touching, use gloves, wash hands, don’t touch eye (dilates)

Pituitary Agents
Growth hormone (Somatropin)

Action:
o Tx linear growth failure, before epiphyseal closure
o Stimulates growth of long bones/cell growth

Adverse effects: ^ glucose levels, decreased TSH

o Adm: Per kg of body weight- IM 3x weekly

Nursing Implications:
o Monitor TSH function & BS levels

ADH- Tx Diabetes Insipidus (Desmopressin-DDAVP)

o Large urine output and low specific gravity
o Monitor: Dehydration
o Water Intoxication
o I&O/specific gravity- If working, levels go up
Vasopressin(Pitressin)
o Do not use insulin syringe

Oxytocin(Pitocin)- induces labor

o Ensure Dr is present
o Keep mag sulfate available (also have calcium gluconate on hand)
o Infusion pump, never gravity drip
o Assess FHR, contractions- D/C infusion, administer O2, call Dr, if contractions too
strong/frequent

Desmopressin(DDAVP)
 nasal spray- inspect nasal passages for ulcerations & severe nosebleeds
 Teach to never increase # of sprays
 TQ on mod 5: N/I: monitor urine output, specific gravity, and serum osmolality
 Monitor vital signs and wt. (monitor I&O and BP)
 Hypoglycemic Agents

Onset Peak Duration

Rapid Acting- Novolog/Humalog 5-15m 1-3h 3-5h
Short Acting- Humalin R 30m 2-5h 6-8h
Intermediate Acting- Humalin N 1-2h 6-12h 18-24h
Long Acting- Lantis/Levimir 3-4h 6-8h 24h

S/S of Hypoglycemia S/S of Hyperglycemia(hot, dry-sugars high)

Diaphoresis Polyuria
^ HR Polyphagia
Confusion Polydipsia
TREMORS

*ADMINISTER FAST ACTING INSULIN WHEN TRY IS IN

FRONT OF THE PATIENT*
*AFTER ADMIN: How to verify blood glucose?
Humalin N: Do bedside blood glucose or serum

Type 1 diabeties:
 no oral meds
 must have insulin injection
 oral meds not effective

Oral hypoglycemics

Expected actions: NOT indicated for type 1 (need functioning pancreas- no endogenous insulin to release)
Glypozide(Gluocotrol)

Metformin(Glucophage)-
 1x a day w/evening meal.
 Not for renal pts/ Withhold 48 hrs before IV contrast
o Hold before IVP & barium studies
 o CAN GIVE for XRAYS!
o If pt. vomits: give pt. 15g Carb and a protein.

Acarbose(Precose)/Miglitol(Glyset)-
 don’t bring up BS fast enough when BS is low

Symlin, Byetta- Not insulin,

 injectable SQ

side effects: photosensitivity

patient teaching:
o Infection, stress, surgery- BS raised d/t increased need for insulin
o When should these meds be held?
o Fasting BS
o Barium Study
o Do not hold if having X-ray- no effects

Thyroid Agents

Hypothyroidism- Levothyroxine Sodium(Synthroid)

When indicated: thyroid hormone replacement patient teaching:
These pts are tired and lethargic all the time.
S/S of Low TSH= weight gain

***Question: Assessing a pt w/ hypo TSH after adm of TSH

agent, it is ineffective if they still show S/S of LETHARGY,
fatigue, weight gain***
s/s of levothyroxine: hypotension: check B/P before admin
Nursing Implications: Hold med if resting pulse is over 100/min
Time of day to administer thyroid med? Before breakfast to
mimic the natural stimulation
Therapeutic effect: 1-3 weeks
Effective: pt will feel energetic. (if pt. feels tired they are under
dosed).

Hyperthyroidism:
Propylthiouracil (PTU)- take with or after meals, avoid
seafood
Monitor for iodism: salivation, swelling of
parotid/submaxillary glands, rhinitis, GI distress,
depression
Instruct client taking Methimazole(Tapazole) to report s/s
of infection(< immune system)
S/S of thyroid toxicity:
If pt has these s/s- hold med
o Nervousness/ irritability
 o Chest pain
o HTN

Why are anti thyroid drugs given prior to thyroidectomy?

 Firm the gland and decrease vascularity before surgery

Agents to treat Osteoporosis

Biphosphonates:
 How they work:
o inhibit osteoclast, mediated bone reabsorption
AlenDRONATE(Fosamax)/ RiseDRONATE(Actonel)
Patient teaching:
o Adm: 30 min before breakfast w/ full 8 oz.glass of water- take a walk
side effects:
o GI problems
nursing implications:
o Test to be performed? measure bone density
o Deccascan: Measures hip and spine

Uterine Motility Agents

Tocolytics: Inhibit contractions to prevent preterm labor

o Mag Sulfate-
o Tx seizures in PIH/Calcium Antagonist/ CNS depressant
o Relax smooth muscle of the uterus which will slow the contraction

Ergot Alkaloids
Mechanism of action: Tx postpartal/postabortion hemorrhage, CNS relax/depressant, relaxes smooth
muscle of uterus, slows contractions
o Methylergonovine Maleate(Methergine)-
o decreases postpartum hemorrhage but increases uterine contractions
How do you know if it’s effective?
o Decreased bleeding d/t increased contractions (after baby delivered)
N/I: have calcium gluconate for antidote available
33 Module VI
Antihistamines - side effects
1 generation: Diphenhydramine (Benedryl)-
st

o Side effects:
o AntiCholernergic 3D (Dry mouth/Urinary Retention/Blurred vision/Drowsy)
o Fatigue
o Drowsiness
o Abd. Pain
o Photosensitivity
o Excitation in children
 o Take at night/ don’t drive-due sedation effects
o No alcohol!
o Pupils Dilate (Mydriasis- NO Glaucoma/BPH pts)
o Check labels for anticholinergic ingredients
nd
2 gen: Zyrtec- Not as much sedation/ No dry mouth

Antigout medications
Actions: Helps kidneys excrete uric acid

anti-inflammatory gout drugs:

Colcrys/Colchicine- SEVERE attack/ acute attack (dose Q1/hr until vomiting)↓ inflammation
o Does not inhibit uric acid synthesis
o Does not promote uric acid secretion

Uric acid inhibitor:

Allopurinol /(Zyloprim): Chronic Gout: Avoid Purine rich foods (Prevent formation of Uric Acid)

o Mechanism of action: not an anti-inflammatory drug, instead inhibits the final steps of uric
acid. (preventing exacerbations of gout!)
o Patient teaching:
o ↑fluids to flush out uric acid
o No Alcohol/Purine rich foods (organ meats)
o Tylenol NOT aspirin (too acidic)
o Avoid acidic juices
nursing implications (Monitor)
o Monitor for adverse effects: diarrhea/vomiting
o BUN/Creat
o LFT (ALP/AS/ALT)

Uricosurics
Sulfinpyrazone (Anturane)
o Blocks reabsorption of uric acid and promotes excretion
o Record pt. output: risk for kidney stones

Antibacterials

PCN & Probenecid (work together)

o Procenecid ↑ level of PCN concentration
o PCN- Allergic ? = Cephalosporin allergy ?
o Diarrhea=Watch for (C-diff AAMC) CALL DR
 1st - STOP The MEDICINE
 Dr. rx Flagyl
 (you have killed all the good bacteria, now all that is left is bad bacteria)
o Full course to avoid resistance (Take all the meds)
o Oral BC= ↓ effectiveness
o Adverse effects:
o Anaphylactic reaction
o SOB
o Wheezing
o Tightness of throat
 TX: epinephrine

Aminoglycosides (Big Gun)-

Gentamycin IV slow 30-60min
 Ototoxic- Hearing disturbances (REPORT)
 Nephrotoxic- BUN/Creat labs
 Neurotoxic- Streptomycin TB pts (PERIPHERAL NEURITIS)
 Take B6 : (B6 is taken to prevent peripheral neuritis)
 Monitor:
o Peak /Trough-
 right after you give it (w/in 1hr)
 Right BEFORE you give med
o Changes in Urinary patterns
 Hematuria-kidneys could be damaged
 Dizzy, ringing in the ears- ototoxic
 Tingling/Numbness/Twitching- neurotoxic

Sulfa drugs-
Bactrium/Septra (empty stomach/ with H2O)
TQ: UTI drug/SJS
o S/S-
o INCREASED TEMP, MALAISE, TACHY, LESIONS ON SKIN & MUCOUS MEMBRANES
o TOXIC EFFECTS: Blood dyscrasias (destroys bone marrow)
 WBC- fever, sore throat
 Platelets- bruising
 RBC- anemia
Monitor Urine= crystals can happen
 Fluids (3L/day) (pt. needs to stay hydrated)

Tetracyclines-
Doxycycline
 ACNE -Longterm tx
 Photosensitivity
o Don’t go outside between noon-5pm
o Wear sunscreen
o Don’t go in tanning beds
 CI – pregnant/kids (teeth mottleing)
  ↑ Risk for SUPER infection (know s/s)
o Stomatitis
o Diarrhea
o Thrush
o Yeast infection
 THROW OUT outdated meds

Cephalosporins-
 Allergy ?= PCN allergy?
 Reaction: Itching
o Angioedema
o Wheezing
 Monitor for: c-diff/ super infection

Chloramphenocol (Chloromycetin)
 TQ: TOXIC to BONE MARROW – APLASTIC ANEMIA
 Monitor CBC
 Pale skin/ fatigue- RBC
 Sore theroat/ fever- WBC
 Unusual bleeding-Platetes

Clindamycin(Cleocin)
 AAPMC/ Cdiff: if developed, expect Dr. to change to Vanc
o Stop drug/ Give Flaygl

Vancomycin
 Peak/Trough labs
 Oto/Neph
o Neurotoxic: tremors, tinnitus, numbness, tingling, twitching of extremities
o Ototoxic: esp. when admin w/ Lasix
 Report s/s
 Dizzy
 Ringing in the ears
 TQ: RED MAN SYNDROME-After BOLUS or too FAST infusion
 inflammatory response to drug (TOO MUCH)
 Histamine release= Vasodilation-
o HYPOTENSEION
o Fever/chills
o Paresthesia
Griseofulvin- Antifungal for NAILS (ring worm)
o Longterm tx protect skin
o Photosensitivity
o HA/Gastric issues
o (give w/food) need HIGH FAT DIET
o Good oral hygiene (pvt thrush)
o Avoid alcohol
C-diff, AAPMC- FLAYGL
 Anorexia
 Stomach pain
 Dehydration (due to diarrhea) KEEP HYDRATED
o Ele/Fluuid Imbalnace

Antiviral, Antifungal

o Antiviral therapy aids : decline in # of CD4 Cells

Metronidazole (Flagyl)- Tx Cdiff

o With food
o NO ALCOHOL makes you sick!!!
o NO ALCOHOL HAND SANITIZERS
o Turn urine
o Peripheral Neuropathy sym
o Monitor for Blood dyscrasias

Amphotericin B- BIG GUN ANTIFUNGAL

o Causes HYPOKALEMIA
o Muscle Weakness
o Lethargy
o Muscle cramps
o N/V
o Cause Febrile Reaction
o PreMedicate:
o Benadryl
o Tylenol/
o Hydrocortisone
o Monitor:
o BUN/Creatinine
o Electrolytes
o for Bone Marrow depression
o Teach: Prevention
o No wet bathing suits/ No tight jeans
o Dry area thoroughly- hairdryer/ Between toes
o White sock- change daily- 2 pair of shoes rotate

Acyclovir (Zovirax) – Tx Herpes

 Controls OUTBREAKS (does NOT cure)
 Shortens duration
 Infusion over 1hr.
  ↑ Fluids (2000-3000mL/day)
 Monitor for Acute Glomulerous Nephritis
 Extravasation

Corticosteroids
(Prednisone/ Deltasone)
Action: mimics release of natural corticosteroids from the body
Give in AM
With food

S/E:Cushing Syndrome
o Weight Gain
o Big Belly/ Thin arms-
legs
o ↑ Glycemia
o ↑Na & water (low salt
diet)
o ↓ K (potassium foods/
supplements)
o HTN
o Monitor: BBG, K level
o Need to report: FEVER- stat to nurse (mask
s/s of illness/infection)
o Do NOT stop abruptly d/t can cause corticoid insufficiency: adrenocortical insufficiency

TB Drugs
(acid-fast bacillus test)
Isoniazid (INH)- Take B6(pyroxidine)
*INH can be used prophylactically to tx exposed family*
o Foods: Spinach/ Green beans/ Lima beans/ cereals/ bran
o Teaching implications: INH causes jaundice for people who have been exposed to TB (even family
members)

Rifampin-
o Pt. teaching: changes urine to red/orange but is a harmless effect!
o Teaching implications: With meals
o Adverse effects
o Liver Toxic – get baseline LFT’s/Bili/ALT/AST/ALKPHOS
 ABD Pain
 N/V
 Neuro Toxic: clumsiness/ Numbness of fingers

o Drug interactions- NO ORAL BC

 Chemotherapeutic drugs
Action: Work on different stages of cell division
o Teach pt: when they ask why on multiple meds that more drugs will kill more cells d/t the
different stages*

Side effects:
o #1 PRIORITY ASSESSMENT FOR PTS ON CHEMO= TEMP!
o means pt. may have infection!
o Alopecia
o Leukopenia: low WBS, ^ risk of infection (tired, weak, SOB)
o N/V
o Bone Marrow Depression (TIRED)
o No plants- No WBC
o URIC ACID BUILD UP- killing off cells= hyperuricemia
o Thrombocytopenia- decrease of platelets in blood- (This causes bleeding in tissues,
petechiae, slow blood clotting after injury, anemia)
o Implications for thrombopenia:
 Assess urine/stool for blood
 Pad rails to prevent bruising
 Monitor CBC labs
o Nursing implications to address side effects
 ↑ Fluids
 Give Allopurinol: after chemo pt. will have hyperuricemia
 Good oral care (to encourage eating)
 MILD mouthwash NO ALCOHOL
 If you have a pt that has N/V d/t chemo, what can you administer?
 Nurse can administer antiemetic 1-2 hrs before chemo

Cytoxin Therapy
 ↑ Fluids 2-3L/day
 Void Q2hrs
 AM dosing

Methotrexate
 Bone Marrow Depression
 LIVER TOXIC
 Abd Pain
 N/V
 Clay colored stools
 Jaundice
 Lab values to monitor
 Bun/Creat/LFT
 WBC/RBC/Platelets
 URIC ACID LEVELS

\
Meds that impact lab values to reverse S/E of chemo drugs:
 Use Numega to increase platelets
 Allopurinol if pt on chemo has hyperuricemia(^uric acid)
 Leucovorin rescue (for Methotrexate) Folic Acid form- protects normal cells from toxic
effects
Antidote
↓ time that normal cells are exposed to ↑ dose toxic chemo