Pharmacology Notes PDF

Pharmacology …for the NCLEX! © 2010- 2024 USMLE Galaxy LLC  How would you rate your current pharmacology knowledge? Click Present with Slido or install our Chrome extension to activate this ⓘ poll while presenting. Drugs for Pain Morphine Therapeutic cla...

Pharmacology …for the NCLEX! © 2010- 2024 USMLE Galaxy LLC  How would you rate your current pharmacology knowledge? Click Present with Slido or install our Chrome extension to activate this ⓘ poll while presenting. Drugs for Pain Morphine Therapeutic class: Opioid analgesic Indication: Pain Action: Binds to opiate receptors in the CNS and alters perception of pain while producing a general depression of the CNS. Nursing Considerations: Common side effect: constipation CNS depressant ○ Decreased respiration, decreased heart rate, etc. ○ Monitor respiratory rate Antidote = naloxone Ibuprofen Indication: Inflammation (RA, OA, bursitis), mild to moderate pain, fever Action: Block prostaglandin which causes inflammation, pain, and fever. Nursing Considerations: Side effects: Gastric ulceration Bleeding ○ Typically avoided in trauma and surgical clients Renal impairment ○ Monitor BUN/Cr Acetylsalicylic Acid (Aspirin) Therapeutic class: Antipyretic, non-opioid analgesic Indication: Pain (best for joint, muscle, and head pain. Very common in arthritis), fever, protects against thrombotic disorders (MI, stroke prevention). Action: Inhibits the production of prostaglandins which leads to a reduction of fever and inflammation, decreases platelet aggregation leading to a decrease in ischemic diseases Nursing Considerations: Risk of bleeding ○ Don’t administer with other anticoagulants ○ D/c 5-7 days prior to surgery Caution with pediatric clients ○ Reye’s syndrome can occur with viral infections ○ Only time it is commonly used in peds is in Kawasaki's disease Salicylism ○ ASA toxicity ○ S/S: tinnitus, sweating, headache, dizziness, metabolic acidosis Acetaminophen Therapeutic class: antipyretic, analgesic *No anti-inflammatory properties Indication: Pain, fever Action: Inhibit the synthesis of prostaglandins which play a role in transmission of pain signals and fever response Nursing Considerations: Overdose, or taking acetaminophen with alcohol, causes a toxic metabolite to build up. ○ Can cause major liver damage Max daily dose = 4g ○ For long term use - the maximum daily dose is only 3 grams per day!! Antidote = n-acetylcysteine Quiz Time  What are the major adverse effects associated with long-term use of NSAIDs? Click Present with Slido or install our Chrome extension to activate this ⓘ poll while presenting.  Answer: Major adverse effects associated with long-term use of NSAIDs includes: GI ulcers, bleeding, renal impairment, increased risk of cardiac events and increased bleeding risk.  What are the side effects of opioid use? Select all that apply. Click Present with Slido or install our Chrome extension to activate this ⓘ poll while presenting.  What condition can be caused by administering acetylsalicylic acid (Aspirin) to pediatric clients? Click Present with Slido or install our Chrome extension to activate this ⓘ poll while presenting.  Answer: Reye’s Syndrome. This can occur in children who are given Aspirin at the same time as a viral infection like a cold or flu. This condition causes swelling in the liver and brain. The Cardiovascular System Pharmacology Antihypertensives *Diuretics *ACE inhibitors ○ Captopril ○ Enalapril ○ Lisinopril *Angiotensin II Receptor Blockers ○ Losartan, olmesartan Calcium Channel Blockers ○ Amlodipine ○ Nifedipine ○ Verapamil Arterial and Venous Dilators ○ Hydralazine ○ Nitroglycerin Beta Blockers ○ Atenolol, metoprolol, esmolol, propranolol Angiotensin-Converting Enzyme Inhibitors (ACEs) Names: Enalapril, lisinopril, captopril, fosinopril, moexipril, perindopril…. Indication: Hypertension, CHF Action: Blocks conversion of angiotensin I to angiotensin II, increases renin levels and decreases aldosterone leading to vasodilation Nursing Considerations: Can cause a dry cough - should be discontinued if it does Monitor BP Contraindicated during pregnancy Angiotensin II Receptor Blockers (ARBs) Names: Losartan, olmesartan, valsartan, irbesartan, azilsartan, candesartan… Indication: hypertension, DM neuropathy, CHF Action: inhibits vasoconstrictive properties of angiotensin II Nursing Considerations: Monitor BP Monitor fluid levels Monitor renal and liver status Contraindicated during pregnancy Calcium Channel Blockers: Act on the heart and the blood vessels Names: Verapamil and Diltiazem Indication: Hypertension, angina, dysrhythmias (a-fib/flutter) Action: Blocks calcium channels in the heart and blood vessels. In the blood vessels- cause vasodilation (decreasing BP), and increased coronary perfusion. In the heart - can slow the heart rate, slow AV node conduction, and decrease the force of contraction. Nursing Considerations: Side effects: ○ Constipation → Increase dietary fiber/fluid intake ○ Dizziness, facial flushing, HA, edema in ankles and feet Interactions: ○ Enhances cardiac suppression of digoxin and β-blockers. If given together, monitor closely! ○ Caution in HF ○ DO NOT GIVE in AV block Calcium Channel Blockers: Act ONLY on the blood vessels Names: Nifedipine, amlodipine, felodipine, isradipine, nicardipine, nimodipine Indication: Hypertension, angina Action: Blocks calcium channels in the blood vessels; causes vasodilation (decreasing BP), and increased coronary perfusion Nursing Considerations: Side effects: ○ Dizziness, facial flushing, HA, edema in ankles and feet ○ Gingival hyperplasia → use a soft bristle toothbrush and have good dental care ○ *Reflex tachycardia Can combine with a β-blocker to prevent this side effect *No constipation *Preferable for clients with HF or AV block Interacts with grapefruit juice Venodilators Arterial Names: Hydralazine, Minoxidil Indication: Hypertension, hypertensive crisis, HF Action: Relaxes arterial smooth muscle to promote dilation. Arterial dilation decreases BP (afterload), which increases CO. Nursing Considerations: Reflex tachycardia can occur → can combine with a BB to reduce! Hypotension can trigger volume expansion → can combine with a diuretic to reduce! Long term use can cause SLE–like symptoms - should be d/c’d Increased fall risk Venodilators Arterial and Venous Names: Nitrates- nitroglycerin, nitroprusside Indication: Hypertension, hypertensive crisis, angina Action: Venous dilation reduces venous return to heart (preload), causing a decrease in ventricular contraction. Decreases the workload of the heart! Arterial dilation decreases BP (afterload), which increases CO. Nursing Considerations: Headache is an expected side effect Other common side effects: dizziness, flushing, orthostatic hypotension ○ Increased fall risk Quiz Time  The nurse is providing discharge instructions to a client with accelerated hypertension who has been newly started on nifedipine. His home medications including calcium supplements for osteoporosis, omeprazole for heartburn, furosemide, and lisinopril. Which statement(s) by the client demonstrates the need for additional teaching regarding nifedipine? Select all that apply. Click Present with Slido or install our Chrome extension to activate this ⓘ poll while presenting. NCLEX Question The nurse is providing discharge instructions to a client with accelerated hypertension who has been newly started on Nifedipine. His home medications include calcium supplements for osteoporosis, omeprazole for heartburn, furosemide, and lisinopril. Which statement(s) by the client demonstrates the need for additional teaching regarding Nifedipine? Select all that apply. a. “My gums may swell because of this medication.” b. “I will avoid getting up too quickly from sitting or lying position.” c. “I will stop taking calcium supplements since they may negate the effects of Nifedipine.” d. “It is highly likely that I will get constipated from this drug” e. “If I get cough and tongue swelling, I will hold Nifedipine” Answer: C, D, and E A is incorrect. Gum/gingival hyperplasia is a common side effect with extended-standing use of Nifedipine. B is incorrect. The client should avoid getting up too quickly from sitting or lying position. Because of peripheral vasodilation, Nifedipine causes postural or orthostatic hypotension. So, the client should be aware of getting up slowly from the lying/sitting position so they do not become dizzy. C is correct. The client should not stop taking their calcium supplements. There is no evidence to say oral calcium supplements will reduce the effects of CCBs. Also, this client needs calcium supplements for his osteoporosis. Therefore, this does not reflect correct understanding by the client and needs additional teaching. D is correct. There is a less than 2% chance that the person can get constipated from Nifedipine, so it is not true that the client is highly likely to get constipated from Nifedipine. Therefore, this statement does not reflect correct understanding by the client and needs additional teaching. E is correct. The client should not hold Nifedipine if they get cough and tongue swelling. Cough and tongue swelling (Angioedema) are common side effects seen with ACE inhibitors, not with CCBs. The client is also on Lisinopril (ACEI), which may lead to this side effect, so the nurse will need to explain this to the client.  Which antihypertensive drug class is often used as an alternative treatment for patients who cannot tolerate ACE Inhibitors due to a dry cough? Click Present with Slido or install our Chrome extension to activate this ⓘ poll while presenting.  Answer: ARBs. These have a similar mechanism of action as ACE Inhibitors, but have a significantly lower risk of dry cough or angioedema. Antiarrhythmics Class 1 = Sodium channel blockers: Anticholinergic and antiarrhythmic: Procainamide Lidocaine Atropine → used for bradycardia Class 2 = Beta blockers: Misc: Propranolol Esmolol Adenosine Digoxin Class 3 = Potassium Channel blockers: Amiodarone Sotalol Ibutilide Class 4 = Calcium Channel Blockers: Diltiazem Verapamil Atropine Therapeutic class: Antiarrhythmic; anticholinergic Indication: excessive secretions, sinus bradycardia, heart block Action: Inhibition of acetylcholine, increasing the HR, causing bronchodilation, and decreasing secretions Nursing Considerations: Monitor for urinary retention and constipation Avoid in clients with glaucoma Adenosine Therapeutic class: Antiarrhythmic Indication: SVT Action: Slows conduction through the AV node, interrupts re-entry pathways through AV node, restoring normal sinus rhythm Nursing Considerations: There will be a period of asystole after administration Warn the client- it will feel like someone kicked them in the chest! Warn the family - they will flatline on the monitor! Rapid push - or it will not work. Use with extreme caution in asthmatics Digoxin Therapeutic class: Cardiac glycoside Indication: Heart failure, a-fib, a-flutter, CHF, cardiogenic shock Action: Increases contractility (how strong the heart pumps), and decreases the rate (how fast the heart beats). Acts on the cellular sodium-potassium ATPase, making the heart more efficient! Quiz Time  Which of the following are indications for atropine use? Select All That Apply. Click Present with Slido or install our Chrome extension to activate this ⓘ poll while presenting.  Answer: Sinus bradycardia, excessive secretions and heart blocks. This drug works by inhibiting acetylcholine, which increases the HR and decreases secretions.  Why should caution be taken with clients with diabetes who are taking Beta Blockers? Click Present with Slido or install our Chrome extension to activate this ⓘ poll while presenting.  Answer: Beta Blockers can mask the symptoms of hypoglycemia (tachycardia) in clients with diabetes.  What electrolyte imbalances increase the risk for digoxin toxicity? Select all that apply. Click Present with Slido or install our Chrome extension to activate this ⓘ poll while presenting. Answer: Hypokalemia, hypomagnesemia, and hypercalcemia. The Respiratory System Pharmacology Respiratory System Medications Antihistamines ○ H₁ Antagonists Anti-inflammatory drugs ○ Glucocorticoids ○ Leukotriene receptor antagonists ○ Monoclonal antibodies Bronchodilators ○ β₂-adrenergic agonists Short acting Long acting ○ Methylxanthines ○ Anticholinergics H₁ Antagonists Names: Diphenhydramine, chlorpheniramine,, clemastine, promethazine, hydroxyzine, loratadine, fexofenadine… Indication: Allergy, anaphylaxis, sedation Action: Blocks H₁ receptors: decreases flushing, edema, secretions, itching, and pain Nursing Considerations: Monitor for drowsiness Anticholinergic effects Possible paradoxical excitation (also seen in OD) Education: ○ No alcohol ○ Take at night and avoid driving etc. ○ Take with food to reduce GI side effects Glucocorticoids Inhaled: Budesonide, Ciclesonide, Flunisolide, Fluticasone PO: Methylprednisolone, Prednisolone, Prednisone Indication: Asthma, COPD Action: Decreases inflammatory mediators, infiltration of inflammatory cells, and vascular permeability (to decrease edema). Suppresses the inflammatory response! Nursing Considerations: Inhaled: ○ Can cause oral candidiasis → rinse/gargle after use! ○ Not for acute attack: take on a schedule. Take SABA 1st! (5 min before) Oral ○ Systemic therapy used in acute attacks. Best to use < 10 days. ○ Long term use - risk of: adrenal suppression, osteoporosis, hyperglycemia, PUD, and growth suppression NEVER d/c abruptly! Stress dose needed in times of high stress if used chronically Leukotriene receptor antagonists Names: Zafirlukast, montelukast Indication: Asthma Action: Suppress leukotrienes: decrease smooth muscle constriction, bronchoconstriction, edema, and mucus secretion Nursing Considerations: Long-term control; cannot abort ongoing attack Can cause liver injury → monitor ALT Rare adverse effects: Neuropsychiatric effects and Churg-Strauss Syndrome ○ If SI - need to change meds Bronchodilators β₂-adrenergic agonists Anticholinergics ○ Albuterol ○ Ipratropium ○ Levalbuterol ○ Tiotropium ○ Salmeterol ○ Umeclidinium ○ Arformoterol ○ Glycopyrronium bromide ○ Olodaterol ○ Aclidinium bromide Methylxanthines ○ Theophylline ○ Aminophylline β₂-adrenergic agonists Short acting (SABA): Albuterol, Levalbuterol, Long- Acting (LABA): Salmeterol, Arformoterol, Olodaterol, Formoterol Indication: Asthma, COPD Action: Binds to Beta2 adrenergic receptors in the airway leading to relaxation of the smooth muscles in the airways Nursing Considerations: Can cause tachycardia, angina, tremor Be very cautious when using in clients with heart disease (increases HR), diabetes (can mask s/s of hypoglycemia), or glaucoma (can increase IOP) When using 2 inhalers: use SABA 1st, ensure at least 1 min interval between Methylxanthines Names: Aminophylline, Theophylline Indication: Asthma (maintenance) Action: Relaxes bronchial smooth muscles leading to bronchodilation Nursing Considerations: Has a narrow therapeutic window ○ Monitor drug levels. If a dose is missed, do NOT double the next dose. ○ Toxicity: N/V/D, insomnia, restlessness, palpitations, dysrhythmias, convulsions Avoid caffeine - it intensifies the effects Avoid tobacco/marijana - increases theophylline clearance leading to ineffective levels Anticholinergics Names: Ipratropium, Tiotropium, Glycopyrronium bromide, Aclidinium bromide Indication: Asthma, COPD Action: Block muscarinic receptors in bronchi, leading to decreased bronchoconstriction Nursing Considerations: Can be used to abort an ongoing attack Available in combo products with SABAs (ex: Albuterol + Ipratropium) Monitor for anticholinergic side effects Asthma Medications Quiz Time  What effect does an antihistamine have on the lungs? Click Present with Slido or install our Chrome extension to activate this ⓘ poll while presenting. Answer: Bronchodilation and decreased mucus production.  True or false? When using two inhalers for the treatment of conditions like asthma and COPD, you should use the SABA second. Click Present with Slido or install our Chrome extension to activate this ⓘ poll while presenting.  Answer: False. You should always use the SABA (like albuterol) first. Also ensure that there is at least a minute pause between each inhaler.  Which of the following are quick relief medications for Asthma. Select all that apply. Click Present with Slido or install our Chrome extension to activate this ⓘ poll while presenting. Answer: Anticholinergics, SABAs The Nervous System Pharmacology Central Nervous System Drugs Anti-Parkinson Drugs Names: Levodopa, Levodopa/Carbidopa Carbidopa inhibits the breakdown of levodopa so it lasts longer! Indication: Parkinson’s disease Action: Increases dopamine synthesis resulting in more dopamine, and less motor symptoms in parkinson's disease Nursing Considerations: Full therapeutic response takes a few months to develop Beneficial effects wear off over time Side effect: nausea/vomiting. Take with low-fat, low protein foods. Can cause postural hypotension/dizziness - move slowly when changing positions Adverse effect: psychosis (visual hallucinations, vivid dreams, paranoid ideation) Cholinesterase inhibitors Names: Donepezil, rivastigmine, galantamine Indication: Alzheimer's, Dementia Action: Prevent breakdown of acetylcholine; increasing its’ bioavailability which results in better transmission in central cholinergic neurons. Causes improved memory, thought, and reasoning. Nursing Considerations: These medications do not cure AD or stop it’s progression - they improve symptoms in mild to moderate AD Cholinergic side effects, bronchoconstriction*, CV effects (bradycardia) *Caution in clients with asthma or COPD Anticonvulsants - Long Term Names: Phenytoin, fosphenytoin, carbamazepine, phenobarbital, valproic acid Indication: Seizures Action: Selectively inhibits sodium channels, suppressing action potentials in hyperactive neurons. Stops the ‘seizure-generating neurons’ activity - while leaving healthy neurons alone! Nursing Considerations: Phenytoin therapeutic level: 10-20 mcg/mL Side effect: gingival hyperplasia → Regular dental check-ups + Use soft bristle toothbrush Antacids can reduce the effect of phenytoin and should be avoided Serious pregnancy effects ○ Phenytoin is a known teratogen Interact with many drugs ○ No alcohol/other CNS depressants ○ Consult with HCP Anticonvulsants - Rapid Acting/Emergent Names: Lorazepam, diazepam Indication: Seizures Action: CNS depression Nursing Considerations: Monitor for respiratory depression Antidote - flumazenil Peripheral Nervous System Drugs  Peripheral: Sympathetic Nervous System Alpha Adrenergic Agonists Epinephrine, Norepinephrine, ephedrine, phenylephrine Indication: Cardiac arrest, shock, hypotension, control bleeding anaphylaxis | nasal decongestant Action: Activates the alpha receptors of the sympathetic nervous system → FIGHT OR FLIGHT Results in: vasoconstriction, pupil constriction Nursing Considerations: Adverse effects: ○ Hypertension, tachycardia angina, hyperglycemia, necrosis is drug extravasates Drug interactions ○ MAOIs ○ TCAs ○ Alpha or beta blockers Ephedrine/Phenylephrine - local effects of vasoconstriction used in nasal sprays for congestion Beta Adrenergic Agonists Epinephrine, Norepinephrine, Dopamine, dobutamine, Isoproterenol, *Albuterol Indication: AV block, cardiac arrest, shock, heart failure, *asthma, preterm labor Action: Activates the beta receptors- causing sympathetic nervous system stimulation → FIGHT OR FLIGHT. Results in: Beta 1: heart → increased HR Beta 2: lungs → bronchodilation Beta 2: uterus → uterine relaxation Nursing Considerations: Adverse effects: tachydysrhythmias, angina, hyperglycemia, necrosis if extravasation occurs Drug interactions: ○ MAOIs ○ TCAs ○ Beta blockers Alpha Adrenergic Antagonists Prazosin, Doxazosin, Terazosin, Tamsulosin, Alfuzosin, Silodosin, Phentolamine Indication: Hypertension, BPH, Raynaud’s disease, pheochromocytoma Action: Blocks activation of alpha receptors in the sympathetic nervous system - stops fight or flight resulting in: vasodilation, decreased BP Nursing Considerations: Adverse effects: hypotension, reflex tachycardia, nasal congestion ○ First dose effect: significant orthostatic hypotension with first dose. Take at bedtime! Not safe in children, pregnancy, or breastfeeding Beta Adrenergic Antagonists - Non-selective Propranolol, nadolol, pindolol, sotalol, timolol Indication: HTN, angina, dysrhythmias, MI Action: Blocks activation of beta ONE and TWO receptors in the sympathetic nervous system - stops fight or flight resulting in: decreased HR, decreased force of contraction, suppression of impulse conduction through the AV node (𝛃-1) AND bronchoconstriction, decreased gluconeogenesis (𝛃-2) Nursing Considerations: Adverse effects: ○ Bradycardia → Avoid if client is in SB or has an AV block ○ HF → Avoid in clients with HR (it decreases the CO!) ○ Bronchoconstriction → Extreme caution in asthmatics! ○ Hypoglycemia → Caution in diabetics! Warn them will mask typical symptoms of hypoglycemia! ○ Rebound cardiac excitation → never discontinue abruptly - taper off! ○ Depression → Caution in clients with mental health conditions Caution in clients with life threatening allergies (if on a BB, epi will be less effective if they have a reaction) Beta Adrenergic Antagonists - Selective Metoprolol, Acebutolol, Atenolol, Betaxolol, Bisoprolol, Esmolol, carvedilol, labetalol Indication: HRN, angina, HF, MI Action: Blocks activation of beta ONE receptors in the sympathetic nervous system - stops fight or flight resulting in: decreased HR, decreased force of contraction, suppression of impulse conduction through the AV node Nursing Considerations: Adverse effects: ○ Bradycardia → Avoid if client is in SB or has an AV block ○ Rebound cardiac excitation → never discontinue abruptly - taper off! *Safer for asthma! No 𝛃-2 action = no bronchoconstriction *Safer for diabetics! No 𝛃-2 action = no hypoglycemia Parasympathetic Nervous System Receptors: Muscarinic & Nicotinic Transmitter: Acetylcholine Increase activation: Cholinergic Decrease activation: Anticholinergic Cholinergics Muscarinic Agonists: Bethanechol, Cevimeline, Pilocarpine Cholinesterase Inhibitors: Pyridostigmine, neostigmine, physostigmine, edrophonium, rivastigmine Indication: Urinary retention, GERD, MG, Alzheimer's, Glaucoma Action: The neurotransmitter of the parasympathetic nervous system is acetylcholine. Cholinergic drugs stimulate cholinergic receptors or increase acetylcholine and therefore cause REST AND DIGEST: Increase GI secretions and motility, increase urination and urinary function, pupil constriction (miosis), decrease HR Nursing Considerations: Monitor for cholinergic side effects: increased secretions, increased urination, miosis, etc. Monitor for bradycardia Contraindications: Intestinal obstruction, urinary tract obstruction, asthma, hyperthyroidism, hypotension Education: take on an empty stomach Anticholinergics Muscarinic Antagonists: Atropine, scopolamine, ipratropium bromide, dicyclomine, oxybutynin, tolterodine Indication: Sinus bradycardia, AV block, eye exams, asthma, excessive secretions, intestinal hypertonicity, overactive bladder Action: Block acetylcholine in the parasympathetic nervous system thereby blocking REST AND DIGEST functions. Causes: increased HR, pupil dilation, bronchodilation, decreased secretions, sweating, GI motility, urinary retention Nursing Considerations: Adverse effects: ○ Increased IOP (→blurry vision/photophobia) - avoid in glaucoma! ○ Urinary retention → caution in BPH ○ Bronchial plugging → caution in asthma ○ Constipation, xerostomia, tachycardia, anhidrosis Contraindication: MG, glaucoma, urinary or intestinal obstruction, tachycardia The Gastrointestinal System Pharmacology Antiulcer agents H₂-antagonists ○ Famotidine ○ Cimetidine ○ Nizatidine Proton Pump Inhibitors ○ Omeprazole ○ Lansoprazole ○ Pantoprazole Antacids ○ Calcium carbonate (alka-seltzer, tums) ○ Magnesium hydroxide ○ Bismuth subsalicylate (Pepto-Bismol) GI protectant ○ Sucralfate H₂-antagonists Names: Cimetidine, famotidine, nizatidine, ranitidine Indications: Gastric and duodenal ulcers, GERD, Zollinger-Ellison syndrome, hypersecretion of stomach acid conditions, chronic NSAID/ASA use and GI distress Action: Block the release of histamine. Histamine is found in mast cells within GI mucosa and causes secretion of gastric acid and pepsin when it binds with H2 receptors in the mucosal parietal cells. When blocked, acid secretion is blocked. Nursing considerations: Monitor CBC and kidney function Can be given with meals Peak absorption of famotidine is within 2-3 hrs Famotidine is available OTC in lower strengths than prescription dosages. Teach clients to only take as directed and only for a short duration. Proton Pump Inhibitors Names: Omeprazole, pantoprazole, lansoprazole, rabeprazole Indication: GERD, ulcers Action: prevents the transport of H ions into the gastric lumen by binding to gastric parietal cells to decrease gastric acid production Nursing Considerations: Administer 30-60 minutes before meal Report black, tarry stools Mucosal Protectant Names: Sucralfate Indications: PUD, peptic esophagitis, NSAID/ASA induced GI damage Action: Promotes healing of ulcers by providing a barrier over them. It creates a paste when exposed to hydrochloric acid and binds to proteins that are excreted by damaged cells in ulcerated tissue. Nursing considerations: Take on an empty stomach 1 hour before meals or 2 hours after meals and at bedtime; often given up to 4 times a day Don’t give within 30 min of antacids as they can decrease the effectiveness of sucralfate Use caution giving antacids containing aluminum to clients with kidney failure due to aluminum toxicity Monitor blood sugar in diabetics as sucralfate contains sucrose Can decrease the bioavailability of warfarin, digoxin, phenytoin, levothyroxine, and several classes of ABX - separate these drugs from sucralfate for at least 2 hours Antiemetics Serotonin antagonists: ○ Ondansetron (Zofran) Dopamine Antagonists: ○ Promethazine ○ Chlorpromazine Antihistamines ○ Diphenhydramine (Benadryl) ○ Dimenhydrinate (Dramamine) Anticholinergics ○ Scopolamine: Patch form, place behind ear. Wash hands after touching. Do not rub eyes after touching the patch. Total Parenteral Nutrition Complications Big infection risk….. Scrub that hub! Wash your hands!! Gloves!!! ○ Bag and tubing is changed every 24 hours ○ Refrigerated until ready to hang Fluid overload ○ Daily weight ○ Check electrolytes Hyper OR hypoglycemia ○ Do not turn on or off suddenly If you run out of TPN give Dextrose 10% at the SAME rate the TPN was running ○ Titrate up when turning on and down when turning off ○ Check blood glucose levels every 4-6 hours Embolism Quiz Time  What are the key teaching points for PPIs? Click Present with Slido or install our Chrome extension to activate this ⓘ poll while presenting. Answer: PPIs must be dosed at least 30-60 minutes before eating. Clients should watch for black, tarry stools.  What EKGs changes can occur if IV ondansetron is pushed too fast? Select all that apply. Click Present with Slido or install our Chrome extension to activate this ⓘ poll while presenting. Answer: QT prolongation and VT.  If you unexpectedly run out of TPN, what IV solution should you give at the same rate? Click Present with Slido or install our Chrome extension to activate this ⓘ poll while presenting.  Answer: Dextrose 10% in Water should be given at the same rate. This will help prevent the complication of hypoglycemia. The Renal System Pharmacology Diuretics Osmotic diuretics ○ Mannitol Loop diuretics ○ Bumetanide ○ Furosemide ○ Torsemide Thiazide diuretics ○ Chlorothiazide ○ Hydrochlorothiazide Potassium sparing diuretics ○ Eplerenone ○ Spironolactone Loop Diuretics Names: Bumetanide, Furosemide, Torsemide Indication: Low urinary output, edema, CHF, blood pressure management Action: Act on the loop of Henle to increase urine output by affecting sodium reabsorption within the nephron. Inhibits the sodium potassium chloride cotransporter causing sodium to be excreted in the urine, therefore increasing diuresis. Nursing considerations: Adverse effects: ○ Hyponatremia, -chloremia, -kalemia → Monitor potassium levels Caution in clients also on digoxin ○ Ototoxicity → do not combine with other ototoxic meds (aminoglycosides) ○ Dehydration → hypotension These are the most effective of all diuretics Thiazide Diuretics Names: Chlorothiazide, Hydrochlorothiazide Indications: Hypertension, edema Action: These diuretics act on the distal convoluted tubule to inhibit the sodium-chloride cotransporter. This decreases sodium reabsorption, causing more fluid loss in the urine. Nursing Considerations: Adverse effects: ○ Hyponatremia, -chloremia, -kalemia (less severe than in loop diuretics) ○ Dehydration → hypotension Monitor BP Potassium Sparing Diuretics Names: Spironolactone, Eplerenone Indications: Hypertension, edema, HF Action: Inhibit sodium and potassium exchange via sodium channels in the distal parts of the nephron. This ‘spares’ potassium!! Nursing considerations: Can cause hyperkalemia ○ Monitor K levels ○ Don’t combine with other drugs that increase the K (ACE, ARB, K+ supps, or salt substitutes) Response develops slowly; over a few days These medications are not as strong as other diuretics, so are often combined with a loop or thiazide diuretic! Quiz Time  Which diuretic is the most effective at causing diuresis, often making it the 1st choice for clients requiring diuretics? Click Present with Slido or install our Chrome extension to activate this ⓘ poll while presenting. Answer: Loop Diuretics  Which diuretic will clients transition to if they are experiencing electrolyte imbalances like hypokalemia with the first line diuretic? Click Present with Slido or install our Chrome extension to activate this ⓘ poll while presenting.  Answer: Potassium Sparing Diuretics. Because these work at the end of the nephron, the collecting duct, the potassium has already been reabsorbed. K levels can actually rise on this medication. The Hematologic System Pharmacology Drugs of the Hematologic System Prevent clotting Anticoagulants ○ Heparin ○ LMWH ○ Antiplatelet drugs ASA Clopidogrel Break up a clot Thrombolytics Blood products Heparin Classification: Indirect Thrombin Inhibitor ○ Anticoagulant! How it works ○ Thrombin → converts fibrinogen to fibrin → Fibrin forms clots! ○ Antithrombin III inhibits thrombin ○ Heparin ENHANCES antithrombin III ○ This stops thrombin from being activated, which therefore prevents clots from forming This is the intrinsic coagulation pathway End result? SLOWS DOWN CLOTTING. Low Molecular Weight Heparin Names: Enoxaparin Indication: DVT prophylaxis Action: Contain an active anticoagulant fraction of heparin - enhances antithrombin III, which stops thrombin from being activated, which therefore prevents clots from forming Nursing Considerations: Always given SC Porcine derived, may have cultural or religious implications No need for anticoagulation tests/monitoring, dose is based on body size ○ DO monitor platelets… HITT Only anticoagulant that CAN be used in pregnancy Warfarin Therapeutic class: Anticoagulant Indication: venous thrombosis, pulmonary embolism, A-fib Action: disrupts liver synthesis of Vitamin K-dependent clotting factors Nursing Considerations: Monitor for bleeding Monitor PT and INR ○ PT Normal: 10-12 seconds ○ INR Normal: 0.9-1.2 Therapeutic INR: 2-3 Antidote: Vitamin K Contraindicated during pregnancy Fibrinolytics/Thrombolytics Names: Urokinase, streptokinase, alteplase (tissue plasminogen activator: tPA) Indication: Established clot: PE, ischemic stroke Action: Enzyme converts plasminogen to plasmin -plasmin destroys the clot! Nursing Considerations: Must be given ASAP to have good effects (door to tPA time - 60 min!) Adverse Effects: Hemorrhage ○ Don’t give with other anticoagulants or antiplatelets if you can help it Mild allergic reactions common - give antihistamines or corticosteroids Blood Administration Blood is administered as a medication… so follow the same “rights”! Checked by 2 RNs to ensure compatibility and correct order ○ Client should have an active Type & Screen to determine compatibility Blood should be administered with special blood tubing that has a filter with a larger gauge IV ○ Normal saline is the approved compatible IV fluid to infuse with/after blood Ensure vital signs are taken before, during, and after infusion per hospital policy ○ Baseline vitals are crucial to determine if your client is having a reaction!! Closely monitor client for the first 30 minutes, which is the most likely time a reaction could occur Transfusion Reactions If a reaction is suspected, first STOP the infusion! Remove the tubing with the blood and flush the IV only if it is the only IV access ○ Blood product and all tubing should be returned to lab/blood bank Follow hospital policy to initiate the Rapid Response team Prepare to administer diphenhydramine and oxygen (if needed) and treat the client’s symptoms Quiz Time  Name the most common symptoms of a transfusion reaction. Click Present with Slido or install our Chrome extension to activate this ⓘ poll while presenting. Answer: Fever, chills and urticaria.  What anticoagulants are safe in pregnancy? Select All That Apply. Click Present with Slido or install our Chrome extension to activate this ⓘ poll while presenting. Answer: heparin and LMWH  How do you treat heparin Induced Thrombocytopenia and Thrombosis (HITT)? Click Present with Slido or install our Chrome extension to activate this ⓘ poll while presenting.  Answer: Discontinue all Heparin products and start a different anticoagulant.  How do you rate your pharmacology knowledge now? Click Present with Slido or install our Chrome extension to activate this ⓘ poll while presenting.