Pharm Midterm
Neuro:
Drug Therapy for Muscle Spasms:
Centrally acting muscle relaxers
Baclofen: Makes GABA work better and suppresses hyperactive reflexes
Adverse effects:
Drowsiness
Weakness
Fatigue
N/V/C
Urinary retention
Interventions:
Start low dose and increase slowly
Take with food
Increase fluids, exercise, and fiber
Taper off over 1-2 weeks
Education:
Change positions slowly
Do not stop abruptly
Contraindications:
SSRIS
MAOIs
Alcohol
CNS depressants
Peripherally acting muscle relaxers
Dantrolene: inhibits calcium to prevent muscle contraction
Adverse effects:
Muscle weakness
Drowsiness
Dizziness
Liver failure (check LFTs)
Monitor for:
CNS issues
Assist ambulation
Diarrhea
Liver function
Education:
Avoid driving
Avoid CNS depressants
Report signs of liver failure
Abdominal pain
Jaundice
Ascites
Contraindications:
Liver disease
Interacts with alcohol/CNS depressants
Interacts with calcium channel blockers
Drug Therapy for Seizures:
What do seizure meds do?: Delay influx of sodium ions and slows sodium firing. They are slowed and provide effective seizure suppression.
Phenytoin: desensitizes sodium channels, treats epilepsy
Adverse effects:
CNS depression
Gingival hyperplasia
Skin rash
Cardiac dysrhythmias
Hypotension
Monitor:
Serum drug levels
Signs of toxicity
Bleeding disorders
Liver and kidney function (LFTS BUN CREATININE)
Contraindications:
Patients with hypersensitivity to hydantoin
Rash, seizures due to hypoglycemia, sinus bradycardia, and heart block
Carbamazepine
Nursing Actions:
Start low and slow
monitor labs
Watch CBC and WBC
Protect from sun (photosensitivity)
Give with food
Don't drive
Valproic Acid
Nursing Actions:
Monitor platelets/bleeding
Monitor for rash
LFTs
Give with food
Don't drive
*Should be seizure free for at least 3 years before stopping
*Resume medications if seizures return
*Oral care
Drug therapy for Active Seizures:
Benzodiazepines
Diazepam
Lorazepam
Midazolam
Drug Therapy for Parkinson's Disease
*As we get older, we have delayed gastric emptying, amino acids compete for absorption
*Meds may take awhile to have full effect, safety, symptom diary, Avoid high protein meals, LFT and kidney tests
Dopamine replacement
levodopa/carbidopa
Pramipexole
Adverse effects:
Skin irritation
Dizziness
Lightheadedness
Difficulty concentrating/confusion
Anxiety
Headache
Sleep dysfunction
Weight loss
Fatigue
nausea/vomiting/constipation
Orthostatic hypotension
Tremors
MI
Suicidal thoughts
Liver failure
Hallucinations
Sleep attacks
Complications:
Motor fluctuations
Wearing off
Delaying on or no on at all
Dyskinesias (involuntary movements)
Consequences of poor medicating
Increased anxiety
Reduced motor function
Reduced rehab potential
Delayed discharge
Reduced confidence
*Take meds at same time
*fluctuations are real
*Unpredictable
Drug Therapy for Alzheimers
*Goals of AD therapy: slow memory loss, improve ADLS, improve cognition/behavior
Cholinesterase inhibitors
Donepezil
Prevents breakdown of acetylcholine and enhances transmission in cholinergic neurons
Slows progression of AD
Adverse effects:
Headache
Dizziness
Insomnia
Nausea
Diarrhea and vomiting
Muscle cramps
Anorexia and abdominal pain
Hepatotoxicity
Renal toxicity
Bradycardia
Heart block
Extreme weight loss
Darkened urine
Administration
Give prior to bedtime
Give on regular schedule
Long term for best benefits
- NMSA receptor antagonist
- memantine
- reduces abnormally high levels of glutamate
- reduces neuronal calcium overload
- Adverse effects
- constipation
- CNS effects
- Interaction with tums and antacids
Treat Migraine Headaches
Sumatriptan - serotonin agonists
Take at onset of headache
Short half life
Contraindications - CAD (coronary artery disease), cardiovascular problems
Causes vasoconstriction of vessels to brain to decrease pain
Side effects - nausea, dizziness, chest discomfort
Avoid common triggers: lack of sleep, stress, certain foods
GI meds
Drug therapy for peptic ulcers
H2 antagonists
Cimetidine “-tidines”
Block H2 receptors and decrease the amount of acid secretions in the stomach
For GERD and duodenal/gastric ulcers
ADRs
Confusion
Arrhythmias
Anemia
Bradycardia
Interventions - safety, ECG monitoring, labs (CBC)
Admin - with or without food, give slowly via IV to prevent bradycardia, no antacids within 1 hour - affects absorption!!!
Avoid smoking, do not stop taking if feeling better, avoid irritating foods/ETOH, no NSAIDS, report signs of GI bleed
Interactions - warfarin and phenytoin
Contraindications - hepatic/renal impairment
PPIs - proton pump inhibitors
Omeprazole “-prazole”
Binds to an enzyme that releases acid to decrease acid production
Use for peptic ulcers and GERD
ADRs
hypocalcemia
hypomagnesemia
bone loss
n/v/d- c.diff
Headache
increased risk of pneumonia
Interventions
monitor Mg, Ca, LFTs, bone density scans (osteoporosis risk), assess severe V/D
Admin - daily 1 hr before meals (taken in relation to eating), take with fluids, delayed release capsules (do not crush/split)
Instructions
increase calcium and vit D, weight bearing exercises, drink clear fluids (know if vomit is bloody), report V/D
Interactions - warfarin and phenytoin
Contraindications - liver dysfunction
Mucosal protectant
Sucralfate
Made of sugar and antacid, coat stomach
Promote peptic ulcer healing
ADRs
constipation
Interventions
monitor BMs, stool softeners as needed
Admin - take on empty stomach prior to eating and at bedtime, no antacids 30 min before, do not give within 1 hr of warfarin, phenytoin and digoxin
Instructions
increase fluid, fiber and activity, report s+s of GI bleeding
Contraindications - CKD, diabetes, difficulty swallowing
Interactions - meds that rely of therapeutic levels - warfarin and phenytoin
Antacids
Aluminum hydroxide
Neutralize stomach acid
Dysphagia and GERD
Can be aluminum, magnesium or calcium based
ADRs
constipation with aluminum and calcium based
diarrhea with magnesium based
hypophosphatemia (affect bones)
Interventions
monitor mg and phosphorus levels
monitor bowel function
Admin - can take up to 4 per day, chew tabs with 8oz of water, take within 1-3 hrs after meal, do not take within 1-2 hr of meds that interact, do not take with milk
Instructions
eat frequent small meals
increase fluids, fiber and activity
report abdominal pain/diarrhea
monitor phosphorus intake
Contraindications - hypercalcemia, hypophosphatemia, severe abdominal pain unknown origin
Prostaglandin E analog
Misoprostol
Inhibit gastric acid secretion and help stimulate protective mucous
Prevent peptic ulcers w patients on NSAIDS or steroids
Contraindicated in pregnancy!!!!
ADRs
abdominal cramping, diarrhea, dysmenorrhea
Interventions
monitor abdominal pain/diarrhea, mid cycle menstrual bleeding
Instructions - report continued cramping/diarrhea, diarrhea should resolve after 1st week, take w food, drink fluids, report menstrual changes, NEED to take contraception if on, avoid ETOH/GI irritants
Interactions - antacids with mg may worsen diarrhea
Drug therapy for Nausea
Serotonin antagonists
Ondansteron “-setron”
Given post op to treat nausea
ADRs - headache, dizziness, diarrhea/constipation, serotonin syndrome (agitation, restless, sweating, dilate pupils, tremors, muscles - hyper reflex/twitch, high BP), steven johnson syndrome, torsades de pointes - lethal cardiac rhythm
Interventions - monitor headache, dizziness, monitor QT - ECG, safety risk (dizziness)
PO, IV, IM
Education - report HA/dizziness, change position slowly, do not get up without assistance, drink fluids, report diarrhea
Interactions - meds that affect serotonin - increased risk of serotonin syndrome
Contraindications - liver dysfunction, pregnancy, phenylketonuria, prolonged QT
Antihistamines/anticholinergics
Dimenhydrinate *** do not focus on a ton
Anticholinergics dry you out - lower secretions therefore lower nausea
Use for end of life or pts who are not tolerating PO
Contraindicated in pregnancy, hepatic disease, CNS depressants, enlarged prostate, glaucoma
Dopamine antagonists/prokinetic
Metoclopramide “-amide” or “-azine”
Block dopamine to decrease nausea, inhibit dopamine/serotonin
Promote gastric motility - decrease nausea
Contraindicated with a bowel obstruction
ADRs - tardive dyskinesia (EPS - extrapyramidal symptoms) - odd movements of lips, tongue and cheeks, neuroleptic malignant syndrome - muscle rigidity, tachycardia, fever
Can make you drowsy/dizzy, no driving/heavy machinery
No alcohol
For all antiemetics:
No ETOH, opioids, sedatives
Change position slowly, potential decrease in BP
No driving or heavy machinery
They have sedative effects!!!
Drug therapy for constipation
Bulk forming agents
Psyllium
Stool regulation, constipation
Admin - mix power with 8 oz of fluid, drink immediately after mixing
Results in 1-3 days, soft formed stool
ADRs - esophageal or GI obstruction
Education - take w fluids, report retrosternal pain
Contraindications - esophageal or GI obstruction, dysphagia, n/v, undiagnosed abdominal pain
Surfactant laxatives/stool softeners
Docusate sodium
Reduce straining constipation
Take with 8 oz of water on an empty stomach, DO NOT open capsule
Results in up to 3 days, easier to pass stool
ADRs - diarrhea, cramps, rash
Education - monitor abdominal assessment, take on empty stomach w 8 oz of water
Contraindications - GI obstruction or perforation, nausea/vomiting, undiagnosed abdominal pain, IBDs, mineral oil use??????
Stimulant laxatives
Bisacodyl
Colon prep, opioid induced constipation
Results - PO 6-12 hrs, PR 15-60 mins
Admin - PO do not take with milk or antacids, do not rush
ADRs - diarrhea, rectal burning, proctitis (inflammation of rectum/lower lg intestine)
Education - monitor for dehydration, not for long term use, monitor stools blood
Contraindications - ulcerated hemorrhoids, IBDs, nausea/vomiting, GI obstruction/perforation, undiagnosed abdominal pain
Drug therapy for diarrhea
Opioids
Diphenoxylate and atropine
Loperamide
Decrease stool frequency
Admin - may require 2 RN waste
Results - onset within 24-36 hrs, stop if no results after 48 hrs
ADRs - drowsiness, dry mouth, constipation
Education - monitor for dehydration, rule out bacterial infection (C.diff), do not take with ETOH, increases risk of megacolon
Contraindications - hepatic disease, prostate hypertrophy, GI bleeding, IBDs
Drug therapy for Irritable Bowel Syndrome (IBS)
5-HT3 Blocker
Alosetron - loose=diarrhea
Decreases peristalsis and increase absorption of water through intestinal wall
ADRs - constipation, ischemic colitis
Interventions - monitor bowel function, goal is one formed bowel per day
Admin - only for women with >6 mo of persistent IBS-D
Instructions - should work within 1-4 wks, stop taking if constipation occurs, report bloody stools, abd pain or rectal bleeding immediately
Contraindications - severe/complicated constipation, bowel obstruction, toxic megacolon (bowel given up - VERY dilated and not toned)
5-HT4 Receptor Agonist
Lubiprostone - stone=constipation
Increases peristalsis and decreases water absorption from intestine
ADRs - diarrhea, nausea, headache
Interventions - monitor frequency of stools and n/v/d
Men and women - chronic idiopathic constipation
Instructions - take with food to decrease nausea, hydrate, report severe d/v and HA
Contraindications - severe diarrhea, IBD, GI obstruction, volvulus (twisting)
Musculoskeletal
Drug Therapy for Rheumatoid Arthritis
Rheumatoid arthritis: inflammatory autoimmune disease of synovial joints but also in connective tissue
nonbiologic traditional DMARDS: have an immunosuppressive effect by interfering with normal B and T lymphocytes activity
Methotrexate
Folate antagonist
Decreases joint inflammation and subsequent joint damage
Causes immunosuppressive effect
Suppresses bone marrow (monitor RBC, WBC, platelets)
Patient susceptible to infection
ADR:
Infection
Liver damage
GI ulcers
Pulmonary fibrosis
Dizziness
Nursing interventions
Monitor for low platelets
Monitor for signs of infection
Monitor LFTS and jaundice
Monitor for GI bleeding
Monitor for respiratory distress and low O2
Monitor for abdominal pain, N/V/D
Administration
Once a week (oral, SubQ, IM)
Folic acid to decrease toxicity
Education
Report bleeding
Report signs of infection
Avoid alcohol
Report jaundice/signs of liver failure
Drink <2L per day
Contraindications
Pregnancy
Renal insufficiency
Liver insufficiency
Precautions
Peptic ulcers
Active infections
can affect digoxin
Caffeine may reduce effectiveness
Warfarin can cause excess bleeding
No alcohol
Biologic DMARDS: bind to tumor necrosis factor which prevents attachment to the cells of joint tissue preventing inflammation
Etanercept
Tumor necrosis factor blocker
Assess for infection before injection
Monitor for symptoms
Monitor for skin reactions
Monitor for redness, warmth, at injection site
Monitor for symptoms of heart failure, cough, SOB, pink sputum, and high HR and BP
Administration
Once weekly (subQ)
Monitor site
Education
Report infection
Avoid immunizations and live vaccines
Report skin rash
Report symptoms of heart failure, cough, SOB, pink sputum, high HR and BP
Contraindications
Active infections
Hematologic disease
Malignancy
Precautions
Autoimmune
Live vaccines
Heart failure
Interactions
Chemo drugs
Live vaccines
Drug Therapy for Osteoporosis
Osteoporosis: progressive bone disease resulting in reduced bone mass
Goal is to increase bone strength and decrease risk for fractures
SERMS: activate estrogen receptors in tissue needed to decrease bone loss and increase bone density
Raloxifene
Used for prevention or treatment of postmenopausal osteoporosis
Administered orally daily
Increased risk of DVT, pulmonary emboli and stroke
Patients may report hot flashes (due to estrogen blockage in other tissues)
Risk for clotting in legs, lungs, risk for stroke
Legs: cramps, redness, swelling, warmth
Lungs: SOB, decreased oxygen saturation, difficulty breathing
Monitor RBCs and coagulants
Education
Consume calcium and vitamin D
Running and weight lifting
Avoid pregnancy
Report signs of clotting
Bisphosphonates: inhibit osteoclasts and decrease bone reabsorption
Alendronate
Used for prevention of treatment of postmenopausal or glucocorticoid related osteoporosis
Administered orally daily
Remain upright and avoid eating or drinking or taking calcium supplement for 30 minutes after
May cause GI upset
ADR
N/V/Abd pain
Esophagitis
Muscle and joint pain
May need to stop or take pain meds
Monitor for decreased bone reabsorption
Calcitonin: decreases bone reabsorption by inhibiting osteoclasts
Calcitonin-salmon: used for treatment of established postmenopausal osteoporosis or hypercalcemia related to hyperparathyroidism
Administered intranasally or as injection
Avoid in patients with salmon or fish allergy
Watch for hypocalcemia
Calcium Supplements: non-dietary source of calcium to promote bone growth
calcium citrate/carbonate: Used for treatment of hypocalcemia for the prevention of osteoporosis or in conjunction of another medication for the treatment of it
Administered orally often with vitamin D
Watch for hypercalcemia, nausea, vomiting, constipation
Monitor for signs of kidney stones
Hematology:
Drug therapy for anemia
Ferrous sulfate
Treats iron deficiency anemia
GI side effects are common, so take with food
Other side effects are constipation and black, tarry stools
IV may leave a metallic taste in the mouth, or may dye teeth w the liquid form
No antacids, they can reduce the absorption
Vit C can increase absorption
Iron toxicity (GI issues, shock, liver and HF) - give deferoxamine
Cyanocobalamin
Treat pernicious/vit B12 deficiency anemia caused by lack of intrinsic factor
Often IM injection
Schilling test to see gastric absorption rate
Hypokalemia is a common adverse reaction
Encourage intake of B12 rich foods - dairy, enriched cereal, egg yolk
No alcohol it affects the level of B12 absorption
Common adverse reaction of folic acid is that it can turn pee an intense yellow color
Folic acid absorption can be impaired by chronic alcohol use
Drug therapy for bleeding disorders
Hemophilia - inherited bleeding disorder d/t defect of coagulation factor VIII or IX
Plasma derived VIII, recombinant factor VIII
Plasma derived IV, recombinant factor IX
Replace the factors in clients with hemophilia
Factors are obtained from plasma of human donors
IV bolus admin
Adverse reactions: itching, rash, difficulty breathing
Desmopressin (DDAVP)
ADH hormone that stimulates release of stored factor VIII in the body
IV or intranasal
Adverse reactions: fluid retention, hyponatremia (neuro symptoms seizures, HA, nausea, dizzy), CHF and HTN
Monitor I+O and monitor Na+
Retain fluid in the legs or lungs
Pt education - daily weights, report weight gain/edema, instruct on techniques, HTN and HF precautions
Drug therapy to prevent and dissolve (thromboembolic drugs- stop blood from coagulating)
Some interfere with factors, some inhibit vitamin K
S+S of clots or under anticoagulation - DVT, pulmonary embolism (difficult breathing, chest pain, coughing up blood)
S+S of bleeding or over anticoagulation - blood in urine/stool, GI ulcers, bruising easily, petechiae
Heparin, enoxaparin (lovenox)
Thrombin inhibitor - inhibits factors and clotting
Monitor VS, lab values (CBC), signs of bleeding, assess for bruising at the injection site, avoid NSAIDS and ASA
Protamine is the antidote
Warfarin
Vit K antagonist
Impacts the INR, important to monitor the range, high INR=blood to thin
Vitamin K is the antidote
Monitor VS and signs of bleeding
Advise clients to watch vit. K rich food intake
Aspirin
Small daily dose for prevention of cardiovascular/cerebrovascular events
Antiplatelet drug, suppresses platelet aggregation
Clopidogrel
ADP receptor inhibitor
Given to patients who have had a heart attack
Adverse reaction: GI upset/bleeding, thrombocytopenic purpura-rare but serious reaction
Alteplase
Thrombolytic drug - breaks up clots
Given to pts with an embolic stroke (tPA)
Watch for bleeding
Do not give to pt w a history of intracranial hemorrhage
Do not give w additional thromboembolic drugs
tPA considerations: interventions related to bleeding
Contraindicated if you are already bleeding
Drug therapy to support hematopoiesis
Epoetin alpha
Stimulates formation of RBCs
Used for anemia, after dialysis, chemo pts
Increases risk for clots
IV or SQ
Monitor lab values
Filgrastim
Stimulates formation of WBCs
Reduce risk of infection
ADR: bone pain and fever
Splenomegaly w prolonged use
IV or SQ
Monitor CBC weekly
Oprelvekin
Stimulate formation of platelets
In the plasma
Treat thrombocytopenia
Fluid retention is common ADR - monitor I+O and weights
Admin SQ after chemo treatment
Blood products
RBCs
FFP - fresh frozen plasma
can be used for warfarin overdose
Give to pt w elevated PTT bc it replaces coagulation factor and bleeding
Platelets
Cement truck, has to be infused quickly
Active bleeding
Reaction symptoms: chills, fever, lower back pain, headache, HTN, tachycardia, tachypnea
Need a type and screen lab within 72 hrs
Watch for circulatory overload
Pain and inflammation:
First generation NSAIDs (cox 1 and cox 2 inhibitors)
Aspirin (ASA), ibuprofen (advil/motrin)
Naproxen
Ketorolac - IV motrin(ibuprofen)
Only take for 5 days max - super toxic to kidneys
Uses - suppress inflammation, mild to moderate pain, reduce fever, dysmenorrhea
Inhibits platelet aggregation - anticoagulant - use with caution
Inhibits cox 1 which decreases platelet aggregation and helps with protection of gastric mucosa and promotes renal function
Side effects - bleeding, renal failure, GI upset and bleeding
Reye’s syndrome - giving ASA to children is a no go
Salicylism - ASA buildup in the body = overdose
Second generation NSAIDs (cox 2 inhibitors)
Celecoxib
Cox 2 stimulates inflammatory response so inhibiting this would decrease inflammation
Interventions: Monitor for signs of bleeding, monitor I+O, BUN and CRE, monitor for ASA overdose (salicylism) - tinnitus, dizzy, HA, sweating, tachypnea
Administration: do not crush or chew, D/C before surgery, take w food to prevent GI upset, avoid ETOH, report ringing in ears
Contraindications: bleeding disorder, ETOH disorder, peptic ulcers, kidney disease, HTNS
Avoid anticoagulants, steroids, and ETOH, effects cardiac meds
Acetaminophen
Own category
Non-opioid
Mild to moderate pain
Reduces fever - antipyretic
No anti-inflammatory effects and no anticoagulant effects
ADRs - liver damage, 4GM max at home 3GM in hospital or liver disease
Interventions: s+s of overdose, abdominal discomfort, nausea, vomiting
Antidote - mucomyst or acetadote
Contraindications - ETOH, anemia, hepatic disease
Monitor LFTs
Drugs for neuropathic pain
Gabapentin
Used for neuropathic pain or seizures
Adrs: suicidal ideation and depression, dizzy/drowsy
Interventions and education: no CNS depressants, ETOH or operating heavy machinery
Interactions with antacids so avoid
Opioid agonists
Morphine
Fentanyl
Bind to opioid receptors and turn them on
Mild to moderate pain
May cause sedation, respiratory depression
ADRs: resp depression, sedation, lightheaded/dizzy, constipation, n/v, urinary retention, cough suppression, tolerance
Interventions: monitor VS, monitor bowel function, monitor I+O and urinary retention, turn, cough and deep breathe, use incentive spirometer
Admin: base VS, low and slow, round the clock, narcan and resuscitation equipment at bedside
Contraindications: renal failure, respiratory disease, other CNS depressants (ETOH, Benzos), other anticholinergics (drying out effects)
Opioid antagonists
Naloxone (narcan)
Reverse effects of opioids and reverse overdose
Block opioid receptors
IV, SQ, IM, or intranasally
Short half life, has to be given often
ADR: HR and RR decrease, ventricular arrhythmias, withdrawal - HTN, vomiting, tremors
Amin every 2-3 minutes until pt wakes up (reversal)
Drugs for inflammation
antihyperuricemics/uricosurics - allopurinol
Treat gout - high levels of uric acid, crystals develop in the joints
Inhibits the conversion of enzymes to uric acid and promotes excretion of uric acid in the kidneys
ADR: hypersensitivity - fever, rash, increase in WBCs, GI - n/v/diarrhea, CNS - drowsy, ha, bone marrow depression - low WBCs
Avoid foods with purines - organ meats, red meats, alcohol
No heavy machinery
Liver and kidney monitoring
Ingest 3L of fluid per day, can develop cataracts so use sun protection, metallic taste in the mouth
Glucocorticoids - prednisone
Anti inflammatory effects in body and immune system
Side effects - suppress adrenal function, hyperglycemia, myopathy (muscle pain), GI upset/ulcers, risk for infection (low WBCs), fluid and electrolyte imbalances, fat redistribution (moon face, buffalo hump), truncal obesity
Can cause osteoporosis
Interventions: monitor for adrenal insufficiency (HTN, fatigue), monitor blood glucose, GI bleed, infection, monitor I+O
Has to be tapered, do not stop abruptly
Avoid NSAIDs d/t GI distress
Increase calcium and vitamin D
Contraindications: avoid vaccines bc decreased immunity, hypokalemia careful, NSAIDS, may need more insulin
Drug therapy that supports anesthesia
Local anesthesia - lidocaine: local/topical can come in patch form
Benzodiazepine - midazolam: post op pain or sedation, priority is airway bc it decreases RR
Opioid - fentanyl: post op pain or sedation, very strong give with care