Pharmacology Midterm PDF

PHARMACOLOGY MIDTERM Pharmacology of the GIT system LECTURE Outline\ REVIEW the Anatomy of the GIT\ REVIEW the Physiology of the GIT\ Review common GI drugs in the following\ categories:\ ϒ 1. Drugs affecting GI secretions\ ϒ 2. Laxatives\ ϒ 3. Anti-diarrheals\ ϒ 4. Emetics and anti-emetics ![](m...

PHARMACOLOGY MIDTERM Pharmacology of the GIT system LECTURE Outline\ REVIEW the Anatomy of the GIT\ REVIEW the Physiology of the GIT\ Review common GI drugs in the following\ categories:\ ϒ 1. Drugs affecting GI secretions\ ϒ 2. Laxatives\ ϒ 3. Anti-diarrheals\ ϒ 4. Emetics and anti-emetics    Drugs affecting GI secretions\ There are five types of drugs that affect gastric\ acid secretions and are useful for the\ treatment of peptic ulcer.\ 1. Histamine (H2) receptor antagonist/blockers\ 2. Antacids\ 3. Proton pump inhibitors\ 4. Mucosal protectants\ 5. Prostaglandin analogs General indication of the drugs\ affecting gastric acid secretion\ Peptic ulcer\ Gastritis\ Patient on NPO to prevent stress ulcer Pharmacodynamics\ Histamine (H2) receptor blockers\ These drugs BLOCK the release of\ hydrochloric acid in the stomach in\ response to gastrin Drugs affecting GI secretions\ Antacids\ These drugs interact with the\ gastric acids at the chemical\ level to neutralize them Drugs affecting GI secretions\ Proton pump inhibitors\ These drugs suppress the\ secretion of hydrochloric acid\ into the lumen of the stomach Drugs affecting GI secretions\ Mucosal protectants\ These are agents that coat any\ injured area in the stomach to\ prevent further injury from acid Drugs affecting GI secretions\ Prostaglandin analogs\ These are agents that inhibit the\ secretion of gastrin and\ increase the secretion of mucus\ lining of the stomach, providing a\ buffer.  HISTAMINE 2 RECEPTOR BLOCKER The H2 Blockers- "tidines"\ Prototype: Cimetidine\ 1. Ranitidine\ 2. Famotidine\ 3. Nizatidine The H2 Blockers- "tidines"\ Pharmacodynamics: Drug Action\ The H2 blockers are antagonists at the receptors\ in the parietal cells of the stomach.\ The blockage results to inhibition of the hormone\ gastrin.\ There will be decreased production of gastric\ acid from the parietal cells.\ Also, the chief cells will secrete less pepsinogen. The H2 Blockers- "tidines"\ Therapeutic use of the H2 blockers\ Short-term treatment of active duodenal ulcer or\ benign gastric ulcer\ Treatment of hypersecretory conditions like the\ Zollinger-Ellison syndrome\ Prevention of stress-induced ulcers and acute GI\ bleeding\ Treatment of erosive GERD (reflux disease)\ Relief of Symptoms of heart burn and acid indigestion The H2 Blockers- "tidines"\ Precautions and Contraindications\ Any known allergy is a clear contraindication\ to the use of the agents.\ Conditions such as pregnancy, lactation, renal\ dysfunction and hepatic dysfunction should\ warrant cautious use.\ Nizatidine can be used in hepatic dysfunction. The H2 Blockers- "tidines"\ Dynamics- Side effects/adverse effects\ GIT= diarrhea or constipation\ CNS= Dizziness, headache, drowsiness, confusion\ and hallucinations\ Cardio= arrhythmias, HYPOTENSION (related to H2\ receptor blockage in the heart)\ Cimetidine= Gynecomastia and impotence in males The H2 Blockers- "tidines"\ Drug-drug Interactions\ Cimetidine, Famotidine, Ranitidine\ are metabolized in the liver- they\ can cause slowing of excretion of\ other drugs leading to their\ increased concentration. The H2 Blockers- "tidines"\ Drug-drug Interactions\ These drugs can interact with CIMETIDINE\ Anticoagulants\ Phenytoin,\ Alcohol\ Antidepressants. The H2 Blockers- "tidines"\ Nursing considerations:\ Administer the drug WITH meals at\ BEDTIME to ensure therapeutic level\ One hour after Antacids\ Stress the importance of the continued\ use for the length of time prescribed The H2 Blockers- "tidines"\ Nursing considerations\ Monitor the cardiovascular status\ especially if the drugs are given IV\ Warn patient of the potential problems\ of increased drug concentration if the\ H2 blockers are used with other drugs\ or OTC drugs. Advise consultation first! The H2 Blockers- "tidines"\ Nursing considerations:\ Provide comfort measures like analgesics for\ headache, assistance with ambulation and safety\ measures because of confusion\ Warn the patients taking cimetidine that\ drowsiness may pose a hazard if driving or\ operating delicate machines. The H2 Blockers- "tidines"\ Nursing considerations:\ Provide health teaching as to the dose,\ frequency, comfort measures to initiate when\ side-effects are intolerable\ Evaluate the effectiveness\ Relief of symptoms of ulcer, heart burn and GERD ANTACIDS The Antacids\ These are drugs or inorganic chemicals that have\ been used for years to neutralize acid in the stomach The Antacids\ The following are the common antacids that can be\ bought OTC:\ Aluminum salts (hydroxide)\ Calcium salts (carbonate)\ Magnesium salts (milk of magnesia)\ Sodium bicarbonate\ Magaldrate (aluminum and magnesium\ combination) The Antacids\ Pharmacodynamics: drug action\ These agents act to neutralize the acidic pH in the\ stomach.\ They do not affect the rate of gastric acid\ secretion. The Antacids\ Pharmacodynamics: drug action\ The administration of antacid may cause an acid\ rebound.\ Neutralizing the stomach content to an alkaline\ level stimulates gastrin production to cause an\ increase in acid production and return the\ stomach to its normal acidic state. The Antacids\ Therapeutic Indications\ Symptomatic relief of upset stomach associated\ with hyperacidity\ Hyperacidic conditions like peptic ulcer, gastritis,\ esophagitis and hiatal hernia\ Special use of AMPHOGEL (aluminum hydroxide):\ to BIND phosphate The Antacids\ Precautions of Antacid Use\ Known allergy is a clear contraindication\ Caution should be instituted if used in electrolyte\ imbalances, GI obstruction and renal dysfunction.\ Sodium bicarbonate is rarely used because of\ potential systemic absorption◊ metabolic\ alkalosis!!! The Antacids\ Pharmacokinetics\ These agents are taken orally and act locally in\ the stomach The Antacids\ Pharmacodynamics: Effects of drugs\ 1. GIT= rebound acidity; alkalosis may occur.\ Calcium salts may lead to hypercalcemia\ Magnesium salts can cause DIARRHEA\ Aluminum salts may cause CONSTIPATION\ and Hypophosphatemia by binding with\ phosphates in the GIT.\ 2. Fluid retention due to the high sodium\ content of the antacids. The Antacids\ Nursing Considerations:\ Administer the antacids apart from any other\ medications by ONE hour before or TWO hours after-\ to ensure adequate absorption of the other\ medications\ Tell the patient to CHEW the tablet thoroughly before\ swallowing.\ Follow it with one glass of water\ Regularly monitor for manifestations of acid-base\ imbalances as well as electrolyte imbalances The Antacids\ Nursing Considerations:\ Provide comfort measures to alleviate constipation\ associated with aluminum and diarrhea associated\ with magnesium salts.\ Monitor for the side-effects, effectiveness of the\ comfort measures, patient's response to the\ medication and the effectiveness of the health\ teachings The Antacids\ Nursing Considerations\ Evaluate for effectiveness:\ Decreased symptoms of ulcer and pyrosis\ Decreased Phosphate level (Amphogel) in patients\ with chronic renal failure PROTON-PUMP INHIBITORS The PPI\ These are the newer agents for ulcer treatment\ The "prazoles"\ Prototype: Omeprazole\ Lanisoprazole\ Esomeprazole\ Pantoprazole The PPI\ Pharmacodynamics: drug action\ They act at specific secretory surface receptors\ to prevent the final step of acid production and\ thus decrease the level of acid in the stomach.\ The "pump" in the parietal cell is the H-K ATPase\ enzyme system on the secretory surface of the\ gastric parietal cells The PPI\ Clinical use of the PPIs\ Short-term treatment of active duodenal ulcers,\ GERD, erosive esophagitis and benign gastric\ ulcer\ Long-term- maintenance therapy for healing of\ erosive disorders. The PPI\ Precautions with the use of the PPIs\ Known allergy is a clear contraindication\ Caution if patient is pregnant The PPI\ Pharmacodynamics: Adverse effects\ CNS- dizziness, headache, asthenia (loss of\ strength), vertigo, insomnia, apathy\ GIT- diarrhea, abdominal pain, nausea,\ vomiting, dry mouth and tongue atrophy\ Respi- cough, stuffy nose, hoarseness and\ epistaxis. The PPI\ Nursing considerations:\ Administer the drug BEFORE meals. Ensure that\ patient does not open, chew or crush the drug.\ Provide safety measures if CNS dysfunction\ happens.\ Arrange for a medical follow-up if symptoms are\ NOT resolved after 4-8 weeks of therapy. The PPI\ Nursing considerations:\ Provide health teaching as to drug name, dosages\ and frequency, safety measures to handle\ common problems.\ Monitor patient response to the drug, the\ effectiveness of the teaching plan and the\ measures to employ The PPI\ Nursing considerations:\ Evaluate for effectiveness of the drug\ Healing of peptic ulcer\ Decreased symptoms of ulcer MUCUSAL PROTECTANTS The Mucosal Protectant\ Sucralfate (Caralfate/ Iselpin)\ This is given to protect the eroded ulcer sites in\ the GIT from further damage by acid and digestive\ enzymes Sucralfate\ Pharmacodynamics: Action of drug\ It forms an ulcer-adherent complex at duodenal\ ulcer sites, protecting the sites against acid,\ pepsin and bile.\ This action prevents further breakdown of\ proteins in the area and promotes healing. Sucralfate\ Clinical use of sucralfate\ Short and long term management of duodenal\ ulcer.\ NSAIDs induced gastritis\ Prevention of stress ulcer\ Treatment of oral and esophageal ulcers due to\ radiation, chemotherapy or sclerotherapy. Sucralfate\ Precautions on the use of Sucralfate\ This agent should NOT be given to any person\ with known allergy to the drug, and to those\ patients with renal failure/dialysis because of\ build-up of aluminum may occur if used with\ aluminum containing products. The Mucosal Protectant\ Pharmacodynamics: Side-effects & adverse\ reactions\ Primarily GIT= CONSTIPATION, occasionally\ diarrhea, nausea, indigestion, gastric discomfort,\ and dry mouth may also occur\ CNS= dizziness, drowsiness, vertigo\ Others= rash and back pain The Mucosal Protectant\ Drug-drug interactions\ If used with aluminum salts= high risk of\ accumulation of aluminum and toxicity.\ If used with phenytoin, fluoroquinolones and\ penicillamines- decreased levels of these drugs\ when taken with sucralfate The Mucosal Protectant\ Nursing Considerations\ Administer drug ON AN EMPTY stomach, 1 hour\ before meals , or 2 hour after meals and at BEDTIME\ Monitor for side-effects like constipation and GI upset\ Encourage intake of high-fiber foods and increased\ fluid intake\ Administer antacids BETWEEN doses of sucralfate,\ NOT WITHIN 30 minutes of sucralfate dose The Mucosal Protectant\ Nursing Considerations\ Provide comfort measures if CNS effects occur\ Provide health teaching as to drug name, dosages\ and frequency, safety measures to handle\ common problems.\ Monitor patient response to the drug, the\ effectiveness of the teaching plan and the\ measures employed The Mucosal Protectant\ Nursing Considerations\ Evaluate effectiveness of therapy\ Healing of ulcer\ No formation of ulcer PROSTAGLANDIN ANALOGUE Prostaglandin analogue\ Misoprostol\ This agent is a synthetic prostaglandin E1 analog\ that is employed to protect the lining of the\ mucosa of the stomach Prostaglandin analogue\ Misoprostol: Pharmacodynamics\ Being a prostaglandin analog, it inhibits gastric\ acid secretion to some degree\ It INCREASES mucus production in the stomach\ lining. Prostaglandin analogue\ Misoprostol: Clinical use\ NSAIDs-induced gastric ulcers\ Duodenal ulcers unresponsive to H2 antagonists Prostaglandin analogue\ Precautions of Misoprostol Use\ This drug is CONTRAINDICATED during pregnancy\ because it is an abortifacient.\ Women should be advised to have a negative\ pregnancy test within 2 weeks of beginning therapy\ and should begin the drug on the second or third day\ of the next menstrual cycle.\ They should be instructed in the use of contraceptives\ during therapy. Prostaglandin analogue\ Pharmacodynamic effects: drug reactions\ GIT= Nausea, diarrhea, abdominal pain,\ flatulence, vomiting, dyspepsia\ GU effects= miscarriages, excessive uterine\ CRAMPING and bleeding, spotting, hyper-\ menorrhea and menstrual disorders. Prostaglandin analogue\ Nursing Considerations\ Administer to patients at risk for NSAIDs-induced\ ulcers during the full course of NSAIDs therapy\ Administer four times daily with meals and at bedtime\ Obtain pregnancy test within 2 weeks of beginning\ therapy.\ Begin the therapy on second or third day of menstrual\ period to ensure that the woman is not pregnant Prostaglandin analogue\ Nursing Considerations\ Provide patient with both written and oral\ information regarding the associated risks of\ pregnancy\ Provide health teaching as to drug name, dosages and\ frequency, safety measures to handle common\ problems.\ Monitor patient response to the drug, the\ effectiveness of the teaching plan and the measures\ to employ LAXATIVES Laxatives\ Generally used to INCREASE the passage of the\ colonic contents\ The general classifications is as follows:\ 1. Chemical stimulants- irritants\ 2. Mechanical stimulants- hyperosmotic agents\ and saline cathartics\ 3. Lubricants and stool softeners Laxatives\ They promote bowel evacuation for various\ purposes\ They are classified into their mode of action Therapeutic Indications of the Laxatives\ SHORT term relief of Constipation\ Prevention of straining in conditions like CHF,\ post-MI, post partum, post-op\ Preparation for diagnostic examination\ Removal of poison or toxins\ Adjunct in anti-helminthic therapy\ To remove AMMONIA by use of lactulose Contraindications in Laxative use\ ACUTE abdominal disorders\ ϒAppendicitis\ ϒDiverticulitis\ ϒUlcerative colitis Chemical Stimulant Cathartics\ Prototype: Bisacodyl\ Irritant laxatives:\ 1. Castor oil\ 2. Senna\ 3. Cascara\ 4. Phenolphthalein Chemical Stimulant Cathartics\ Pharmacodynamics\ These agents DIRECTLY stimulate the nerve\ plexus in the intestinal wall\ The result is INCREASED movement or motility of\ the colon Mechanical Stimulant Cathartics\ Prototype: LACTULOSE (Cephulac)\ Bulk-forming laxatives\ 1. Magnesium (citrate, hydroxide, sulfate)- saline\ cathatic\ 2. Psyllium\ 3. Polycarbophil Mechanical Stimulant Cathartics\ Pharmacodynamics\ These agents are rapid-acting laxatives that\ INCREASE the GI motility by\ ϒ Increasing the fluids in the colonic material\ ϒ Stimulating the local stretch receptors\ ϒ Activating local defecation reflex Lubricants-Stool softener\ Prototype: Docusate\ 1. Glycerin\ 2. Mineral oil Lubricants-stool softeners\ Pharmacodynamics\ Docusate increases the admixture of fat and\ water producing a softer stool\ Glycerin and Mineral oil form a slippery coat on\ the colonic contents Pharmacokinetics:\ Common Side-effects of the Laxatives\ Diarrhea\ Abdominal cramping\ Nausea\ Fluid and electrolyte imbalance\ Sympathetic reactions- sweating, palpitations,\ flushing and fainting\ CATHARTIC dependence The Nursing Process and Laxative\ ASSESSMENT\ Nursing History- elicit allergy to any laxatives,\ elicit history of conditions like diverticulitis and\ ulcerative colitis\ Physical Examination- abdominal assessment\ Laboratory Test: fecalysis, electrolyte levels The Nursing Process and Laxative\ NURSING DIAGNOSIS\ Alteration in bowel pattern\ Alteration in comfort: pain\ Knowledge deficit The Nursing Process and Laxative\ IMPLEMENTATION\ 1. Emphasize that it is use on a SHORT term basis\ 2. Provide comfort and safety measures like ready\ access to the bathroom, side-rails\ 3. Administer with a full glass of water The Nursing Process and Laxative\ IMPLEMENTATION\ 4. Encourage fluid intake, high fiber diet and daily\ exercise\ 5. DO NOT administer if acute abdominal condition\ like appendicitis is present\ 6. Advise to change position slowly and avoid\ hazardous activities because of potential\ dizziness The Nursing Process and Laxative\ IMPLEMENTATION\ 7. Record intake and output to assess fluid\ alteration\ 8. If possible, observe the character of stools\ 9. Caution the patient that chronic use may\ promote dependence and use during pregnancy\ may cause uterine cramping and Vitamin\ deficiency The Nursing Process and Laxative\ EVALUATION of drug effectiveness\ 1. Evaluate relief of GI symptoms, absence of\ staining and increased evacuation of GI tract\ 2. For Lactulose: decreased ammonia\ 3. Normal bowel fucntion is restored The Anti-diarrheals\ These are agents used to calm the irritation of the\ GIT for the symptomatic relief of diarrhea\ General Classifications\ 1. Local anti-motility\ 2. Local reflex inhibition\ 3. Central action on the CNS  Clinical Indications of drug use\ Relief of symptoms of acute and chronic diarrhea\ Reduction of fecal volume discharges from\ ileostomies\ Prevention and treatment of traveler\'s diarrhe Contraindications of anti-diarrheal Use\ Poisoning\ Drug allergy\ GI obstruction\ Acute abdominal conditions Pharmacokinetics: Side effects\ Constipation\ Nausea, vomiting\ Abdominal distention and discomfort\ TOXIC MEGACOLON Nursing process and anti-diarrheals\ ASSESSMENT\ Nursing History -- Elicit history of drug allergy,\ conditions like poisoning, GI obstruction and\ acute abdominal conditions\ Physical Examination- Abdominal examination\ Laboratory test- electrolyte levels Nursing process and anti-diarrheals\ NURSING DIAGNOSIS\ Alteration in bowel pattern\ Alteration in comfort: pain Nursing process and anti-diarrheals\ IMPLEMENTATION\ 1. Monitor patient response within 48 hours.\ Discontinue drug use if no effect\ 2. Provide comfort measures for pain\ 3. Provide teaching regarding its short term use\ only Nursing process and anti-diarrheals\ EVALUATION\ 1. Monitor effectiveness of drug- RELIEF of\ diarrhea\ 2. Monitor adverse effects, effectiveness of pain\ measures and effectiveness of teaching plan EMETIC AND ANTI-EMETICS Emetics and Anti-emetics\ Emetic Agent\ Syrup of Ipecac\ Anti-emetics\ 1. Phenothiazines\ 2. Non-phenothiazines\ 3. Anticholinergics/Antihistamines\ 4. Serotonin receptor Blockers\ 5. Miscellaneous EMETIC\ Prototype: Ipecac Syrup EMETIC\ Pharmacodynamics\ Ipecac syrup irritates the GI mucosa locally,\ resulting to stimulation of the vomiting center\ It acts within 20 minutes EMETIC\ Clinical Use of ipecac\ To induce vomiting as a treatment for drug\ overdose and certain poisonings EMETIC\ Contraindications of Ipecac use\ Ingestion of CORROSIVE chemicals\ Ingestion of petroleum products\ Unconscious and convulsing patient EMETIC\ Pharmacokinetics: side effects of Ipecac\ Nausea\ Diarrhea\ GI upset\ Mild CNS depression\ CARDIOTOXICITY if large amounts are absorbed\ in the body Nursing process and the EMETIC\ ASSESSMENT\ Nursing History- elicit the exact nature of\ poisoning\ Physical Examination- CNS status and abdominal\ exam Nursing process and the EMETIC\ IMPLEMENTATION\ 1. Administer to conscious patient only\ 2. Administer ipecac as soon as possible\ 3. Administer with a large amount of water\ 4. Vomiting should occur within 20 minutes of the\ first dose. Repeat the dose and expect\ vomiting to occur with 20 minutes Nursing process and the EMETIC\ IMPLEMENTATION\ 5. Provide comfort measures like ready access to\ bathroom, assistance with ambulation 6\. Offer support Nursing process and the EMETIC\ EVALUATION\ 1. Evaluate patient response within 20 minutes of\ drug ingestion\ 2. Monitor for adverse effects\ 3. Evaluate effectiveness of comfort measures and\ teaching plan ANTI-EMETICS\ These are agents used to manage nausea and\ vomiting\ They act either locally or centrally\ In general, they may inhibit the chemoreceptor\ trigger zone in the medulla by blocking DOPAMINE\ receptor\ Others act by decreasing the sensitivity of the\ vestibular apparatus  ANTIEMETICS\ Indications\ 1. Prevention and treatment of vomiting\ 2. Motion sickness ANTIEMETICS\ Contraindications\ 1. Severe CNS depression\ 2. Severe liver dysfunction ANTIEMETICS\ Pharmacokinetics:\ Oral absorption is good if vomiting is not\ present\ IV drugs can be given if vomiting is active\ Most drugs are metabolized in the liver\ excreted in the kidneys ANTIEMETICS\ Pharmacokinetics: Side-effects\ 1. PHOTHOSENSITIVITY\ 2. Drowsiness, dizziness, weakness and tremors\ and DEHYDRATON\ 3. Phenothiazines= autonomic anti-cholinergic\ effects like dry mouth, nasal congestion and\ urinary retention\ Metoclopramide= EPS due to dopamine receptor\ blockage Nursing Process and the\ ANTIEMETICS\ ASSESSMENT\ Nursing History- elicit allergy, impaired hepatic\ function and CNS depression\ Physical Examination- CNS status and abdominal\ examination\ Laboratory test- Liver function studies Nursing Process and the\ ANTIEMETICS\ NURSING DIAGNOSIS\ 1. Alteration in comfort: pain\ 2. High risk for injury\ 3. Knowledge deficit Nursing Process and the\ ANTIEMETICS\ IMPLEMENTATION\ 1. Assess patient's intake of other drugs that may\ cause dangerous drug interaction\ 2. Emphasize that this is given on a short term\ basis Nursing Process and the\ ANTIEMETICS\ IMPLEMENTATION\ 1. Assess patient's intake of other drugs that may\ cause dangerous drug interaction\ 2. Emphasize that this is given on a short term\ basis Nursing Process and the\ ANTIEMETICS\ IMPLEMENTATION\ 4. Protect from sun exposure\ ϒ Sunscreens\ ϒ Protective covering\ 5. Provide health teaching Nursing Process and the\ ANTIEMETICS\ EVALUATION\ 1. Monitor for the drug effectiveness\ Relief of nausea and vomiting\ 2. Monitor for adverse effects\ 3. Evaluate effectiveness of comfort measures and\ teaching plan Renal Pharmacology\ Drugs affecting the Kidney Outline of review\ Recall the anatomy of the urinary system\ Recall the physiology of the urinary system\ Review- drugs of the following categories:\ ϒ 1. Diuretics\ ϒ 2. Drug for BPH  Diuretics\ Agents that increase the amount\ of urine produced by the kidneys Classes of Diuretics\ Five major classes\ 1. Thiazides and thiazide-like\ 2. Loop diuretics\ 3. Potassium-sparing\ 4. Carbonic anhydrase inhibitors\ 5. Osmotic diuretics General indications for the use of the\ diuretics\ Treatment of edema\ ϒUrine output will increase and\ excess fluid is flushed out of the\ body General indications for the use of\ the diuretics\ Treatment of CHF\ ϒThe sodium loss in the kidney is\ associated with water loss General indications for the use of\ the diuretics\ Treatment of Hypertension\ ϒDiuretics will decrease the blood\ volume and serum sodium General indications for the use of\ the diuretics\ Treatment of Glaucoma\ ϒDiuretics will provide osmotic pull\ to remove some of the fluid from\ the eye to decrease the IOP Time of administration of the\ diuretics\ Usually in the morning!! Thiazides\ Prototype: Hydrochlorothiazide\ 1. Bendroflumethiazide\ 2. Benthiazide\ 3. Chlorothiazide (Diuril)\ 4. Hydroflumethiazide\ 5. Methylclothiazide\ 6. Trichlormethiazide Thiazide-like\ 1. Indapamide\ 2. Quinethazone\ 3. Metolazone\ 4. Chlorthalidone Thiazides\ Pharmacodynamics\ These drugs BLOCK the chloride pump\ This will keep the Chloride and Sodium in the distal\ tubule to be excreted into the urine\ Potassium is also\ flushed out!! Thiazide\ Special Pharmacodynamics: Side effects\ ϒ Hypokalemia\ ϒ DECREASED calcium excretion◊ hypercalcemia\ ϒ DECREASED uric acid secretion◊ hyperuricemia\ ϒ Hyperglycemia Loop Diuretics\ Prototype: Furosemide\ 1. Bumetanide\ 2. Ethacrynic acid\ 3. Torsemide Loop Diuretics\ Pharmacodynamics\ High-ceiling diuretics\ BLOCK the chloride pump in the ascending loop of\ Henle\ SODIUM and CHLORIDE reabsorption is prevented\ Potassium is also excreted together with Na and Cl Loop Diuretics\ Special Pharmacodynamics: side-effects\ ϒ Hypokalemia\ ϒ Bicarbonate is lost in the urine\ ϒ INCREASED calcium excretion◊ Hypocalcemia\ ϒ Ototoxicity- due to the electrolyte imbalances Potassium sparing diuretics\ Prototype: Spironolactone\ 1. Amiloride\ 2. Triamterene Potassium sparing diuretics\ Pharmacodynamics\ Spironolactone is an ALDOSTERONE antagonist\ Triamterene and Amiloride BLOCK the potassium\ secretion in the distal tubule\ Diuretic effect is achieved by the sodium loss to\ offset potassium retention Potassium sparing diuretics\ Pharmacokinetics: Side effects\ ϒ HYPERkalemia!\ ϒ Avoid high potassium foods:\ ′ Bananas\ ′ Potatoes\ ′ Spinach\ ′ Broccoli\ ′ Nuts\ ′ Prunes\ ′ Tomatoes\ ′ Oranges\ ′ Peaches Osmotic Diuretics\ Prototype: Mannitol\ 1. Glycerin\ 2. Isosorbide\ 3. Urea Osmotic Diuretics\ Pharmacodynamics\ Mannitol is a sugar not well absorbed in the nephron◊ osmotic pull of water◊ diuresis  Osmotic Diuretics\ Pharmacokinetics: side effects\ ϒ Sudden hypovolemia\ Important for the nurse to warm the solution to allow\ the crystals to DISSOLVE in the bottle!\ A.A. TENORIO, RN, MAN, MAEd 27 Carbonic Anhydrase Inhibitors\ Prototype: Acetazolamide\ 1. Methazolamide Carbonic Anhydrase Inhibitors\ Pharmacodynamics\ Carbonic Anhydrase forms sodium bicarbonate\ BLOCK of the enzyme results to slow movement of\ hydrogen and bicarbonate into the tubules\ plus sodium is lost in the urine Carbonic Anhydrase Inhibitors\ Pharmacokinetics: side effects\ ϒ Metabolic ACIDOSIS happens when bicarbonate is lost\ ϒ Hypokalemia The Nursing Process and the\ diuretics\ ASSESSMENT\ Assess the REASON why the drug is given:\ \_\_\_\_\_\_\ \_\_\_\_\_\_\ \_\_\_\_\_\_\ \_\_\_\_\_\_ The Nursing Process and the\ diuretics\ ASSESSMENT\ The nurse must elicit history of allergy to the drugs\ ϒ Allergy to sulfonamides may contraindicate the use of\ thiazides\ Assess fluid and electrolyte balance\ Assess other conditions like gout, diabetes,\ pregnancy and lactation The Nursing Process and the\ diuretics\ ASSESSMENT\ Physical assessment\ ϒ Vital signs\ ϒ Special electrolyte and laboratory examination\ Assess symptom of body weakness which may\ indicate hypokalemia The Nursing Process and the\ diuretics\ Nursing Diagnosis\ ϒ Fluid volume deficit related to diuretic effect\ ϒ Alteration in urinary pattern\ ϒ Potential for injury (ototoxocity, hypotension)\ ϒ Knowledge deficit The Nursing Process and the\ diuretics\ IMPLEMENTATION\ Administer IV drug slowly\ Safety precaution for dizziness/hypotension\ Provide potassium RICH foods for most diuretics,\ with the exception of spironolactone\ Provide skin care, oral care and urinary care The Nursing Process and the\ diuretics\ IMPLEMENTATION\ Monitor DAILY WEIGHT- to evaluate the\ effectiveness of the therapy\ Monitor urine output, cardiac rhythm. Serum\ electrolytes\ ADMINISTER in the MORNING!\ Administer with FOOD! The Nursing Process and the\ diuretics\ EVALUATION: for effectiveness of therapy\ Weight loss\ Increased urine output\ Resolution of edema\ Decreased congestion\ Normal BP Hematologic Drugs Hematologic drugs\ There are numerous agents utilized to maintain, preserve\ and restore circulation. The three important\ dysfunction of blood are thrombosis, bleeding and\ anemia are commonly treated with various agents. The\ common ones that nurses must REVIEW are the:\ 1. Anticoagulants\ 2. Antilipedemics\ 3. Antiplatelets (antithombotics)\ 4. Thrombolytics\ 5. Anti-anemics or Hematinics\ 6. Drugs to treat bleeding The Anti-Coagulants\ The anticoagulants interfere with the coagulation process\ by interfering with the clotting cascade and thrombin\ formation. These agents are used to inhibit clot\ formation, but they do NOT dissolve existing clots.\ The Anticoagulants commonly used are:\ Heparin\ Warfarin (Coumadin)\ Dicumarol\ Anisindione (Miradon) Heparins\ These are anticoagulants given orally or\ parenterally- SQ and IV.\ Heparin is naturally found in the human liver that\ normally prevents clot formation.\ Heparin is strongly acidic because of the presence\ of sulfate and carboxylic acid groups in the\ heparin chain. Heparin\ The mechanism of action of Heparin\ Heparin (Liquamen Sodium) acts prophylactically to\ prevent the formation of blood clots in the\ vasculature.\ It combines with ANTITHROMBIN III, a substance in our\ blood sometimes called heparin factor that inactivates\ THROMBIN.\ By inhibiting the action of thrombin, conversion of\ fibrinogen to fibrin does not occur and the formation\ of a fibrin clot is prevented Heparins\ Clinical Indications of Heparins\ deep vein thrombosis\ pulmonary embolism\ coronary thrombosis,\ patients with artificial heart valves and stroke\ patients Heparins\ Contraindications of heparin\ Anticoagulants are not given to patients with bleeding\ disorders, peptic ulcers and patients who underwent\ recent eye/brain/spinal surgery.\ It is NOT given to patients with severe liver and renal\ disease, hemophilia, and CVA.\ Heparin is a large protein molecule that cannot pass\ through the placenta easily and can be given to\ pregnant women Heparins\ Pharmacokinetics: the Adverse Effects of Heparin\ INCREASES the clotting time and also DECREASES the\ platelet count. In this regard, monitoring of the\ aPTT/PTT (N= 20-30 seconds) and platelet count is\ required.\ Hematologic effects: increased bleeding,\ thrombocytopenia\ Skin-itching and burning\ Hypersensitivity reactions like chills, fever, urticaria or\ anaphylaxis can occur since heparin is obtained from\ animal sources.\ Life threatening adverse effect is Hemorrhage Heparins\ The Nursing process and Heparin\ Assessment\ Patient history\ Physical examination- the nurse obtains baseline\ vital signs and physical assessment.\ She must obtain laboratory results of the\ complete blood count, platelet count and\ activated partial thromboplastin time (aPTT),\ and clotting time. Heparins\ IMPLEMENTATION:\ Monitor the aPTT closely (it should be 1.5-2.5\ times normal value)\ Monitor vital signs and hematological status\ regularly.\ Monitor signs of bleeding- hematuria, epistaxis,\ ecchymoses, Hypotension and occult blood in\ stool\ Have available ANTIDOTE for heparin-\ PROTAMIME SULFATE Heparins\ IMPLEMENTATION:\ Instruct the client not to use any over the counter drug\ without notifying the physician\ Administer heparin subcutaneously in the abdominal\ region, using a 25-28-gauge needle at a 90-degree angle.\ DO NOT MASSAGE OR RUB THE AREA as this may cause\ bruising.\ Advise patient not to smoke, use electric razors to\ shave, use soft toothbrush and control sudden\ hemorrhage by direct pressure for 5-10 minutes.\ Provide gently skin and oral care Heparins\ Evaluation\ Monitor the effectiveness of the medication:\ ϒ Decreased formation of clot\ ϒ PTT is 2x the normal The Oral Anticoagulants\ There are three commonly used oral\ anticoagulant agents in the hospital\ Warfarin- most commonly used, synthesized\ from dicumarol\ Dicumarol\ Anisindone The Oral Anticoagulants\ Pharmacodynamics: the mechanism of Action\ of the Oral agents\ These agents INHIBIT the liver synthesis of\ the Vitamin K clotting factors -- factors II, VII,\ IX, and X The Oral Anticoagulants\ Clinical indications of oral anticoagulants\ These drugs are used to prevent blood\ clotting in patients with thrombophlebitis\ pulmonary embolism and embolism from\ atrial fibrillation.\ Because Warfarin crosses the placental\ barrier, it is NOT given to pregnant mothers The Oral Anticoagulants\ Contraindications and precautions\ Oral anti-coagulants are NOT given to\ patients with bleeding disorders, peptic\ ulcers, severe renal/liver diseases,\ hemophilia, CVA blood dyscrasias and\ eclampsia.\ It is NOT given to pregnant mothers because\ it is teratogenic and can cause abortion The Oral Anticoagulants\ Pharmacokinetics:\ Oral anticoagulants prolong the clotting time and are\ monitored by the Prothrombine Time (PT- average of 9-\ 12 seconds). This is usually performed before\ administering the next dose. The PT level should be\ 1.5-2 times the reference value to be therapeutic.\ The normal INR(international normalized ratio) is 1-2. If\ the patient is on oral anticoagulant therapy, the INR is\ maintained at an INR of 2.0-3.0. If the INR is below the\ recommended range, warfarin is increased. If it is above\ the recommended range, warfarin should be reduced. The Oral Anticoagulants\ Pharmacokinetics: the Adverse Effects of\ Warfarin\ ϒ Hematologic effects: increased bleeding,\ thrombocytopenia\ ϒ Anorexia, nausea, vomiting, diarrhea,\ abdominal cramps, rash and fever.\ ϒ Alopecia, bone marrow depression, and\ dermatitis.\ ϒ Life threatening adverse effect is Hemorrhage The Oral Anticoagulants\ The Nursing process and Warfarin\ Assessment\ Patient history-. The nurse determines the\ current medications taken, PREGNANCY, and\ history of recent surgery.\ Physical examination- the nurse obtains baseline\ vital signs and physical assessment.\ laboratory results of the complete blood count,\ platelet count and Prothrombin time, INR and\ clotting time The Oral Anticoagulants\ Implementation\ Monitor vital signs and hematological status\ Monitor signs of bleeding- hematuria, epistaxis,\ black tarry stools, echymoses, Hypotension and\ occult blood in stool\ Have available ANTIDOTE for warfarin- VITAMIN\ K or phytomenadione. The Oral Anticoagulants\ Implementation\ Advise patient not to smoke, use electric razors\ to shave, use soft toothbrush and control sudden\ hemorrhage by direct pressure for 5-10 minutes.\ Provide gently skin and oral care.\ Instruct the patient to avoid foods high in\ vitamin K like spinach, nuts The Oral Anticoagulants\ Evaluation\ Monitor the effectiveness of the medication\ ϒ Decreased formation of blood clots\ Check the PT and INR\ ϒ Should be 2x the normal Anti-platelets\ These are agents decrease the formation of the platelet\ plug by decreasing the responsiveness of the platelets\ to various stimuli that would cause them to stick and\ combine together on a vessel wall\ ϒ Aspirin\ ϒ Dipyridamole\ ϒ Sulfinpyrazone\ ϒ Ticlopidine\ ϒ Clopidogrel\ ϒ Glycoprotein receptor antagonists\ ′ Abciximab\ ′ Eptifibatide\ ′ Tirofiban Anti-platelets\ The mechanism of action of platelet\ inhibitors\ These agents INHIBIT the aggregation of\ platelets in the clotting process by blocking\ receptor sites on the platelet membrane,\ preventing platelet-to-platelet interaction,\ thereby prolonging the bleeding time Anti-platelets\ Clinical indications\ Prevention of myocardial infarction and\ stroke\ Prevention of a repeat myocardial infarction\ Prevention of stroke for those with transient\ ischemic attack\ In patients with graft to maintain its patency Anti-platelets\ Pharmacodynamics: the adverse effects of\ Antiplatelets\ Bleeding is the most common side effect\ GIT- gum bleeding, gastric bleeding, tarry\ stools\ CNS- headache, dizziness and weakness\ Skin- petechiae, bruising, allergy\ ASPIRIN toxicity: tinnitus Anti-platelets\ Nursing considerations\ Determine if the patient is allergic or sensitive\ to the medications\ Monitor closely the vital signs and bleeding\ areas\ Instruct the patient to take drug with food\ Monitor the bleeding time, clotting time and\ platelet count Anti-platelets\ Nursing considerations\ Suggest safety measures including the use of\ an electric razor and avoidance of contact\ sports.\ Provide increased precautions against\ bleeding during invasive procedures.\ Use pressure dressings and ice to decrease\ excessive blood loss.\ Monitor for tinnitus The Thrombolytics\ These thrombolytic agents are used to activate the\ natural anticlotting fibrinolytic mechanism to convert\ plasminogen to plasmin, which destroys and breaks\ down the fibrin threads in the blood clot\ (FIBRINOLYSIS). The result is clot disintegration.\ The commonly used thrombolytics "\-\--ase"\ Streptokinase\ Urokinase\ Tissue plasminogen activator (t-PA) or alteplase\ Anistreplase\ Reteplase The Thrombolytics\ The mechanisms of actions of each agent\ Streptokinase and urokinase are ENZYMES that act\ SYSTEMICALLY to dissolve the blood clots by activating\ plasminogen to plasmin The Thrombolytics\ Clinical indications of thrombolytics\ Myocardial infarction\ Pulmonary embolism\ Thromboemboilic stroke\ Peripheral arterial thrombosis and\ to open clotted IV catheters. The Thrombolytics\ Pharmacokinetics: The adverse effects of\ Streptokinase\ CVS- Hypotension and dysrhythmias (usually\ upon reperfusion of the heart)\ Hematological: increased bleeding- the most\ common effect.\ Headache, nausea, flush, rash and fever\ Allergic reaction- especially steptokinase and\ urokinase\ Major adverse effect- hemorrhage The Thrombolytics\ Implementation.\ Monitor signs of active bleeding from mouth and\ rectum bleeding- hematuria, epistaxis, echymoses\ Have available ANTIDOTE for thrombolytics:\ AMINOCAPROIC ACID!\ Have available blood for emergency use.\ Advise patient not to smoke, use electric razors to\ shave, use soft toothbrush and control sudden\ hemorrhage by direct pressure for 5-10 minutes.\ Provide gently skin and oral care. As much as possible,\ avoid frequent venipuncture. The Thrombolytics\ Evaluation\ Monitor the effectiveness of the medication\ ϒ Clot lysis The Agents to treat bleeding\ Aminocaproic acid and tranexamic acid\ ϒ These are fibrin stabilizers that maintain or stabilize the\ clot in the bleeding vessels The Agents to treat bleeding\ Protamine sulfate\ ϒ This agent antagonizes the anticoagulant effects of\ heparin. It is derived from fish testis and is high in\ arginine content.\ ϒ The positive charge interacts with the negative charge of\ heparin to form a stable inactive complex. The Agents to treat bleeding\ Vitamin K\ ϒ Vitamin K is given to antagonize the effects of the oral\ anticoagulants.\ ϒ The response to Vitamin K is slow, requiring about 24\ hours\ ϒ thus, if immediate hemostasis or bleeding control is\ required, fresh frozen plasma should be ordered by the\ physician Antihyperlipidemics-These drugs target the\ problem of elevated serum lipids\ Resins and bile acid\ sequestrants\ ϒ Cholestyramine\ ϒ Colestipol\ Fibric Acid\ Derivatives\ ϒ Clofibrate\ ϒ Gemfibrozil\ ϒ Fenofibrate\ HMG CoA reductase\ inhibitors= "statins"\ ϒ Atorvastatin\ ϒ Cerivastatin\ ϒ Fluvastatin\ ϒ Lovastatin\ ϒ Pravastatin\ ϒ Simvastatin\ Nicotinic acid\ Probucol Statins\ Pharmacodynamics: The mechanism of action of\ the Statins\ These agents INHIBIT the enzyme HMG CoA\ reductase in the synthesis of cholesterol.\ By inhibiting the important enzyme in\ cholesterol production in the liver, the statins\ decrease the plasma concentration of\ cholesterol and lower the LDL level with slight\ increase in the HDL level. Statins\ Therapeutic indications\ These agents are given to patients with\ CORONARY ARTERY DISEASE and\ hyperlipidemia, hypercholesterolemia\ These statins are very effective in all types of\ hyperlipidemias The antianemics: Iron\ preparations and Epoetin\ Iron preparations\ Iron is important for hemoglobin formation.\ The iron preparations are:\ Ferrous sulfate\ Ferrous fumarate\ Ferrous gluconate The antianemics: Iron\ preparations and Epoetin\ Side-effects:\ GIT- constipation (usually), diarrhea, vomiting,\ epigastric pain, gastric ulceration and\ darkening of stools.\ Liquid preparation can stain the teeth, and\ injectable iron can cause tissue discoloration\ Other- dizziness The antianemics: Iron\ preparations and Epoetin\ Drug-Drug interaction\ Tetracyclines and penicillamine- combine with iron\ preparations and render the iron unabsorbable.\ Antacids and cimetidine- decrease iron absorption and\ effects\ Foods can impair iron absorption but they should be\ taken with iron to reduce GI discomfort.\ Milk containing foods, coffee, tea and eggs are NOT\ given with iron because they delay iron absorption The antianemics: Iron\ preparations and Epoetin\ Implementation\ Encourage the patient to eat iron-rich foods like liver, lean\ meat, egg yolk, dried beans, green leafy vegetables.\ Administer iron preparations orally with foods to decrease GI\ discomfort.\ If increased absorption is necessary, administer IN BETWEEN\ meals with full glass of water or juice.\ It is best to offer citrus juices because the vitamin C\ content can increase iron absorption. The antianemics: Iron\ preparations and Epoetin\ Implementation\ Instruct the patient to swallow the whole tablet and remain\ upright for 30 minutes to prevent esophageal corrosion from\ reflux.\ DO NOT administer iron together with or within 1 hour of\ ingesting tetracyclines, antacids, milk and milk-containing\ products.\ Advise clients to increase fluid intake and consume fiber rich\ foods if constipation becomes a problem The antianemics: Iron\ preparations and Epoetin\ Implementation\ Warn the patient of possible iron poisoning if tablets are left within\ child's reach. Emphasize that the therapeutic effect of iron therapy\ may not be apparent until several weeks.\ If injecting a parenteral iron preparation, inject DEEP IM utilizing\ the Z-track method to avoid leakage into the subcutaneous\ tissues and skin.\ Offer straw if giving liquid iron preparation to avoid staining the\ teeth.\ To prevent undue alarm, instruct the patient that the stools may\ turn black or dark green. This is a harmless occurrence. The antianemics: Iron\ preparations and Epoetin\ Evaluation\ The nurse evaluates the effectiveness of the\ drug therapy by determining that the client\ is not fatigued, with absence of pallor, and\ with hemoglobin results within desired range Erythropoietin\ The mechanism of action of epoetin alfa\ (Epogen)\ This drug acts like the natural glycoprotein\ erythropoietin to stimulate the production of RBC in\ the bone marrow Erythropoietin\ Clinical indications\ It is given SUBCUTANEOUSLY or INTRAVENOUSLY for\ the treatment of anemia associated with renal\ failure or for patients on dialysis.\ It is also used in patients for blood transfusion to\ decrease the need for blood in surgical patients Erythropoietin\ Pharmacodynamics: the adverse effects of epoetin\ alfa\ CNS- headache, fatigue, asthenia, dizziness and\ seizures- these are due to the cellular response to\ the glycoprotein.\ GIT- nausea, vomiting and diarrhea\ CVS- hypertension, edema and chest pain due to\ increase RBC number Erythropoietin\ Implementation\ Administer the drug SC or IV usually 3 times per week.\ Monitor the IV access line if given IV. Do not mix with\ other solutions\ Determine periodically the level of hematocrit and iron\ stores during therapy. If patient does not respond to the\ drug, reevaluate the cause of anemia Erythropoietin\ Implementation\ Maintain seizure precaution on stand by as seizure can\ occur.\ Provide comfort measures like small frequent feedings\ and pain medications for headache.\ Provide thorough health teaching: need for lifetime\ injection Erythropoietin\ Evaluation\ Monitor patient response to the drug= increased\ hemoglobin