Pharmacology Lecture Notes PDF

PHARMACOLOGY MRS. SALVE T. ZUÑIGA, MAN, RN  RENAL and UROLOGIC DRUGS Drugs used to treat Disorders of the Urinary Chemical System Generic Trade Uses/Indications Side Class Name Name Effects Urinary...

PHARMACOLOGY MRS. SALVE T. ZUÑIGA, MAN, RN  RENAL and UROLOGIC DRUGS Drugs used to treat Disorders of the Urinary Chemical System Generic Trade Uses/Indications Side Class Name Name Effects Urinary Anti- Fosfomyc First antibiotic Nausea, microbial in Monurol to be approved Diarrhea, agents/antibioti 3g as single dose Abdominal cs anti- packets treatment for cramps infectives are of UTIs. flatulence subs. that are Fosfomyc Used to treat (mild & secreted in the in uncomplicated resolve urine in granules acute cystitis in w/o tx) sufficient effect + 90-120 women. Causes Side Effects to Drug Nursing Report Adverse Interactions Interventions/ Reactions Implications Perineal burning Metoclopramide – 1. Record voiding lower the se characteristics to concentration and serve as baseline Dysuria urinary excretion of for monitoring Fosfomycin therapy. 2. Assess and record Cisapride – lower the existing GIT se concentration and complaints before urinary excretion of initiation of drug Fosfomycin therapy. 3. Record baseline V/S 4. Do not use hot CHEMICAL CLASS GENERIC TRADE NAME USES/ INDICATIONS NAME Quinolone Cinoxacin Cinobac Effective in teaching initial and antibiotics recurrent UTI caused by E-coli, proteus mirabilis & other gm (-) org. Nalidixic acid Negram 1g. 4x daily Monas species for 7-14 days take w/ meals Has a broad spectrum activity against gm (+) & (-) microog (E- Norfloxacin Neroxin 400 mg 2x a coli, P mirabilis Pseudomonas, tabs 400 mg day for 7-10 days take staph aureus, S. saphophytecies, 1o or 2o after meals epidermidis)  SIDE EFFECTS SIDE EFFECTS TO DRUG INTERACTIONS NURSING INTERVENTIONS/ REPORT/ ADVERSE IMPLICATIONS REACTIONS Nausea, vomiting, Hematuria, Perineal Probenecid & urinary 1. Record voiding anorexia, burning excretion of cinovin & characteristics abdominal cramps, Urticaria, Pruritus Hives norfloxacin 2. When using nalidixic acid flatulence Headache, Tinnitus Quinolones may enhance check for history of G6 PD Drowsiness, Dizziness anticoagulant effect of def. when present withhold dizziness, Tingling sensation Warfarin drug & contact the doctor. headache Photophobia Antacids, sucralfate, Iron 3. When using cinoxin or Mg, Calcium & Aluminum nalidixic acid record asso. Visual disturbance Decrease absorption of Complaints of visual Photosensitivity quirolones disturbances before initiation of therapy Nitrofurantoin – antagonize 4. Assess & record GIT the antibacterial effect of complaints norfloxacin 5. Record baseline v/s  CHEMICAL CLASS GENERIC NAME TRADE NAME USES/ INDICATIONS Yields formaldehyde in Methenamine Mandelamine 1g, 4x )D Used only in patients the presence of acidic mandelate 0.5 – 1g @ H.S/p.c. susceptible to urine – the enteric coated tabs or chronic recurrent formaldehyde suppress 0.5g (5 ml susp) UTI. Not potent in the growth & patients with pre- multiplication of existing infection. bacteria Given to prevent recurrent of infection  SIDE EFFECTS SIDE EFFECTS TO DRUG INTERACTIONS NURSING INTERVENTIONS/ REPORT/ ADVERSE IMPLICATIONS REACTIONS Nausea, Hives, pruritus, rash Acetazolamide & 1. Record voiding vomiting Bladder irritation NaHC03 produce characteristics belching dysuria, frequency alkaline urine thereby 2. Check urine for acidification, inactivating the give prescribed Vit. C to medication. maintain urine acidity 3. Record baseline V/S Sulfamithezole – form 4. Do not crush the tablets an insoluble 5. Perform urine pH @ regular precipitate, therefore intervals. Report values it should be avoided. above 5.5  CHEMICAL CLASS GENERIC NAME TRADE NAME USES/ INDICATIONS An antibiotic that acts Nitrofurantoin 25, 50, Macrodantin Active agst. gm(+) & by interfering with 100 mg caps. or 25mg/ Furadantin 50-100mg gm (-) organisms, like several bacterial 5 ml susp. 4x OD for 10-14d strep. Focalis, E-coli, enzyme – systems. Proteus species. Not active agst. Pseudemonas & Serratia species.  SIDE EFFECTS SIDE EFFECTS TO REPORT/ DRUG NURSING ADVERSE REACTIONS INTERACTIONS INTERVENTIONS/ IMPLICATIONS Nausea, vomiting, Dyspnea, chill, fever, rash, anorexia peripheral neuropathy, Urine discoloration – second infection. rusty brown-yellow  CHEMICAL CLASS GENERIC NAME TRADE NAME USES/ INDICATIONS Bladder – active drugs Bethanicol – chloride Urecholine 10-50 mg. 2- Bethanicol is a para- 50, 10, 25mg tabs. 4x OD symphatetic nerve Bethnicol – is a stimulant used in non- parasympathetic nerve obstructive urinary stimulant that causes retention. contraction of detrusor May also stimulate muscle in the bladder gastric motility, resulting in urination increased gastric tone & impaired rhythmic peristalsis  SIDE EFFECTS SIDE EFFECTS TO DRUG INTERACTIONS NURSING REPORT/ ADVERSE INTERVENTIONS/ REACTIONS IMPLICATIONS Flushing of skin Nausea, vomiting Quinidine, Record voiding headache sweating, colicky Procainamide – characteristics to pain, abdominal counteract effects of serve as baseline for cramps, diarrhea bethanicol monitoring belching, Record GIT symptoms involunatary present to serve as defecation. baseline. Atropine SO4 be available to counteract serious adverse effects.  CHEMICAL CLASS GENERIC NAME TRADE NAME USES/ INDICATIONS An anti-cholinesterase Neostigmine Prostigmin Used to prevent and treat agent that binds to postoperative distention cholinesterase preventing & urinary retention the destruction of acetylcholine. SIDE EFFECTS SIDE EFFECTS TO DRUG NURSING INTERVENTIONS/ REPORT/ INTERACTIONS IMPLICATIONS ADVERSE REACTIONS Take baseline v/s if bradycardeic withhold the drug. Heck for pregnancy, iniestinal/ urinary obstruction, if present – withhold drug. Check for recent coronary event, epitepsy hyperthyroidism, asthma, peptic ulcer – if present – drug must be used with caution. CHEMICAL CLASS GENERIC NAME TRADE NAME USES/ INDICATIONS Oxybutynin Chloride – Ditropan – 5 mg, 2-3x To reduce the 5, 10, 15mg extended – OD maximum of 20 frequency of release tabs or 5mg/ mg. bladder antractions 5 ml syrup & delay the initial Pedia: 5 mg 2x OD, desire to void in max. of 15 mg. patients with neurogenic bladder.  SIDE EFFECTS SIDE EFFECTS TO DRUG INTERACTIONS NURSING REPORT/ ADVERSE INTERVENTIONS/ REACTIONS IMPLICATIONS Dry mouth urinary If any side effects No clinically hesitance retention, intensity, it should significant constipation, bloating, be reported. distractions have blurred vision been reported  CHEMICAL CLASS GENERIC NAME TRADE NAME USES/ INDICATIONS An agent that is Phenazopyridine hcl 95, Pyridium Relieves burning pain excreted thru the 100, 150 – 200 mg. urgency, frequency Urinary tract, produces tabs. Adult: 200 mg 3x daily asso. With UTI a local anesthetic effect Reduce bladder on the mucosa of Pedia: 6-12 y.o 100 mg spasm – used to ureters & bladder. – 3x daily relieve discomfort due to indwelling catheter.  SIDE EFFECTS SIDE EFFECTS TO DRUG NURSING REPORT/ ADVERSE INTERACTIONS INTERVENTIONS/ REACTIONS IMPLICATIONS Reddish – orange Yellow – selera or skin Record urine color urine before initiation of discoloration therapy. CHEMICAL CLASS GENERIC NAME TRADE NAME USES/ INDICATIONS Used to reduce Tolterodine Detrol urgency and frequency if bladder contraction. Delay desire to void in patients with overactive bladder.  SIDE EFFECTS SIDE EFFECTS TO DRUG INTERACTIONS NURSING INTERVENTIONS/ REPORT/ ADVERSE IMPLICATIONS REACTIONS Dry mouth, If SE intensifies Erythromycin, Flucxetine Record voiding urinary it should be clarithromycin, Ketoko characteristics to nazole Miconazole, hesitance/ reported. sserve as baseline Itraconazole – inhibit the retention data. metabolism of tolterodine. constipation, Dosages should be lowered Obtain baseline v/s bloating, to 1 mg 2x daily if patient is blurred vision. taking these meds. Concurrently. DRUGS THERAPY WITH DIURETICS DIURETICS Are drugs that act to increase the flow of urine. The purpose of diuretics is to increase the net loss of water. To achieve this, they act on the kidneys in different locations to enhance the excretion of sodium (Na)  Methylxanthines – increase glomerular filtration  Spironolactone – inhibits tubular reabsorption of Na by inhibiting aldosterone.  Thiazides and loop diuretics – act directly on the kidney tubules to inhibit the reabsorption of Na and Cl from the lumen of the tubule.  Na and Chloride (Cl) that are not absorbed are excreted into the collecting ducts & then into the ureters to the bladder, taking large volumes of water to be excreted from the body thru urination. USES: 1. Treatment of 2 majors diseases affecting the CVS: a. Heart failure – to remove excessive Na & H20 to relieve symptoms asso. With pulmonary congestion and edema. 2. As treatment for hypertension – because they have shown to reduce cardiovascular morbidity & mortality asso. With hpn. Nursing Process for Diuretic Therapy A. Assessment 1. History of related causative 9. Overhydration disorders/factors 10. Edema 2. History of current symptoms 11. Electrolyte imbalance 3. Pattern of urination 4. Medication history 12. Hyperkalemia – K < 3.5 mEq/L 5. Hydration status 13. Hypokalemia – K > 135 mEq/L 6. Skin turgor 14. Hyponatremia – Na < 135 mEq/L 7. Oral mucus membranes 15. Hypernatremia – Na > 145 mEq/L 8. Lab changes in hct, hgb, BUN & Electrolyte B. Implementation 1. I & O – recorded accurately q shift, totalled = 24o 2. Serum electrolytes – monitored 3. Nutrition – order prescribed special diet – restricted or low Na diet 4. Order requested lab studies relating to disease process. 5. Patient is required to eat K-rich foods when taking diuretics other than K-sparing drugs. RENAL and UROLOGIC DRUGS DRUG CLASSES ARE: 1. Carbonic Anhydrase Inhibitor (CAI) Acetazolamide – Diamox Acetazolamide – Diamox is a weak diuretic that acts by inhibiting the enzyme CA within the kidney, brain & eye. It promotes the excretion of Na, K, H20 & HCO3. USES: Not used frequently as a diuretic however it is used to reduce IOP in patient’s with glaucoma & reduce seizures activity in patients with epilepsy. 2. Methyxanthines  Aminophylline Aminophylline – a methyxantine deriuactive used for its diuretic effect in cardio-renal disease and as bronchodilator in patients with pulmonary disease – like asthma. Examples of Methyxantine are: 1. Theophylline Has weak 2. Caffeine diuretic properties. All 3. Theobromine act by improving blood flow to the kidney 3. Loop diuretics Bumetanide – bumex Ethacrynic acid – Edecrine Furosemide – Lasix Torsemide - Demadex  Bumetanide – Bumetadine – bumex – is a potent diuretic that acts by bumex inhibiting Na & Cl reabsorption from the ascending limb of the loop of Henle. It also acts by increasing blood flow into the glumerule and inhibits electrolyte absorption the proximal tubule, enhancing NaCl phosphate & bicarbonate excretion in the urine. - Effect starts 30-60 min. after adm. & peak w/in 1-2o lasts 4-6o USES: 1. Tx edema due to HF 2. Cirrhosis of the liver 3. Renal disease – nephrotic syndrome  Ethacrynic acid – Side Effect to Expect: Edecrine 1. Orthostatic hypotension - Is a diuretic that acts Side Effects to Report: primarily on the ascending 1. Electrolyte imbalance/ dehydration limb of loop of Henle to 2. GIT bleeding 4. Diarrhea prevent Na & Cl reabsorption. 3. Dizziness, deafness, tinnitus 5. Hyperglycemia - Onset of activity is within 30 min. peaks in 2o and last Nursing Intervention: 6-8o 1. Obtain baseline data before initiation of therapy as v/s, wt, lung sounds, edema, lab. Studies. USES: 2. Obtain data related to patient’s mental status (orientation, 1. Treat edema from HF alertness, confusion, tremors etc.) 2. Cirrhosis of liver 3. Obtain baseline blood glucose level. 3. Renal disease Drug Interactions 4. Malignancy 1. Aminoglycosides – potential for ototoxicity is increased 5. Children w/ congenital H.D. 2. Cispating – caused ototoxicity 6. Used in combination w/ 0.9 NaCl 3. NSAIDS – inhibit the diuretic activity of ethacrynic acid in patients w/ hypercalcemia (10 4. Digoxin – cause excess potassium excretion enhance excretion of calcium) 5. Corticosteroids – enhance loss of potassium hypokalemia Furosemide – Lasix USES: - Acts primarily on the ascending limb of the loop of Henle, the Furosemide is one of the most potent and effective diuretics proximal & distal portions of currently available. the tubule, to prevent Na & Cl 1. Treat edema caused by heart failure, renal reabsorption. disease, cirrhosis of the liver. 2. Treat hypertension & hypercalcemia - Diuresis results in enhanced excretion of: NA, Cl, K, Ca, Mg hydrogen, ammonium bicarbonate and possibly Side Effects to Expect: phosphate. 1. Oral irritation dry mouth Effect occurs in 1-2o after p.o - Oral hygiene w/1 tsp hydrogen peroxide adm. Lasts 4-6o (maximum in 608 oz H2D, mouth wash effect 1-2o) 2. Orthostatic hypotension Effect occurs 5-10 min after IV adm. Peaks within 30 min & lasts for 2 hrs. Side Effects to Report: Drug Interactions: 1. Electrolyte 1. Digoxin - cause excessive excretion of K imbalance/dehydration hyperkalemia 2. Hyperuricemia – furosemide 2. Propramolol – action maybe increased – adjust inhibit the excretion of uric dose acid. 3. Theophylline – action maybe increased 3. Hyperglycemia 4. Cuminoglycosides – potential for ototoxicity 4. Hives, preuritus rash 5. Cesplatin 6. NSAIDS – inhibit diuretic activity of furosemide 7. Salicylates – potential for salicylate toxicity increased 8. Phenytoin – inhibit absorption of furosemide Torsemide - Demadex - Is a sufonamide type of loop USES: diuretic, it acts on the ascending 1. Treat edema caused by heart limb of the loop of Henle to failure, renal disease, cirrhosis prevent Na & Cl reabsorption of the liver. - Does not affect GF or renal blood 2. Treat hypertension & flow hypercalcemia - Onset of action = 1-2o after p.o adm. Lasts 6-8o - IV adm. = 5-10 min. peaks w/in 60 min lasts up to 6 hrs. Drug Interactions: Nursing Intervention: 1. Digoxin - cause excessive excretion of K 1. Obtain baseline data hyperkalemia before initiation of therapy 2. Propramolol – action maybe increased – as v/s, wt, lung sounds, adjust dose edema, lab. Studies. 3. Theophylline – action maybe increased 2. Obtain data related to 4. Cuminoglycosides – potential for patient’s mental status ototoxicity (orientation, alertness, 5. Cesplatin confusion, tremors etc.) 6. NSAIDS – inhibit diuretic activity of 3. Obtain baseline blood furosemide glucose level. 7. Salicylates – potential for salicylate toxicity increased 8. Phenytoin – inhibit absorption of furosemide 4. Thiazide Diuretics Benzothiadiazides – commonly called the thiazides, as diuretics they act Therapeutic Outcomes: primarily on distal tubules of the kidney 1. Diuresis with reduction of edema to block the reabsorption of Na & Cl 2. Reduction of elevated BP from the tubules. 3. Improvement of symptoms related to excessive fluid accumulation USES: Premedication Assessment: 1. Treat edema asso. With HF renal disease 1. Obtain baseline data (V/S, lung sounds weight, hepatic disease pregnancy, obesity, degree of edema, lab studies on se electrolytes premenstrual syndrome (PMS) and medicines liver/renal function tests) like adrenocortical steroids. 2. Data related to mental health status 2. treatment of hypertension – the anti hpn 3. Baseline blood glucose level 4. Note reduction of hearing, S/S of gout properties of thiazides result from direct vasodilatory action on peripheral arterioles. Sample Drugs (Thiazide Diuretics) Generic Brand Name Dosage Form 1. Bendroflumethiazide Naturetin 5-10 mg tabs 2. Benzthiazide Exna 50 mg tabs 3. Chlorothiazide Duiril 250 – 500 mg 4. Hydrochlothiazide Esidrix, Oretic 50 – 100 mg 5. hydroflumethiazide Saluron 50-100 mg 6. methychlothiazide Enduron, Acquatensen 5 mg tab 7. Polythiazide Renese 2-4 mg tab 8. Trichlorimethiazide Diurise, Naqua 2-4 mg tab 9. Chlorthalidone Hygroton, Thalitone Tabs 10. Indopamide Lozol 1.25 – 2.5 mg 11. Metalazone Mykrox Zaroxolyn 5-10 mg tab.  Side Effect: 1. Orthostatic hypotention SE to Report/Adverse Effects 1. GI irritation, nausea, vomiting, constipation 2. Electrolyte imbalance/dehydration 3. Hyperucemia, hyperglycemia, hives, rash Drug Interactions: 1. Digoxin – cause excessive excretion of K 2. Corticosteroids – enhance K –loss 3. Lithium – induce toxicity to lithium 4. NSAIDS – inhibit diuretic activity 5. Hypoglycemics – Insulin – can inhibit activity so dosage adjustment is required 5. Potassium-Sparing Diuretics 1. Amiloride – acts on distal renal tubules to retain K & excrete Na has weak antihypertensive activity. Used in combination of other diuretics in HF hypertensive and prevent hypokalemia. 2. Spinorolactone – Aldoctone – blocks the Na-retaining K and Mg excreting properties resulting in loss of water & excretion of Na. Useful in edema of ascites not relieved by usual diuretics Reduce morbidity/mortality of patients with heart failure. 3. Triamterene – Dyrenium – very mild diuretic, that acts by blocking the exchange of K & Na in the distal tube of kidney – resulting in retention of K and excretion of Na & water. 6. Combination Diuretics – given to minimize adverse effect promote diuresis & antihypertensive effect. While normal se K level is maintained e.g. spironolactone + hydrochlorothiazide triamterene + hydrochlothiazide Drug Interaction: 1. ACE inhibitors – inhibit aldosterone lead to hyperkalemia 2. Salt – substitutes 3. NSAIDS – inhibit diuretic activity  CHEMICAL CLASS GENERIC NAME TRADE NAME USES/ INDICATIONS Barbiturates Sedative Hypnotics Barbiturate - Barbiturates first Amobarbital Amytol Used primarily as sedative barbiturate placed on 250-500 mg vials before anesthesia or during the market Dose: 30-50 mg labor - Reverse the activity of Butabarbital-tabs, 3x a day all excitable tissues 15/30/50-100mg Used as daytime sedative and Pentobarbital – caps Butisol bedtime hypnotic. 30, 50 mg inj. 50mg/ml Short-acting, used as daytime supp. 30-60 mg sedative/pre- anesthetic Nembutal sedative  SIDE EFFECTS SIDE EFFECTS TO REPORT/ DRUG INTERACTIONS NURSING INTERVENTIONS/ ADVERSE REACTIONS IMPLICATIONS Hangover, Excessive Antihistamine, alcohol, 1. Seek information re: sedation lethargy use/abuse analgesics, anesthetic, prior use of sedative- Hypothesis: 100- Paradoxical tranquilizes, valproic acid, hypnotic meds. 200mg response MAOI’s, chloramphenicol 2. Obtain baseline Sedation – 30 mg hypersensitivity Increase toxic effects of neurologic function blood dyscrasias barbiturates. 3. Take V/S & pain rating Hypnosis 100 mg Barbiturates reduce the at bedtime effect if: Warfarin, steroids, estrogens, BB metronidazole, quinidine chlorpromazine, doxycycline CHEMICAL CLASS GENERIC NAME TRADE NAME USES/ INDICATIONS Mephobarbital Mebaral Long-acting, used as an anticonvulsant as daytime Phenobarbital Luminal Solfoton sedative tabs 15,16, 30, Long-acting, used as an 60, 100mg anticonvulsant, or daytime Elixir – 15-20 sedative pre-anesthetic or mg/5ml hypnotic agent Sedation: 8-30mg 2-3x a day Hypnosis: 100-320 mg Secobarbital caps Seconal – short- anticonvulsant 60-100 2-3x a day 100mg acting Hypnosis: 100-200 mg @ bedtime  CHEMICAL CLASS GENERIC NAME TRADE NAME USES/ INDICATIONS Benzodiazipines – are the most commonly used sedative hypnotics. Therapeutic outcomes are:  Produce mild Midazolam Versed Short – acting, onset am = sedation 15 min causes amnesia in  Short-term use to Triazolam most patients produce sleep  Preop sedation w/ Used to tx insomnia amnesia Halcion Rapid onset of action, no morning hangover Novo-triolam  SIDE EFFECTS SIDE EFFECTS TO REPORT/ DRUG INTERACTIONS NURSING INTERVENTIONS/ ADVERSE REACTIONS IMPLICATIONS Drowsiness, Excessive use/abuse Drugs that increase toxic Record baseline v/s esp. hangover, blood dyscrasia effects are: alcohol, BP in sitting and lying sedation, hepatotoxicity antihistamines, analgesics, position lethargy anesthetics, narcotics, cimetidine, isoniazid, rifampin, Check hx of blood erythromycin dyscrasias/ hepatic disease or if the patient Smoking enhances the is in first trimester of metabolism of benzodiazepines pregnancy. – larger doses is needed in patients who smoke. CHEMICAL CLASS GENERIC NAME TRADE NAME USES/ INDICATIONS Estrozolam 1-2 mg Prosom Used to tx insomnia tabs. intermediate–acting Intermediate acting rebound, Temazepam 15,30 Restoril insomnia may occur. mg H.S Treat insomnia, also for preop anxiety Lorazepam 0.5-1.2 Ativan Long-acting, short-term mg tabs Nevolorazepam Treatment of insomnia – morning hangover may be Flurazepam Dalmane significant used as sedative hypnotics to produce sleep. Quazepam Doral SIDE EFFECTS SIDE EFFECTS TO REPORT/ DRUG INTERACTIONS NURSING INTERVENTIONS/ IMPLICATIONS ADVERSE REACTIONS Tapering therapy recommended to reduce rebound insomnia.  CHEMICAL CLASS GENERIC NAME TRADE NAME USES/ INDICATIONS Non-Barbiturate Non- Chloral hydrate Aquachloral Produce mild sedation & Benzodiazepine Novochlorhydrate short-term use to produce Sedative – hypnotic sleep. agents Ethchlorvynol Placidyl Bedtime hypnotic and preop sedative Paraldehyde Paral Used as sedative in treating delirium tremens Zaleplon Sonata Short-acting hypnosis – 10 mg @ bedtime Zolpidem Ambien  SIDE EFFECTS DRUG NURSING INTERVENTIONS/ INTERACTIONS IMPLICATIONS Hangover Sedation CNS depressants, Record baseline V/S esp. BP lethargy restlessness analgesics, Check for hx of blood dyscracias anxiety anesthetics, hepatic disease nareotics, alcohol, Check BP & pain rating tranquilizers – Has a bitter taste, strong foul odor increased the to the breath, administer milk or sedative effect iced Diminished the anti- Fruit juice to mask odor/ taste coagulant effect of Dispense only in glass container, do Warfarin not use plastic spoon Drug Therapy for Depression It is known that patients with depression have changes in the brain neurotransmitter – norepinephrine serotonin and dopamine but other unexpected life events (sudden death of a love one) may also play a major role. Excessive secretion of cortisol & abnormal TSH – have been found in 45-60% of patients with depression Depressive disorders ^ suicide tend to cluster in families & relatives of patients with depression are 2-3x more likely to develop depression. Drug Therapy for Depression Onset of depression tend to be in late 20s can be classified (accr. to American psychiatric Asso.) into MILO – have minor functional impairment MODERATE – between mild & severe, intermediate SEVERE – have several S/S that exceed the minimum criteria, patients experiencing depression display varying degrees of emotional, physical cognitive & psychomotor symptoms. Drug Therapy For Depression The MAOIs used today are phenelzine, tranylcypromine and isocarboxazid. They are equally effective and have very similar side effects. Primary therapeutic outcome are elevated mood and reduction of symptoms of depression  CHEMICAL CLASS GENERIC NAME TRADE NAME USES/ INDICATIONS A. Mondamine Oxidase Phenelzine Nardil 15 mg Most effective in Inhibitors (MAOIs) – act by tab atypical blocking the metabolic depression, panic destruction of Isocarboxa – 10 Larplan disorder, OCD and norepinephrine, dopamine mg tab phobic disorders. & serotonin cid neurotransmitters by the enzyme MAO in the Tranylcypromine Parnate presynaptic neurons of the 10 mg tabs. brain  SIDE EFFECTS DRUG INTERACTIONS NURSING INTERVENTIONS/ IMPLICATIONS Orthostatic Drug that increase toxic Obtain BP & PR before & at regular hypotension effects: intervals Drowsiness sedation TCAs , SSRI, Gen Monitor blood glucose if pt. is diabetic Restlessness, anesthesia, Diuretics, because MAOI cause hypoglycemia agitation antihypertensives, Insulin, Instruct to avoid tyramine containing Insomnia, blurred Oral hypoglycemic agents foods as it may cause life threatening vision Meperidine hypertension Constipation, dry Medication history to ensure the patient mouth urinary has not taken the ff: dextromethorphan, retention ephedrine propylpropanolamine, a mphetamine, methylphenidate, levodopa & meperidine B. Selective Serotonin Reuptake Inhibitors (SSRIs) SSRIs – are a newer class of antidepressant chemically unrelated to other antidepressants. Do not have the anticholinergic & CVS side effects. They act by inhibiting the reuptake and destruction of serotonin neurotransmitter. Takes 2-4 wks to obtain the full therapeutic benefit. Example of SSRIs GENERIC NAME TRADE NAME USES SIDE EFFECTS Citalopram 20 mg Celexa tabs Effective in Restlessness, daily treating agitation, anxiety, Escitalopram 20 Lexapro Prozac depression, also insomnia mg in a.m for treatment of Sedative effects Fluvoxamine 20 Paxil OCD, obesity Suicidal actions mg daily Paxil CR eating disorders, Paroxitine 20 mg Zoloft panic disorder, daily bipolar, autism. Example of SSRIs DRUG INTERACTIONS NURSING INTERVENTIONS/ IMPLICATIONS TCAs – can lead to toxicity as Obtain baseline BP, record & report significant arrhythmias seizures, CNS reduction to help. stimulation. Obtain baseline weight Lithium & MAOIs Haloperidol, Note GI S/S present before start of tx Phenytoin, Phynobarbital, Carbama, Monitor CNS symptoms such as insomnia, Zepine, Alprozolam, Cimetidine, nervousness. should be avoided. Warfarin – Check hepatic studies before start of enhance anticoagulant effect. administration & throughout therapy Use caution while driving Monitor for changes in feelings thoughts, actions/behaviors.  C. TRICYCLIC ANTIDEPRESSANTS (TCAs) TCAs – have been the most widely medication in the Nursing Interventions treatment of depression. The TCAs prolong the action of Anticholinergic effects of TCAs norepinephrine, domanine and serotonin by blocking the Dry mouth reuptake of these neurotransmitters in the synaptic cleft Constipation between neurons. The exact mechanism of action when Urinary retention used as antidepressant is unknown. Blurred vision CV effects – postural TCAs – produce antidepressant & mild tranquilizing hypotension, arrhythmia, effect after 2-4 weeks of therapy. They elevate mood, tachycardia improve appetite and increase alertness in patients with Aggravated glaucoma endogenous depression. Allergy Fld. Retention Tremors, seizures  CHEMICAL CLASS GENERIC NAME TRADE NAME Tricyclic Amytriptyline Elavil Antidepres- AD: 10, 25, 50, 95, 100 mg, I.D: 25 mg 3x a day sants 150 mg Amoxapine Asendin Clomipramine Anatranil Desipramine Norpramin Doxepin Sinequan, Zonalon Imipramine Tofranil, Apo-linipromine Aventyl, Pamelor Nortriptyline Vivactil, Tipramine Protriptyline Surmontil Trimipramine  USES/ INDICATIONS SIDE EFFECTS Produce antidepressant mild tranquilizing effect, Blurred vision improve appetite. Constipation Elevate mood Urinary retention Increase awareness Dryness of mucosa Mode-severe anxiety Throat/nose/ mouth Treat depression of schizophrenia Orthostatic hypotension Protriptyline – has sedative properties & may produce Sedative effects mild stimulation in patients Doxapin – is approved for treating anxiety Imipramine – is approved for treating enuresis in children 6 year old & above  Adverse Effects DRUG INTERACTIONS Tremor, numbness, Drugs that enhance the anticholinergic effects: tingling Antihistamines Parkinsonian symptoms Phenothiazines arrhythmias, CHF, Benztropine, meperidine tachycardia, seizures Trihexyphenidyl. Suicidal actions Drugs that enhance sedative effect when given with TCAs Ethanol, barbiturates narcotics tranquilizers anesthetics, antihistamines sedative-hypnotics Nursing Interventions: Obtain baseline BP in supine/standing position, record & report significant hypotension to HCP/doctor. Note consistency of BP, constipation is common when taking TCS. Check history of arrhythmias, CHF tachycardia before starting therapy (may require ECG before initiating tx. If patient has hx of seizures, check with HCP to see if dosage need to be adjusted. Dosage should be initiated at low levels and gradually increased. Suicide precaution should be maintained Barbiturates – enhance metabolism of TCA – dosage adjustment may be needed. D. MISCELLANEOUS AGENTS - other Antidepressants CHEMICAL CLASS GENERIC NAME TRADE NAME OTHER Bupropion Wellbutrin – ID – 100 mg 2x a day may ANTIDEPRESSANTS be increased to 3x a day No single dose should exceed 150 mg Maprotilline hcl Remeron Mirtazepine Serzone Netazadone Desyrel Trazadone hcl Effexor Venlafaxine e  D. MISCELLANEOUS AGENTS - other Antidepressants USES/ INDICATIONS SIDE EFFECTS Give to TCA & cannot tolerate the adverse GIT effects Restlessness effects of TCA Agitation Anxiety Insomnia Disadvantages include seizure activity. Not to be used in patients with psychotic disorders Drawssiness Contusion, First TCA released for clinical use. Dizziness, O. hypotension Used in rx of depression & depressive phase of bipolar disorder. Anorexia, nausea Is a tetracyclic antidepressant Restlessness, anxiety, Similar tp trazodome in chemical structure insomnia D. MISCELLANEOUS AGENTS - other Antidepressants Adverse Effects DRUG INTERACTIONS Seizures Carbamazepine, Cimetidine, Phenobarb, Phenytoin May be an inducer of hepatic enzyme Suicidal actions Carbomazepine – may pharmacologic effect Nicotine may cause hpn. Levodopa increased in adverse effect Ritonavin – increased in se conc’n of bupropion Nursing Interventions: Obtain baseline weight, schedule weekly weights Obtain baseline BP Check for hx of seizures, if present notify HCP before starting tx Check hepatic studies. Drug Therapy for Lower Respiratory Disease A. Expectorants – liquefy mucus by stimulating the secretion of natural lubricant fluid from the serous glands. Are used to treat non-productive cough, bronchitis, pneumonia, in which mucus plugs inhibit the expulsion of irritants and bacteria that cause bronchitis or pneumonia. B. Antitussives/ cough suppressants – act by suppressing the cough center in the brain. They are used when the patient has dry, hacking, non-productive cough. Under, normal circumstances it is not appropriate to suppress a productive cough. Drug Therapy for Lower Respiratory Disease C. Mucolytic agents – reduce the stickiness and viscosity of pulmonary secretions by acting directly on the mucus plugs to cause dissolution. Are most effective in removing mucus plugs obstructing the tracheobronchial airway. They are used in the treatment of patients with acute and chronic pulmonary disorders, before and after bronchoscopy, after chest surgery and ass part of the treatment of tracheostomy care. D. Bronchodilators – relax the smooth muscle of the tracheobronchial tree. This allows an increase in thee opening of the bronchioles and alveolar ducts which decreases the resistance to airflow into the alveolar sacs. The primary bronchodilators used in the treatment of airway obstructive diseases include: beta-adrenergic agents, anti- cholinergic aerosols and xanthine derivatives. E. Anti-Inflammatory Agents – play an important role in the treatment of asthma to reduce inflammation. Corticosteroids are the most effective agents, most commonly used are those administered by inhalation- because of their minimal side effects. Other anti- inflammatory agents are Leukotriene modifiers – are a new class of anti-inflammatory agents that block leukotriene formation. Leukotrienes are part of the inflammatory pathway that causes bronchoconstriction. Omalizumab – is the first of a new class of agents known as – immune-modulators, used to treat patients with asthma exacerbations caused by reaction to airborne allergies. Nursing Process for Lower Respiratory Disease 1. ASSESSMENT a. History of Respiratory Symptoms What pulmonary symptoms has the individual had (childhood allergies, pneumonia, TB, etc.) b. History of Respiratory Medications What prescribed meds. OTC meds. or herbal products have been used. How effective have the meds been in the tx of current symptoms. Nursing Process for Lower Respiratory Disease c. Description of current Symptoms. What is the patients chief complaints, when the symptoms started. d. Perform Respiratory Assessment (IPPA) Respiratory patter, rate, depth, & regularity in breathing e. Lab & diagnostic data – review hematology, sputum test, Cxray ABG’s & allergy testing. 2. Nursing Diagnosis 3. Planning Ineffective airway clearance Order medications prescribed, schedule (indication) these on med. adm. record (MAR) Activity intolerance Ensure that has needed PRN meds are Impaired gas exchange readily available for use. Ineffective breathing pattern Plan appropriate teaching for med. administration techniques & drug therapy. 4. Implimentation Assist the patient as needed to perform self-care activities. Adm. O2 as ordered & as needed. Record spirometer readings as required. Adm. Prescribed meds & treatments that can best alleviate the patients symptoms & provide the maximum level of comfort. Encourage physical activity as prescribed, but do not allow to over exert or become fatigued. Institute measures to reduce anxiety, support the patient in a calm manner.  Drugs to Treat Asthma (Lower Respiratory Disease) A. Drug Class: Beta- Adrenergic Generio Trade name Bronchodilators Albuterol Volmax Proventil, Ventolin tabs Bitolterol Tornalate aerosol Actions: Ephedrine For inhalation sol & cap Beta-adrenergic agonists Epinephrine Primatene, Mist-nebulization sol. & aerosol stimulate the beta Formoterol Foradil-inhaler cap receptors within the Isoetharine Sol. For inhalation smooth muscles of the Isoproterenol Isoprel Inj. & sol. tracheobronchial tree to Levalbuterol Xopenex Inhalation relax thereby opening the Metaproterenol Alupent Syrup, aerosol airway passage to greater Pirbuterol Maxar Aerosol volumes of air. Salmeterol Serevant, Serevent Diskus Inhalation Terbutaline Brothine Tabs & inj. Uses/Inidcations mainstay of all asthma therapy SIDE Effects to Report: reverse airway constriction caused by; Tachycardia, palpitations  Bronchial asthma, bronchitis, emphysema short-acting beta agonists have rapid onset Tremors, nervousness, and are used to tx acute bronchospasm dizziness e.g. albuterol, levalbuterol, pirbuterol, Anxiety, restlessness, headache terbutaline, metaproterinol Nausea, vomiting Long acting forms of inhaled bronchodilators – are not to be used for acute episodes – but for patients with nocturnal asthma & those who wheeze with excessive. Onset of action is 15-30 min. e.g. salmeterol and formoterol Nursing Interventions Drugs Interactions 1. Obtain & Drugs that enhance toxic effects record baseline V/S TCAs (ticlopidine, imipramine, amitryptiline 2. Assess for presence of palpitations arrhythmias doxepin), MAOIs (paragyline) before adm. of beta-adrenergic agents. HCP should be informed if present. Sympathomimetics (metaproterenol, 3. Perform baseline mental status (anxiety, isoproterenol) nervousness, alertness) Drugs that reduce Therapeutic effect 4. Make sure patient understand how to use the BABA (propranolol, timolol, nadolol) (Higher inhaler, wait 10 min. between inhalations doses of bronchodilator maybe needed) Antihypertensive agents – may reduce the TE of these drugs.  B.Anti-Cholinergic Bronchodilating Agents Actions: USES: Anticholinergic agents- have been used - Is used as bronchodilator for long-term as bronchodilators in treating OPD for treatment of reversible bronchospasm asso. more than 200 yrs, but the potent With COPD. anticholinergic adverse effects (dry mouth, throat irritation reduced - Used in patients with asthma in combination secretions, urinary retention) have with BAB. limited their use in pulmonary disorders. - Prophylaxis & maintenance treatment of Ipratropium bromide – is adm. by bronchospasm asso. with COPD than for acute acrosol inhalation & produce episodes of bronchospasm. broncholdilation by competitive inhibition - Ipratropium nasal spray is used for of cholinergic receptors on bronchial symptomatic relief of rhinorrhea asso. with smooth muscles allergic rhinitis & common cold. Side effects to Drug Interactions expect: No significant interactions have been Mouth dryness, throat irritation reported Nursing Implementation Adverse Effects: 1. Record baseline V/S Tachycardia, urinary retention exacerbation of pulmonary 2. Check for history of angle closure glaucoma if so report to HCP symptoms 3. Usual dose is 2 inhalations (36 mcg) 4x a day should not exceed 12 inhalation in 24o 4. Ensure that the patient understands how to inhale medication.  C. Xanthine - Derivative Bronchodilators Actions: Generic Trade name Methylxanthines more commonly Amninophyline Tabs, 100-200 mg known as xanthine-derivatives, Liquid: 105 mg/5 ml acts directly on smooth muscle Dyphyllin Dilor 200-400 mg tab of the tracheobronchial tree to Oxtriphylline Choledyl SA – 100-200-400mg dilate the bronchi, thus Elixir: 100mg/5ml increasing airflow in and out of Theophylline Bronkodyl tabs/cap the alveolar sacs. Elixophyllin elixir Theolair - liquid/syrup USES: Side Effects to Expect: - Used in combination with 1. Nausea, vomiting, epigastric pain, abdominal sympathomimetic cramps. bronchodilators to reverse airway constriction caused by Side Effects to Report: acute & chronic bronchial Tachycardia, palpitations tremors, asthma, bronchitis & emphysema. nervousness, anxiety, restlessness, headache. Nursing Interventions: 1. Obtain & record baseline V/S 2. Assess presence of palpitation & arrhythmias Drug Interactions Drug that enhance toxic effects limetidine, erythromycin, diltiazem nifedipine, verapamil, propranolol zileuton, allopurinol, thiabendazole flu vaccine Drugs that reduce T.E., tobacco or marijuana smoking Lithium – increase the renal excretion of this drug, hence increased lithium is required. BABA – xanthine derivative may have mutually antagonistic actions.