NCM 206 - Pharmacology

types of drugs and their information

**Natural Penicillin** - Penicillin G

* first antibiotic used clinically
* primarily bactericidal; drug of choice for infections
* oral dose - 1/2 of dose is absorbed
* parenteral dose - more effective
* Ex. Procaine (Wycillin) - extends action, less painful IM
* Ex. Aqueous - short duration, IM very painful

**Natural Penicillin** - Penicillin V

* preferred orally, 2/3 absorbed in GIT
* less potent
* effective against mild-moderate infection in URT
* effective against ANTHRAX

**Semisynthetic** - Broad Spectrum Penicillin / Aminopenicillin

* effective against both gram (+) and gram (-)
* not penicillinase resistant
* Ex. ampicillin (ampicin) - causes maculopapular rash
* Ex. amoxicillin (amoxin)
* Ex. bacampicillin (penglobe)

**Semisynthetic -** Penicillinase-resistant Penicillin / Antistaphylococcal Penicillin

* effective against gram (+)
* Ex. cloxacillin (postaphlin-a) - ORAL
* Ex. dicloxacillin (dynapen) - ORAL
* Ex. methicillin (staphcillin) - PARENTERAL, causes interstitial nephritis
* Ex. nafcillin (vigopen) - PARENTERAL, causes neutropenia (dec. WBC)

**Semisynthetic** - Extended Spectrum Penicillin / Antipseudomonal Penicillin

* effective against gram (-)
* not penicillinase-resistant
* less toxic than aminoglycosides
* Ex. piperacillin, ticarcillin disodium

Beta-Lactamase Inhibitors

* protects penicillin from enzyme
* combine penicillinase-sensitive penicillin with beta-lactamase inhibitor
* Ex. \[ORAL\] amoxicillin + clavulanic acid = Augmentin, Amoxyclav
* Ex. \[PARENTERAL\] ampicillin + sulbactam = Unasyn
* Ex. \[P\] piperacillin + tazobactam = Tazocin

Penicillin - Mode of Action

MOA: interfere with ability of bacteria to build cell walls by making bacteria swell then burst from osmotic pressure

Duration: 6 - 8 hrs

* absorbed rapidly in GIT (sensitive to gastric acid levels)

Penicillin - Contraindications

CI:

* allergies (to penicillin, cephalosporins, etc.)
* renal disease - require lower dose due to dec. excretion
* pregnant + lactating - diarrhea & superinfections in infant (penicillin carried thru breastmilk)

Penicillin - Adverse Effects

AE:

* organs involved in GIT
* N/V, Diarrhea
* Mouth - glossitis, stomatitis, sore mouth, furry tongue
* hypersensitivity rxn - rash, fever, wheezing, anaphylactic shock, death
* Pain & inflammation at injection site

Penicillin - Drug Interactions

DI:

* aspirin - inc. effect
* probenecid - reduces uric acid = dec. swelling
* tetracycline, erythromycin - dec. effect, antagonistic
* oral contraceptive pills (OCP) - dec. effect
* taken with food, acidic, juice - dec. effect

Penicillin - Nursing Interventions

NI:

* Monitor for superinfections
* Evaluate renal \[elev. BUN & creatinine\] & liver \[elev. AST, ALT\] functions
* Diarrhea r/t superinfections {mgt: take yogurt; more fluids}
* Inform physician before taking other meds
* Cultures - prior to 1st dose, if medication effective
* Alcohol is OUT! / Ask about allergies
* Take full course of meds
* Evaluate cultures, WBC, C&S
* mgt. small frequent feedings (prevent diarrhea)
* mgt. ice chips, sugarless candy (furry mouth)
* mgt. administer slowly, remove IV line, warm compress (injection site)

Cephalosporins

* antibiotics related to penicillin
* discovered in seawater (1948)
* effective against gram (+) and (-)
* Beta-lactamase resistant
* bactericidal or bacteriostatic depending on
* susceptibility of organism being treated
* dose
* tissue concentration of drug
* rate of bacterial multiplication
* A: PO well absorbed
* D: PB 75-85%
* M: HL - t1/2 = 1.5-2.5hr
* E: unchanged in urine 60-80%
* 6 hrs interval

**Cephalosporins** - 1st Generation

* “fa”, “pha” drugs
* effective against gram (+) and (-); BROAD SPECTRUM
* can be destroyed by B-lactamase
* RI, skin, GU, bone, myocardial infections
* Ex. Ce__fa__droxil, ce__fa__zolin, ce__pha__lexin
* Often used as surgical prophylaxis
* Bacteria susceptible: PEcK

**Cephalosporins** - 2nd Generation

* “fo”, “fu” drugs
* effective against gram (-), diminished activity against gram (+)
* not affected by B-lactamase
* Ex. Ce__fu__roxime, ce__fo__tetan, ce__fo__nicid, ce__fo__xitin
* Bacteria susceptible: PEcK & HEN

**Cephalosporins** - 3rd Generation

* “ft” drugs
* effective against gram (-), diminished activity against gram (+) \[less activity than 2nd gen\]
* B-lactamase resistant
* Ex. Ce__ft__riaxone, ce__ft__azidime, ce__f__ixime, ce__f__dinir"
* Bacteria susceptible: HENPEcK, Serratia marcescens

**Cephalosporins** - 4th Generation

* “fe” drugs
* greater action against gram (-), minimal action against gram (+)
* Resistant to most B-lactamase
* Ex. Ce__fe__pime (Maxipime), Ce__f__pirome
* Bacteria susceptible: PEcK, staph & strep, pseudomonas aeruginosa

**Cephalosporins** - 5th Generation

* broad spectrum
* Ex. Ceftaroline, ceftobiprole
* Bacteria susceptible: Methicillin-resistant staphylococcus auerus, Vancomycin-resistant enterococci
* mgt: use gloves for contact precaution and avoid transmission

PEcK

Proteus mirabilis

Escherichia coli

Klebsiella pneumoniae \[strepto & staph\]

HEN

Haemophilus influenzae

Enterobacter aerogenes

Neisseria gonorrhea / meningitis

Gram (+) Bacteria

* lack an outer membrane
* surrounded by layers of peptidoglycan

Gram (-) Bacteria

* has an outer membrane containing lipopolysaccharide
* surrounded by a thin peptidoglycan cell wall

Cephalosporins - Side Effects

* ORAL - GI: Flatulence, NAVDA, bloody stool
* best to be taken on an empty stomach
* if with gastric irritation, take with food or milk to inc. absorption
* CNS symptoms - fever, rash, pruritus, headache, vertigo \[HYPERSENSITIVITY RXN\]
* IV, IM - prolonged / high doses = phlebitis or thrombophlebitis
* mgt: use small gauge needle, look for large veins, alternate infusion sites, administer slowly

Cephalosporins - Adverse Effects

* NEPHROTOXICITY - Renal Failure
* Superinfections - alter the normal flora
* Anaphylaxis - allergic reaction

Cephalosporins - Drug Interaction

* Cefmetazole (1stGen) / Cefoperazone moxalactam (3rdGen) + **alcohol** = DISULFIRAM-LIKE REACTION: flushing, dizziness, headache, N/V, muscular cramps, chest pain, palpitations, dyspnea
* may lead to extreme CV collapse, convulsion, death
* Aminoglycosides / vancomycin = INCREASED NEPHROTOXICITY
* anticoagulant / thrombolytics / NSAIDS = increased risk of bleeding
* mgt: monitor blood loss

Angiotensin-Converting Enzyme Inhibitors

* “pril” drugs
* AKA ACE inhibitors
* MOA: blocks conversion of angiotensin I to angiotensin II
* Uses: hypertension, MI (myocardial infarction)
* SE: cough, hypotension, HA, dysgeusia, insomnia, N/V, diarrhea
* AE: reflex tachycardia, angina, cardiac arrhythmia, CHF, ulcer, liver & renal problems, photosensitivity, hyperkalemia, neutropenia, angioedema
* DI:
* probenecid = dec. elimination
* potassium supplement & diuretics = potent vasoconstrictor
* NSAIDS = dec. hypotensive effect
* antacid = dec. absorption
* tetracycline = dec. absorption of tetracycline


* CI: renal disease, severe Na depletion, CHF, pregnant or lactating

**Angiotensin-Converting Enzyme Inhibitor** - Nursing Considerations

* encourage implement lifestyle changes
* administer on an empty stomach for better absorption
* alert if the patient is for surgery/dialysis/situations which may drop fluid volume
* Parenteral form only if oral form is not available
* Adjust dose if with renal failure
* Do not give if BP is below 90/70, monito BP esp. for 2 hrs after the first dose \[check for hypotension\]
* Avoid ambulation \[dizziness\]
* Report cough or angioedema
* Report dysgeusia if more than 1 month

Angiotensin II Receptor Antagonist

* “sartan” drugs
* MOA: selectively bind the angiotensin II receptors in the blood vessels and adrenal cortex \[relaxation of blood vessels\]
* Uses: when ACE inhibitors are not tolerated
* SE: HA, diarrhea, dyspepsia, cramps
* AE: angioedema, hyperkalemia
* CI: Kidney dysfunction, CHF, pregnancy

**Angiotensin II Receptor Antagonist** - Nursing Considerations

* ensure female patient is not pregnant
* take without food

Calcium Channel Blockers

* “dipine” drugs
* MOA: prevents movement of calcium ions in the myocardium and vascular smooth muscles \[prevents contraction of blood vessels\]
* Uses: angina, hypertension, atrial fibrillation (abnormal heart rhythm)
* SE: HA, dizziness, hypotension, syncope, reflex tachycardia, constipation, AV block, bradycardia, peripheral edema

**Calcium Channel Blockers** - Nursing Interventions

* monitor ECG, CR, BP
* Have “E” cart available with IV administration
* Position to decrease peripheral edema \[if edema is in lower extremity, elevate legs\]
* Protect drug from light and moisture
* Increase OFI and fiber in diet
* Avoid overexertion when anginal pain is relieved
* may give paracetamol if with HA
* take with meals or milk
* do not chew or crush = sustained release

Vasodilators

* MOA: relaxes smooth muscles of blood vessels, promotes inc. blood flow
* ex. hydralazine (apresoline), minoxidil (loniten), diazoxide (hyperstat), nitroprusside (nitropress)
* Uses: severe hypertension, emergencies

SE/AE:

* hydralazine
* tachycardia (beta blockers), palpitations, edema (diuretics), HA, dizziness, GI bleed, lupus like (autoimmune disease), neurologic symptoms
* Minoxidil
* similar effects, excess hair growth, precipates angina
* Nitroprusside & diazoxide
* hyperglycemia
* CI: allergy, pregnancy, lactation, cerebral insufficiency
* DI: + other antihypertensive drugs = additive effect

**Vasodilators** - Nursing Considerations

* __d__irectly acts on vascular smooth muscle
* __i__ncrease renal and cerebral flow
* __l__upus-like reaction (fever, facial rash, muscle-joint pain, splenomegaly)
* __a__ssess peripheral edema
* __t__ake with food \[inc. absorp.\]
* __o__ther side effects (HA, dizziness, anorexia, inc. cardiac, dec. BP)
* __r__eview BP (orthostatic hypotension), Blood Glucose

Beta-Adrenergic Blockers

* “olol” drugs
* MOA: block beta 1 (cardiac) and/or beta 2 (lungs) adrenergic receptor sites, dec. effect of SNS
* Uses: hypertension, dysrhythmias, angina pectoris
* AE: rebound hypertension
* CI: asthma, heart block, COPD, diabetes mellitus, electrolyte imbalance \[ABCDE\]
* DI:
* +antacids = delayed drug absorption
* +lidocaine = inc. plasma level of lidocaine
* +insulin/OHA = hypo/hyperglycemia
* +cardiac glycosides = additive bradycardia
* +calcium channel blockers = inc. pharmacologic and toxic effects of both
* +cimetidine = dec. metabolism of beta blockers
* +theophylline = impaired bronchodilation effect

**Beta-Adrenergic Blockers** - Nursing Considerations

* lifestyle modification; compliance (rebound hypertension)
* monitor blood sugar with diabetic pt.
* monitor triglycerides and cholesterol level
* monitor BP & pulse before and after
* withhold if pulse is

Alpha-Adrenergic Blockers

* MOA: blocks alpha 1 adrenergic receptors, results in vasodilation of arteries and veins
* use in benign prostatic hyperplasia
* dec. VLDL (very low density lipoprotein) and LDL = dec. fat deposits
* does not affect glucose metabolism & resp. function
* causes Na & H2O retention with edema; given with diuretics
* Warnings: renal disease, elderly more sensitive
* Potent Alpha Blockers (very strong effect on blood vessels) hypertensive crisis (180 systolic BP) & severe hypertension from catecholamine secreting tumors of the adrenal medulla (pheochromocytoma- non-cancerous tumor that grows on adrenal gland)
* Ex. tolazoline - to lower inflammation of prostate gland
* Ex. prazosin (minipress) - CHF
* SE: orthostatic hypertension, first dose syncope, nausea, drowsiness, nasal congestion, weakness, loss of libido
* DI:
* +other antihypertensive, alcohol, nitrates = inc. hypotensive effect
* prazosin + anti inflammatory drugs = peripheral edema
* prazosin + nitroglycerin = syncope

**Alpha-Adrenergic Blockers** - Interventions & Education

* monitor BP frequently
* protect from falling/injury
* assess BP and HR before each dose
* if dose is during the day, client must remain recumbent for 3-4 hrs
* assist with ambulation if pt. is dizzy
* implement safety precautions
* report if edema is present
* sugarless gum, sips of tepid H2O to relive dry mouth

Centrally Acting Alpha 2 Agonist

* MOA: decrease sympathetic response from brainstem to the peripheral vessels, dec. peripheral vascular resistance & BP
* dec. epinephrine, norepinephrine, renin release
* SE/AE: drowsiness, HA, dry mouth, dizziness, bradycardia, hypotension, constipation, occasional edema or weight gain
* DI: paradoxical hypertension - difficult to control, life threatening with propranolol
* +methyldopa (aldomet) = chronic pregnancy induced hypertension (PIH)
* +clonidine (catapres) = sublingual
* +diuretics = causes Na & water retention

**Centrally Acting Alpha 2 Agonist** - Nursing Considerations

* monitor baseline VS (q30 mins until stable during initial therapy) & weight (refer: wt. gain > 4 lbs/week)
* abrupt D/C = hypertensive crisis (restlessness, tachycardia, tremors, HA, inc. BP), compliance
* taper dose gradually over more than one week
* recommend the last dose to be taken at bedtime
* sugarless gum, sips of tepid water to relieve dry mouth

Adrenergic Neuron Blockers

* AKA Peripherally Acting Sympatholytics
* MOA: block norepinephrine release from the sympathetic nerve endings that results in decrease BP
* SE: orthostatic hypotension, Na & water retention, vivid dreams, nightmares, suicidal intention (reserpine)
* Ex. reserpine (serpasil), guanethidine monosulfate (ismelin)

**Adrenergic Neuron Blockers** - Nursing Considerations

* take with meals
* no alcohol

Alpha 1 & Beta 1 - Adrenergic Blockers

* MOA: blocks both alpha 1 and beta 1 receptor sites, dec. BP, moderately dec. PR
* SE: orthostatic hypotension, GI disturbances, nervousness, dry mouth, fatigue
* AE: heart block
* CI: large doses could block beta 2 receptors = inc. airway resistance in pt. with asthma
* Ex. labetalol (normodyne), carteolol (cartrol)

**Alpha 1 & Beta 1 - Adrenergic Blockers** - Health Teachings

* **P**ressure (blood) monitor
* **R**ise slowly
* **E**ating must be considered
* **S**tay on medication
* **S**kipping or abrupt stopping is No-No
* **U**ndesirable responses
* **R**emind to exercise, dec. alcohol
* **E**liminate smoking

Diuretics

* produces increased urine flow by inhibiting sodium and water reabsorption from kidney tubules
* decrease hypertension, edema
* Indication: CHF, pulmonary edema, liver failure & cirrhosis, renal diseases, hypertension, glaucoma
* CI: allergy, fluid & electrolyte imbalances, several renal diseases, SLE, DM

Thiazide Diuretics

* MOA: increase Na & water excretion, inhibiting Na reabsorption in the distal tubule of kidney
* Uses: mild-moderate HPN, edema associated with CHF, cirrhosis with ascites
* Warning - decrease K, renal/hepatic dysfunction, gout
* DI:
* +lithium = lithium toxicity (N: 0.6-1.2 mEqs/L)
* +digoxin = digoxin toxicity (signs: bradycardia, N/V, visual changes; 1.0 to 2.6 nmol/l)
* +corticosteroids, amphotericin, ticarcillin = hypokalemia
* +sulfonamides = cross sensitivity


* SE/AE: hypokalemia, hyponatremia, hypomagnesemia, hypotension, bicarbonate loss, hypercalcemia, hyperglycemia, hyperuricemia, N/V, constipation, rashes, dizziness, weakness, increase LDL, photosensitivity, HA, dehydration, blood dyscrasias
* Ex. Chlorothiazide (diuril), hydrochlorothiazide (hydroduril), metalazone (zaroxolyn)

**Thiazide Diuretics** - Nursing Responsibilities

* monitor BP, wt. OD, urine output, edema
* monitor K, Na, blood glucose, LDL, triglycerides
* change position slowly
* no alcohol
* take with meals, preferably in AM
* eat foods high in K
* signs of hypokalemia (muscle weakness, cardiac dysrythmias, cramps, dizziness, N/V, tingling sensation, “U” wave on the ECG (3.5- 5.0 mEq/L)
* manage photosensitivity
* weight the patient in same clothes, same time w/o meals

\
**T**ake time to check VS

**H**yperglycemia, hypokalemia, hyperuricemia monitoring

**I**nstruct to weigh in daily

**A**void sudden position

**Z**ugar monitoring

**I**&O monitoring

**D**iuresis is expected

**E**at potassium rich foods

Loop Diuretics

* MOA: inhibits Na & CI absorption from the loop of Henle and distal tubules, causes rapid diuresis, little effect on glucose
* Uses: HPN, edema associated with CHF, cirrhosis with ascites, hypercalcemia
* DI: same with thiazides
* SE/AE: hypokalemia, hyponatremia, hypocalcemia, hypomagnesemia, hypochloremia, hyperuricemia, orthostatic hypotension, constipation, N/V, decrease platelet, ototoxicity (IV bumetanide), dehydration, photosensitivity, thiamine deficiency, hyperglycemia (glycogenolysis), elevated BUN & creatinine
* Ex. furosemide (lasix)

**Loop Diuretics** - Nursing Responsibilities

* Monitor VS, edema, urine output, serum K, Na, Ca, Cl, thiamine, blood glucose & platelet levels, Mx of digoxin & lithium toxicity
* Potassium rich foods
* Give slow IVTT (2 mins) to prevent hearing loss
* With food, in AM to avoid sleep disruption

**C**heck for weight gain/loss

**E**nsure VS prior to administration

**I**& O monitoring

**L**aboratory values assessment

**I**nstruct to rise slowly

**N**octuria prevention: frequent voiding during night time

**G**ive it with meals

Osmotic Diuretics

* MOA: increase osmotic pressure in the glomerular filtrate, preventing reabsorption of water & electrolytes


* Uses: increase ICP (Intracranial Pressure 7-15 mmHg), edema, prevention of renal failure, oliguria (low urine output), inducing diuresis during chemotherapy
* CI: anuria (absence of urine)
* DI: increase hypokalemia which may increase digoxin toxicity
* SE/AE: pulmonary edema d/T rapid fluid shifting, NV, tachycardia, decrease Na, K, Cl, Ca, dehydration
* Ex. mannitol (osmitrol) - prone for crystallization; glycerin (osmoglyn) - dec. IOP

**Osmotic Diuretics** - Nursing Responsibilities

* Monitor VS, wt, urine output, serum Na, K, Cl, Ca
* Watch for rapid inc in BP & rapid sympathetic overactivity (inc HR, tremor, agitation)
* Assess lung and heart sounds
* Check skin turgor, LOC, Mx of dec ICP
* Mannitol: check bottle or vial for crystallization, warm bottle & shake vigorously to dissolve crystals, if it doesn’t dissolve= DO NOT administer

\:use IV line with filter

\:infuse for 30-60 minutes

\n Cushing’s Triad

* ICP: inc. systolic BP, dec. pulse, respirations \[HYPER, BRADY, BRADY\]
* Shock: dec. BP, inc. pulse, respirations \[HYPO TACHY TACHY\]

Potassium Sparing Diuretics

* MOA: acts on the distal tubule to promote Na and water excretion & prevent potassium excretion; AKA: Aldosterone antagonist
* Uses: HPN, edema = CHF, nephrotic syndrome (too much protein in urine) to counteract hypokalemia caused by other diuretics
* CI: severe renal disease, severe hyperkalemia
* DI:
* +lithium= lithium toxicity
* +ACE inhibitor= hyperkalemia
* +digoxin= digoxin toxicity
* +K supplements (eg kalium durule)= hyperkalemia


* SE/AE: hyperkalemia, N/V, diarrhea, dry mouth, rash, dizziness, weakness, bluish colored urine (triamterene) hypotension, increase potassium level result in peaked T wave in ECG
* AE: HA, photosensitivity, anemia, decrease platelet
* Ex. Spironolactone (aldactone)

**Potassium Sparing Diuretics** - Nursing Responsibilities

* Monitor VS, urine output, serum K level
* Inform client that hypotensive effects may not be seen for 2 weeks
* Avoid potassium rich foods
* Manage photosensitivity
* Avoid salt substitutes
* Take with meals
* Bluish colored urine is harmless
* Administer in AM

\
Interventions

**D**iet; decrease sodium intake

**I**ntake & output monitoring

**U**ndesirable effects

**R**eduction of edema

**E**lectrolytes review

**T**ake early in the day; with meals

**I**nteractions; digoxin, lithium

**C**ause/aggravate diabetes

**S**ensitivity to sunlight

Tetracyclines

* “-cycline” drugs
* effective against gram (+) and most organisms; ineffective against S. aureus, Pseudomonas, Proteus
* \
* metronidazole and bismuth subsalicylate = treat Helicobacter pylori (peptic ulcer)
* ORAL and TOPICAL tetracycline = treat severe acne vulgaris
* MOA: inhibit bacterial protein synthesis
* Classifications:
* short acting - HL 6-12 hrs, ex. tetracyn, panmycin, terramycin, broad spectrum indication
* immediate - HL 10-17 hrs, ex. declomycin, broad spectrum indication
* long acting - HL 11-20 hrs, ex. vibramycin, minocin, bacterial infection and acne indication
* ROUTE:
* oral - frequently prescribed
* IM - can cause pain at injection site, tissue irritation
* IV - treat severe infections
* SE: N/V, diarrhea, teratogenic, discolors teeth, balance difficulty, nephrotoxicity with high doses, superinfection, photosensitivity
* DI:
* +antacids, iron containing drugs, milk = prevent absorption
* +oral contraceptive = lessened effect of OCP
* +penicillin = decreased activity of penicillin
* +aminoglycosides = increased risk nephrotoxicity

**Tetracyclines** - Health Education

* Sunlight sensitivity - drug decomposes in time
* Take full glass of water - could cause gastritis
* Antacids, Iron, Milk - stop, it will only decrease absorption
* Put on empty stomach - for faster absorption (primary)
* Mgt. for GI symptoms - small frequent feeding, ice chips, replace fluids
* Mgt. Safety precaution for ambulation
* Mgt. oral hygiene
* Mgt. sunblock, dark clothing, store out of light and heat
* Do not give to pregnant clients and children

Aminoglycosides

* “-mycin” drugs
* MOA: inhibit bacterial protein synthesis (bactericidal)
* effective against gram (+)
* ROUTE: primarily administered IV, PO \[given to treat bacteria in bowel\], IM
* treats tularemia and bubonic plague
* SE: N/V, rash, numbness, tremors, visual disturbances, tinnitus, muscle cramps or weakness, photosensitivity
* AE: urticaria/hives, palpitations, ototoxicity, nephrotoxicity, neurotoxicity
* DI:
* +penicillin = less effective aminoglycoside
* +anticoagulant (warfarin) = increased activity

**Aminoglycosides** - Nursing Interventions

* Monitor periodical audiograms, BUN/creatinine & vestibule function studies over 10 days therapy
* Adjust renal insufficiency
* Monitor VS. peak and serum levels
* For IV admin., dilute and administer slowly to prevent toxicity
* Monitor I&O, hydrate well before and during therapy (flush in between)
* If anorexia or nausea occurs, SFF (small frequent feeding) meals
* Establish plan for safely if vestibular nerve effects occur (ototoxicity)
* Administer other antibiotics 1 hour before/after aminoglycoside
* Recommend using sunblock & protective clothing when exposed to the sun

Macrolides

* “-thromycin” drugs
* MOA: inhibits protein synthesis, bacteriostatic (low dose) or bactericidal (high dose)
* used for mild-moderate infections of the respiratory tract, sinuses, GIT, skin, soft tissues; treat diphtheria, impetigo, STD
* No IM or IV = too painful, ROUTE: PO
* SE: hepatotoxic, superinfection
* AE: superinfection, urticaria, hearing loss, hepatotoxicity “yellow sclera”, anaphylaxis
* DI:
* +acetaminophen, phenothiazine, sulfonamide = inc. hepatotoxicity
* +antacid = dec. absorption
* +erythromycin & verapamil, diltiazem, clarithromycin, fluconazole = inc. erythrocyte concentration
* +digoxin, carbamazepine, theophylline, cyclosporine, warfarin, triazolam = inc. effect
* +penicillin, clindamycin = dec. effect

**Macrolides** - Nursing Care

* Do not refrigerate suspension form of Clarithromycin
* Monitor liver enzymes - signs & symptoms of hepatotoxicity (check liver function tests)
* Administer IV slowly (prevent phlebitis)
* GIve IM into deep muscle
* Avoid fruit juices (reduced absorption)
* Manage NAVDA
* Check for superinfections. (Give YOGURT / BUTTERMILK)
* Check drug interactions
* Evaluate effectiveness (Check WBC level, temperature, cultures)

Lincosamides

* MOA: change protein function & prevent cell division or cause cell death (both)
* more toxic but similar to macrolides
* Clindamycin
* widely prescribed against most gram (+) organism; absorbed better, more effective, fewer toxicity
* for severe infections caused by same strains of bacteria that are susceptible to macrolides
* Lincomycin
* to treat severe infections when penicillin cannot be given
* AE: GI reaction, pain, skin infection, bone marrow depression

**Lincosamides** - Nursing Care

* Do not refrigerate suspension form of Clarithromycin
* Monitor liver enzymes - signs & symptoms of hepatotoxicity (check liver function tests)
* Administer IV slowly (prevent phlebitis)
* GIve IM into deep muscle
* Avoid fruit juices (reduced absorption)
* Manage NAVDA
* Check for superinfections. (Give YOGURT / BUTTERMILK)
* Check drug interactions
* Evaluate effectiveness (Check WBC level, temperature, cultures)
* Careful monitoring
* GI activity & fluid balance
* STOP if with bloody diarrhea

Vancomycin

* MOA: inhibits bacterial cell wall synthesis
* Used against staphylococcal infections drug-resistant S. aureus and in cardiac surgical prophylaxis with Penicillin allergies
* Oral form - not absorbed systemically, excreted in the feces
* IV form - for severe infections due to MRSA, septicemia, bone, skin and lower respiratory tract infections that are resistant to other antibiotics
* DI:
* +amphotericin B, polymycin, furosemide, cisplatin = inc. nephrotoxicity
* +methotrexate = inc. methotrexate toxicity
* SE/AE: Chills, dizziness, fever, rashes, nausea, vomiting, thrombophlebitis at injection site
* DOSE-RELATED TOXICITY: Tinnitus, high tone deafness, hearing loss & nephrotoxicity
* RAPID IV INFUSION

**“RED-NECK or RED MAN SYNDROME”** resulting in Histamine release & chills, fever, tachycardia, profound fall in BP, pruritus or red nose / neck / arms / back

**Vancomycin** - Nursing Care

* Refrigerate IV solution after reconstruction, use within 96 hrs
* Flush IV line in between antibacterials. Evaluate IV site for phlebitis, avoid extraversion.
* Ensure safety
* Check baseline hearing. Refer to ENT. Report ringing in ears or hearing loss, fever and sore throat.
* Monitor blood pressure during administration
* Monitor renal function tests - creatinine, BUN and urine output and liver enzymes
* Yogurt for superinfection
* Check for pregnancy & lactation

Fluoroquinolones

* MOA: interfere with the enzyme DNA gyrase (needed to synthesize bacterial DNA) = broad spectrum bactericidal
* TYPES
* Negram, cinobac - for UTI, LRTI, skin, soft tissue, bone, joint infections
* Cipro, noroxin - broad spectrum targeting P. aueroginosa
* Levaquin, zagam - resp. problems, acute sinusitis, UTI, skin infection
* Tequin, avelox - more active against S. pneumoniae
* SE: photosensitivity, dizziness, N/V, diarrhea, flatulence, abdominal cramps, tinnitus, rash

Fluoroquinolones - Nursing Management

* Assess RENAL function: I/O, BUN, Creatinine
* Drug & diet history
* Avoid caffeine
* Antacids & Iron prep = decreases absorption of Fluoroquinolones
* Monitor serum theophylline & blood glucose levels - with Theo, caffeine, oral hypoglycemics  = INCREASE their effects
* With NSAIDS = CNS reactions = seizure
* Administer 2 hrs ac or after antacids
* If with IRON preparation = give with full glass of water
* IV - infuse over 30 mins, dilute with approximate amount
* Check S/S of SUPERINFECTIONS (stomatitis, furry black tongue, genital discharge, itching)
* Check symptoms of CNS stimulation = nervousness, insomnia, anxiety & tachycardia (avoid hazardous machinery)

Sulfonamides

* “sulfa” drugs
* MOA: Inhibit bacterial synthesis of FOLIC ACID, essential for bacterial growth, necessary for synthesis of PURINE & PYRIMIDINES, which are precursors of RNA & DNA
* well absorbed in GIT, excreted in urine
* common route: oral, may be ophthalmic ointment or in cream
* two types:
* short acting - sulfadiazine, sulfisoxazole
* intermediate - sulfamethoxazole, sulfasalazine, cotrimoxazole
* DI:
* Increase effects of Warfarin
* Decrease absorption if taken with antacids
* Increase hypoglycemic effect of sulfonylureas
* Decrease effectiveness of contraceptives

**Sulfonamides** - Nursing Management

**S**unlight sensitivity (limit sun exposure), stomach upset (small frequent feeding), skin reactions (rash), superinfections (frequent oral care, ice chips, sugarless candy- to relieve discomfort), STEVEN’S JOHNSONS SYNDROME (D/C drug).

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**U**ndesirable effects - Renal toxicity (check creatinine BUN), CNS effects (HA, dizziness, vertigo, ataxia, convulsions, depression (d/t effect to nerves), hepatotoxic (liver enzymes (AST, ALT, alkaline, phosphatase); monitor for jaundice, icteric sclera).

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**L**ook for urine output (Crystalluria, Hematuria-Increase OFI), fever, sore throat & bleeding.

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**F**luids galore - prevent kidney damage due to poor solubility of drugs

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**A**norexia, anemia (hemolytic anemia, aplastic anemia, pancytopenia (prolonged and high dosages)- due to BM depression).

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Steven Johnson’s Syndrome

a rare and serious disorder that affects skin, mucous membranes, genitals and eyes. It causes flu like symptoms along with painful rash that spreads and blisters

**Unclassified** **Antibacterial Drugs** - Chloramphenicol

* AKA Chloromycetin
* MOA: bacteriostatic - inhibits bacterial protein synthesis; broad spectrum
* Uses: serious infections of SKIN, SOFT TISSUE, CNS infections- including meningitis, ophthalmic infections— when less toxic drugs cannot be used.
* SE:
* BM depression- blood dyscrasias
* NEURO- confusion, peripheral neuritis, depression
* GRAY SYNDROME- in newborn characterized by: abdominal distention, vomiting, pallor, cyanosis; NB may die due to immature liver function.

**Unclassified** **Antibacterial Drugs** - Chloramphenicol

**NURSING CARE:**

* Monitor infection, bleeding
* Monitor for anemia,CBC
* Monitor level of consciousness (LOC)

**Unclassified Antibacterial Drugs -** Spectinomycin Hydrochloride

* AKA Trobicin
* For allergic to PCN, Cephalosporins, Tetracycline
* Administered IM single dose- BACTERIOSTATICS

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***PREGNANCY CATEGORY: B***

**Unclassified Antibacterial Drugs** - Quinupristin / Dalfopristin

* AKA Synercid
* Treat VREF- Vancomycin-resistant Enterococcus faecium bacteremia & skin infected by S. eus & S. pyogenes.
* Disrupts CHON synthesis of the organism.
* When administered through peripheral IV line= PAIN, EDEMA & PHLEBITIS
* SE: N/V, diarrhea, pseudomembranous colitis, HA, anaphylaxis, elevated AST & ALT

**Unclassified Antibacterial Drugs** - Quinupristin / Dalfopristin

**NURSING CARE**:

* Check for dehydration, monitor stools
* Check for patency of IV line; infuse over 1 hr mix in D5W (Dextrose 5% in water)
* Check for S/S of anaphylaxis
* Monitor ALT, AST, jaundice, icteric sclerae
* Give ice chips, SFF

**Unclassified Antibacterial Drugs** - Peptides

* Ex. polymyxin
* MOA: interferes with cellular membrane; bactericidal
* affects gram (-)
* recommended route: IV (slow admin.)
* SE/AE: dizziness, nephrotoxicity, neurotoxicity

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* ex. bacitracin
* MOA: inhibits cell wall synthesis; bactericidal/bacteriostatic
* effective against most gram (+), some gram (-)
* given IM/IV
* SE/AE: N/V, nephrotoxicity, respiratory paralysis, blood dyscrasia, anaphylaxis

**Treatment** - Influenza and Respiratory Viruses

Medications:

* Amantadine (Symmetrel) - PO
* Oseltamivir (Tamiflu) - PO
* Ribavirin (Virazole) - aerosol inhalation
* Rimantadine (Flumadine) - PO
* Zanamivir (Relenza) - inhaler

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MOA: inhibit viral replication by interfering viral nucleic acid synthesis in the cell (STEP 3)

CI: allergy, pregnancy & lactation, renal & liver disease

AE: lightheadedness, dizziness, insomnia, nausea, orthostatic hypotension & urinary retention

DI: with anticholinergic drugs = increase atropine like effect

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Nursing Considerations

* Start regimen as soon after the exposure to the virus as possible (achieve best effectiveness and decrease the risk of complications)
* Administer the full course of drug
* Provide safety measures (protect patient from injury)

**Treatment** - Herpesvirus

Medications:

* Acyclovir (Zovirax)
* Famciclovir (Famvir)
* Valacyclovir (Valtrex)
* Cidofovir (Vistide)
* Foscarnet (Foscavir) = both; IV
* Ganciclovir (Cytovene) = long term treatment & prevention of CytomegaloVirus; IV

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TOPICAL ANTIVIRALS (HSV)

* Idoxuridine
* Penciclovir
* Trifluridine \n

CI: CNS disorders, allergy, pregnancy & lactation, renal disease

SE: N/V, HA, depression, rash, hair loss, inflammation & burning sensation at the site of injection and topical

AE: renal dysfunction

DI: + other nephrotoxic meds = increase toxicity

* Zidovudine = increase drowsiness

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Nursing Considerations

* Extreme caution to children (carcinogenic); foscarnet (affect bone growth & development)
* Good hydration (decrease toxic effects of the kidney)
* Administer as soon as possible, monitor for compliance
* Wear protective gloves when applying the drug topically (to decrease risk of exposure to the drug and inadvertent absorption)
* Safety precautions = CNS effects (monitor orientation, raise side rails, provide good lighting. Offer assistance)
* Warn that GI upset, N/V can occur (prevent undue anxiety, increase awareness of the importance of nutrition)
* Monitor renal function
* Avoid sexual intercourse if with genital herpes
* Avoid driving and hazardous tasks if with dizziness & drowsiness

NRTIs

AKA Nucleoside / Nucleotide Reverse Transcriptase Inhibitors

* MOA: blocks the reverse transcriptase enzyme needed for viral replication
* Fixed dose: combinations of antiretrovirals are multiple antiretroviral drugs combined into a single pill, which helps reduce pill burden
* SE: less tenofovir = renal toxicity, GI - nausea, diarrhea, abdominal pain (transient 2 weeks), mitochondrial toxicity, lactic acidosis, peripheral neuropathy, myopathy, pancreatitis, lipoatrophy

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Nursing Considerations

* Should be taken with food except Didanosine (60 min AC or 2 hours PC)
* Requires dosage adjustment except abacavir (creatinine clearance < 50mL/min)
* Fixed dose avoided if with renal insufficiency

NNRTIs

AKA Non-nucleoside Reverse Transcriptase Inhibitors

* MOA: prevent viral replication by competing with binding of the reverse transcriptase enzyme at the active site
* Used to reserve protease inhibitors (resistance)
* Ex. Efavirenz \[Sustiva\] (rec.)
* first choice; preg. cat. D
* CNS toxicities: dizziness, sedation, nightmares, euphoria, loss of concentration
* Administered as a component of Atripia (fixed dose)
* Taken once a day at hour of sleep
* Take on empty stomach / with low fat meal (prevent excessive drug absorption)
* Ex. Nevirapine \[Viramune\] (alt.)
* Pregnancy (1st tri)
* Recommended for those planning to conceive
* For those not using effective / consistent contraception
* < risk: rash hepatotoxicity

Protease Inhibitors

* MOA: act at the end of the HIV cycle to inhibit the production of infectious HIV virus
* Note
* Ritonavir boosting - mainstay of Protease Inhibitor therapy (potent inhibitory effect)
* Take with food
* + didanosine = one hour before or two hours after ritonavir

Entry Inhibitors

* MOA: prevents HIV cell entry (fusion of HIV and CD4)


* Enfuvirtide - the only agent approved
* Indicated in combination with 3 - 5 other antiretroviral agents (for clients with limited treatment option)
* Expensive
* Recommended dose: 90mg subcutaneous twice a day
* Injection site reaction
* subcutaneous nodules, redness
* Others: rash, diarrhea, serious allergic reaction (anaphylaxis)

Cardiac Glycosides

* MOA: inhibits Na-K pump which increases intracellular calcium and allows contraction (inc. myocardial contraction, dec. heart rate, dec. conduction velocity)
* Uses: CHF, Atrial fibrillation, atrial flutter
* Digoxin toxicity - rapid onset excreted thru kidney, narrow margin of safety
* anorexia, diarrhea, N/V, bradycardia, cardiac dysrhythmias, HA, malaise, blurred vision, visual illusion (white, green, yellow halos around objects), confusion and delirium
* **Antidote**: digoxin immune Fab (intoxication with serum level of > 10ng/mL)
* CI: hypersensitivity, ventricular tachycardia and fibrillation, heart block, renal insufficiency, electrolyte imbalance
* DI:
* +verapamil, quinidine, quinine, erythromycin, tetracycline, cyclosporine = inc. toxic effect
* +loop diuretics / hydrochlorothiazide = hypokalemia
* +cortisone preparations = sodium retention & potassium excretion
* +thyroid hormones, metoclopramide = less effect
* +antacids = dec. digitalis absorption

**Cardiac Glycosides** - Nursing Considerations

* Consult prescriber about loading dose (large dose for first set then next is lower doses Na).
* Monitor apical pulse in one full minute, monitor for quality and rhythm.
* Check dosage & preparation carefully.
* Check pediatric dose with extreme care.
* Follow dilution carefully for IV preparation.
* Administer IV dose very slow over at __least 5 minutes.__
* Weigh patient.
* Avoid administering oral drug with food or antacid.
* Maintain emergency equipments on standby = lidocaine (arrhythmias), phenytoin (seizure), atropine SO4 (inc cardiac rate), cardiac monitor (to monitor cardiac heart rhythm)
* Monitor therapeutic level of digoxin (0.5 - 2 ng/mL). Digoxin toxicity

Types of Angina

1. Classic (stable) - occurs with stress exertion.

* may prior activity kung bakit nag chest pain si pt.

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2. Unstable (preinfarction) - occurs frequently over the course of a day with progressive severity.

* nagluluto lng tapos bigla nag chest pain and throughout the day pasikip ng pasikip ang chest pain

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3. Variant (Prinzmetal, vasospastic) - occurs during rest.

* naka upo lng pero biglang nag chest pain
* natutulog pero nag chest pain

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CAD, Angina Pectoris, MI

Anti-anginals

**Types:**

* Non-nitrates (beta blockers, calcium channel blockers)
* Nitrates: isosorbide mononitrate (Imdur, isoket, isordil); nitroglycerin (Deponit, Nitrostat)

Nitrates

* MOA: dilation of the veins = less blood return to the heart (decrease preload), dilation of arteries = less vasoconstriction and resistance (dec. afterload)
* Uses: treatment & prevention of angina, decrease BP
* SE: HA, dizziness, hypotension, reflex tachycardia, decrease CR, GI distress, flushing
* AE: some degree of hepatotoxicity / nephrotoxicity

**Nitrates** - Nursing Considerations

* Assess  chest pain: Precipitation factors, Quality, Radiation, Severity/ symptoms, and Time


* **PO**: take on empty stomach; undergoes hepatic first pass effect
* **SL:** every 5 min x 3(maximum) doses; effects lasts for 10 minutes
* store in dry & dark bottle (it is photosensitive)
* check expiration date
* take sips of water BEFORE administration
* allow drug to dissolve before taking anything PO 
* burning / stinging sensation means the drug is potent or taking effect (normal)


* **Buccal:** place drug between upper lip and gum or between cheek and gum
* **IV infusion**: dilute drug in glass IVF bottles via infusion pump, onset 1-3 minutes same with SL
* **Topical Ointment**: (put ointment directly) remove previous application
* spread drug over 6x6 in. area on chest, back, upper arm, and cover with a plastic wrap
* rotate site, avoid touching the ointment 


* **Patch:** patch is waterproof
* apply working gloves, non hairy portion
* you can shave it (in some institutions) or clip it shorter
* remove previous patch, rotate sites
* anterior chest wall (common site)
* remove after 12 hours to prevent tolerance
* do not apply defibrillator paddles over the drug, may cause burn
* If flatline CPR agad, don’t defibrillate
* Do not place defibrillator on patch, will cause burn


* **Spray:** lift tongue then spray, avoid inhaling the drug
* **General**: withhold: BP < 90/60, HR

**Anticoagulant** - Warfarin

* MOA: works by interfering with the formation of vitamin K- dependent clotting factors and prolongation of clotting times
* Uses: AF, artificial heart valves, prevent thrombus and embolization affecting MI and pulmonary embolism
* Antidote:  __phytonadione__ (Aquamephyton) - a form of vitamin K
* LAB: prothrombin time (PT) - maintained at 1.25-2.5 times the laboratory control value; INR 2:3

**Anticoagulant** - Heparin

* MOA: inhibits the conversion of prothrombin to thrombin, thus blocking the conversion of fibrinogen to fibrin which is the final step of clot formation
* Route: SQ, IV
* DOES NOT cross placenta and NOT enter breastmilk 
* Uses**:** treatment and prevention of venous thrombosis and pulmonary embolism, AF with embolization, prevent clotting of blood samples in dialysis and venous tubing
* Antidote: protamine sulfate - reverses effect by forming stable salt with heparin
* LAB: Whole blood clotting time (WBCT) 2.5-3 x control, Activated partial thromboplastin time (aPTT - has reagent) up to 40 sec, Partial Thromboplastin time (PTT) 1.5-2.5 x control in secs
* CI: hypersensitivity, bleeding tendencies, psychosis , diarrhea (loss of vitamin K or plasminogen)
* AE: bleeding, warfarin = alopecia, dermatitis, prolonged & painful erections (less frequent)
* DI:
* +aspirin, NSAIDs, sulfonamides = inc. effect
* +nitroglycerine, protamine = dec. effect
* +oral contraceptives, phenytoin, rifampin = dec. effect
* +alcohol = inc. bleeding

**Anti-coagulants** - Nursing Considerations

* Avoid large amount of green leafy vegetables, fish (OMEGA 3), liver, coffee, and tea (inhibits/blocks platelets which inc. of anticoagulants) ; NO alcohol
* Evaluate therapeutic levels
* Signs of bleeding - epistaxis, hematochezia, melena
* Safety precautions (electric razor, avoid contact sports, use pressure dressing, no IM injection, inform dentist, soft bristled toothbrush)
* Maintain antidote standby
* Medic alert card, do not smoke, NO aspirin

Anti-platelet

* MOA: alter formation of platelet plug
* Uses: adjunct (pampadag dag) to thrombolytic therapy in the treatment of MI & prevention of re-infarct, prevention of MI and stroke
* Ex.
* aspirin (generic), PO
* cilostazol (Pletaal), PO
* clopidogrel (Plavix), PO


* CI: hypersensitivity, pregnancy, lactation, bleeding disorder, recent surgery
* AE: bleeding, GI discomfort, HA

**Anti-platelet** - Nursing Considerations

* Avoid large amount of green leafy vegetables, fish (OMEGA 3), liver, coffee, and tea (inhibits/blocks platelets which inc. of anticoagulants) ; NO alcohol
* Evaluate therapeutic levels
* Signs of bleeding - epistaxis, hematochezia, melena
* Safety precautions (electric razor, avoid contact sports, use pressure dressing, no IM injection, inform dentist, soft bristled toothbrush)
* Maintain antidote standby
* Medic alert card, do not smoke, NO aspirin

Thrombolytic Agents

* MOA: converts plasminogen to plasmin to dissolve clot
* Uses: pulmonary embolism, DVT, MI, acute ischemic CVA (stroke)
* CI: severe hypertension, active bleeding, hemophilia (excessive bleeding), thrombocytopenia, GI bleed, hypersensitivity
* DI: inc bleeding with NSAIDs, antiplatelet, anticoagulant
* SE: bleeding, rash (streptokinase), febrile reaction, N/V, flushing, hypotension
* AE: hemorrhage
* Ex.
* Streptokinase (Kabikinase, Streptase)
* Urokinase (Abbokinase)
* Anistreplase

**Thrombolytic Agents** - Nursing Considerations

* Check BP prior (if mababa wag ibigay)
* Monitor bleeding time, hgb, platelet count, APTT
* Monitor signs of bleeding up to 24 hrs post the last dose
* Check for allergic reactions esp to streptokinase (Benadryl may be given prior)
* IV drugs that are mixed should be used within 24 hrs, infusion pump 
* Avoid invasive procedure
* Apply pressure for 5-10 mins on all discontinued IV
* **ANTIDOTE**: aminocaproic acid (Amicar)
* Prevent bleeding

Hemostatic Agents

* MOA: hasten clotting of blood (pinapabilis ang clotting process) by inhibiting the substance that activate plasminogen
* Uses: to stop bleeding
* CI: elevated BP, clotting disorder
* SE: __increase BP (most common)__, HA, N/V, abdominal cramps, diarrhea, fatigue, muscle pain
* AE: __intrarenal obstruction__ d/t clot formation, anaphylaxis (esp with aprotinin)
* DI: aminocaproic acid + oral contraceptives = increase coagulation
* Ex. - Systemic hemostatic
* Vitamin K
* Aminocaproic acid
* Tranexamic acid
* Somatostatin
* Ex. Topical drug form
* Gelfilm / gelfoam
* Microfibrillar collagen
* Thrombin
* Oxidized cellulose

**Hemostatic Agents** - Nursing Considerations

* Monitor clotting time, urine output (increase or hematuria), signs of anaphylaxis (hematuria-  presence of blood in a person's urine.
* Leave gelfoam until bleeding stops, remove immediately after bleeding is controlled & wash the site to decrease risk for infection
* Check BP prior (defer if >140/90)

Narcotic vs. Opioid

**Narcotics** - relieves pain and induces drowsiness, stupor or insensibility \[commonly abused\], affects mood or behavior ex. morphine

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**Opioid** - broad group of pain-relieving drugs, interact with opioid receptors in cells by blocking pain signals between brain and body

Aspirin

* non-narc/ non-op
* MOA: inhibit synthesis of prostaglandin
* analgesic, antipyretic, anti-inflammatory, anti-platelet
* Not rec. due to bleeding tendencies, diet modification; rec. for antiplatelet
* CI: children < 12 y.o (Reye’s syndrome)
* DI:
* +warfarin, heparin, thrombolytics = inc. bleeding
* ibuprofen + insulin / OHA = hypoglycemia
* SE: gastric irritation, excess bleeding during first 2 days of menstruation

**Aspirin** - Nursing Responsibilities

* take with food (gastric irritant)
* with glass of water
* monitor platelet bleeding time PT (how fast clotting)
* discontinue 7 days prior to surgery

Acetaminophen

* non-narc / non-op
* MOA: weakly inhibits prostaglandin synthesis which decreases pain sensation and heat
* analgesic, antipyretic
* no gastric distress, not anti-inflammatory
* CI: severe hepatic / renal disease, alcoholism, hypersensitivity
* DI:
* +caffeine = inc. effect
* +oral contraceptive, anticholinergics = dec. effects
* SE/AE: hepatotoxicity, early symptoms of hepatic damage (N/V, diarrhea, abdominal pain = NVDA)

**Acetaminophen** - Nursing Considerations

* If hepatotoxic si pt - Check liver enzymes, self medication should not alabe used or more than 10 days for adults & 5 days for children
* Keep out of children’s reach
* Acetylcysteine (antidote) acetaminophen toxicity \*overdose sa biogesic
* No alcohol when pt. is on med

Narcotic and Opioid Analgesic

* MOA: binds to opiate receptors in the **CNS**, reduces stimuli from sensory nerve end, pain threshold is increased
* Uses: moderate to severe pain, suppresses pain in muscles, resp. and coughing (acts on medulla), antitussive property (except meperidine), levo (analgesic) and dextro (prevent dependence) isomers = antitussive response
* CI: with respiratory dysfunction, head injuries, increase ICP (increased intracranial pressure), hepatic & renal disease, alcoholism
* DI: + Alcohol, sedatives, hypnotics & other CNs depressants = inc. CNS depression
* SE: N/V, constipation, moderate dec. of BP, orthostatic hypotension, antitussive effect, CNS - drowsiness, dizziness, confusion, sedation
* TOXICITY = pupil constriction / pinpoint pupil (less than 2-3mm)

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**Codeine:** not as potent as morphine

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**Morphine sulfate**: potent analgesics (can depress respiration) effective against MI, dyspnea - pulmonary edema, pre-op meds

* \*if pt has chest pain give morphine (pwede siya sa pt with heart problem pero with precautions)

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**Meperidine (demorol):** shorter duration of action tha morphine, potency varies according to dosage

Meperidine

* AKA Demerol
* alleviate post-op pain, no antitussive property
* **Abstinence syndrome** : withdrawal symptoms occurring 23-48 hours after last narcotic dose ex. irritability, diaphoresis, restlessness, muscle twitching, tachycardia, hypertension