Pharm Exam 4
H2 Receptor Antagonists (e.g., Famotidine)
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MOA: H2 antagonists block the H2 receptor of acid-producing parietal cells, leading to reduced hydrogen ion secretion and consequently reduced gastric acid secretion, which in turn increases the pH of the stomach1 .
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Patient Teaching:
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Take as prescribed, even if symptoms have decreased2 .
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Avoid alcohol, aspirin, and NSAIDs that increase GI irritation2 .
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Avoid smoking2 .
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Monitor older adults for confusion3 .
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For optimal results, take 1 to 2 hours before antacids4 .
Aluminum Hydroxide (as an example of Aluminum-containing antacids)
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Adverse Effects: Constipation5 , hypophosphatemia (due to binding with phosphate)5 .
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Patient Teaching: Chew tablet thoroughly and follow with at least 8 oz of water6 . Take as directed (up to 4 times a day)6 .
Sucralfate (Carafate)
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Patient Education:
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May cause constipation, nausea, and dry mouth7 .
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May impair absorption of other drugs; give other drugs at least 2 hours before sucralfate7 .
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Antacids will decrease the effects of sucralfate, so give 1-2 hours apart8 .
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Administer on an empty stomach8 .
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Do not administer with other medications8 .
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Administration Recommendations: Administer on an empty stomach8 . Give other drugs at least 2 hours before or after sucralfate7 . Antacids should be given 1-2 hours apart8 .
Metoclopramide (Reglan)
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Adverse Effects: Drowsiness, sedation9 , extrapyramidal symptoms10 , long-term use may cause irreversible tardive dyskinesia10 , Neuroleptic Malignant Syndrome (NMS) characterized by fever, altered mental status, muscle rigidity, and autonomic dysfunction10 ....
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Indications: Gastroesophageal reflux disease (GERD), delayed gastric emptying (paralytic ileus)9 .
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MOA: Blocks dopamine receptors in the CTZ (chemoreceptor trigger zone), causing the CTZ to be desensitized to impulses it receives from the GI tract. It also stimulates peristalsis in the GI tract, enhancing emptying of stomach contents9 .
Ondansetron (Zofran)
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Classification: Serotonin blocker12 .
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MOA: Blocks serotonin receptors in the GI tract, CTZ, and vomiting center (VC)10 .
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Indications: Nausea and vomiting in patients receiving chemotherapy and for postoperative nausea and vomiting10 .
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Contraindications: Long QT syndrome (risk of Torsade's de pointe)12 .
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Nursing Pearls: Administer 30 minutes before surgery, 1 hour before chemotherapy12 . Could mask signs of an ileus, so assess GI frequently12 .
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Adverse Effects: Serotonin Syndrome (with SSRIs, tricyclic antidepressants)12 , Torsade's de pointe12 , Stevens-Johnson Syndrome (SJS)12 , headache, dizziness, constipation12 .
Docusate Sodium (Colace, Surfak)
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MOA: Emollient; promotes more water and fat in the stools and lubricates the fecal material and intestinal walls, preventing straining with a softer stool13 ....
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Patient Teaching: Encourage a healthy, high-fiber diet and increased fluid intake as an alternative to laxative use15 . Long-term use of laxatives often results in decreased bowel tone and may lead to dependency15 . All laxative tablets should be swallowed whole with 8 oz of water16 .
Bisacodyl (Dulcolax)
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MOA: Stimulant; increases peristalsis via intestinal nerve stimulation17 ....
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Patient Teaching: Encourage a healthy, high-fiber diet and increased fluid intake as an alternative to laxative use15 . Long-term use of laxatives often results in decreased bowel tone and may lead to dependency15 . All laxative tablets should be swallowed whole with 8 oz of water, not crushed or chewed, especially if enteric coated16 . Give with water because of interactions with milk, antacids, and juices16 . Inform patients to contact their prescribers if they experience severe abdominal pain, muscle weakness, cramps, or dizziness, which may indicate possible fluid or electrolyte loss19 .
Loperamide (Imodium)
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MOA: Antimotility drug; opioid that decreases bowel motility and reduces pain by relief of rectal spasms. It decreases transit time through the bowel, allowing more time for water and electrolytes to be absorbed8 ....
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Patient Teaching: Teach patients to take medications exactly as prescribed and to be aware of their fluid intake and dietary changes21 . Assess fluid volume status, input and output, and mucous membranes before, during, and after initiation of treatment21 . Clients should avoid spicy or diarrhea-inducing foods until symptoms resolve21 .
Omeprazole (Prilosec)
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Patient Teaching: Orally once daily before the first meal of the day22 . Limit drug use to the lowest dose for the shortest duration22 . Encourage weight-bearing activities to decrease bone loss22 . Capsule contents may be opened and mixed with apple juice, but do not chew or crush delayed-release granules22 .
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Indications: GERD, erosive esophagitis, short-term treatment of active duodenal and benign gastric ulcers, NSAID-induced ulcers, stress ulcer prophylaxis, treatment of H. pylori-induced ulcers (given with an antibiotic)23 ....
Calcium
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Drug Interactions: Chelation25 . If hypercalcemia is present in patients taking digoxin, serious cardiac dysrhythmias can occur25 . Glucocorticoids, cereals, rhubarb, and spinach decrease the absorption of calcium25 . Take one hour before or 2 hours after glucocorticoids, thyroid supplements, tetracycline, and quinolone26 . Give calcium-based antacids one hour before meals with a full glass of water26 .
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Signs of Hypocalcemia: Convulsions, Arrhythmias, Tetany (Chvostek's and Trousseau's signs), Spasms & stridor, Numbness (paresthesia) in fingers, face, limbs25 .... (Mnemonic: CATS GO NUMB)
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Signs of Hypercalcemia: Bone pain, Arrhythmias, Cardiac arrest (bounding pulses), Kidney stones, Muscle weakness (low DTR), Excessive urination25 . (Mnemonic: BACK ME)
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MOA: Essential for normal maintenance and function of the nervous, muscular, and skeletal systems; cell membrane and capillary permeability; catalyst in many enzymatic reactions; essential in many physiologic processes including transmission of nerve impulses, contraction of cardiac, smooth, and skeletal muscles, renal function, respiration, and blood coagulation28 .... Efficient absorption requires adequate amounts of vitamin D30 .
Alendronate (Fosamax)
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Adverse Effects: Headache, gastrointestinal (GI) upset, joint pain31 , risk of esophageal burns if medication lodges in the esophagus before reaching the stomach31 , risk of osteonecrosis of the jaw31 , possible severe (incapacitating) bone, joint, or muscle pain31 .
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Patient Teaching: Client must take with a full glass of water and remain sitting upright or standing for at least 30 minutes after taking the medication31 . Clients should only remain on for roughly 5 years due to its extremely long half-life2 .
Celecoxib (Celebrex)
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Adverse Effects: Headache, sinus irritation, diarrhea, fatigue, dizziness, lower extremity edema, and hypertension32 . Black box warning for GI bleed and cardiovascular thrombotic events33 .
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Patient Teaching: Celecoxib is not to be used in patients with known sulfa allergy32 . Be aware of the black box warning for GI bleed and cardiovascular thrombotic events33 .
Methotrexate
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Adverse Effects: Bone marrow suppression, dizziness, hepatotoxic, pulmonary fibrosis, GI ulcers, teratogenic34 , risk for infection34 .
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Toxicity: Toxicity can be increased by interactions with digoxin, NSAIDs, salicylates, sulfonamides35 . Caffeine may reduce its effectiveness35 , and alcohol (ETOH) should be avoided35 . Advise to take a folic acid supplement to lessen the likelihood of adverse effects and toxicity35 .
Etanercept (Enbrel)
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Adverse Effects: Suppression of the immune system, pancytopenia, heart failure, tuberculosis36 , patients must be screened for latex allergy (some dosage forms may contain latex)37 , reactivation of hepatitis and tuberculosis has been reported38 .
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Patient Education: Must be screened for latex allergy (some dosage forms may contain latex)37 . Patients must be assessed for the presence of infection before starting therapy38 . Teach patients to report signs of infection immediately (sore throat, diarrhea, vomiting, fever of 100.5°F or higher)39 .
Raloxifene (Evista)
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Adverse Effects: Hot flashes, leg cramps40 , increased risk of venous thromboembolism (VTE)40 , teratogenic40 , leukopenia leading to infection40 . Contraindicated in women with a history of venous thromboembolic disorder (DVT, PE, retinal vein thrombosis)40 .
Calcitonin-Salmon (Calcimar)
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Patient Teaching: Nasal form may cause nasal dryness30 . Report flushing of the face, nausea, diarrhea, and reduced appetite30 . Watch for signs of hypocalcemia30 .
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Adverse Effects: Flushing of the face, nausea, diarrhea, and reduced appetite30 , nasal dryness (with nasal form)30 , hypocalcemia30 , potential for anaphylaxis in patients with drug allergy or allergy to salmon30 . May decrease lithium levels30 . Bisphosphonates may decrease the body's response to calcitonin30 . Cannot prevent osteoporosis2 .
Pharmacological Management of Rheumatoid Arthritis
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Treatment consists of nonsteroidal anti-inflammatory drugs (NSAIDs) and disease-modifying antirheumatic drugs (DMARDs)41 .
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DMARDs modify the disease of RA and exhibit anti-inflammatory, antiarthritic, and immunomodulating effects. They inhibit the movement of various cells into an inflamed, damaged area, such as a joint, and have a slow onset of action (several weeks)34 ....
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DMARDs can be nonbiologic (traditional) or biologic43 .
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Nonbiologic DMARDs: Methotrexate (immunosuppressant)34 , Leflunomide (immunosuppressant)34 , Hydroxychloroquine34 , Sulfasalazine34 .
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Biologic DMARDs (Biologic Response-Modifying Drugs): Alter the body’s response to diseases such as cancer and autoimmune, inflammatory, and infectious diseases41 . Examples include monoclonal antibodies and TNF receptor antagonists35 . Biologic DMARDs like Adalimumab (Humira), Etanercept (Enbrel) inactivate TNF resulting in reduced inflammation and immunosuppression36 .
Allopurinol (Zyloprim)
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Nursing Implications: Assess uric acid levels and kidney function with use44 . Encourage patients to drink 3L of water a day unless contraindicated45 . Significant drug interactions can occur44 .
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Adverse Effects: Exfoliative dermatitis, Stevens-Johnson syndrome, and toxic epidermal necrolysis (potential fatal hypersensitivity syndrome)44 .
Oxybutynin (Ditropan)
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Indications: Neurogenic bladder, incontinence46 .
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Adverse Effects: Increased heart rate, dysrhythmias46 , CNS excitation, restlessness, irritability, disorientation, hallucinations, delirium47 , dilated pupils (blurred vision), increased intraocular pressure47 , decreased salivation (dry mouth), decreased gastric secretions, decreased motility (constipation)47 , urinary retention47 , decreased sweating (potentially leading to heatstroke in older adults)47 ....
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Patient Teaching: Overdosing can cause life-threatening problems48 . Blurred vision will cause problems with driving or operating machinery48 . Patients may experience sensitivity to light and may want to wear dark glasses or sunglasses48 . Dry mouth may occur; can be handled by chewing gum, frequent mouth care, and hard candy48 . Anticholinergics taken by older adult patients may lead to a higher risk for heatstroke; limit physical exertion and avoid high temperatures and strenuous exercise48 . Emphasize the importance of adequate fluid and salt intake49 . Report urinary hesitancy or retention, constipation, tachycardia, palpitations, tremors, confusion, sedation, hallucinations, and decreased sweating49 .
Pseudoephedrine (Sudafed)
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MOA: Exclusively adrenergic (sympathomimetic). Activates alpha1-adrenergic receptors in the nose, causing vasoconstriction of small blood vessels that supply upper respiratory tract structures. This shrinks tissues, allowing nasal secretions to drain better50 ....
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Patient Teaching: Prolonged decongestant effects but delayed onset50 .... No rebound congestion50 .... Do not use for more than 3 to 5 days to avoid rebound congestion (though this is more typical of topical decongestants)54 . Patients should avoid caffeine and caffeine-containing products55 . Patients should report a fever, cough, or other symptoms lasting longer than 1 week55 .
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Nursing Implications: Monitor for intended therapeutic effects (relief of nasal congestion)55 .
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Contraindications: Drug allergy54 , narrow-angle glaucoma54 , uncontrolled cardiovascular disease, hypertension54 , diabetes and hyperthyroidism54 , history of cerebrovascular accident or transient ischemic attacks54 , long-standing asthma54 , BPH54 . Use with systemic sympathomimetic drugs and MAO inhibitors should be avoided due to the risk of toxicity and increased blood pressure54 .
Inhaler Patient Education (General)
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To use the inhaler, the client: exhales normally just prior to releasing the medication, inhales deeply for 3-5 seconds as the medication is released, holds the medication in the lungs for approximately 10 seconds prior to exhaling56 .
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The client should wait approximately 20 to 30 seconds between inhalations of the same medication and 5 minutes between inhalations of different medications for maximum benefit56 .
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Teach patients to monitor disease with a peak flow meter56 .
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Encourage the use of a spacer device to ensure successful inhalations56 .
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Teach the patient how to keep inhalers and nebulizer equipment clean after use56 .
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If a beta-agonist bronchodilator and corticosteroid inhaler are both ordered, the beta agonist bronchodilator should be used several minutes before the corticosteroid to provide bronchodilation before administration of the corticosteroid57 ....
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Same process for nasal corticosteroids: use nasal decongestant first59 .
Dextromethorphan (Delsym)
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MOA: Nonopioid antitussive; suppresses the cough reflex by direct action on the cough center in the medulla18 ....
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Indications: May be used in cases where coughing is harmful (hernia surgery)18 . Used to stop or reduce coughing61 .
Diphenhydramine (Benadryl)
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MOA: H1 antagonist (H1 blocker). Blocks the action of histamine at H1 receptor sites by competing with histamine for binding at unoccupied receptors62 .
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Side Effects: Anticholinergic effects (you will need to provide specific examples), sedation63 ....
Albuterol (Ventolin)
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MOA: Short-acting beta2-adrenergic agonist (SABA). Stimulates Beta-2 receptors in the sympathetic nervous system, causing bronchodilation (relaxation of bronchial smooth muscles)66 ....
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Indications: Relief of acute bronchospasm or prevention of exercise-induced bronchospasm. Quickly reduces airway constriction and restores normal airflow67 .
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Adverse Effects: Nervousness, restlessness, tremors68 , at larger doses loses beta2 specificity and can stimulate beta1 receptors, causing chest pain, palpitations, nausea, increased anxiety, increased heart rate68 ....
Formoterol (Foradil)
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MOA: Long-acting beta2-adrenergic agonist (LABA) bronchodilator. Stimulates Beta-2 receptors in the sympathetic nervous system, causing bronchodilation66 ....
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Indications: Maintenance treatment of asthma and COPD; used in conjunction with an inhaled corticosteroid. Never to be used for acute treatment70 ....
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Adverse Effects: Similar to other beta-adrenergic agonists: nervousness, restlessness, tremors, chest pain, palpitations, increased heart rate68 .
Theophylline
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Patient Teaching: Be aware of drug interactions with cimetidine, fluoroquinolones, and caffeine, which increase the risk of toxicity72 . If they stop smoking (cigarettes or marijuana), they need to let the provider know as the dose might need to be decreased because smoking enhances theophylline metabolism72 .... Report nausea, vomiting, diarrhea, restlessness, insomnia, irritability, or tremors, which may indicate elevated therapeutic levels72 .
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Nursing Implications: Be aware of drug interactions72 . Monitor for signs of exceeding therapeutic levels (nausea, vomiting, diarrhea, dysrhythmias, restlessness, insomnia, irritability, tremors, and seizures at toxic levels)72 ....
Cetirizine (Zyrtec)
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MOA: H1 antagonist (H1 blocker); blocks the action of histamine at H1 receptor sites62 .
Ipratropium (Atrovent)
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Side Effects: Dry mouth or throat66 , increased intraocular pressure66 , urinary retention66 .
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MOA: Anticholinergic. Binds to the acetylcholine (ACh) receptors in the bronchial tree, preventing ACh from binding. Since ACh causes bronchial constriction and narrowing of the airways, blocking its action prevents bronchoconstriction, and airways dilate71 .... Indirectly causes airway relaxation and dilation75 . Helps reduce secretions in COPD patients75 .
Fluticasone (Flovent inhaled, Flonase if intranasal)
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Patient Teaching: Teach patients to gargle and rinse the mouth with lukewarm water and spit after use of inhaled fluticasone to prevent oral candidiasis (thrush)57 .... If a beta-agonist bronchodilator and fluticasone inhaler are both ordered, the beta agonist bronchodilator should be used several minutes before fluticasone57 .... Same process for nasal fluticasone: use nasal decongestant first58 .... May take several weeks before full effects are seen58 .... Does not relieve symptoms of acute asthma attacks58 ....
Montelukast (Singulair)
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MOA: Leukotriene receptor antagonist (LTRA). Suppresses the effects of leukotrienes, which are inflammatory agents that cause inflammation, bronchoconstriction, and mucus production, leading to coughing, wheezing, and shortness of breath77 .... Nonbronchodilating78 .
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Nursing Implications: Ensure that the drug is being used for chronic management of asthma, not acute asthma78 .... Teach the patient the purpose of the therapy78 . Take daily in the evening78 . Improvement should be seen in about 1 week78 . Be aware of the black box warning regarding serious mood-related changes and behaviors79 .st-MOA, nursing implications