TOPIC 11: Quiz #2 and Math Calculations Exam

Preparation for Exam:

The theory quiz will cover content from Class 6-9 Please review Learning Objectives

Please note: Class 9 and Class 10 both are about the Nervous System. Quiz 2 includes the Learning Objectives for Class 9 ie ANS, meds for Anti-Parkinson, Seizures, Anti-anxiety, Mood, Psychosis etc

As a partial study guide, you may want to review;

Medication Administration - Principles of med admin, 10 rights, 3 checks, understand all components of a medication order, types of orders, phone orders, abbreviations, including dangerous abbreviations, types of meds and routes i.e. suspension, liquid, tablet, capsule, lozenge, SC, IM, IV, pr, po, inhaler, sl, eye drops, parenteral, enteral, topical, percutaneous. What do you need to know before administering a medication

Nursing Process and Specific Disorders - assessment, diagnosis, planning, implementation and evaluation related to medication administration

Meds- bowel meds, classifications, common meds, actions/uses, side effects, nursing considerations, etc...

Alternative Therapies, use of traditional/indigenous/complementary/alternative meds and the nurse's role - do the readings - common herbs, vitamins, minerals, etc...

Nervous System - part 1 - adrenergic, cholinergic, Parkinson's, antidepressants, antipsychotics, seizures, anxiety, mood, sedative-hypnotics.

There are multiple choice questions and matching questions on the theory quiz.

TOPIC 12: Respiratory System and Antimicrobials

Learning Objectives:

Upon completion of the class, the learner will be able to:· Describe major classes of drugs used to treat diseases/illnesses of the respiratory system and

antimicrobials.

· Describe the main nursing considerations related to these groups of drugs.

· Explain drug interactions, polypharmacy, and food/drug effects to medication used across the lifespan, particularly the older adult.

· Explain the potential interaction of complementary, Indigenous and herbal preparations with respiratory and antimicrobial drugs.

· Organize research of drugs used to treat diseases/illnesses of the respiratory system, and antimicrobial medications, in a way that allows for easy and accurate reference.

· Identify drugs used to treat infectious diseases.

  Explain the relationship between antimicrobials and drug resistance.

Preparation:

Consider your own experience with use of antibiotic/antimicrobial medications What kind of infection were you taking the medication for?

Did you experience any side effects from the medication?

Respiratory System Medications

Med Orders – Critical Thinking

Make sense of this in your head...

MD order reads – “acetaminophen 325-650 mg q4 - 6h PO PRN for pain”

What is the lowest & highest dose you can give in 4 hours?

What is the lowest & highest dose you can give in 6 hours?

Drug Calculations

You may give:

325mg q4h - q6h 650mg q4h – q6h

You may also give 325mg q2h if that schedule works better for your client… Explain why...

Why can’t you give 650mg q2h?

If you’re struggling with this, do the math review covered in class 4. If you are still struggling, contact the Health Sciences Tutor or your Pharmacology instructor.

Respiratory Drug Classes

Decongestants (pseudoephedrine) Antihistamines (diphenhydramine, ipratropium)

Expectorants (guaifenesin)

Antitussives (dextramethorphan)

Mucolytics (acetylcysteine) 

Bronchodilators (ipratropium, albuterol)

Corticosteroids (fluticasone, budesonide phosphate)

URT - Terms & some A&P

Autonomic innervation

Alpha adrenergic receptor stimulation → vasoconstriction Cholinergic stimulation → vasodilation

Rhinitis– inflammation of nasal mucosa → congestion, sneezing, discharge

o Causes – URTI (bacterial/viral), allergy, chronic sinusitis

Allergic rhinitis – allergen-induced rhinitis

Sinusitis – inflammation/infection of sinuses

Histamine– found in most body tissues

o Released in allergic reactions, tissue trauma → inflammatory response

o Actions of histamine – vasodilation (redness, heat), ↑ capillary permeability (edema, pain)

o Also responsible for dramatic drop in BP in severe allergic reactionWhy does this happen?

Sympathomimetic Decongestants

Action – alpha adrenergic agonists → vasoconstriction & possible bronchodilation (β 2 receptors)

Uses – common cold, adjunct to antihistamine in allergic rhinitis

Precautions - reflex vasodilation with overuse, systemic effects of adrenergic stimulation - Who is at risk & for what ?

Meds - pseudoephedrine (Sudafed)

     Pseudoephedrine (Sudafed)

Precautions – diabetes, hyperthyroidism, ischemic heart diseaseWhy?

Adverse effects – anxiety, nervousness, palpitations, anorexiaWhat do the adverse effects remind you of?

NC - ↑ fluid intake, monitor VS, chest & sputum What assessments would you make?

Do not take any herbs containing ephedra or ma huang when taking this medication as there could be potentially serious interactions. Coleus should also be avoided as it might increase the effects of the medication.

Tannin containing herbs such as green and black teas, uva ursi, black walnut, red raspberry, oak and witch hazel might interfere with the absorption of pseudoephedrine.

Caffeine can increase the side effects of pseudoephedrine.

Antihistamines

Action – histamine receptor antagonists in arterioles, capillaries, secretory glands of mucous membranes

Uses – allergy, conjunctivitis

Meds – ipratropium (Atrovent), diphenhydramine hydrochloride (Benadryl), loratadine (Claritin)

Diphenhydramine (Benadryl)

Action – as for antihistamines, CNS depressant Uses – allergy, anaphylaxis, mild hs sedation, prevention of motion sickness

Adverse effects – anticholinergic effects (dry mouth, constipation, urinary retention, tachycardia), confusion, drowsiness

NC – know why the med is ordered, monitor airway/rashes in allergy, monitor for excessive CNS depression.

avoid the use of henbane and other herbs that may cause anticholinergic effects.

LRT - Terms and A&P

SaO2/oxygen saturation/O2 sat – percentage of oxygen that is bound to hemoglobin compared to 100% which “could” be bound, measured by an oximeter

Spirometry – assesses client’s ability to move air in and out of lungs (airway compliance, thoracic excursion & respiratory muscle strength on inspiration & expiration), measure by spirometer

Expectorants - guaifenesin

Action - liquefy mucous by stimulating secretions → better expectoration of ‘tenacious’ secretions when coughing

Uses – bronchitis, pneumonia, treatment of productive cough – Why?

Med – guaifenesin (Robitussin)

Adverse effects – well tolerated

NC – monitor chest & sputum, ↑ fluids

avoid foods and herbs that contain caffeine when taking this medication as BP may increase.

Licorice, ginseng and ephedra may interact with this medication.

Antitussives

Action – suppresses cough centre in the brain Uses – for dry, hacking, non-productive cough, especially helpful when sleep is disturbed

by coughCompare the indication for an expectorant versus an antitussive…

Precaution – CNS depressant

Meds – codeine, dextromethorphan (Benalyn DM)

      Antitussive - dextromethorphan

Uses – viral URTI, chronic non-productive cough, common ingredient in OTC cough & cold remedies

Precautions – safety uncertain in children, CNS depression, do not give to anyone who is taking or has taken an MAOI within the last 14 days

Adverse Effects – tolerated well

NC – monitor chest & for sputum, ↑ fluidsWhy? What will you do if you assess a productive cough?

Do not take with herbs that have a stimulating effect without the advice of a health care professional.

Mucolytic Agents

Action – dissolves mucous plugs & ↓ viscosity of pulmonary secretions Uses – pre-med for postural drainage & suctioning, acute and chronic pulmonary

disorders (bronchitis, emphysema, pneumonia)

Meds – acetylcysteine (Mucomyst) – CPS

Adverse effects – foul odour may cause nausea, bronchospasm

NC – What will you assess? When?

LRT - Bronchodilators

Action – relax smooth muscle from trachea to alveolar ducts → bronchodilation → ↓ resistance to air flow

Uses – bronchodilation in asthma, chronic bronchitis, possibly emphysema

Meds - (several classes): beta-adrenergic agonists (albuterol - Ventolin, Salmeterol), anticholinergics (ipratropium bromide), xanthine derivatives (aminophylline)

      Albuterol (Ventolin)

Action – β2 adrenergic agonist in pulmonary smooth muscle → bronchodilation Uses – COPD (asthma, chronic bronchitis, emphysema)

Adverse Effects – restlessness, tremor, chest pain, palpitations What meds would act as antagonists?

NC – VS, chest, sputum, teach proper administration (client & family)

Coleus may increase the bronchodilating effects of albuterol. These two should only be combined under a doctor's supervision.

Steroid Anti-Inflammatories

Action – somewhat unknown, antiinflammatory, immune suppression, some bronchodilation action

Uses – severe asthma, COPD if unresponsive to other bronchodilatorsWhy?

Meds – budesonide (Pulmicort), fluticasone (Flovent), beclomethasone

      Fluticasone - Flovent

Action – locally acting anti-inflammatory & immune suppressant Uses – diminish frequency & severity of asthma, to delay need for systemic steroid

controlWhy is this advisable?

Adverse Effects – HA, oropharyngeal fungal infections, dysphonia/hoarsenessWhat are the nursing implications for this class of inhalers?

Coleus should be avoided when taking this medication.

Antimicrobial Medications

Antimicrobial Agents

Antimicrobial agents are meds used to treat infections with pathogens, there are three main types:

1. Antibacterial agents – prevention & treatment of bacterial infections2. Antifungal agents – treatment of fungal infections

3. Antiviral agents – treatment of viral infections

Antibacterial Subclasses

Aminoglycosides – gentamicin, tobramycin Cephalosporins – cephalexin (Keflex), ceftazidime

Macrolides – azithromycin (Zithromax), erythromycin

Penicillins – amoxicillin (Amoxil), ampicillin, penicillin G

Tetracyclines – tetracycline (Apo-Tetra)

Quinolones – ciprofloxacin (Cipro), norfloxacin

Sulphonamides – cotrimoxazole (Septra, Bactrim)

Antituberculars – rifampin, isoniazid

Antifungal & Antiviral Meds

Antifungal Agents - clotrimazole, ketoconazole (Nizoral), nystatin Antiviral Agents - acyclovir (Avirax), oseltamivir (Tamiflu)

Antibacterial Agents

Antibacterials or antibiotics are drugs derived from living organisms like penicillin which is derived from a mould

Drug choice is made according to the sensitivity of the pathogen to a specific antibiotic – a culture & sensitivity (C&S) test is usually done in order to select an antibacterial agent that is sure to kill the specific pathogen

Activity -

Define & describe the C&S procedure to your partner…

Sub-classifications:

Aminoglycosides Class

Action – inhibit protein synthesis Uses – kill pathogens that cause UTIs, meningitis, wound infections, septicemia

Meds – gentamicin, tobramycin, neomycin, streptomycin

Ototoxicity!!

Cephalosporin Class

Action – chemically similar to penicillins, inhibit cell wall synthesis, 3 “generations” of drugs

Uses – with caution in clients allergic to penicillins, UTI, RTI, bacteremia, osteomyelitis

Meds – cephalexin (Keflex), ceftazidime

Macrolide Class

Action – inhibit protein synthesis Uses – RTI, GIT infections, skin and soft tissue infections, useful in client sensitivity to

penicillins, cephalosporins or tetracyclines

Meds – azithromycin (Zithromax), erythromycin

Penicillin Class

First antibiotic to be cultured and used Bacteria may develop resistance to penicillin, so researchers have developed penicillinase

resistant penicillin drugs

Action – inhibits cell wall synthesis

Uses – middle ear infection, meningitis, pneumonia, UTI, syphilis, gonorrhea

Meds – amoxicillin (Amoxil), ampicillin, penicillin G

Quinolone Class

Action – interfere with DNA replication Uses – broad spectrum antibiotics for UTI, RTI, STDs, important group for nosocomial

and community acquired infections

generally better tolerated than many others

Meds – ciprofloxacin (Cipro), levofloxacin, norfloxacin

Sulphonamide Class

Are synthetic Bacterial resistance is a problem so, has led to development of combination of meds

Action – inhibit folic acid → cell death

Uses – UTI, middle ear infections

Caution – penicillin allergy

Meds – cotrimoxazole (Septra, Septra DS, Bactrim, Bactrim DS)

Tetracycline Class

Action – inhibit protein synthesis Uses – allergy to penicillin, UTIs, some STDs, URTI and LRTI, some skin infections

Meds – tetracycline (Apo-Tetra, Novo tetra), doxycycline

products containing milk, iron or magnesium can decrease the absorption and serum levels of these types of antibiotics.

Antitubercular Agents

Action – by various mechanisms, often used in combination with other antitubercular drugs

Uses – prevention & treatment of tuberculosis

Adverse effect - discolouration of body fluids to red-orange with rifampin

Meds – ethambutol, rifampin, isoniazid

There is not a lot of information on possible interactions between antibiotics and herbal supplements. It is recommended that individuals on antibiotic therapy take probiotics to help

restore and maintain normal intestinal flora. Probiotics can be consumed through foods containing live bacterial cultures or as a supplement.

Antimicrobials - Common Adverse Effects

Anaphylaxis – what will you assess? What med is commonly ordered? Allergy – what S/S will you see?

Nausea, vomiting & diarrhea – why? What are the consequences?

Secondary infection – what are the common ones? Which can be fatal?

NC and Hypersensitivity

Allergies – known & unknown! Reporting - Who needs to know?

Documentation of known medication allergies & the S/S experienced is critical

Close monitoring of clients receiving antibiotics is also critical for early detection of allergic signs/symptoms

What findings will make you suspect a hypersensitivity reaction?

NC for the ‘big three’

Take with lots of fluid to ↓ gastritis Concurrent use of probiotics to help replace lost flora (lactobacillus acidophilus) – what

would be the benefits of this?

Monitor, document & report secondary infections – what would you expect?

Give antiemetics prn

Monitor electrolytes, emesis & stool, skin

More NC in Antimicrobial Therapy

Strictly adhere to isolation/infection control policies per facility Pt must take all & on time

Monitor TACT – describe these assessment components

Monitor for adverse effects – ??

Topical Antifungal Agents

Actions – unknown, cause leaky cell walls Uses – tinea infections, candida infections of skin & mucous membranes

Adverse Effects – vaginal irritation, hypersensitivity (swelling, redness)

Meds – clotrimazole, ketoconazole (Nizoral), nystatin

NC – wash & dry area, wear gloves for application, don’t double dip into container!

Antiviral Agents

Viruses are not “free-living” organisms as they require a host cell for growth & multiplication

Have very sneaky ways of controlling host cells and replicating their own DNA

Many antivirals have been produced to combat HIV by various mechanisms

A new HIV drug prevents entry of the HIV organism into the host’s cells

Actions – many mechanisms (interference with viral enzyme production, protein synthesis inhibition, block entry into host cells, inhibit cell replication)

Uses – treatment of viral infections (influenza, herpes, HIV)

Adverse Effects – nausea, vomiting, diarrhea, rash

Meds – acyclovir (Avirax), oseltamivir (Tamiflu)

TOPIC 13: Endocrine System

Learning Objectives:

Upon completion of the class, the learner will be able to:· Describe major classes of drugs used to treat diseases/illnesses of the endocrine system.

· Describe the main nursing considerations related to these groups of drugs.

· Explain drug interactions, polypharmacy, and food/drug effects to medication used across the lifespan, particularly the older adult.

· Explain the potential interaction of complementary, Indigenous and herbal preparations with endocrine drugs.

· Organize research of drugs used to treat diseases/illnesses of the endocrine system in a way that allows for easy and accurate reference. 

Preparation

· Refer to Reading List for required reading

· Explore the Canadian Diabetes Association website and on-line Health Canada resources related to diabetes 

 - Complete the checklist “are you at risk” on the Canadian Diabetes website under ‘Diabetes and you’

· Compare and contrast Type I and Type 2 diabetes

Medications Used To Treat Disorders in the

Endocrine System

Client Teaching in General

For each class that we study in Pharmacology, ask yourself:

What are the important client teaching topics for this class of medications? What resources will you use?

How will you know your teaching has been successful?

Endocrine System – A & P

Glands or glandular tissues – pituitary (anterior & posterior), thyroid, parathyroids, adrenals, pancreas, ovaries, testes…

Endocrine system together with the nervous system regulates your body's growth and development, metabolism and maintains internal equilibrium

Hormones – A & P

Are chemical messengers secreted into the bloodstream & distributed to target cells at distant sites

Hormone-binding causes target cells to start or stop doing a “pre-programmed” function

Insulin & glucagon are examples of chemical messengers

Effects of Aging on the Endocrine System

1. ↓ thyroid function → hypothyroidism2. ↓ parathyroid secretion → ↓ calcium absorption → osteoporosis

3. ↓ glucose tolerance → Type 2 DM

4. ↓ ovarian function → ↓ estrogen

5. ↓ hormones of adrenal cortex and medulla - decrease in stress response

Thyroid Dysfunction

TSH is released from anterior pituitary gland → stimulation of thyroid gland to secrete T3 and T4 (thyroxine)

Major role in metabolism, temperature regulation, CV function

Hypothyroidism, hyperthyroidism

Goal of therapy is to return thyroid function to normal

Thyroid HormoneToo Much... Too Little...

Tachycardia, bounding pulse, arrhythmia, cardiac hypertrophy, palpitations, diaphoresis

Tremors

Wt loss

↑ T

Lethargy, slowed motor responses

Cold intolerance

↓ appetite with wt gain

↑ sensitivity to sedatives

Hypotension, bradycardia

Meds for Hypothyroidism

Under function of the thyroid → hypothyroidism and is treated with thyroid hormone replacement

Thyroid hormone replacement

o levothyroxine (Eltroxin, Synthroid)

o ↑s metabolic rate of tissues – with what effect on VS/QPA?

Nursing Considerations in TH Replacement

Assessment:o Baseline weight and vital signs!

o Labs - thyroid levels (initial & ongoing)

o Objective & subjective data – like…

Evaluation:

o Assess TACT or signs of toxicity (arrhythmia, tachycardia, angina, hypotension, insomnia

Lemon balm may interfere with thyroid hormone action.

Levothyroxine

Action – replacement of T4 hormone Uses - hypothyroidism

Adverse Effects – hyperthyroidismWhat S & S will alert you to possible toxicity?

Nursing Considerations – low dose for elders, give in am, hold if apical HR >100, monitor wt & VSWhy give in am?

Use of Corticosteroids

Subclasses organized according to area of use and duration of action In smaller doses to replace adrenal insufficiency

In larger doses – potent antiinflammatory & immunosuppressant action

Systemic corticosteroids – cortisone, prednisolone, prednisone

Uses – severe inflammatory conditions (↓pain too), autoimmune disorders, allergic disorders/diseases, asthma, to suppress immune system in transplant

Only treats symptoms

Causes decline in body function over time, therefore only used if other drugs ineffective

Nursing Considerations for Corticosteroids

Prolonged treatment → adrenal gland suppression, immunosuppressionWhat are some potential consequences of long term use?

Baselines needed – VS, electrolyte/glucose levels, weight, LOC

Assess for hyperglycemia in diabetes!

Discontinue slowly

Monitor - for onset of diabetes mellitus, thyroid hormone levels, Cushing’s Syndrome (“moon” face, elevated blood glucose levels)

Compare findings with baselines – wt, VS, electrolytes (hypokalemia, altered Na+ & Cl-), blood glucose

Signs of infection, delayed/poor wound healingWhy?

Certain herbs may lead to a potassium deficiency when taken with hydrocortisone over a prolonged period of time. These include aloe and buckthorn.

Licorice has been found to reduce the metabolism of prednisone in the body, thereby possibly increasing the amount of circulating prednisone. It might also prevent the immunosuppressive actions of cortisone.

Because corticosteroids are often prescribed for immunosuppression in individuals with autoimmune disorders or those who have undergone organ transplant, herbs that alter the immune response should be avoided. Some of these include astragalus, echinacea, goldenseal and zinc among others.

 Prednisone (potent)

Actions – suppress inflammation, immunosuppression, metabolic effects Uses – immune system suppression (autoimmune disorders, transplant), chronic

inflammatory conditions

Adverse Effects – infection, poor wound healing, immunosuppression, altered body image, adrenal suppression, very damaging to collagenWhere is collagen in the body?

Hormone Therapy - Estrogen

Action – maintenance of secondary sex characteristics, ↓ serum cholesterol Uses – palliative treatment/slow progression of prostatic & some breast cancers, relief of

menopausal symptoms, contraception, HRT, treatment of menopausal OP, acne in females

Adverse effects – MI, thromboembolism

Meds –estradiol (Estrace, Evra, Estring, Estrogel) conjugated estrogen (Premarin) can be taken orally, topically, vaginally

St. John's Wort is thought to make estrogen medications less effective. Herbs that act as "blood thinners" may interact with estrogens. Other herbs have estrogen like effects and should only be taken under the advice of a health care professional if the client is also taking estrogen medications. Some of these herbs include black cohosh, red clover, dong quai, and soy.

Hormones of the Pancreas

The pancreas is located posterior to the stomach Pancreatic islets or Islets of Langerhans produce and secrete insulin and glucagon

They are concerned with regulating blood glucose levels

Their effects are antagonistic to each other

Hormone - Glucagon

Potent hyperglycemic ↑s blood glucose

Secretion is activated by:

o Hypoglycemia

o Sympathetic NS stimulation

Why is glucagon activated by ↑ in sympathetic activity?(Why does this make sense?)

Effects of Glucagon in the Body

Glucagon - target site of action is liver Effect - Raise blood glucose by:

increase glycogenolysis (makes glucose from glycogen) increase gluconeogenesis (formation of new glucose from non-carb sources)

What body states would trigger this?

Hormone - Insulin

Potent hypoglycemic ↓s blood glucose

Secretion is activated by:

o Hyperglycemia or ↑ blood glucose levels (after a meal)

o ↑ amino acid and fatty acid levels in blood (after a meal)

o ↑ ACh levels from parasympathetic effectsWhy does this make sense?

Effects of Insulin in the Body

Insulin - target is body cells

Effect - ↓ blood glucose by:

↑ cellular uptake of glucose ↑ glycogen formation

↓ glycogenolysis and gluconeogenesis

What body states would trigger this?

Diabetes Mellitus

Greek word origins:

diabetes derives from a word meaning “to pass through” (polyuria) mellitus derives from a word meaning “sweet”

What is Diabetes Mellitus?

DM is a chronic disease of absent or deficient insulin & cell receptor resistance to insulin Characterized by disturbance in carbohydrate, protein, and fat metabolism → elevated

levels of glucose in the blood with ‘glucose starvation’ inside cells

What happens to body weight?

Type 1 DM

10% of all diabetes – rapid onset Autoimmune and/or infectious origin

Pancreas stops producing insulin

Tx – require insulin injections & balance between energy intake and energy output

Type 2 DM

Caused by chronically high blood glucose levels 90% of all DM, slow onset (years)

o occurring now in children! – why?

↓ insulin secretion & cellular resistance to insulin

Tx – diet & exercise → oral anti-glycemics → insulin

Goals for Client’s with DM

1. Maintain normal blood glucose levels by balancing diet, medication & activity2. Early diagnosis and effective lifestyle changes & medical treatment

3. Avoid states of hypo/hyperglycemia

4. Prevent complications of hyperglycemia – most diabetics die from theseCan you think of some?

Antidiabetic Classifications

Oral Agents

Biguanideso metformin

Sulfonylureas

o glipizide

o glyburide

Injectible Agents

Insulinso rapid insulin

o regular insulin

o NPH insulin

o NPH/regular insulin mixtures (eg. 30/70)

o lente

o ultralente

Certain herbs have been found to have hypoglycemic effects. These may be effective for those individuals with mildly elevated blood glucose levels when used in conjunction with other lifestyle modifications and under the supervision of a qualified health care professional. However, they should be used with caution when taking any prescription hypoglycemic agent. Some of these herbs include fenugreek, cinnamon and momordica charantia.

Antidiabetics – Oral Agents

Use – next treatment for Type 2 diabetes when changing diet isn’t workingWhy wouldn’t it work to change diet?

1. Biguanides (metformin)2. Sulfonylureas (glipizide, glyburide)

Metformin

Metformin (Glucophage, Novo-metformin) Indication/Use – type 2 diabetes

Action - ↓s hepatic glucose production, ↓s intestinal glucose absorption, ↑s cell’s sensitivity to insulin

Adverse reactions – abd bloating, diarrhea, nausea, vomiting

Nursing Considerations:

o Assess – S/S hyper/hypoglycemia, ketoacidosis; fasting blood glucose (am glucometer), HbA1c, urine for glucose & ketones, food/snack intake, exercise

o Implementation – DO NOT CRUSH extended release formulas, glucometer per schedule & prn, have glucogel & carb snack easily available, teaching

o Evaluate – glucometer, S & S, HbA1c

Antidiabetics - Insulins

Use - treatment of Type 1 & some Type 2 diabetes Action- lowers blood glucose by:

o ↑s transport of glucose into cells

o ↑s conversion of glucose to glycogen

o ↓s glycogenolysis & gluconeogenesis in the liver

Insulin - Onset, Peak, Duration

You must know insulin’s onset & peak in order to predict potential hypoglycemia

ONSET of action – initial effect PEAK of action – maximum effect

DURATION of action – remains active in the body

Many types of action (rapid…long acting)

Types of Insulins

Rapid-acting Short-acting

Intermediate-acting

Long-acting

Mixed types

Rapid-Acting Insulin

lispro insulin (Humalog)

Use - Types 1 & 2 DM to control hyperglycemia associated with meals

Onset 10 – 15 min Peak 1 – 2 hours

Duration 3 – 5 hours h

Short-Acting Insulin

regular insulin (Humulin R, Novolin R)

Use – treatment of Types 1 & 2 DM given 30 min ac meals & prn

Onset 30 - 60 min Peak 1 - 4 hrs

Duration 5 - 10 hrs

Intermediate-Acting Insulin

NPH insulin (Humulin N, Novolin N)

Use – treatment of Types 1 & 2 DM

Given 30 min ac meals, often mixed with short-acting (regular insulin) Onset 1 – 2 hours

Peak 4 – 12 hours

Duration 18 – 24 hours

Long-Acting Insulin

ultralente insulin (Humulin UtraLente, Novolin U)

Onset 4 – 6 hours Peak 18 – 24 hours

Duration 36 hours

Mixed Insulins

Regular/NPH (Humulin 50/50, Novolin 70/30)

Use – treatment of Types 1 & 2 diabetes

Given 30 min ac meals Onset 30 min

Peak 4 – 12 hours

Duration 24 hours

Nursing Process - Insulin

Assess:

Client’s understanding of use, action & it’s effects on blood glucose (related to diet, exercise, illness)

Client’s usual diet and usual level of exercise/activity

Client’s ‘compliance’

Client & family knowledge of S/S & treatment for hypoglycemia

Assessment & Insulin

Assess for S/S of hypoglycemia

Possible causes - ↓ food intake, missed hs snack, N & V, illness, too much insulin for current diet/exercise

Assess for S/S of hyperglycemia

Possible causes – corticosteroids, ↑food intake, snacking, too little insulin, stresses (that activate sympathetic activity in body - fever, illness, surgery), failure of oral antidiabetics to control Type 2 DM

Which is Which & Why?

Pallor

Diaphoresis

Tremors

Weakness

Anxiety

Irritability

Altered/↓ LOC

Hypotension

Tachycardia

Bradycardia

Polyuria

Polydipsia

Polyphagia

Glucosuria

Headache

N & V

Abdominal pain

Dizziness

Tachycardia

Tachypnea

Fruity acetone breath

Assessment & Insulin

T - A -

C -

T -

Glucometer, HbA1c, chemstrip prnDo you need an MD order to assess BG by glucometer?

Interventions & Insulin

Obtain BG by glucometer

MD’s order is checked against the MAR

Ensure accuracy with sliding scale dose

Insulin prep is checked by another nurse

Give insulin 30 min ac meals & prn/order

Ensure client eats meals & snacks

o Snacks are often forgotten or not eatenWhat is the consequence of this?

NI for Hypoglycemia

Assess glucometer, → facility policy

Administer ½ c sweetened fruit jc (thin or thickened) if able to swallow (glucose gel if unable to swallow)

Stay with client - ongoing asmt, support, encouragement

Re-evaluate glucometer in 15’

Continue to monitor x 24 hoursWhy?

In some facilities, glucagon may be used for hypoglycemia

Given SC, IM, IV

Action - breaks down stored glycogen to glucose therefore increasing blood glucose levels

Preventing Hypoglycemia

Client must eat within 30’ of receiving short acting insulin – why? Ensure hs snack has been eaten

Hold insulin if client has not been eating, is vomiting or you assess potential risk for hypoglycemia

Report to supervisor or call physician

Evaluation & Insulin

Apply TACT Continue to monitor BG as ordered & prn (are oral agents still enough to maintain normal

blood glucose levels?)

Monitor chart for HbA1c values

Client teaching

Sliding Scale Insulin

See most recent sliding scale MD order Dose of regular insulin is determined by glucometer value assessed immediately prior to

insulin administration

Is often checked by 2 nurses (per facility policy)

Is often given with NPH insulin in same syringe

Sample MD order:

Regular insulin by sliding scale ac meals & hs:

Glucometer:

0 – 9.9 give Ø u 10.0 – 14.9 give 6 u

15.0 – 19.9 give 8 u

20.0 – 24.9 give 10 u

Sliding Scale Insulin Scenarios

Your diabetic client is also taking PO prednisone to ↓ symptoms of myasthenia gravis.Based on the previous MD order, how much regular insulin will you give?

At 0730, your client’s glucometer reading is 8.4 mmol/L At 1130, the reading is 17.0 mmol/L

At 1730, the reading is 13.7 mmol/L

At 2200, the reading is 12.5 mmol/L

TPS - Sliding Scale Insulin

You come on shift the following morning at 0700. In report, you are told that this client was vomiting in the night. As per the MD order, his insulin is due at 0730. When you go to him to do his QPA, you see his hs snack at the bedside. You assess hypoglycemia and confirm this with a glucometer value is 2.1 mmol/L…

1. List all possible QPA data for this client2. List other assessment findings for this client

3. List your nursing interventions in the order that you will perform them

Nursing Practice Tip: When you are in clinical or have started working, keep an index card in your pocket with the signs and symptoms of hypo and hyperglycemia; the onset, peak and duration of action of each type of insulin; and, the names (or initials) of the clients on your unit who are diabetic. That way if you come upon a diabetic client in distress you will have a better idea of how to respond in a timely fashion.

TOPIC 14: Cardiovascular System

Learning Objectives:

Upon completion of the class, the learner will be able to:· Describe major classes of drugs used to treat diseases/illnesses of the cardiovascular system.

· Describe the main nursing considerations related to these groups of drugs.

· Explain drug interactions, polypharmacy, and food/drug effects to medication used across the lifespan, particularly the older adult.

· Explain the potential interaction of complementary, Indigenous and herbal preparations with cardiovascular drugs.

· Organize research of drugs used to treat diseases/illnesses of the cardiovascular system in a way that allows for easy and accurate reference.

Preparation:

Refer to reading list for required reading

Drugs Used to Treat

CARDIOVASCULAR DISORDERS

Classes in this Group

Dyslipidemics/Lipid Lowering Agents (statins) Antihypertensives (ACE inhibitors, angiotensin II blockers, beta adrenergic blockers,

Ca+ channel blockers, diuretics)

Antianginals (nitrates, beta blockers)

Antiarrythmics (digitalis glycosides)

Platelet Inhibitors (aspirin)

Anticoagulants warfarin (Coumadin), heparins (dalteparin - Fragmin, enoxaparin - Lovenox)

Thrombolytic / Fibrinolytic Agents – dissolve existing clots (streptokinase)

1. Dyslipidemia Drugs aka Lipid Lowering Agents / Statins

o Hyperlipidemia – ↑ serum cholesterol & triglycerides (genetic & lifestyle factors)o → atherosclerosis, arteriosclerosis → hypertension → CAD, angina, MI, CHF,

PVD

o Antilipemics (statins) used when diet, exercise & weight reductions fail – why ?

o Goal is to ↓ LDL-C to < 100 mg/dL

o In case you were wondering, the US, and other parts of the world, measure cholesterol in milligrams of cholesterol per decilitre of blood. In this system of measurement, < 200 is considered acceptable. In Canada, and most of Europe, cholesterol is measured in millimoles of cholesterol per litre of blood. In this system of measurement, < 5.2 is considered acceptable.

Statins

Uses – reduce cholesterol thereby ↓ing risk for CAD, atherosclerosis, hypertension…

Action - inhibits enzyme responsible for cholesterol production in liver (↓cholesterol production → removal of LDL from blood), also ↓s inflammation, platelet aggregation, thrombin formation, plasma viscosity!

Drugs – atorvastatin (Lipitor), simvastatin (Zocor)

Simvastatin (Zocor)

o Uses - hypercholesterolemiao Action – see above

o Adverse Reactions – rhabdomyolysis (disintegration of striated muscle with myoglobin in urine), abdominal cramps, constipation, diarrhea, flatus

o NC – obtain baseline for somatic pain & abd symptoms, monitor for development of myalgia, monitor diet & exercise, monitor cholesterol & triglycerides, monitor LFTs

Grapefruit juice is know to inhibit the metabolism of statins. This means that the drug is not being broken down in the body and therefore, the client may end up with a toxic level of the statin.

2. Antihypertensives

Drugs are indicated when either SBP ≥ 140 mmHg or DBP is ≥ 90 mmHg on two or more separate occasions

Goal (in conjunction with lifestyle changes) is maintenance of a BP < 140/90 mmHg thereby ↓ing risk of angina, MI, CHF, CVA, renal failure, retinopathy…

Goal for clients with diabetes <130/80 mmHg

[IMAGE: Layers_of_Artery.jpg]

Antihypertensive Classes

A is for Angiotensin Converting Enzyme Inhibitors (ACE inhibitors)

Uses – alone or with other agents for hypertension, mgmt of CHF Action - inhibits angiotensin II production (inhibits aldosterone secretion from kidneys

→ systemic vasodilation, blocks conversion of angiotensin 1 to angiotensin 2) – with what effect?

Drugs – Ramipril (Altace), captopril, trandolapril

Ramipril:

o Uses – alone or with other agents for hypertension, prevention of MI, CVA in those with high risk (ramipril only) – recall the risk factors!

o Adverse Effects – renal impairment in elders, agranulocytosis, neutropenia, cough, hypotension

o NC – monitor VS, monitor CBC, differential & electrolytes, KFTs, monitor for OH

A is for Angiotensin II Receptor Blockers (ARBs)

Uses – hypertension & secondary HF, hypertension in clients with Type 2 DM (prevention or delay of nephropathy)

Action – blocks receptors for angiotensin II

Adverse effects – less hyperkalemia than ACE inhibitors, hypotension

NC – monitor for S/S of CHF, orthostatic hypotension

Drugs – losartan (Cozaar), valsartan (Diovan)

B is for Beta Adrenergic Blockers

Uses – hypertension, angina, tachyarrhythmia, migraine HA, MI prevention, stable CHF

Actions - inhibits cardiac response to SNS stimulation → ↓CO, ↓HR, ↓BP, inhibits renin secretion by kidneys

Drugs – metoprolol, timolol, atenolol, propanolol

Metoprolol (Lopresor, Betaloc):

o Uses - hypertension, angina

o Action – selectively blocks myocardial β1 receptors – with what effects?

o Adverse Effects - weakness, CHF, OH, bradycardia, pulmonary edema, impotence

o NC – monitor VS, chest/PVD baseline & ongoing, ensure safety, monitor for additive effects with similarly acting drugs

C is for Calcium Channel Blockers

Uses – hypertension, prevention of angina & antiarrhythmic Actions - inhibits Ca+ ion movement across smooth & cardiac muscle cell membrane →

↓HR, ↓ in vascular smooth muscle tone (promotes systemic vasodilation) & ↓ in dysrrhythmias, ↑ excretion of Na+ by kidneys → ??

Drugs – diltiazem (Cardizem), nifedipine, amlodipine

Diltiazem (Cardizem):

o Uses – hypertension, angina pectoris & vasospastic angina, tachyarrhythmias, atrial fibrillation

o Adverse Effects – peripheral edema, arrhythmias, CHF

o NC – monitor VS, monitor for CHF (list ALL of these asmts), ensure safety

When used with melatonin, there may be an increase in BP and HR

Use caution with any herbal supplements that might affect blood clotting.

D is for Diuretics

Most commonly prescribed subclass of antihypertensives Three types:

o Thiazide Diuretics – commonly used (hydrochlorothiazide)

o Loop Diuretics – furosemide (Lasix)

o K+ sparing Diuretic (spironolactone)

o Furosemide (Lasix):

Uses – all stages of hypertension, edema associated with CHF

Action – promotes blood volume depletion through diuresis, Na+ excretion, peripheral vasodilation

Adverse Effects – hypokalemia, hyperkalemia (with supplements), dehydration, OH Peak is 1-2 hr, what is the significance?

NC – ensure safe access to BR, monitor VS, monitor serum K+

Use of calcium supplements while on hydrochlorothiazide may lead to hypercalcemia. Care should also be taken when taking herbs such as ginko in combination with this drug as it may actually cause an increase in BP.

There are possible interactions between ginseng and loop diuretics.

TPS – Nursing Considerations for Antihypertensive Medications

Activity -

List rationale for each assessment Document potential “positive” asmt findings

Monitor VS, O2 sat

Orthostatic BP, safety

CHF prn Weight, skin turgor, edema, breath sounds, peripheral circulation

Bronchospasm

Labs – CBC, electrolytes (especially K+)

Hawthorn has BP lowering properties. Taking hawthorne with an antihypertensive could lead to hypotension.

3. Antiarrhythmics

Impulse begins in SA node → atria → AV node → ventricles Ventricular contraction is from the apex toward the base

New arrhythmias should be assessed with ECG (electrocardiogram) & documented

Many classes - beta adrenergic blockers (propanolol, metoprolol), Ca+ channel blockers (diltiazem), Na+ channel blockers (lidocaine), digitalis glycoside class (digoxin – Lanoxin)

oUses – tachyarrhythmia, atrial fibrillation, CHF

o Action – prolongs refractory period at AV node (↓s conduction velocity → ↓ HR), ↑s force of contraction - both of these actions improve chamber filling and result in ↑ CO

o Adverse Effects – toxicity, bradycardia, arrhythmia, N&V, weakness

o NC – monitor BP & apical, hold & notify MD for bradycardia (HR < 60 or per policy) or arrhythmia (assess serum K+), monitor safety especially to ambulate, digitalization may or may not be ordered (check & monitor levels), monitor for sign/symptoms of toxicity (if suspected, hold & report to MD), monitor chest and extremities for edema - how could this occur?

Digoxin Toxicity!

o The half-life of digoxin is 36 – 48 hours!

o Based on your knowledge, who is most at risk for developing toxicity?

o What other concurrent pathology increases the risk of toxicity?

o What lab values will you assess & report prn?

o Sign & Symptoms – abdominal pain, anorexia, mild nausea, altered HR or rhythm, confusion, altered behaviour – are these signs/symptoms unusual in the elder? What is the significance of this ? (check serum K+)

o Antidote may be ordered for digoxin toxicity, inactivates digoxin by binding & excreting via kidneys – digoxin immune Fab (Digibind, DigiFab)

There could be a possible interaction between hawthorn and digoxin. Use with caution.

Ginseng may increase risk of digoxin toxicity. Ephedra and ma huang may cause dysrhythmias in clients taking digoxin. It is not advisable for a client on digoxin to take any herbal remedies without first discussing it with their physician.

Amiodorone, used to treat ventricular tachycardia interacts with a number of drugs and herbs, including echinacea, aloe and grapefruit juice.

4. Antianginals - Nitrates

Goal - to ↓ O2 demand of myocardium, eliminate symptom of angina, prevent MI Activities that precipitate angina – exercise, cold exposure, caffeine, smoking, big meals,

emotional stress

Co-morbidity risk factors – dyslipidemia, diabetes, hypertension

Adjunctive therapies – platelet aggregation inhibitors, statins – does this make sense?

Nitrate type – Nitroglycerine:

o Uses – drug of choice for angina

o Actions

1. Peripheral vasodilation → ↓ preload in the heart → ↓ myocardial stretch (Starling’s law) → ↓ oxygen demand of myocardium while ↑ing CO

2. Coronary artery vasodilation prevents ischemia by ↑ing perfusion & delivery of O2

o Available in SL with half-life 1-4 min (treatment) & prophylactic SR transdermal forms

o Adverse Effects – hypotension, dizziness, tachycardia, intense HA, tolerance

o NC - prevent tolerance (remove transdermal patch at hs or observe nitrate-free periods per order), monitor BP, HR, pqrst, administer SL per protocolWhat is the protocol?

5. Drugs for Thromboembolic Disorders

These disorders are a major cause of morbidity & mortality – what can they cause? Thrombus - formation of a clot

Embolus – thrombus ‘embolizes’ and circulates until it gets stuck → ischemia and infarction with CVA, PE, MI depending on site

Risk factors – immobility with venous stasis, dehydration, surgery/trauma, heart failure, hypertension (atherosclerosis, arteriosclerosis), chronic inflammatory diseases/disorders/stress

Associated diagnostic tests – PT, INR, platelets, doppler US, angiogram

Thromboembolic Meds

Three classes:

1. Platelet Inhibitors – Aspirin, Clopidogrel (Plavix)o Aspirin

Action – inhibits platelet aggregation, prolongs bleeding time (DOES NOT dissolve clots)

Uses – unstable angina, ↓s risk of TIA, CVA, MI

Adverse Effects – GI bleeding & irritation, dyspepsia, nausea

NC – may mask fever, monitor VS, & hematocrit, assess emesis & stool for blood, give with food

o Heparin

Uses – prevent & treat DVT, PE, acute embolisms, prevention (prosthetic heart valves, pre/post op, immobility)

Action - interferes with clotting cascade, prevents soluble fibrin clots from becoming insoluble, does not dissolve existing insoluble clots

Adverse Effects – hemorrhagic stroke, anemia, thrombocytopenia, bleeding, ecchymosis

NC – NOTE onset is rapid, give SC in abdomen & monitor site, assess labs (hgb, hematocrit, platelets, OB prn), continually assess for S/S of:

bleeding - ? hemorrhage - ?

What’s the difference?

o Warfarin:

Action – potent, interferes with clotting cascade (inhibits vitamin K synthesis)

Uses – prevention of venous thrombosis, embolism from atrial fibrillation or heart valve replacement, PE, post MI

NC – the same as for heparin (assess for S/S of bleeding), monitor INR

Describe potential QPA data if client is bleeding or hemorrhaging

A number of herbal supplements may interfere with clotting (causing increased or decreased clotting) or may increase the risk of bleeding. Make sure you do research so that you may provide your clients with the appropriate education. Some of these herbs include, but are not limited to, arnica, feverfew, chamomile, clove, ginko, garlic and ginger.

Related Lab Values

Prothrombin Time (PT)

Time in seconds that it takes blood to clot ‘normal’ ~ 10 – 14

Anticoagulating range is 50% higher ~ 18 (if ‘normal’ is 12)

Therapeutic Range – enough anticoagulant to maintain the anticoagulating range without bleeding

International Normalizing Ratio (INR) – standardized calculation value for PT needed because labs were using different reagents resulting in different reference values

Therapeutic Range – 2.0 – 3.0 Assessed frequently during initiation of warfarin therapy & when dose is changed – why?

6. Anticoagulants - NC

Assess all skin/mucous membranes for ecchymosis & bleeding Assess for blood in emesis, stool, urine, sputum, nasal secretions

Monitor VS

Monitor INR & evaluate target range per MD’s order – call MD prn with result

o Usual anticoagulating range 2.0 - 4.5

Monitor other labs – hematocrit, CBC

Activity - Abbreviations

1. How many doses in 24 hours if a drug is ordered: q8h, TID, OD, BID, q12h, q4h, ac meals, hs, QID, q6h, pc meals ?

2. How many doses in a month if doses are ordered q weekly, q monthly ?

3. How many times is a STAT drug given ?

TOPIC 15: Quiz#3

TOPIC 16: Gastrointestinal System

Learning Objectives:

Upon completion of the class, the learner will be able to:· Describe major classes of drugs used to treat diseases/illnesses of the gastrointestinal system.

· Describe the main nursing considerations related to these groups of drugs.

· Explain drug interactions, polypharmacy, and food/drug effects to medication used across the lifespan, particularly the older adult.

· Explain the potential interaction of complementary, Indigenous and herbal preparations with gastrointestinal drugs.

· Organize research of drugs used to treat diseases/illnesses of the gastrointestinal system in a way that allows for easy and accurate reference.

Gastrointestinal System Drugs

Review Medication Calculations

1. Ordered - Nitroglycerin 0.3 mg, SL, Q5min prn for chest pain x 3 doses maximum. On hand - Nitroglycerin 0.15 mg SL tablets.How many tablets will you give per dose?

2. Ordered - Potassium Chloride 30mEq po BID. On hand - Potassium Chloride oral solution 80 mEq/5ml. How many mL will you administer per dose?

Gastrointestinal System Classes & Subclasses

1. Antacids (aluminum hydroxide)2. Histamine (H2) Receptor Antagonists (ranitidine)

3. GI Prostaglandins (misoprostol)

4. Proton Pump Inhibitors (omeprazole)

5. Antiemetics - dopamine antagonist (metoclopramide), anticholinergic (dimenhydrinate and/or diphenhydramine)

6. Anticholinergics - dimenhydrinate

7. Laxatives – stimulant (bisacodyl), saline (magnesium hydroxide), lubricant (mineral oil), stool softeners (docusate sodium), bulk-forming (psyllium)

8. Antidiarrheals – locally acting (bismuth subsalicylate), systemically acting (loperamide)

Meds for GERD & PUD

Gastro-Esophageal Reflux Disease (GERD) – reflux of gastric acid into esophagus with inflammation, corrosion & scarring of esophageal wall

Peptic Ulcer Disease (PUD) – ulceration in wall of stomach or duodenum

Drug classes used to treat the above are antacids, prostaglandins, H2 receptor antagonists, proton pump inhibitors

Antacids

Action – buffers gastric acid from pH 1 - 2 to pH 3 – 4 → ↓ damage to tissues Uses – symptomatic relief by reducing gastric acidity for treatment of GERD, PUD,

gastritis, hiatus hernia

Adverse Effects – constipation (aluminum & calcium based), diarrhea (magnesium based)

NC - give 1 hr ac or 2 hr pc other meds (↓ absorption of digoxin & antibiotics, ↑ absorption of levodopa), overuse & self-medicating can mask underlying diseaseWhat accounts for an antacid’s ability to interfere in absorption of other meds?

Meds:

o aluminum hydroxide (Amphojel, Maalox, Mylanta)

o magnesium hydroxide/oxide (Milk of Magnesia)

o calcium carbonate (Tums)

Antacids may interfere with the actions of many herbal preparations in the same way that they interfere with the absorption of other medications.

Histamine (H2) Receptor Antagonists

Action – ↓s hydrochloric acid secretion Uses – GERD, PUD, stress-induced ulcers

Adverse Effects – diarrhea, constipation

NC – usual bowel pattern, maintain hydration, underlying infection/disease should be ruled out (eg. H. Pylori infection)

Meds – ranitidine (Zantac)Why is cimetidine no longer a drug of choice in GERD & PUD?

Nicotiana species herbs (tobacco) affect the acid blocking effects of ranitidine.

GI Prostaglandins

Action – inhibits gastric acid & pepsin secretion Uses – prevention & treatment of gastric ulcers caused by NSAIDs and salicylates

Adverse Effects – constipation, diarrhea

NC – assess for adverse effects & intervene prn – With what NI?

Med – misoprostol (Cytotec) Clients with what conditions might also be taking these?

There are a number of herbs that influence prostaglandins. There is little information regarding their interaction with GI prostaglandins, however, it is always better to consult a health care professional when taking both herbs and western medications. Some of the herbs or supplements that affect prostaglandins are curcumin, mangosteen, and pomegranate juice.

Proton Pump Inhibitors

Action – inhibit gastric acid secretion Uses – treatment of severe GERD, esophagitis, PUD, hypersecretory disorders, with

antibiotics in tx of H. Pylori infectionWhat can this cause?

Adverse Effects – diarrhea, rash

Meds – omeprazole (Losec), rabeprazole (Aciphex)

One study showed that taking St. John's wort greatly decreased blood levels of omeprazole by accelerating the metabolism of the omeprazole. This could affect the action of the omeprazole.

NI – Drugs for GERD & PUD

Assess for C/O esophageal or epigastric pain, reflux, blood in emesis, stool if indicated, ? tested for HP?

Assess reason & pattern of use of OTC antacids

Teach about adverse effects & appropriate NIs (diarrhea, constipation)

Teach about taking antacids ac or pc other meds

Antiemetics

Vomiting - a reflex originating in the medulla (stimulated by cholinergic & dopaminergic fibres)

We do have some cortical control

N&V common in antineoplastic therapy (chemo and/or radiation), post op, pregnancy, motion sickness, intoxication

Possible consequences - dehydration, malnutrition, electrolyte imbalance, aspiration, GI bleeding/trauma, aspiration

Ginger is know to have antiemetic properties and has been found helpful in nausea and vomiting due to motion sickness, pregnancy and post-operative procedures.

Dopamine Antagonist Antiemetics

Action – block dopamine receptors along vomit centre pathways (but also at other CNS sites)

Uses – antineoplastic therapy, post-op

Adverse Effects – extrapyramidal effects in larger doses (dystonia, parkinsonism, tardive dyskinesia)Make sense of this adverse effect...

Meds – metoclopramide (Maxeran), prochlorperazine (Stemetil)

These medication have a number of very serious side effects. They interact with a number of drugs, therefore, it stands to reason that they may also interact with certain herbal supplements. If you have a patient on a dopamine antagonist, educate them regarding the importance of discussing their use of ALL medications and herbal supplements with their physician.

Anticholinergic Antiemetics

Action – reduces Ach on vomit centre pathways & those associated with vestibular apparatus

Uses- pregnancy and (What else? _______________________ )

Adverse Effects – variable effectiveness, sedation is common, anticholinergic effects (constipation, urinary retention, dry mouth)

Meds – scopolamine, diphenhydramine (Benadryl), dimenhydrinate (Gravol)

Herbs such as henbane which have anticholinergic side effects should not be taken with anticholinergic antiemetics as the anticholinergic side effects may be increased.

Some of these medications cause drowsiness so herbs that also cause drowsiness should be avoided.

NC - Antiemetics

Assess – underlying cause (chemo/radiation therapy, illness, medication side effect), emesis (amount, presence of blood, mucous, colour, consistency), pattern of nausea, food/fluid preferences, meds that may be responsible, VS & weight baselines, oral asmt, abdominal asmt, hydration status, labs (electrolytes, albumin, pH, hgb, hct)…

NC – give prior to expected onset of symptoms to ↑ therapeutic effect, frequent oral asmt & oral care, smaller meals of well tolerated foods/fluids, pre-med for known meds that cause N&V, prevent aspiration, suction equipment available, consult dietician prn, try supported side lying position or ¾ prone, quiet room with low light, restful music per client’s preference

Constipation & Laxatives

Constipation – infrequent, incomplete or painful BMs due to ↓GI motility

Prolonged constipation → drier stool

Causes – low fibre and/or fluid, immobility or sedentary lifestyle, smooth muscle weakness (from failure to go, excessive laxative use), tumours, drug effects – Which classes particularly?

Frequently → hemorrhoids & blood loss

Treatment - start with non-drug interventions to the clients abilities (fibre, hydration, exercise, teach stress management techniques)

Contraindications – unexplained abdominal pain, N & V, fever, prolonged useWhat is the risk associated with prolonged use?

Nursing Asmts – usual pattern, size, consistency, colour, time of day, behaviour (does the client respond immediately to the urge to have a BM), exercise/dietary fibre/fluid intake, history of surgery, current medications, baseline wt/VS, abdominal asmt, labs as ordered, current/past use of laxatives

What is the consequence of long term use? 

A number of herbs have laxative effects. These should be avoided when taking other laxative drugs as severe diarrhea could result and, if diarrhea continues over a prolonged period of time, electrolyte imbalance could occur. Some herbs with laxative properties include cascara sagrada, aloe, senna, rhubarb and others.

NC - Laxatives

ABDOMINAL ASMT – Why? Assess and treat underlying cause if possible

Promote physical activity within client’s limits

Consult with client & dietician for added fibre and fluids of choice

Assess for/teach prevention of dependency

Assess for adverse effects – abdominal discomfort

Teach not to strain! – What is this called and what happens to HR?

Stimulant Laxatives

Action - stimulates smooth muscle to promote peristalsiso PO act in 6 – 10 hours

o PR act in 60 – 90 minutes

Adverse Effects – cramping, continuous use can cause loss of muscle tone → dependency

Meds - bisacodyl (Dulcolax) – do not give with milk or antiulcer/antacids, sennosides (Colace) → dissolution of enteric coating

Saline Laxatives

Action - hypertonic fluid attracts water → distends bowel → promotes peristalsiso PO acts in 1 – 3 hours

o continuous use can cause electrolyte imbalance & loss of muscle tone → dependency

Meds - magnesium citrate (Citromag), magnesium hydroxide (Milk of Magnesia)

Adverse Effects – diarrhea, dependency, cramping

Stool Softening Laxatives

Action – soften stool by drawing water into bowel, PO takes up to 72 hours to act Uses – post MI to prevent straining, drug of choice for active geriatric & pregnant client

with constipation

Med – docusate sodium (Colace)

Bulk Forming Laxatives

Action – promotes bulk (combines with water & intestinal contents), promotes peristalsis Uses – drug of choice for immobile client requiring ongoing laxative use, irritable bowel

syndrome, control of some forms of diarrhea

Med – psyllium (Metamucil)

Adverse Effects – bowel obstructionHow can this occur? Be prevented?

Antidiarrheals

Diarrhea - frequent or watery stools, may be acute/chronic, mild/severe

IS A SYMPTOM, not a disease, may be a sign of colorectal ca Causes – intestinal infection (food poisoning or clostridium difficile), fatty foods,

excessive laxative use, medication adverse effect, emotional stress, irritable bowel syndrome, hyperthyroidism

NC - Diarrhea

Nursing asmts are the same as for constipation Specimen for C&S may be ordered

Skin/mucous membrane asmt

Frequent peri-care & application of barrier cream

Comfort measure & privacy (call bell and/or bedpan, TP and hand wipes within reach)

Assess for dehydration, orthostatic BP, wt loss, bloodworkWhat specifically?

Tannin containing herbs such as green and black teas, black walnut, uva ursi, red raspberry, oak and witch hazel may decrease the activity or absorption of antidiarrheals such as Lomotil.

Herbs with a laxative effect may decrease the action of antidiarrheal medications.

Locally-acting Antidiarrheals

Action – absorb excess water, irritants or bacteria → production of a soft stool Uses – diarrhea of sudden onset lasting 2-3 days with dehydration and electrolyte losses,

IBS, post GI surgery

Meds - bismuth subsalicylate (Pepto-Bismol, Kaopectate), psyllium (Metamucil)

Systemic Antidiarrheals

Uses – adjunct for acute diarrhea, ileostomy, irritable bowel disease (IBD)o Do not use in GIT infection - Why?

Adverse Effects – abdominal distension, constipation, worsening of diarrhea

Med – loperamide (Imodium)

Action – decrease autonomic stimulation of peristalsis → ↓ GIT motility → slows transit time → ↑ time for intestinal water absorption → production of formed stool

What class of meds could cause this effect (mimic this mechanism of action)?( Hint - see "Anticholinergic Antiemetics")

TOPIC 17: Genitourinary and Musculoskeletal System

Learning Objectives:

Upon completion of the class, the learner will be able to:

· Describe major classes of drugs used to treat diseases/illnesses of the genitourinary and musculoskeletal system. 

· Define the major classes of drugs used totreat disease\illness in the reproductive system.

· Describe the main nursing considerations related to these groups of drugs.

· Explain drug interactions, polypharmacy, and food/drug effects to medication used across the lifespan, particularly the older adult.

· Explain the potential interaction of complementary, Indigenous and herbal preparations with genitourinary and musculoskeletal drugs.

· Organize research of drugs used to treat diseases/illnesses of the genitourinary and musculoskeletal system in a way that allows for easy and accurate reference. 

Genitourinary and Musculoskeletal Systems

Calculation Practice

1. A physician orders erythromycin 1G daily in 2 equally divided doses. On hand you have 250 mg capsules.How many capsules will you give per dose?

2. Acetaminophen elixir is stocked as 160 mg/5 mL. The physician has ordered 15 mL to be given q4-6h prn for pain.How many mg will you be administering?How many mL in 0.5 oz?

Genitourinary System Drugs

UTI is the second most common infection (treated with antibiotics) UTI includes infection in the kidneys, bladder, prostate & urethra

Urinary retention can → UTI (Why?) & is treated with cholinergic agonists – Why?

Women at 10 x risk than men – Why?

80% of UTIs caused by Escherichia Coli – How does this occur?

Estrogens and progestins as oral contraceptives - most common use of hormone therapy is to prevent pregnancy.

Hormone replacement therapy used to treat symptoms of menopause and to prevent conditions caused by estrogen loss. HRT refers to replacement of both estrogen and

progesterone whereas estrogen replacement therapy (ERT) refers solely to estrogen replacement.

Oxytocics - uterine stimulants used to stimulate contractions.

Tocolytics - uterine relaxants used to inhibit contractions in preterm labour. 

Male hypogonadism - insufficient testosterone production - numerous causes -What are the causes of hypogonadism?

Erectile dysfunction -What are the possible causes of erectile dysfunction?

Benign prostatic hyperplasia (BPH) - most men will experience at least some enlargement of their prostate as they age.

Renal failure -What is it? What is the primary treatment goal?

Diuretic therapy -What is the purpose of diuretic therapy?

UTI Treatment - norfloxacin

Action – inhibits DNA synthesis, broad spectrum (What does this mean?) Uses – treatment of UTI, RTI, GU infection, bone & joint infections

Adverse Effects – colitis, diarrhea, abdominal pain, N/V/D – Why these effects?

NC – assess urine (how?), evaluate S/S of UTI, teach importance of finishing Rx as ordered, ↑ fluid intake 2L/day to ↑ urine outputWhy?

Anticholinergics - oxybutynin

Use – overactive bladder syndrome (frequency, urgency, urinary incontinence) Action – blocks Ach receptors in smooth muscle of bladder – Does this make sense to

you?

Adverse effects – Based on your knowledge of this general class (anticholinergics):What would these be? What bladder condition would CI this med?

NC – monitor & document urine & voiding pattern, monitor VS & compare with baselines

Cholinergic - bethanechol

Action – increases Ach action in GU & GI system smooth muscle Uses – treatment of non-obstructive urinary retention

Adverse Effects – skin flushing, HA, nausea, diaphoresis, abd. cramps, diarrhea, involuntary voiding or bowel evacuation

NC – assess urine & voiding pattern

Contraceptives - estrogens and progestins Action - prevent fertilization by inhibiting ovulation and changing the cervical mucus and

the lining of the uterus to make implantation of an embryo less likely.  Uses - to prevent pregnancy

Adverse effects -What are the adverse effects of oral contraceptives?

NC -Based on what you know about the adverse effects of oral contraceptives, what are the NC?

Hormone Replacement Therapy Uses - to treat symptoms of menopause, prevent long-term consequences of estrogen loss,

and in some cases, to treat prostate and breast cancer. Adverse effects - there are a number of adverse effects related to hormone replacement

therapy and estrogen replacement therapy.According to your pharm text or drug guide, what are these adverse effects? What are the drug interactions that you must monitor for when a pt is on HRT or ERT?

NC -Based on your knowledge of the adverse effects, what are the most important nursing considerations when caring for a patient on HRT or ERT?

Avoid herbs that are purported to have an effect on hormones while undergoing hormone replacement therapy. Some of these include black cohosh, wild yam, chaste berry, damiana, licorice, evening primrose. 

Drugs Used in the Management of Labor/Preterm Labor

Oxytocics

Action - stimulate uterine contractions. Uses - induce labor. 

Adverse effects - fetal complications may include dysrhythmias or intracranial hemorrhage. Complications in the mother may include uterine rupture, seizures or coma. Oxytocics interact with several drugs including vasoconstrictors which may lead to hypertension. 

NC - monitor fetal heart rate, maternal vital signs, frequency, duration and intensity of contractions, monitor fluid balance, monitor for post-partum hemorrhage.

Tocolytics - Terbutaline (beta -2-adrenergic agonist) Action - inhibit uterine contractions.

Uses - prevent preterm labor.

Adverse effects - tachycardia in mother and fetus.Based on your knowledge of adrenergic agonists, what other adverse effects might you see?

NC - monitor heart rate in mother and fetus. 

Used at the same time as caffeine containing products such as colas, teas, coffee, guarana, yerba mate will increase the stimulant effect of these products.

Treatment for Male Hypogonadism  - testosterone or other androgens Use - to restore normal gonadal development and secondary male sex characteristics. Adverse effects - water retention, edema, potential for liver damage, acne, skin irritation.

Testosterone, when taken by women for other disorders, may cause virilization.What is virilization?

NC - provide education to client, monitor client's condition, monitor liver enzymes, physical assessment for signs of increased or decreased sex hormone production.What might you expect to see?

Treatment for Erectile dysfunction - sildenafil (Viagra) Use - treatment of erectile dysfunction Action - acts by relaxing smooth muscle in the corpus cavernosum, allowing increased

blood flow into the penis, resulting in a firmer and longer-lasting erection.

Adverse effects - hypotension occurs in men also taking nitrates for angina. Other side effects are HA, dizziness, flushing, rash, nasal congestion, GI upset, UTI and chest pain. There have also been reports of erections lasting longer than 6 hrs which could lead to permanent damage to the penile tissues.

NC - educate client re: not taking sildenafil and nitrates for angina at the same time; do not take with high fat meals as absorption will be decreased; avoid grapefruit juice when taking sildenafil. 

Viagra should not be taken with any herbs that claim to enhance sexual performance.

Benign Prostatic Hyperplasia (BPH) 

Treatment - alpha-adrenergic blockers (doxazosin, prazosin, tamsulosin, terazosin) and 5-alpha reductase inhibitors (finasteride)

Use - to relieve symptoms of BPH - do not cure the disease. May take 6-12 months of treatment before relief of symptoms is noted.

Action - alpha-adrenergic blockers act by relaxing smooth muscle in the prostate gland, bladder neck, and urethra, easing the urinary obstruction.

Adverse effects - HA, fatigue and dizziness, reflex tachycardia, hypotension, depression

NC - assess for changes in urinary elimination (what might you see?), assess vital signs (why?), monitor emotional status.

Studies have shown that saw palmetto is as effective as finasteride in treating mild to moderate BPH and has less undesirable side effects. Do not take finasteride and saw palmetto at the same time.

Renal Failure Treatment - focuses on the cause of the renal failure - what are some of the causes of

acute and chronic renal failure?Diuretics are usually prescribed for renal failure. Loop diuretics, thiazide diuretics, potassium-sparing diuretics, miscellaneous diuretics.

Use - to increase urine output.

Action - act by blocking sodium reabsoroption in the nephron and sending more sodium to the urine. Chloride follows the sodium. Water molecules also tend to move with the sodium which blocks the reabsorption of the sodium, increasing urine volume.

Adverse effects - dehydration, electrolyte imbalance, hypotension, dizziness, fainting. Ototoxicity may rarely occur with loop diuretics. Thiazide diuretics may cause hyperglycemia in diabetic patients.

NC - with loop and thiazide diuretics potassium loss may lead to hypokalemia resulting in dysrhythmias. Potassium loss is of particular concern to clients also taking digoxin - digitalis induced heart disturbances could result when taken in combination with certain diuretics. Monitor for signs of dehydration, electrolyte imbalances, hypotension, weight loss or gain, monitor intake and output.

Avoid herbs that may increase potassium loss such as licorice, aloe, buckthorn. Also avoid herbs with a diuretic effect such as dandelion, uva ursi, juniper, buchu, cleavers, and horsetail. Avoid herbs that may affect blood pressure - ginko, licorice. 

Musculoskeletal System

Muscle Relaxants – 4 types

Centrally-acting muscle relaxants – what does this mean? Direct-acting muscle relaxants

Blocking Agents

Miscellaneous group

What NC will you implement for this general group of medications?

Muscle Relaxants - central

Use - for acute muscle spasm, not for upper motor neuron lesion (UMNL) spasticity Action - CNS depression

Adverse effects – sedation & other CNS depression S/S – Like…?

NC – monitor pain, muscle strength/ROM, for CNS depression, DB&C prn – What will you assess for?

Med – methocarbamol (Robaxin), benzodiazepines, cyclobenzaprine, others.

Muscle Relaxants - direct (dantrolene, Botox)

Use – for spasticity & hyperreflexia associated with UMNL disorders such as CP, MS, SCI

Action – interferes with Ca+ release in skeletal muscle cells

Adverse effects – weakness, drowsiness, dizziness

NC – ensure safety, assess muscle strength/ROM/pain, onset is 1 week

Muscle Relaxants - Blockers

Use – for general anesthesia, ET tube insertion, ECT, given by anesthetist Action - blocks transmission of motor impulses at neuromuscular junction

Adverse effects - ↓ cough reflex, dysphagia, salivation

NC - What NC make sense for these?

Misc. Muscle Relaxants - baclofen

Action – CNS depression through ↓ reflex activity at spinal cord level Uses – treatment of spasticity from MS, SCI

Adverse Effects – drowsiness, HA, nausea, fatigue

NC – DC slowly, caution if spasticity is providing balance/stability, monitor pain and self-care abilities, RR

Herbs that may have muscle relaxing properties include cayenne, wild yam, saw palmetto, rosemary, goldenrod, chamomile and celery seed.

Treatment of Hypocalcemia

Treatment -  with dietary modification or supplementation with calcium and vitamin D. NC - assess for hypo and hypercalcemia - What would you expect to see in both of

these? Monitor serum calcium levels, obtain thorough health history, provide client education.What will you educate the client regarding? When are calcium supplements contraindicated?

Treatment of Osteomalacia (Rickets) Treatment - calcium and vitamin D supplements Adverse effects - because vitamin D is a fat-soluble vitamin it could lead to toxicity if

accumulation occurs.What are the S&S of vitamin D toxicity?

NC -what assessments and client education are needed?

Bone Resorption Inhibitors

Generally the biphosphonate group Uses - treatment of osteoporosis & hypercalcemia (alendronate, etidronate, ibandronate)

calcitonin-salmon can also be used to ↓ pain in clients with cancer that has metastasized to the bones

Bone Resorption Inhibitors - alendronate

Action – inhibits osteoclast activity Uses – treatment & prevention of OP in men, postmenopausal women and those on

corticosteroids (≥ 7.0 mg/day)Think about why these clients are at risk...

Adverse Effects – well tolerated

NC – MUST be taken at least 30’ before food/drink/vitamins/minerals/other meds

o Give with 8oz water, must sit/stand for 30’ post dose

Adjunctive therapy in OP - wt bearing exercise, Ca+, Mg and vitamin D

Arthritis (osteoarthritis, rheumatoid arthritis and gout) mainly treated with analgesics and anti-inflammatory medications. Other drugs are

specific to each type of arthritis. osteo - NSAIDS, cox-2 inhibitors (celecoxib), sodium hyaluronate

rheumatoid - glucocorticoids, hydroxychloroquine, sulfasalazine, methotrexate

gout - indomethacin, cox-2 inhibitors, colchicine, allopurinol

Adverse effects - specific to individual drug classes

NC - pain assessment, monitor for side effects of medications, use of non-pharmacological therapies for arthritis pain management -what are some non-pharmacological therapies?

Chondroitin and glucosamine are two supplements used to treat osteoarthritis. Many other herbs are suggested for the treatment of arthritis including horsetail, yarrow, celery, gotu kola and many others.

TOPIC 18: Miscellaneous Drug Classifications and Review

Learning Objectives:

Upon completion of the class, the learner will be able to:· Define the major classes of drugs used to treat disease\illness in the reproductive system· Identify miscellaneous classifications of drugs and their respective actions and uses: anti

neoplastic agents and medications for eye/ear disorders· Organize research of drugs used to treat diseases\illnesses covered in this topic in a way that

allows for easy and accurate reference.· Identify the main nursing considerations related to these groups of drugs.

Miscellaneous Drug Classifications

Miscellaneous Systems & Meds

1. Antineoplastics – alkylating agents, antimetabolites, hormones2. Meds for eye disorders – timolol

3. Meds for inflammation, fever, allergies

4. Anaphylaxis & medication administration (epinephrine)

5. Meds for skin disorders

Antineoplastics

Goal of chemotherapy is to administer a “dose large enough to be…cytotoxic to cancer cells, but small enough to be tolerable for normal cells” (Clayton & Stock, 2007, p. 716)

Action - interferes with cell’s metabolism at various points in the cell’s life cycle

Chemotherapy is most toxic to rapidly dividing cells (ca cells & some normal cells)

Cytotoxic Meds – alkylating agents (busulfan, cisplatin), antimetabolites (methotrexate), natural products (etoposide, vincristine), antibiotics (daunorubicin), hormones (flutamide), other agents (interferon a)

Agents are often used together in a “protocol” to provide best specific cytotoxic effect

Uses – ca treatment, to control the disease or for palliation to control symptoms

Adverse Effects – nausea, vomiting, diarrhea, bone marrow suppression - with what potential effects?What systems have rapidly dividing cells so will also be adversely affected?

NC for Antineoplastics

Understand the treatment goals What are the possible options?

Monitor - VS, labs – which labs values? Monitor for S/S of infection due to ___________________

Monitor for anemia due to ____________________________________

Monitor for bleeding due to _________________________________

Manage pain and N&V effectively (give analgesics & antiemetics prophylactically as ordered) – how ill you assess effectiveness?

some herbs and supplements can be helpful managing side effects during cancer treatment but others may interfere with treatment. Some of those that may interfere are curcumin and quercetin which are strong anti-cancer flavonoids but they may disrupt the anti-tumor activity of cyclophosphamide.

Drugs for Eye Disorders - NC

Most meds given topically Ointments may block action of other meds

Lacrimal canal must be blocked for 3 - 5 minutes to prevent drainage of medication and subsequent systemic absorptionWhy does it matter?

More than 1 gtt per eye is not advised (separate by 5 minutes prn)

May cause temporary visual disturbance

β adrenergic blocker – timolol

Action – ↓s production of aqueous humour → ↓ IOP

Uses – tx of open-angle glaucoma

Adverse Effects – bradycardia, hypotension, arrhythmia, bronchospasm – how could these occur?

NC – block systemic absorption by teaching client how to compress lacrimal duct x 5 minutes, monitor VS & compare with baselines – why?do not give with cardiovascular stimulants

do not give with epinephrine

Treatment of Inflammation

NSAIDS - ASA, celecoxib, diclofenac, ibuprofen,naproxen

Action - have analgesic, antipyretic, and anti-inflammatory effects. Used for mild to moderate inflammation. Act by inhibiting prostaglandin synthesis. Block inflammation by inhibiting COX-1 and COX-2 preventing them from forming inflammatory prostaglandins.What are the undesirable side effects of blocking COX-1?

Adverse effects - salicylism with high doses of ASA - what does this refer to? Adverse effects of ibuprofen-like NSAIDS include nausea and vomiting.

NC - assess for sensitivity to NSAIDs, presence of bleeding disorders, peptic ulcer disease, anticoagulant drugs or herbs, CHF, fluid retention, heart disease -why? Why should these drugs not be administered to someone with liver dysfunction? What client teaching should you provide?

do not give any herbs that affect blood coagulation with NSAIDs because of their "blood thinning" properties ginko, ginseng,

SYSTEMIC GLUCOCORTICOIDS - prednisone, betamethasone, cortisone Action - suppress histamine release and inhibit the synthesis of prostaglandins by COX-2.

Can inhibit the immune system by suppressing certain functions of phagocytes and lymphocytes.

Use - suppresses severe inflammation

Adverse effects - suppress normal function of adrenal glands - why is this an issue? can also cause hyperglycemia, mood changes, cataracts, peptic ulcers, electrolyte imbalances and osteoporosis; may mask other infections -What may result from masking infection and suppressing the immune system? What might occur in long-term treatment with glucocorticoids?

NC - screen for existing infection, obtain baseline data - what would this be? monitor diabetic clients closely as well as clients with heart failure, hypertension, or renal disease -why?

avoid ginseng when taking prednisone as it may create an additive effect. Also avoid teas meant to stimulate the immune system as the purpose of prednisone is to suppress the immune system. Some of these include astragalus, cat's claw, licorice and echinacea.

Treatment of Fever - antipyretics

NSAIDs and acetaminophen

Use - to decrease fever Acetaminophen is the antipyretic of choice.Why?

NC - assess temp before and after administration of antipyretic. Assess developmental status and baseline lab data -why?

Treatment of Allergy

all allergies are caused by exposure to an antigen which is anything recognized as foreign by the body.

Antihistamines - diphenhydramine Action - block the actions of histamine at the H1-receptor. Use - prevent allergy symptoms from occurring. 

Adverse effects - first generation antihistamines caused CNS depression and significant drowsiness; newer ones generally don't cause drowsiness. Contraindicated in clients with dysrhythmias and heart failure. Also contraindicated in clients with narrow-angle glaucoma because of anticholinergic effects.

NC - monitor for profound sedation and altered consciousness especially in older clients who are at risk of falling and other injuries.

Herbs that may interfere with antihistamines include St. John's wort; caution should be taken with any herbs that may cause drowsiness or CNS depression.

Intranasal Glucocorticoids - fluticasone Action - act locally to treat inflammation. Adverse effects - when applied to broken mucous membranes, systemic effects may

occur. May mask signs of infection in the mouth and throat

NC - assess mucous membranes of the nose, assess for signs of infection, provide education -what will you educate the client about?

Adrenergics - pseudoephedrine Action - stimulate the sympathetic branch of the autonomic nervous system. Use - relieve nasal congestion when given by oral or intranasal route.

Adverse effects - rebound congestion

NC - because of rebound congestion intranasal adrenergics should not be used for longer than 3-5 days. Possibility of systemic side effects is greater with oral adrenergics. Hypertension and CNS stimulation leading to anxiety and insomnia are potential side effects.

Treatment of Anaphylaxis

Occurs in 6% – 10% of clients Allergic response ranges from delayed hypersensitivity with urticaria → anaphylaxis

upon re-exposure

Any allergic S/S must be documented and that drug identified as an allergen for that clientWhy?

Client must be instructed to tell all MDs, nurses, pharmacists, dentists…

Anaphylaxis - epinephrine

Use – anaphylaxis, cardiac arrest, asthmaWhat class of med is this?

Action - binds rapidly to α (vasoconstriction), β1 (cardiac) & β2 (pulmonary) receptors, blocks histamine releaseWith what effects?

Onset of action is route dependent (IV, IM, SC), SC EpiPen onset is 5’-10’

Adverse effects – palpitations, nervousness, tachycardia, flushing, tremors, angina, arrhythmia, hypertension

Do these make sense?What other medications have similar adverse effects?

NC for Epinephrine

Monitor for hypersensitivity – what would you expect? Continuous VS

Monitor for adverse effects (arrhythmia, angina, HR >110, hypertension)

In DM – monitor glucometer for hyperglycemia

In asthma - ↑ HOB, monitor chest/respirations/sputum, monitor for paradoxical bronchospasm

CAUTION!

Fatalities have occurred because nurses chose:

Wrong concentration! Wrong pre-filled syringe!

How could this happen?

How can you ensure you never do this?

Use tuberculin syringe for SC – Why?

Trade names – EpiPen, Adrenalin, Asthma-Haler Mist

Treatment of Skin Disorders

Skin Infections - bacterial, fungal, viral

topical antibiotics - bacitracin, chloramphenicol, gentamicin, neomycin topical antifungals- fluconazole, nystatin, ketoconazole, miconazole

Treatment with scabicides and pediculicides Use - to kill mites and lice Action - lindane is absorbed into lice, mites and their eggs producing seizures and death

Adverse effects - risk of CNS toxicity. If over-applied or accidentally ingested, ct may experience HA, N&V, irritation of nose, ears or throat, dizziness, tremors, restlessness or convulsions.

NC - wear gloves when applying lindane, provide client education re: possible side effects. Educate client and/or family re: non-chemical approaches to treating head lice such as physically removing all lice and eggs.

Treatment of Acne many OTC formulations available - benzoyl peroxide, salicylic acid Action - keratolytic effect - helps to dry out and shed outer layer of skin.

prescription acne treatments include retinoids, antibiotics, ethinyl estradiol

retinoids have an irritant action that decreases comedone formation and increases extrusion of comedones from the skin, others reduce the size of sebaceous glands - tretinoin, isotretinoin.

antibiotics decrease the redness and inflammation associated with acne - doxycycline, tetracycline.

ethinyl estradiol is an estrogen hormone that is sometimes used to treat acne.

Adverse effects -based on what you know about these drugs, what are the adverse effects you should be aware of?Isotretinoin has been linked to an increase in depression and suicidal ideation

NC - many prescription treatments for acne should not be used during pregnancy

TOPIC 19: Final Comprehensive Exam

Prep for Final

Comprehensive Final Pharm Exam December 9/2013 @ 09:00 35% of final grade 

                                                                                 (If you feel that you are not doing well in pharmacology, please make an appointment to see the health sciences tutor asap.)

This following is a summary prepared by Nicole from the last Pharm course!

"This list may not be completely inclusive. Basically, you are responsible for all the course content. I have not listed every classification and every med on this list, but you are responsible for ALL pharmacology content covered during this course."

- Pharmacology/pharmacokinetics/pharmacodynamics

     Pharmacokinetics – what the body does to the drug: absorption,distribution, metabolism, excretion

     Pharmacodynamics – what the drug does to the body.

     Differences between -generic, brand and trade name

     OTC/controlled substances/prescription drugs/drug schedules

     Food and drug act/ drug legislation

     half-life

     abbreviations

     agonist/antagonist/partial agonist

     drug actions and reactions

-Medication administration - types of med admin, routes of med admin, associated terms, 10 rights, 3 checks, MAR, preventing med errors, what to do in case of an error

-Nursing process – how do the components fit in with medication administration?

- Be clear what controlled substances are and understand the differences between controlled substances and prescriptions.

     Know the drug schedules ie what is a schedule 1 drug? others?

- Make sure you know abbreviations ie. bid, tid, qid, prn, stat, qd, MAR, NPO, IM, PO, IV, SC, SL, others?

-Know the function of the MAR and prn record – when are they completed?

-Classifications- actions, uses, side effects, nursing implications, assessments, etc… of all the meds covered in pharm. (make a big chart or drug cards to keep these all straight).

     bowel meds, eye and ear meds as noted in course material - know actions, uses, nursing considerations

     herbal supplements and vitamins - know the common ones listed in the unit - St. John's wort, ginko, black cohosh, feverfew

     Understand the nurse's responsibility when the client is taking herbal supplements.

     Info specific to older adults and med. Admin.

    Effects of aging on absorption, distribution, metabolism, excretion of drugs

     Cholinergics, anticholinergics, adrenergics, etc… which one mimics the parasympathetic nervous system, etc…

     Polypharmacy in the older adult

     Nursing implications, health teaching, safe med admin for the older adult

     Pain control principles, opioids, methadone, NSAIDS

     What assessments need to be done before and/or after administering certain medications? Why?

     Symptoms of toxicity of certain meds

     Are there certain meds you can/can’t give together? Why or why not?

     Lab tests to monitor blood levels of certain meds

     Reasons for using chemo and side effects, etc… of chemotherapy i.e. chemotherapy is used for aggressive cancer treatment and also palliative cancer treatment.

     Side effects of chemo

     S&S of hypo and hyperglycemia

     Onset of different types of insulin, use of sliding scale

     Oral hypoglycemics

     Antitussives, antihistamines, mucolytics, expectorants

ALL MEDS COVERED IN EVERY UNIT!!!!!!

Good luck