Pharmacology

1. Class: antianginal agents

a. type: nitrates i. action arterial, venous, and capillary vasodilation by relaxing vascular smooth muscle o decreases myocardial oxygen consumption o decreases preload with venous pooling o decreases afterload by decreasing peripheral vascular resistance example nitroglycerin (Nitro-bid IV 10-20 mcg/min, titrate according to blood pressure) (Nitrodur 1 transdermal patch daily, remove for 68 hours daily) (Nitro-stat 0.4 mg sublingual

ii.

iii.
iv.

v.

vi.

(SL) tablet under the tongue, may repeat every 5 minutes up to 3 tablets) uses: prophylaxis, treatment, and management of angina, acute myocardial infarction (MI) adverse effects sudden, severe refractory hypotension when taken with sildenafil citrate (Viagra) or tadanafil (Cialis), methoglobinemia, contact dermatitis headache, nausea, vomiting, dizziness reflex tachycardia, postural hypotension contraindications severe anemia, cardiac tamponade cerebral hemorrhage or trauma hypovolemia, hypotension, shock nursing care establish baseline data and monitor during acute angina or IV administration: blood pressure, heart rate, EKG, chest pain may decrease effectiveness of heparin withdraw treatment gradually to avoid angina toxicity: CNS changes, hypotension, flushing, nausea buccal area must be moist for SL absorption may induce alcohol intoxication (without alcohol intake) maintain a 6-8 hour nitrate-free period every 24 hours after acute episode to avoid tolerance client teaching o apply spray under tongue; do not chew tablets o sit down when taking, change positions slowly o report blurred vision or dry mouth, avoid alcohol o keep tablets away from light, moisture, and body heat; change tablets every 6 months o use spray or sublingual tablets for immediate relief; combine drug with rest for acute attack o rotate site of ointment or patch; remove ointment or patch and clean skin for daily nitrate-free period o for acute angina: take 1 tablet (or 1 spray under the tongue) SL every 5 minutes up to three tablets, if not relieved seek emergency

b. type: isosorbide dinitrate, mononitrate i. action vasodilation by relaxing arterial and venous smooth muscle o decreases preload with venous pooling, peripheral vascular resistance, and myocardial oxygen consumption ii. examples isosorbide dinitrate (Isordil 5-40 mg by mouth daily in 4 doses) isosorbide mononitrate (Imdur 10-20 mg by mouth daily in 2 does) iii. uses: maintenance therapy for angina, coronary artery disease (See also: II.A.1.a nitrates: adverse effects, contraindications, nursing care) c. type: beta-adrenergic blocking agents (See also: II.A.4.e beta-adrenergic blocking agents) d. type: calcium channel blocking agents (See also: II.A.4.d calcium channel blocking agents)

2. Class: Anticoagulants
1. Type: oral

i.
ii.

iii.

iv.

v.

vi.

action: interferes with vitamin K dependent clotting factors in the liver resulting in prolonged bleeding time example: warfarin (Coumadin 2.5-10 mg by mouth daily for 2-5 days; then, titrate according to INR) uses: maintenance therapy and prophylaxis to suppress formation of dangerous clots after MI, mechanical heart valve surgery, atrial fibrillation (a fib) and atrial flutter (a flutter), heart failure, DVT, and pulmonary embolism (PE) adverse effects 1. hemorrhage, peripheral skin necrosis 2. bone marrow depression, liver dysfunction 3. anorexia, many drug-drug interactions 4. high-risk drug with older or incompetent clients contraindications 1. clients at risk for falls, malabsorption syndrome 2. severe hepatic or renal disease 3. bleeding disorders and active bleeding 4. recent invasive procedure to spinal cord nursing care 1. establish baseline data and monitor prothrombin time (PT) and international normalized ratio (INR), bleeding, bruising, liver function tests (LFTs), headache, decreased level of consciousness, and risk of falls 2. high risk therapy for older clients in the community

3. apply prolonged pressure to any puncture wounds to stop bleeding 4. administration of vitamin K suppresses warfarin activity for 1-3 weeks: may need to provide alternate anticoagulation 5. client teaching 1. avoid alcohol, NSAIDs 2. use electric razor for shaving 3. seek emergency treatment for falls 4. wear MedicAlert jewelry, monitor for bleeding 5. take at same time daily, need for follow-up care and testing 6. avoid herbal remedies including Echinacea, licorice, and ginseng 7. avoid foods containing vitamin K (decreases effect of warfarin) especially green leafy vegetables, broccoli, and liver 2. type: low-molecular weight (LMW) heparin i. action: blocks action of Factors Xa and Iia without appreciably affecting thrombin or prothrombin ii. examples 1. dalteparin (Fragmin 2500 international units by subcutaneous injection daily) 2. enoxaparin (Lovenox 1-1.5 mg/kg by subcutaneous injection daily) iii. uses: prophylaxis against thromboembolic disorders associated with surgery and bedrest iv. adverse effects 1. hemorrhage, thrombocytopenia, angioedema 2. increased bleeding times and bruising 3. inflammation at injection site, dyspnea, rash v. contraindications 1. recent GI bleed or invasive spinal cord procedure 2. active bleeding, thrombocytopenia, uncontrolled HTN vi. nursing care (See also: II.A.2.a.vi anticoagulants: oral, nursing care) 1. establish baseline data and monitor CBC and platelets 2. does not effect PT, INR, or activated partial thromboplastin time (aPTT) with therapeutic doses 3. lower risk of heparin-induced thrombocytopenia (HIT) than unfractionated heparin

4. give subcutaneously according to manufacturer's direction 5. client teaching: subcutaneous injection technique 3. type: unfractionated heparin i. action: inhibits conversion of prothrombin to thrombin thus preventing fibrin formation ii. example: heparin sodium (Heparin Sodium Lock Flush Solution) iii. uses: acute illness to suppress dangerous clot formation; unstable angina (USA), MI, CVA, DVT, PE, afib and flutter, disseminated intravascular coagulation (DIC) iv. adverse effects 1. HIT, bronchospasm, increased bleeding time 2. rebound hyperlipidemia, fever, chills, rash 3. impairment of endocrine system v. contraindications 1. extensive burns, trauma; severe HTN 2. recent surgery or invasive spinal cord procedure 3. thrombocytopenia, active bleeding, bleeding disorders vi. nursing care (See also: II.A.2.a.vi anticoagulants: oral, nursing care) 1. establish baseline data and monitor aPTT, CBC, and platelets 2. highest risk of HIT 3. adjust dosage when given with nitroglycerin (NTG) 4. high-risk therapy for women, older clients, and with renal or hepatic insufficiency 5. antidote: protamine sulfate (Protamine Sulfate 1.0% 0.5-1 mg IV/100 units of heparin given) 6. client teaching: subcutaneous injection technique 2. Antidysrhythmia agents (aka antiarrhythmia) 1. information common to antidysrhythmia agents i. use 1. eradication of frequent premature ventricular contractions that cause hemodynamic instability or loss of consciousness 2. emergency eradication of ventricular dysrhythmias 3. cardiopulmonary resuscitation 4. chemical cardioversion of atrial and ventricular dysrhythmias

Conduction System of the Heart

adverse effects 1. heart block 2. most are have dysrhythmogenic potential (capable of causing dysrhythmias) 3. prolongation of QTc interval or QRS complex 1. increased risk of torsades des pointes iii. assist HCT to implement client teaching plan 1. count heart rate and pattern of rhythm, i.e., regularity 2. provide acceptable range for heart rate 3. report 1. new onset of irregular rhythm 2. findings outside of acceptable parameters 3. worsening heart rate, dizziness, lightheadedness, loss of consciousness, and edema 2. type: sodium channel blocking agents (Class I antidysrhythmia agents)

ii.

i.
ii.

iii.
iv.

action: suppresses various phases in myocardial cell action potential by blocking sodium channels; stabilizes myocardial cell membrane example 1. lidocaine (Xylocaine 2 mg/min IV infusion: titrate according to frequency of ventricular ectopy) 2. quinidine gluconate (Quinalan 325-650 mg by mouth every 6 hours, 324-660 mg by mouth every 6-12 hours as extendedrelease tabs) 3. procainamide (Pronestyl 500-1000 mg by mouth every 4-6 hours, 1 gram every 12 hours as sustained-release form) uses: ventricular dysrhythmias, chemical cardioversion with a fib and a flutter (except lidocaine) adverse effects 1. dysrhythmias, heart block, torsades de pointes Torsades de Pointe

2. respiratory depression, bone marrow

depression 3. nausea, vomiting, rash 4. increases risk of digoxin toxicity and risk of bleeding with anticoagulants 5. CNS effects including sedation, confusion, and seizures (especially lidocaine) v. contraindications prolonged QTc interval hypotension and shock heart block without pacemaker prolonged therapy, use with cimetidine nursing care establish baseline data and monitor vital signs, EKG, QTc interval, neurological status, drug levels

vi.

prevent client injury: associated with many adverse effects quinidine and procainamide reserved for use after many other therapies have failed client teaching o avoid citrus juices, antacids, and milk products o take heart rate daily: report change in rhythm e. beta-adrenergic blocking agents (Class II antidysrhythmia agents) (See also: II.A.4.3 beta-adrenergic antagonists) f. type: potassium channel blocking agents (Class III antidysrhythmia agents) 1. action: slows the outward movement of potassium through myocardial cell membranes and prolongs the action potential 2. examples i. amiodarone (Cordarone 400 mg by mouth daily) ii. sotalol (Betapace 160-320 mg by mouth daily in 2-3 doses) 3. uses: ventricular and supraventricular dysrhythmias, chemical cardioversion with a fib and a flutter 4. adverse effects i. pulmonary fibrosis, hypotension ii. heart failure, heart block, sinus arrest, liver damage iii. nausea, vomiting, dizziness, weakness, photosensitivity 5. contraindications i. prolonged QTc interval ii. concomitant use with quinidine or procainamide iii. severe liver disease, heart block, cardiogenic shock 6. nursing care i. establish baseline data and monitor vital signs, EKG, hepatic, pulmonary, endocrine, neurological, and GI function ii. follow oral and IV administration guidelines: timing and rates of infusion are very important iii. client teaching 1. avoid taking with echinacea 2. need for follow-up care and testing 3. protect skin and eyes from UV rays 4. monitor pulse and report changes in rhythm

5. may take with meals but must be

consistent 2. type: anticholinergic agent (See also: II.C.2.iii anticholinergics) 1. action: competes with acetylcholine for muscarinic receptor sites to produce mild vagal excitation 2. example: atropine (!high alert drug) (Atropine 0.51 mg up to 2 mg) 3. use: bradycardia associated with increased vagal tone 4. adverse effects i. paradoxical bradycardia with subtherapeutic dosing; angina, tachycardia ii. anticholinergic effects

iii. atropine flush 15-20 minutes after injection 3. type: acetylcholine-sensitive K+ current activator 1. action: shortens duration of action potential, causes hyperpolarization, and slows normal automaticity 2. example: adenosine (Adenocard 6 mg rapid IV bolus, may administer 12 mg rapid IV bolus in 1-2 minutes) 3. use: chemical conversion of supraventricular tachycardia after failure of vagal maneuver 4. adverse effects i. transient asystole, dysrhythmias ii. dyspnea, chest tightness, hypotension, flushing, nausea

5. contraindications: 2nd or 3rd degree AV block, sick

sinus syndrome, cardiac transplant 6. nursing care i. establish baseline data and monitor continuously during therapy: EKG, heart rate, blood pressure, respiratory rate ii. monitor serum electrolytes Therapeutic class: antihypertensive agent types:

4. Antihypertensive agents
a. information common to antihypertensive agents i. uses: heart failure, primary and secondary HTN ii. adverse effects orthostatic hypotension, reflex tachycardia, bradycardia dizziness, weakness, sexual dysfunction nausea, vomiting, diarrhea, anorexia, and constipation iii. contraindications severe deficiencies in serum electrolytes heart block, pediatrics, hypovolemia iv. nursing care establish baseline data and monitor blood pressure, K+, fluid and electrolyte balance, renal function older clients more susceptible to toxicity, labile hypotension, and orthostatic hypotension

client teaching o avoid OTC drugs, change positions slowly o finding recognition o take medication only as directed, when feeling well, and if blood pressure is controlled (indicates that the therapy is effective) o therapy most effective when combined with weight loss, smoking cessation, and an active lifestyle

b. type: ace inhibitor (ACEI) i. action: inhibits conversion of angiotensin I to angiotensin II in the lungs preventing vasoconstriction from angiotensin II and the release of aldosterone ii. examples

enalapril (Vasotec 10-40 mg twice daily by mouth, initiate therapy at 2.5-5 mg) lisinopril (Zestril 20-40 mg daily by mouth, initiate therapy at 2.5-5 mg) iii. uses: HTN and heart failure iv. adverse effects refractory cough, hyperkalemia rash, renal and hepatic injury v. contraindications: hyperkalemia and renal insufficiency vi. nursing care (See also: II.A.4.a.iv information common to antihypertensive agents) administer on empty stomach client teaching o take 1 hour before and 2 hours after eating o avoid salt substitutes containing potassium o increased risk of hypersensitivity if given with allopurinol c. type: angiotensin II-receptor blocker (ARB) i. action: binds to angiotensin II receptors to block vasoconstriction and release of aldosterone ii. examples losartan (Cozaar 50-100 mg by mouth daily in 1-2 doses) valsartan (Diovan 160-320 mg by mouth twice daily) iii. uses: HTN and heart failure iv. adverse effects: hyperkalemia v. nursing care (See also: II.A.4.a.iv information common to antihypertensive agents) relatively few drug-drug interactions client teaching: may take with food, avoid salt substitutes containing potassium d. type: calcium channel blocker (CCB) i. action: block movement of calcium into muscle cell ii. examples amlodipine (Norvasc 5-10 mg by mouth daily) diltiazem (Cardizem 30-120 mg by mouth 34 times daily, Cardizem SR 180-240 mg by mouth daily) verapamil (Calan XR 120-240 mg by mouth daily; IV 5-10 mg/kg, may repeat with 10 mg in 15-30 minutes) iii. uses: HTN, angina, and dysrhythmias iv. adverse effects precipitous hypotension heart block and heart failure

venous pooling, peripheral edema hypotensive effect of diltiazem potentiated with cycloSPORINE v. contraindications: heart block and sick sinus syndrome vi. nursing care (See also: II.A.4.a.iv information common to antihypertensive agents) client teaching: do not take with grapefruit juice e. type: beta-adrenergic blocking agents (antagonists) i. action: selective (beta1-adrenergic receptors) and non-selective (beta1- and beta2-adrenergic) blockers of the sympathetic nervous system (SNS) resulting in slower heart rate decreased vasoconstriction decreased myocardial oxygen consumption ii. examples selective blockers o atenolol (Tenormin 50-100 mg by mouth daily; IV 5 mg, may repeat 2 times) o metoprolol (Toprol 100-450 mg by mouth 1-2 times daily; IV 5 mg every 2 minutes for 3 doses) non-selective blocker o propranolol (Inderal 80-240 mg by mouth in 2-4 divided doses daily; IV 1-3 mg, may repeat in 2 minutes) iii. uses: heart failure, hypertension, heart rate control, angina, and migraine headache prophylaxis iv. adverse effects bradycardia, heart block, heart failure, hypotension depression, decreased exercise tolerance suppresses clinical indicators of hypoglycemia bronchospasm (not as common with cardioselective forms) v. contraindications thyrotoxicosis, diabetes mellitus (DM) peripheral vascular disease (PVD) chronic obstructive pulmonary disease (COPD) vi. nursing care (See also: II.A.4.iv information common to antihypertensive agents) establish baseline data and monitor breath sounds and peripheral perfusion

avoid concomitant use of clonidine and nonsteroidal anti-inflammatory drug (NSAID) taper dose before discontinuing, do not discontinue before surgery check with provider for administration limits for heart rate and blood pressure client teaching: take pulse or blood pressure before administration f. type: combined alpha and beta-adrenergic blocking agents i. action: blocks all SNS receptors and inhibits release of epinephrine (Epi) and norepinephrine (NE) resulting in decreased vasoconstriction, slower heart rate, and increased renal perfusion ii. examples carvedilol (Coreg 6.25-25 mg twice daily by mouth, increase dose in 2 weeks intervals) labetalol (Normodyne 400-800 mg 2-3 times daily by mouth) guanethidine (Ismelin 25-50 mg daily by mouth) iii. uses: heart failure, HTN secondary to renal failure, refractory HTN iv. adverse effects cerebrovascular accident (CVA), bronchospasm, pulmonary edema serious dysrhythmias when combined with CCBs masks signs of hypoglycemia impaired peristalsis, decreased exercise tolerance v. contraindications: heart block, acute asthma, DM, and shock vi. nursing care (See also: II.A.4.a.iv information common to antihypertensive agents) establish baseline data and monitor for heart block, bronchospasm, pulmonary edema, and liver failure taper dose before discontinuing g. type: alpha-adrenergic blocking agents i. action: non-selective blocker of alpha-adrenergic receptors (of SNS) ii. examples: phentolamine (Regitine 5 mg IV bolus, then 0.5-1 mg/min; subcutaneously 5-10 mg) iii. uses: HTN associated with pheochromocytoma, extravasation of epinephrine and dopamine iv. adverse effects angina and myocardial infarction (MI), CVA, profound hypoglycemia nausea, vomiting, and diarrhea

contraindications: coronary artery disease (CAD) and MI vi. nursing care potentiated by alcohol; suppressed with epinephrine and ephedrine h. type: alpha1-blocking agents i. action: blocks alpha1-receptors of SNS ii. examples prazosin (Minipress 6-15 mg by mouth daily in divided doses, not to exceed 40 mg in divided doses) terazosin (Hytrin 1-5 mg by mouth daily in 2 doses, not to exceed 20 mg daily in 2 doses) tamsulosin (Flomax 0.4-0.8 mg by mouth daily after meals) iii. uses: hypertension, benign prostatic hypertrophy (BPH) iv. adverse effects: angina, priapism, headache, peripheral edema v. contraindications: hepatic and renal failure; do not take with sildenafil (Viagra) or tadalafil (Cialis) vi. nursing care (See also: II.A.4.a.iv information common to antihypertensive agents): provide small frequent meals to manage GI discomfort

v.

i. type: alpha2- agonists

action: displaces NE and stimulates alpha2receptors of SNS resulting in decreased release of norepinephrine in the periphery ii. example: clonidine (Catapres 0.1-0.6 mg by mouth (twice daily), transdermal daily over 1 week) iii. uses: HTN, chronic pain related to cancer iv. adverse effects bradycardia dry mouth, sedation nausea, vomiting, anorexia, headache, urinary retention v. contraindications narrow-angle glaucoma vasospastic disease thyrotoxicosis or DM vi. nursing care (See also: II.A.4.a.iv information common to antihypertensive agents) taper dose before discontinuing do not discontinue before surgery do not administer with tricyclic antidepressants or propranolol type: centrally acting vasodilators i.

j.

i. ii. iii. iv.

v. vi.

vii.

action: directly relaxes arteriolar vascular smooth muscle resulting in lowered peripheral vascular resistance and reflex tachycardia example: hyrALAZINE (Apresoline 200-300 mg by mouth daily divided in 4 doses) (do not confuse with hydrOXYzine) uses: acute hypertension associated with pregnancy, essential hypertension adverse effects shock, myelosuppression, reflex tachycardia, angina headache, tremors, dizziness, peripheral neuritis anorexia, paralytic ileus, rash, nasal congestion, flushing contraindications: maternal bleeding, CAD, mitral valve disease nursing care establish baseline data and monitor FHTs, maternal blood pressure, heart rate, EKG, breath sounds, CBC, weight, edema administration o give orally with food o hypertension in pregnancy: given IV bolus, monitor vital signs every 15 minutes client teaching o report chest pain, severe fatigue, muscle or joint pain o avoid OTC drugs o change positions slowly type: diuretics (See also: II.H.1 diuretics)

5. Antilipid agents i.

ii.
iii.

iv.
v.

vi.

type: bile acid sequestrants action: bind with bile acid in small intestine leading to decreased absorption and increased excretion of fat in stool example: cholestyramine (Questran 4-20 grams by mouth once or twice daily) uses: in combination with low fat diet to lower serum lipids, primary hypercholesterolemia, and elevated low-density lipoprotein (LDL) adverse effects increased bleeding time headache, nausea, constipation decreased absorption of fat-soluble vitamins contraindications bleeding disorders, biliary obstruction

vii.

post-cholecystectomy, abnormal bowel function nursing care bowel sounds administering, serum lipids, bowel pattern, bleeding prevent constipation, monitor: vitamin deficiency and increased bleeding times administration o do not crush or chew tablets o give with food; do not administer in dry form o administer 1 hour before or 4-6 hours after thiazide, diuretics, digoxin, warfarin, thyroid hormone, or glucocorticoids

client teaching o must take with food o report bleeding, muscle pain o prevent constipation with increased fluids, fiber, and physical activity c. type: HMG-COA reductase inhibitors (statins) 1. action: controls final step in cholesterol formation by blocking formation of cellular cholesterol leading to decreased serum cholesterol and slightly increased highdensity lipoproteins (HDL) 2. examples daily) simvastatin (Zocor 5-10 mg by mouth daily at bedtime) rosuvastatin (Crestor 5-10 mg by mouth daily) 2. uses: hypercholesterolemia, arteriosclerosis, and DM in combination with low-fat diet and exercise 3. adverse effects increased risk of rhabdomyolysis when given with erythromycin, cyclosporine, antifungal agents, and other antilipid drugs, and with higher doses cataracts, liver and renal dysfunction flatulence, abdominal cramping, nausea, and vomiting increases estrogen level when taking oral contraceptives increased risk of toxicity when given with digoxin or warfarin
atorvastatin (Lipitor 20-40 mg by mouth

4. contraindications alcoholism, allergy to fungus active liver disease, impaired endocrine function 5. nursing care establish baseline data and monitor liver and renal function tests, LDLs, HDLs, muscle pain, vision administer at bedtime, may take with food client teaching o promptly report vision changes, muscle pain o monitor for bleeding, dark urine, and dark stool o maintain regular follow-up care and testing o most effective when combined with lifestyle changes including low-fat diet, weight loss, high-fiber diet, and exercise

c. type: fibrates

action: decreases synthesis of hepatic LDLs and cholesterol examples o clofibrate (Atromid-S) o gemfibrozil (Lopid 600 mg by mouth twice daily) uses: familial hypercholesterolemia not responding to diet and other therapy adverse effects: rhabdomyolysis contraindications: concomitant use with statins nursing care o establish baseline data and monitor serum lipids, muscle pain, LFTs, RFTs action: inhibits release of fatty acid from adipose tissue, improves removal of triglycerides from plasma example: niacin (Niaspan 1-2 grams three times daily) uses: hyperlipidemia not responding to diet and weight loss adverse effects o increases serum uric acid level

d. type: niacin

intense cutaneous flushing, nausea, and abdominal pain nursing care o establish baseline data and monitor serum lipids, uric acid, joint pain o give at bedtime o often combined with bile acid sequestrants, but administer 4-6 hours after the bile acid sequestrants
o

e. type: LDL absorption inhibitors i. action: inhibits absorption of lipids from small intestines ii. example: ezetimibe (Zetia 10 mg by mouth daily) iii. uses: to decrease serum levels of cholesterol, LDLs, and triglycerides, and to increase HDLs in hypercholesterolemia iv. adverse effects sinusitis, muscle and back pain abdominal pain, diarrhea effect greatly increased when given with cyclosporine v. contraindications: liver disease or unexplained increase in LFTs vi. nursing care establish baseline data before initiating therapy and monitor during treatment: LFTs, lipid levels, muscle pain, bowel pattern do not give with HMG-COA reductase inhibitors (statins) client teaching o take with or without food o most effective when combined with low-fat diet and weight loss 6. Antiplatelet agents a. type: aspirin

vii.
viii.

ix.

x.

action: inhibits prostaglandin formation examples: acetylsalicylic acid (Bayer 81325 mg by mouth daily) uses: prophylaxis against ischemic attacks in brain and heart, to decrease risk of death or MI in clients with angina; also classified as antipyretic, nonsteroidal anti-inflammatory drug (NSAID), and analgesic adverse effects

xi.

xii.

bleeding and bruising, tinnitus, GI upset and erosion hemolytic anemia contraindications asthma, sensitivity to other NSAIDs history of GI bleeding, bleeding disorders within 10 days of invasive procedure or surgery children <14 years-old due to risk of Reyes syndrome nursing care may take with food to decrease GI complaints establish baseline data and monitor for toxicity: muffled hearing and tinnitus; bleeding times increased risk of toxicity in clients with asthma, nasal polyps, and allergic rhinitis client teaching o avoid use with fever-few, garlic, ginger, and ginkgo due to increased bleeding times o report to provider and discontinue use with persistent ringing or buzzing in the ears, impaired hearing, dizziness, or bleeding o take with plenty of fluids

b. type: adenosine diphosphate inhibitor i. action: inhibits platelet aggregation by preventing adenosine diphosphate binding to platelet receptor ii. example clopidogrel (Plavix 75 mg by mouth daily) ticlopidine (Ticlid 250 mg by mouth twice daily with food) iii. uses: secondary prevention of MI, CVA, and unstable angina; established PVD iv. adverse and side effects myelotoxicity, thrombotic thrombocytopenic purpura chest pain, edema, HTN flu-like findings, headache, dizziness, rash epistaxis v. contraindications closed head bleeding or injury history of bleeding or bleeding disorder vi. nursing care establish baseline data and monitor platelet count, lipids discontinue 7-10 days before surgery protect medication from light

client teaching o increased bleeding effect with anticoagulants, NSAIDs, feverfew, garlic, ginger, and ginkgo c. type: non-nitrate vasodilator (See also: II.A.10 vasodilators) 7. Diruetics (Additional Information diuretics II.H.1) 8. Positive inotropes: improve myocardial contractility and cardiac output

a. type: cardiac glycoside i. action: slows A-V conduction, improves cardiac ii. iii.
iv. output, and improves myocardial contractility example: digoxin (Lanoxin 0.125-0.25 mg by mouth daily) uses: heart failure, ventricular rate control in atrial fibrillation (a fib) and atrial flutter (a flutter) adverse effects bradycardia, heart block, dysrhythmias xanthopsia, muscle weakness nausea, vomiting, diarrhea, and anorexia contraindications ventricular fibrillation

v.

Ventricular Fibrillation

Ventricular Tachycardia

heart block hypokalemia vii. nursing interventions establish baseline data and monitor heart rate, intake and output, serum potassium check if heart rate is within parameters established by provider, usually >50 bpm monitor for toxicity o therapeutic range 0.8 to 2.0 ng/ml o pediatrics: dysrhythmias o adults: visual disturbances, nausea and vomiting, anorexia o older clients: higher risk of toxicity client teaching o take medication as prescribed o avoid St. Johns Wort, licorice, ginseng o take heart rate daily before administration o perform daily weight: report > 2 pound increase in 24 hours o finding recognition: irregular pulse or change in rhythm, heart rate < 60 bpm 2. type: phosphodiesterase inhibitor vi. action: blocks action of phosphodiesterase leading to increased myocardial contractility and vasodilation, increased myocardial oxygen consumption, and dysrhythmias vii. examples: inamrinone (Inocor) and milrinone (Primacor) viii. uses: IV therapy for heart failure unresponsive to digoxin, diuretics, and vasodilators; bridge to transplantation ix. adverse effects lethal ventricular dysrhythmias chest pain, hypotension nausea, vomiting, anorexia x. contraindications acute MI, hypovolemia, severe heart valve disease allergy to bisulfites xi. nursing care

establish baseline data and monitor vital signs and (EKG), platelets, fluid balance, BNP administration: protect drug from light, administer in large bore catheter client may be maintained on therapy at home client teaching o establish reliable emergency response for cardiac arrest, unstable angina, syncope, or change in level of consciousness (LOC) o long-term IV therapy

9. Thrombolytics a. action: binds with plasminogen to dissolve thrombi (clots) in coronary arteries within 4 to 6 hours of myocardial infarction. Activated conversion of plasminogen to plasmin. Plasmin is able to break down clots (fibrin). b. examples i. streptokinase (Streptase) ii. urokinase (Abbokinase) c. uses i. myocardial infarction ii. deep venous thrombosis iii. pulmonary embolism iv. thrombosed intravenous catheters d. contraindications i. CNS neoplasms ii. active bleeding or severe hypertension iii. cerebral embolism, thrombosis, hemorrhage iv. recent arterial diagnostic procedure or surgery v. recent major surgery, trauma, invasive spinal procedures e. adverse side effects i. bleeding ii. reperfusion injury, dysrhythmias iii. allergic reactions: urticaria, itching, flushing headache f. nursing interventions i. monitor CBC, coagulation studies, and hypersensitivity ii. monitor for bleeding (overt and occult, abdominal girth) iii. keep available: aminocaproic acid (fibrinolysis inhibitor) iv. avoid IM injections prior to administration v. monitor neurological status, reperfusion injury, and dysrhythmia

10. Vasodilators a. type: non-nitrate i. action: coronary artery vasodilation with action similar to papaverine; antiplatelet properties and mild positive inotrope ii. example: dipyridamole (Persantine 225-400 mg by mouth in 3-4 doses daily) iii. uses reduce need for nitrates peripheral vascular disease (PVD) adjunct for thallium stress test prevention of postoperative thromboembolic complications iv. adverse effects: usually dose related; headache, dizziness, peripheral vasodilation, nausea, and vomiting v. nursing care establish baseline therapy and monitor blood pressure therapeutic effect may take 2-3 months to appear client teaching: change positions slowly b. type: peptide hormone, synthetic i. action: inhibits anti-diuretic hormone (ADH) to increase urine output and relaxes vascular smooth muscle ii. example: beta-natriuretic hormone, nesiritide (Natrecor 0.1 mcg/kg/min titrate to cardiac output) iii. adverse effects hypotension, dysrhythmias insomnia, dizziness, confusion fever, abdominal pain, pruritus, rash iv. contraindications cardiogenic shock or PAP, PCWP cardiac tamponade or constrictive pericarditis v. nursing care establish baseline data and monitor vital signs, PCWP, cardiac output, fluid and electrolyte balance, and urine output continuously during therapy monitor serum creatinine extremely expensive, made from recombinant DNA solution is extremely dilute; very carefully calculate mcg/kg/min; requires loading dose c. type: nitrate (See also: II.A1.a antianginal agents) d. type: calcium channel blockers (See also: antihypertensives II.A.4.d) 11. Vasopressors

a. type: alpha- & beta-adrenergic agonists, sympathomimetic

agents

i.

ii.

action: increases heart rate, vasoconstricts peripheral vessels to increase blood pressure, and dilates renal and splanchnic vessels to improve perfusion via stimulation of sympathetic nervous system; opposite action of alpha- or beta-blockers> examples dopamine hydrochloride, see Agents used as vasopressors (Intropin 0.5-10 mg/kg/min IV titrated to blood pressure)

iv. v.

norepinephrine bitartrate (Levophed 2-30 mcg/min IV titrated according to blood pressure and vasoconstriction) epINEPHrine (Adrenalin 1 mg IV bolus every 3-5 minutes in cardiac arrest) (See also: bronchodilators: epINEPHrine II.B.1) uses: improve cardiac output and perfusion of vital organs in shock states and profound hypotension adverse effects angina, dysrhythmias, vasoconstriction, necrosis impairs glucose metabolism (epi)

nausea, vomiting, headache disproportionate increase in diastolic blood pressure vi. contraindications: pheochromocytoma, PVD, hypovolemia, tachydysrhythmias vii. nursing care establish baseline data and monitor o blood pressure, heart rate, and rhythm every 15 minutes o peripheral perfusion, urine output, chest pain infuse in central venous catheter with infusion pump, protect infusion from light solution is very dilute (epi): carefully calculate dosage, based on mcg/kg of body weight/minute antidote for extravasation o stop infusion and remove IV tubing o phentolamine mesylate 10-15 ml subcutaneously into affected tissue c. type: beta-agonist, sympathomimetic agent

action: selectively stimulates cardiac beta1adrenergic receptors; primarily increases cardiac output; increases blood pressure without concomitant increase in heart rate example o dobutamine hydrochloride (Dobutrex 2.5-15 mcg/kg IV titrated to blood pressure, cardiac output) o isoproterenol (Isuprel 2-6 mcg/kg IV titrated to blood pressure and heart rate) uses: cardiogenic shock, preparation for pediatric cardiac catheterization adverse effects o HTN, tachydysrhythmias, vasoconstriction o angina, nausea, vomiting contraindications: tachydysrhythmias, idiopathic subaortic stenosis nursing care o establish baseline data and monitor cardiac output, peripheral perfusion, urine output, chest pain o monitor blood pressure, heart rate, and rhythm every 15 minutes o control with infusion pump: carefully calculate dosage based on mcg/kg of body weight/minute

o o o

infuse in central venous catheter antidote for extravasation: stop infusion, remove IV tubing increased risk of peripheral vasoconstriction when given with beta-adrenergic blockers

c. type: alpha-agonist action: direct stimulation of SNS resulting in vasoconstriction example: phenylephrine (Neo-Synephrine 100-180 mcg IV, may repeat initial dose every 10-15 minutes) use: profound hypotension adverse effects o dysrhythmias, tachycardia, gangrene, anaphylaxis o headache, dizziness, weakness, anxiety, tremor o insomnia, nausea, vomiting contraindications o narrow-angle glaucoma, pheochromocytoma o ventricular fibrillation, tachydysrhythmias, HTN, peripheral vascular disease nursing care o establish baseline data and monitor blood pressure, heart rate, EKG, urine output, fluid volume status, ventricular filling pressures B. Managing respiratory conditions

1. Bronchodilators

a. information common to bronchodilators

action: most effective agents are short-acting beta adrenergic agonists causing direct relaxation of bronchial smooth muscle ii. nursing care encourage smoking cessation therapy establish baseline data and monitor throughout therapy o breath sounds, oxygen saturation (SaO2) o vital signs and EKG iii. client teaching report worsening findings avoid caffeine and OTC drugs eat small, frequent meals to ameliorate GI upset take medication only as directed; do not take extra doses client teaching: use of delivery method: oral, meter-dose inhaler (MDI), nebulizer b. type: adrenergic agonist (sympathomimetic) i. action stimulates and enhances SNS effects to relax bronchial smooth muscle may increase rate and depth of respirations inhibits release of inflammatory mediators (short-term effect) ii. examples: short-acting o type: alpha1- and beta2-adrenergic agonists, non-selective adrenomimetic 1. epINEPhrine (Adrenalin, Primatene Mist*) (See also: II.A.11.a vasopressors: alpha- & beta-adrenergic agonists, sympathomimetic) 2. isoproterenol (Isuprel) (See also: II.A.11.b vasopressors: beta-agonist, sympathomimetic agents) 3. terbutaline** (Brethine) 4. ritodrine (Yutopar) (See also: III.C.2.b.2 tocolytic agents) o type: beta2-adrenergic agonists, selective adrenomimetic 1. albuterol **(Proventil 2 inhalations via metered-dose inhaler every 4-6 hours) (See also: I.D.5.a metered-dose inhaler)

i.

2. metaproterenol** (Alupent) 3. levalbuterol (Xopenex 0.631.25 mg via nebulizer every 6-8 hours)

long-acting o salmeterol (Serevent 50 mcg inhaled as dry powder every 12 hours)

iii.

uses

acute bronchospasm, anaphylaxis (epi) asthma, chronic bronchitis, and COPD prophylaxis for exercise-induced asthma iv. adverse effects desired effect lost when dose exceeds therapeutic level leading to o angina, dysrhythmia, increased myocardial oxygen consumption o hypertension, peripheral vasoconstriction, hypoperfusion to non-vital organs o *associated with tachydysrhythmias, hypertension, death impaired glucose metabolism (epi) tremor, nervousness, insomnia v. contraindications peripheral vascular disease (PVD) diabetes mellitus, hyperthyroidism unstable angina, hypertension, cardiac disease vi. nursing care establish baseline data and monitor breath sounds, SaO2 and vital signs ** available in oral therapy small frequent meals to ameliorate nausea, vomiting, anorexia client teaching o take before other inhaled medications and 30-60 minutes before exercise o report chest pain or palpitations o avoid OTC drugs, stimulants including caffeinated beverages and dark chocolate, Primatene Mist (may result in death) c. type: xanthines i. actions stimulates the SNS: acts directly on bronchial smooth muscle to dilate airways and on medulla in brainstem to increase rate and depth of respirations

inhibits release of inflammatory mediators in anaphylaxis ii. examples caffeine aminophylline (Truphylline up to 13 mg/kg or 900 mg/day given in 3 doses) theophylline (Slo-bid) iii. uses: bronchospasm, asthma, COPD, chronic bronchitis, anaphylaxis iv. adverse effects respiratory arrest, hypotension and seizures indicative of toxicity dizziness in older clients palpitations, dysrhythmias nausea, anorexia, vomiting, insomnia, nervousness, headache v. contraindications CAD and heart failure ischemic cardiomyopathy severe liver or kidney disease vi. nursing care monitor drug levels: has narrow therapeutic range at 10-20 mcg/ml do not exceed administration rate of 20 mg/min dilute in 5% dextrose in water less effective with smoking and St. Johns Wort client teaching o maintain consistent diet o avoid charcoal-broiled food o take at the same time everyday o drink plenty of caffeine-free beverages d. type: anticholinergic i. action blocks muscarinic receptors, Ach release, and stimulation of vagus nerve results in bronchodilation, diminished secretions, low CNS effect less inhibitory effect on mucociliary clearance parasympatholytic, acts like atropine sulfate ii. examples ipratropium bromide (Atrovent, inhaler 1-4 inhalations 3-4 times daily, not to exceed 24 inhalations in 24 hours) tiotropium bromide, long duration of action (Spiriva, inhaler 18 mcg daily) iii. uses

iv.

v. vi.

COPD prophylaxis for bronchospasm; maintenance therapy for chronic bronchitis; allergic rhinitis not rescue therapy, less effective for asthma adverse effects worsening of narrow-angle glaucoma dry mouth, blurred vision, constipation, urinary retention, cough contraindications narrow-angle glaucoma acute bronchospasm nursing care establish baseline data and monitor urine output client teaching o not for use in acute bronchospasm o wait 5 minutes before administering other inhaled medications or as directed by provider o wait 30-60 seconds between puffs, rinse mouth after each treatment

2. Mucolytics and expectorants

a. mucolytics i. action: thins respiratory secretions by splitting disulfite bonds in secretions; mobilizes secretions ii. type: acetylcysteine (Mucomyst 70 mg/kg every 4 hours for 18 doses) iii. uses clients having difficulty with mobilizing and coughing up secretions COPD, cystic fibrosis, pneumonia acetaminophen overdose iv. adverse effects GI upset stomatitis, rash, bronchospasm v. contraindications acute bronchospasm, esophageal varices peripheral vascular disease vi. nursing care as mucolytics: give by nebulizer as antidote for acetaminophen poisoning: direct instillation, dilute with sterile water for injection most effective when combined with adjunct therapy: encourage ambulation plus coughing and deep breathing b. expectorants

i.

ii.
iii.

iv. v.

action: liquefies respiratory secretions by decreasing the surface tension type: guaifenesin (Robitussin 200-400 mg by mouth every four hours) uses clients having difficulty mobilizing and coughing up secretions dry, nonproductive cough common cold, acute bronchitis, influenza adverse effects low side effect profile GI upset, allergy, headache nursing care identify and resolve etiology of cough establish baseline data and monitor appearance and amount of secretions most effective when combined with adjunct therapy: encourage ambulation, coughing and deep breathing client teaching o guaifenesin found in many OTC combination products: avoid using combination products for expectorant o must be given with plenty of water to be effective o avoid dairy products and caffeinated beverages

3. Antitussive a. type: narcotic [opioid] i. action: cough suppression by depression of cough

ii. center in medulla of brainstem, similar to morphine; moderate histamine releasing action example codeine 30-60 mg by mouth every 4-6 hours hydrocodone bitartrate (Vicodin 5 mg by mouth every 4-6 hours) uses gold standard for cough suppression cough due to pharyngitis, sinusitis, and pneumonia analgesia, analgesia for head injuries, cranial surgery adverse effects dizziness, dependence sedation, over-stimulation constipation, nausea, rash increased viscosity of secretions respiratory depression (weakest of the opioids)

iii.

iv.

contraindications clients who need to cough: asthma, postoperative thoracic surgeries vi. nursing care establish baseline data and monitor level of consciousness, respiratory rate, bowel movements, temperature provide adjunct therapy to relieve cough: expectorants, fluid, humidification, lozenges client teaching o take only as directed o change positions slowly; ask for help before getting up and avoid dangerous activities until full effects of treatment are well established o take with food to avoid nausea o drink fluids, increase fiber in diet, ambulate, and establish personal bowel habits to prevent constipation b. type: non-narcotic i. benzonatate action: cough suppressant without suppression of respiratory center at therapeutic doses; acts like tetracaine hydrochloride example: benzonatate (Tessalon 300-600 mg by mouth three times daily) uses: acute and chronic respiratory condition to decrease frequency and intensity of cough adverse effects o low side effect profile o drowsiness, sedation headache o nausea, constipation, rash nursing care o establish baseline data and monitor appearance and amount of secretions o client teaching 1. swallow soft capsules whole: if dissolves in the mouth, may suppress gag reflex 2. store capsules in air tight container ii. dextromethorphan action: cough suppression by depressing the medulla; in therapeutic doses comparable to codeine but without CNS depression and analgesia, much less likely

v.

to cause constipation, drowsiness, or GI upset examples: dextromethorphan hydrobromide (Benylin DM, Robitussin DM up to 120 mg/day in divided doses) uses: temporary relief of cough spasms in nonproductive coughs adverse effects o GI upset, constipation o dizziness and drowsiness, especially in older clients o hyperexcitability, especially in children contraindications: children < 2 years-old, asthma, productive cough, hepatic dysfunction nursing care o humidify air client teaching o report cough lasting > 7-10 days o do not crush or chew extended release forms o avoid irritants, should not completely suppress cough o do not overdose dextromethorphan by taking combination product 4. Type: antituberculosis agents a. general antituberculosis agents i. actions: bacteriostatic or bactericidal anti-infective agents for treatment of Mycobacterium tuberculosis infection ii. examples first-line therapy second-line therapy iii. use: used in combination with other antituberculosis agents; none indicated for monotherapy iv. adverse effects hepatotoxicity, nephrotoxicity, myelosuppression nausea, vomiting, anorexia, abdominal pain many drug-drug interactions with other therapies and antituberculosis agents v. contraindications hepatic or renal dysfunction seizure disorder and neuritis vi. nursing care establish baseline data and monitor o sputum cultures, liver function tests (LFT) o CBC, PT

o BUN and creatinine (RFTs) review drug-drug interactions for incompatibility M. tuberculosis eradicated after three negative sputum cultures in a row o client teaching 1. report

- worsening symptoms, return of fever - rash, decreased urine output, edema, weight gain - dyspnea, hallucinations, jaundice
o o o o

avoid alcohol take as directed with plenty of fluids change positions slowly when altering dosages duration of therapy months to years; need for long-term care and followup testing continue taking antituberculosis therapy until instructed to stop; continue therapy when feeling good and when noncontagious

b. first-line therapy i. isoniazid (INH 15 mg/kg up to 900 mg by mouth, IM 2-3 times weekly) action: bacteriostatic agent that interferes with DNA of M. tuberculosis use: highly specific treatment for tuberculosis infection; usually included in antituberculosis pharmacotherapy adverse effects o agranulocytosis o visual disturbances, connective tissue syndromes o paresthesias and peripheral neuropathy o impaired vitamin absorption and glucose metabolism contraindication: acute liver dysfunction nursing care o establish baseline data and monitor blood sugar

ii.

administer on empty stomach, 1 hour before or 2 hours after meals; may give by deep IM injection o client teaching 1. monitoring blood sugar 2. avoid foods with histamine: skip-jack tuna, sauerkraut juice, yeast extract 3. report tingling, numbness, or burning of extremities: may indicate toxicity 4. avoid foods with tyramine: aged cheese, cured meat, smoked fish rifampin (Rifadin 10 mg/kg by mouth, IV 2-3 times weekly) action: inhibits RNA synthesis in M. tuberculosis adverse effects o hepatorenal syndrome o pseudomembranous colitis, heartburn contraindications o meningococcal disease o obstructive biliary disease o intermittent therapy with rifampin: significantly increases risk of developing drug resistant organisms and hepatorenal syndrome
o

nursing care o monitor PT o use oral form for pediatrics o client teaching

iii.

report bleeding or bruising do not interrupt prescribed drug regimen benign staining of excreted body fluids and stool ethambutol (Myambutol 15-25 mg/kg by mouth 2-3 times weekly) action: inhibits RNA synthesis adverse effects: anaphylaxis, color blindness, retrobulbar neuritis contraindication: optic neuritis nursing care o encourage regular eye exams o establish baseline data and monitor uric acid level

optic toxicity appears within first 7 months of therapy; usually disappears after therapy is discontinued o client teaching report decreased urine output, edema and weight gain iv. streptomycin (See also: II.K.5.b.1 antibiotics: aminoglycosides)(Streptomycin 1 gram IM 2-3 times weekly) d. second-line therapy
o

ethionamide (Trecator-SC) action: bacteriostatic and bactericidal use: in combination with other antituberculosis therapy when first-line agents have failed adverse effects o exfoliative dermatitis o heartburn, stomatitis, diarrhea o impaired glucose metabolism contraindications o hypersensitivity to ethionamide, isoniazid, and niacin o severe liver dysfunction client teaching o promptly report skin rash o take with food to decrease GI upset o may take as single dose before bedtime 2. pyrazinamide 3. cycloserine (Seromycin) 4. aminoglycoside antibiotics (See also: II.K.5.b.1 antibiotics: aminoglycosides) 2. Anti-inflammatory agents (used in respiratory conditions; available as inhalants) a. glucocorticoid (inhaled) 1. actions inhibits phagocytosis reduces capillary permeability stabilizes leukocyte membrane decreases release of inflammatory mediators examples flunisolide (Nasalide 2 metered-dose inhalations twice daily)

1.

2.

fluticasone propionate (Flovent 88-440 mcg/spray inhalations twice daily) triamcinolone acetomide (Azmacort 55 mcg/spray, 2 inhalations 3-4 times daily) beclomethosone dipropionate (Vanceril 84 mcg/spray, 1-2 inhalations 2-4 times daily)

3. uses long-term prophylactic treatment for asthma bronchial asthma not responding to conventional therapy preferred long-term therapy for adults and children with persistent asthma adverse effects (same side effect profile as oral or IV therapy, much less likely to occur with inhaled therapy) hypothalamic-pituitary-adrenal axis suppression, opportunistic infections, impaired healing, increased skin fragility, impaired glucose metabolism and hypokalemia nausea, vomiting, PUD insomnia, confusion, psychosis muscle wasting, osteoporosis, cataracts, Cushing's disease, fluid retention contraindications renal dysfunction prolonged pediatric therapy immunosuppression, active respiratory infection nursing care establish baseline data and monitor o weight, blood pressure, infection o blood sugar, renal function collaborate with dietitian and provider to manage fluid retention, hyperglycemia, and hypokalemia client teaching o not rescue therapy: not indicated for acute asthma or allergic attack therapeutic effect takes 1-2 weeks be prepared for acute asthma attack o report infections and fever, worsening findings o low-sodium diet, blood glucose testing o avoid sick people, wash hands frequently

4.

5.

meal planning for daily calorie restrictions o rinse mouth after treatment to avoid Candida albicans overgrowth (thrush) d. type: mast cell stabilizer action: inhibits release of histamine and slow reacting substance of anaphylaxis (SRS-A) but without antihistaminic properties examples o cromolyn sodium (Nasalcrom 5.2 mg sprays, 1 inhalation each nostril 3-4 times daily) o nedocromil sodium (Tilade 1.75 mg sprays, 2 sprays each nostril 2-3 times daily) uses: prophylactic treatment of asthma, allergic rhinitis, conjunctivitis; not for use with acute asthma adverse effects o angioedema o dry mouth, bitter aftertaste o nasopharyngeal irritation o nausea, transient ocular stinging contraindications o acute asthma o aerosol administration in clients with CAD or dysrhythmias nursing care o establish baseline data and monitor breath sounds, SaO2, secretions o stop treatment with angioedema or bronchospasm o pediatric dose with MDI: usually onehalf of adult dose o asthma findings may increase while tapering hydrocortisone therapy o client teaching not rescue therapy: not indicated for acute asthma or allergic attack 1. therapeutic effect takes 1-2 weeks 2. be prepared for acute asthma attack may stain soft contact lenses use of inhaler or drug delivery device
o

does not eliminate need for other therapies minimize throat irritation by following treatment with sips of water, lozenges e. type: leukotriene-receptor antagonists action: selectively interferes with leukotrienes to inhibit bronchospasm and airway edema example o zafirlukast (Accolade 20 mg by mouth daily) o montelukast (Singular 10 mg by mouth daily) uses: prophylaxis against asthma and exercise induced asthma adverse effects o fever, headache o Churg-Strauss syndrome o generalized pain, back pain contraindication: acute asthma nursing care o establish baseline data and monitor breath sounds, SaO2, respiratory rate, liver function o administer 1 hour before or 2 hours after meals o client teaching take on regular basis: missing a dose may result in a lapse in therapeutic effect report flu-like findings, worsening condition, jaundice, dark urine or stool

6. Antihistamines (See also antihistamines II.K.2)

a. type: first generation antihistamines (for respiratory tract) i. action: potent H1 receptor antagonist (histamine blocking agent) to block the effects of histamine ii. example: azelastine Optivar 2 sprays per nostril twice daily iii. uses: seasonal allergic rhinitis, itching eyes associated with seasonal allergies iv. adverse effects drowsiness, fatigue bitter taste headache, rhinitis dry mouth, nausea v. contraindications: concurrent use of CNS depressants

nursing care establish baseline data and monitor upper respiratory system congestion; drowsiness; reddened, itchy eyes, other clinical indicators of hypersensitivity prime delivery unit before dispensing client teaching o avoid alcohol getting nasal spray in eyes driving, dangerous activity until adverse effects are wellestablished o blow nose before instillation: tilt head forward slightly and sniff gently b. type: second generation antihistamines i. action: blocks effects of histamine by blocking H1 receptor and mast cell release of inflammatory mediators ii. examples loratadine (Claritin) fexofenadine (Allegra) desloratadine (Clarinex) iii. uses: relief from itchy, watery eyes, nasal congestion, and runny nose due to allergic rhinitis iv. adverse effects: flu-like findings, drowsiness, dizziness, dry mouth, dysmenorrhea v. contraindications: renal or hepatic impairment vi. nursing care establish baseline data and monitor for clients with cardiac disease give every other day for clients with renal impairment renal and liver function blood pressure, cardiovascular status, EKG client teaching o report unusual findings o may cause drowsiness o provide frequent oral care o avoid alcohol and CNS depressants

vi.

7. Decongestants
a. nasal decongestants i. type: sympathomimetic action: stimulate SNS causing vasoconstriction of nasal mucus membranes examples o phenylephrine hydrochloride (NeoSynephrine)

ii.

tetrahydrozoline (Visine, Murine Plus) o xylometazoline (Otrivin) o oxymetazoline (Afrin, Allerest) uses: symptomatic relief of allergies to reduce allergic congestion of nasal passages adverse effects o rebound congestion (requiring steroid therapy) o transient stinging o sneezing, dizziness, shock contraindications o use in children <2 years-old o use within 14 days of MAO inhibitor o use of glaucoma preparations and other serious eye diseases nursing care o establish baseline data and monitor nasal congestion, breath sounds, respiratory rate, heart rate, blood pressure o allow 4-6 hours between doses o cardiac stimulation with excessive use o administer with client in upright position o client teaching report failure to relieve symptoms in 48 hours do not exceed recommended dose type: oral decongestants action: stimulates alpha-adrenergic receptors in nasal passages resulting in vasoconstriction and shrinkage of swollen mucus membranes example: pseudoephedrine hydrochloride (Sudafed 60 mg by mouth every 4-6 hours up to 240 mg/day) use: symptomatic relief of nasal congestion due to rhinitis, coryza, and sinusitis; Eustachian tube congestion adverse effects o palpitations, dysrhythmias o transient stimulation, nervousness, dizziness, insomnia o anorexia, dry mouth, nausea, vomiting contraindications
o

iii.

hypertension, CAD prostatic hypertrophy glaucoma, hyperthyroidism within 14 days of MAO inhibitor not recommended for children <6 years-old nursing care o establish baseline data and monitor nasal congestion, breath sounds, respiratory rate, heart rate, blood pressure o client teaching avoid other OTC drugs discontinue if extreme restlessness occurs do not crush or chew sustained release forms type: glucocorticoid decongestants (See also: II.B.5.c glucocorticoids, inhaled)
o o o o o

8. Pharmacological interventions to help clients to stop smoking a. type: nicotine i. action: stimulates nucleus accumbens reward system in the brain to increase extracellular dopamine, endogenous opioids, and glucocorticoids in the region ii. examples nicotine gum (Nicorette 1 piece every 30 minutes, up to 30/day) nicotine inhaler (Nicotrol 6 cartridges/day, up to 16/day for 12 weeks) nicotine transdermal (Nicoderm) nicotine nasal spray (Nicotrol NS 1 spray/nostril, 1-2 sprays/hour up to 40 sprays/day for 90 days) iii. use: assist client in nicotine withdrawal as nicotinereplacement therapy iv. adverse effects dysrhythmias nausea, vomiting, anorexia insomnia, headache, convulsions, tachycardia, HTN v. contraindications active smoking immediate post-MI recovery period, severe angina vi. nursing care

establish baseline data and monitor breath sounds, frequency of nicotine use, frequency of urge to smoke, nicotine withdrawal, nicotine toxicity nicotine withdrawal: headache, fatigue, drowsiness, irritability, severe cravings nicotine toxicity: GI findings, hypotension, dypsnea, weakness, abdominal cramping, blurred vision, tinnitus o withdraw nicotine therapy immediately client teaching o take only as directed o inhaler: puff on mouthpiece o gum chew slowly for 30 minutes as potent as cigarettes o patch as potent as cigarettes apply daily, rotate sites do not smoke when wearing patch b. type: antidepressants i. example: bupropion (Zyban) (See also: III.D.2.f antidepressants: bupropion) c. type: antihypertensives i. example: clonidine (Catapres) (See also: II.A.4.b.i clonidine)

9. Therapeutic class: therapeutic gases a. type: oxygen i. action: essential gas for cellular energy production and metabolism ii. uses supplemental oxygen to prevent or correct hypoxia hyperbaric oxygenation, extracorporeal circulation ventilatory support for respiratory failure, surgical anesthesia reduce partial pressure of inert gases, air embolism, decompression sickness iii. adverse effects depression of respiratory drive especially for clients breathing due to hypoxic drive, retrolental fibroplasias in neonates increased pulmonary capillary permeability

exacerbation of hypoxemia in hypoventilated lungs atelectasis, irritation of tracheobronchial mucosa, decreased mucociliary transport mask signs of desaturation from obstruction or hypoventilation iv. nursing care establish baseline data and monitor respiratory rate, breath sounds, SaO2, arterial blood gases, level of consciousness, FiO2 humidify supplemental oxygen avoid 100% oxygen for more than 8-12 hours prevent injury: avoid open flames and sparks, ground all equipment FiO2 affected by respiratory rate, tidal volume, inspiratory-expiratory ratio [I:E ratio], inspiratory flow, and characteristics of delivery system o lowest control room air nasal cannula: nasopharnyx is reservoir for O2; client may breathe from mouth or nose with patent nares tracheostomy collar simple face mask o medium control: Venturi mask, oxygen nebulizer, and nonrebreathing mask o high control: endotracheal tube, tracheostomy tube to ventilator o precise control of FiO2 only achieved with airtight, closed delivery system separation of inspired gases from expired gases PaO2 affected by FiO2, serum hemoglobin, SaO2, efficiency of alveolar gas exchange client teaching: cough and deep breath every hour while awake b. type: carbon dioxide i. action: by-product of cellular metabolism carried on the bicarbonate ion (HCO3-) and transported to the lung where it is exhaled as the same rate it is produced ii. uses insufflation during endoscopic procedures

vasoconstriction of cerebral vessels during cranial surgery displacement of air surrounding open heart in cardiac surgery c. type: nitric oxide i. action: cell-signaling molecule that decreases resting vascular tone, prevents platelet aggregation, effector of macrophage-induced cytotoxicity ii. use pulmonary hypertension to vasodilate diagnostic testing in cardiac catheterization, pulmonary function, and for asthma iii. adverse effects toxicity at levels > 50-100 ppm loss of ciliary action, hypertrophy of pulmonary tissue surfactant inactivation, formation of methemoglobinemia increased bleeding time, impaired ventricular function due to increased blood flow to left ventricle iv. nursing care establish baseline data and monitor pulmonary artery pressure, cardiac output, arterial blood gases, breath sounds, methemoglobin level, occult bleeding, pulmonary secretions d. type: helium i. action: low density, low solubility, and high thermal conductivity making other gases easier to breathe ii. uses diagnostic testing for respiratory obstruction, laser surgery of airway, imaging label, pulmonary function oxygen dilution in hyperbaric applications

C. Managing neurological conditions 1. Therapeutic class: anticonvulsants

i. ii.

iii.

action: stabilize neuronal membranes to prevent tissue excitability in the cerebral cortex adverse effects myelosuppression possibly resulting in increased bleeding time, anemia, and leukopenia CNS depression o insomnia, headache o drowsiness, lethargy, fatigue o GI upset, anorexia, constipation nursing establish baseline data and monitor seizure activity, level of consciousness taper dose before discontinuing therapy assist with ambulation, institute seizure precautions client teaching o promptly report seizure activity, easy bleeding or bruising loss of balance, rash, jaundice, severe nausea, vomiting

avoid pregnancy wear MedicAlert tag need for follow-up care and testing avoid OTC drugs and herbal supplements o change positions slowly, ask for help before getting up b. tonic-clonic (grand mal) seizures i. type: hydantoin action: stabilize neuronal membranes in CNS to limit spread of neuronal excitability example: phenytoin (Dilantin maintenance: 300-400 mg by mouth daily in divided doses; emergent 15-20 mg/kg IV bolus, slowly) uses o prevention and treatment of seizures o suppress ventricular excitability in the heart o slow A-V conduction in digoxin toxicity adverse effects (usually dose related) o ventricular fibrillation, nephritis, lupus erythematosus, severe liver toxicity, Stevens-Johnson syndrome o CNS depression, arrhythmias, ataxia, hirsutism, gingival hypertrophy (especially in children) o weight gain, impaired glucose metabolism o poor absorption of folic acid, calcium, and vitamins; osteomalacia, decreased vita min K absorption o toxicity: myelosuppression, vomiting, ataxia, diplopia, CV collapse, confusion contraindications o severe liver disease o seizures due to hypoglycemia o sinus bradycardia, heart block nursing care o establish baseline data and monitor seizure activity, heart rate, blood pressure, EKG: monitor vital signs and EKG continuously during IV push skin, gums, bleeding LFTs, RFTs, CBC, platelets, blood sugar, Ca++, Mg++
o o o o

ii.

establish baseline data and monitor serum levels therapeutic: 10-20 mcg/ml toxic: 30-50 mcg/ml lethal: >100 mcg/ml o provide oral care, assist with ambulation o oral administration avoid giving within 2-3 hours of antacids prompt release forms not suitable for once daily dosing o IV administration slowly warm IV solution to room temperature do not exceed 25 mg/min for older clients and when giving as antidysrhythmic administer 50 mg/min IV push in 0.9% NaCl: precipitates in dextrose solution o client teaching report seizure activity, bleeding, jaundice, dark urine or stool avoid alcohol, sedatives, hypnotics, gingko use soft tooth brush; seek regular dental care do not crush or chew sustained release forms 1. may take calcium with Vitamin D and folic acid: provide exposure to sun to promote Vitamin D formation type: barbiturate (See also: II.C.1.a information common to anticonvulsants) action: interferes with impulse transmission of cerebral cortex leading to CNS depression and unconsciousness examples o phenobarbital (Luminal maintenance: 60-250 mg by mouth daily or in divided doses; emergent: 100-320 mg slow IV bolus up to 600 mg/24 hours)
o

primidone (Mysoline 250 mg by mouth 3-4 times daily)

uses status epilepticus, tetanus acute seizures associated with eclampsia o children: perioperative IV sedation, hyperbilirubinemia, kernicterus adverse effects o respiratory depression, StevensJohnson syndrome, CNS depression, coma, death o hangover, dose-dependent hypotension, bronchospasm o Ca++, folic acid, and Vitamin D deficiencies; tolerance o constipation, nausea, vomiting, liver dysfunction o older or debilitated clients: confusion or excitability o toxicity: ataxia, slurred speech, poor judgment, insomnia contraindications o severe respiratory, renal, or hepatic disease o children: sustained release form and IV push o uncontrolled pain, history of porphyria nursing care o establish baseline data and monitor blood pressure, respiratory rate, airway, bowel sounds, bowel pattern, level of consciousness LFTs, therapeutic drug level: 15-40 mcg/ml o administration prevent extravasation do not exceed IV push rate: 1 mg/second IM injection may not exceed 5 mg at one site dilute in sterile water for injection, gently rotate bottle to dissolve o client teaching drowsiness may improve over time
o o

avoid pregnancy, take only as directed avoid hazardous activity, avoid alcohol provide exposure to sun; take calcium with Vitamin D and folic acid

iii.

type: benzodiazepines (See also: III.D.3.a benzodiazepines; II.C.1.a information common to anticonvulsants) very effective anticonvulsant, emergency drug of choice example: diazepam (Valium 5-10 mg IV by slow IV bolus, may repeat every 10-15 minutes up to 30 mg) adverse effects: respiratory depression

c. petit mal (absence) seizures (See also: II.C.1.a information common to anticonvulsants) i. type: succinimides action: modulates gamma-aminobutryric acid (GABA to inhibit neuronal pathways examples o ethosuximide (Zarontin 250-1500 mg by mouth in divided doses) o methsuximide (Celontin ) uses o ethnosuximide drug of choice for absence seizures due to low side effect profile o in combination with other anticonvulsants when other therapies have failed adverse effects o dose related nausea, vomiting, anorexia, drowsiness, lethargy, euphoria, dizziness, headache o pseudoparkinsonism, photophobia contraindications: renal or hepatic disease, intermittent porphyria nursing care o establish baseline data and monitor LFTs and RFTs, CBC bowel habits, urine output skin, neuro status, vital signs o client teaching: may take with food d. myoclonic (See also: II.C.1.a information common to anticonvulsants)

i.

type: sulfonamides

action: facilitates dopamine and serotonin neuronal transmission example: zonisamide (Zonegran 100-600 mg by mouth daily) use: adjunct therapy adverse effects o hyperthermia (children), deficient sweating possibly resulting in heat stroke o nephrolithiasis, rhinitis, pharyngitis, dysarthria contraindication: allergy to sulfonamide and sulfa drugs nursing care o hold drug for rash of unknown origin o maintain cool environment o monitor RFTs, CBC o client teaching avoid strenuous activity and heat drink fluids to avoid kidney stones avoid alcohol and caffeinated beverages

ii.

type: valproic acid action: stimulates GABA activity to decrease normal neuronal electrical discharge example o valproic acid (Depakote 15-60 mg/kg daily, administer in divided doses when dose > 250 mg) o topiramate(Topamax 200-800 mg by mouth twice daily) o tiagabine (Gabitril up to 56 mg by mouth daily in 2-4 doses) use: drug of choice for myoclonic seizures, also used in absence seizures adverse effects o liver failure, pancreatitis, pulmonary edema, deep coma, death with overdose, hyperthermia in children o somnolence, dizziness, ataxia, fatigue, weight loss, nervousness, problems with memory o nystagmus, paresthesias, decreased sweating, urinary ketones

contraindications o bleeding disorder, liver disease o pancreatitis, metabolic disorders o multiple anticonvulsant therapies nursing care o establish baseline data and monitor platelets, bleeding time, serum ammonia o administer one IV dose over at least 60 seconds o therapeutic level: 50-100 mcg/ml o client teaching 1. do not chew sprinkles 2. swallow tabs and capsules whole 3. do not dilute elixir in carbonated beverages 4. avoid alcohol, OTC drugs, CNS depressants

iii.

type: benzodiazepine (See also: III.D.3. benzodiazepines a) e. partial (focal) seizures (See also: II.C.1.a)

type: benzodiazepine (See also: III.D.3.a benzodiazepines) o example: clorazepate (Tranxene) type: iminostilbene o examples: carbamazepine (Tegretol), oxcarbazepine (Trileptal) o adverse effects: CNS depression, vertigo, ataxia, diplopia, blurred vision type: phenytoin (See also: II.C.1.a information common to anticonvulsants) o examples 1. gabapentin (Neurontin 9001800 mg by mouth daily in 3 doses) 2. lamotrigine (Lamictal 150250 mg by mouth 2 times daily) o uses 1. adjunct therapy for seizures 2. post-herpetic neuralgia, intractable pain o adverse effects 1. Stevens-Johnson syndrome, DIC

2. somnolence, dizziness, ataxia, fatigue, double vision 3. nausea, vomiting, children: rash type: valproic acid (See also: II.C.1.d.ii) o action: stimulates GABA activity to decrease normal neuronal electrical discharge type: unknown o example: levetiracetam (Keppra 1000-3000 mg by mouth daily in 2 doses) o use: adjunct therapy in seizures o adverse effects 1. dizziness, somnolence, tremor 2. asthenia, infection, diplopia o contraindications: generalized absence epilepsy o nursing care 1. make dosage adjustments in 2 week-intervals 2. establish baseline data and monitor CBC, LFTs, phenytoin levels if also taking 3. client teaching: avoid pregnancy, report loss of balance, problems with ambulation

2. Anti-Parkinson's agents a. type: dopaminergic

i. dopamine precursor action: crosses blood-brain-barrier to form dopamine examples: o levodopa (Dopar) o levodopa with carbidopa (Sinemet 200-1200 mg by mouth daily in 2-3 doses) use o gold standard for treatment of Parkinsons o primarily given with carbidopa to decrease amount of levodopa needed for therapeutic effect adverse effects o bone marrow depression, melanoma, depression, suicidal

ii.

ideation, hypertensive crisis, neuroleptic malignant syndrome o decreased therapeutic effect, on/off phenomena, dyskinesias, hallucinations, confusion o dysrhythmias, fatigue, weakness, drowsiness, increased sweating, dark urine, body odor contraindications: o glaucoma, MAO inhibitors o suspicion or history of melanoma nursing care o establish baseline data and monitor blood pressure, mood, extrapyramidal findings involuntary movements, steady gait, muscle tone CBC, urinary frequency o institute fall precautions o client teaching report chest pain, palpitations, depression, urinary retention, severe nausea and vomiting, and involuntary movements protect drug from light do not crush or chew sustained release forms balance activity and rest, ask for help when getting up take consistently with or without food but avoid high protein meals type: dopamine agonists action: acts like replacement therapy to increase dopamine levels but require functioning neurons capable of responding examples o ropinirole (Requip 1.5-24 mg by mouth daily in 3 doses) o bromocriptine mesylate (Parlodel 3.75-40 mg by mouth daily in 2 doses) o amantadine hydrochloride (Symmetrel 100-200 mg by mouth daily in 2 doses) use: clients with Parkinsons who have developed on/off phenomena adverse effects

iii.

dysrhythmias, abnormal breathing patterns, bone marrow depression, hepatic dysfunction o orthostatic hypotension, dizziness, nausea o lethargy, hallucinations, confusion, fatigue, somnolence o ataxia, blurred vision, urinary retention contraindications o MAO inhibitors o glaucoma, severe cardiovascular disease o urinary tract obstruction, psychiatric disorder o suspicious skin lesions associated with levodopa nursing care o establish baseline data and monitor bradykinesia, involuntary movement, gait LFTs, RFTs, CBC blood pressure, urinary retention, mental status o taper dose to discontinue o carefully review medication profile when adding or removing a drug o client teaching void before taking may take with food wear MedicAlert jewelry avoid OTC drugs, especially vitamin B6 ask for help when getting up, avoid dangerous activities type: anticholinergics action: decreases excess cholinergic effect of dopamine deficiency by competing with acetylcholine for muscarinic receptor sites examples o atropine (!high alert drug) (Atropine 0.5-1 mg IV up to 2 mg) o benztropine mesylate (Cogentin 1-2 mg by mouth, IM, IV daily in divided doses) o procyclidine hydrochloride (Kemadrin) o trihexyphenidyl hydrochloride (Trihexy 5-15 mg/day by mouth in 2 doses)
o

use relief of extrapyramidal clinical indicators of parkinsonism; with other anti-Parkinsons drugs o decrease secretions before surgery, decrease sweating and salivation o bradycardia, reversal of anticholinesterase drugs, insecticide poisoning, block vagal tone, mydriasis, cycloplegia adverse effects (See also: III.D.4-1 extrapyramidal findings and anticholinergic effects table) o hypotension, tachycardia, angina, dysrhythmias o paradoxical bradycardia lasting 2 minutes, atropine flush 15-20 minutes after injection o somnolence, confusion, dizziness, involuntary movement, dry mouth and eyes, glaucoma contraindications o tachydysrhythmias, asthma, acute hemorrhage o GI obstructions, ulcerative colitis, BPH, liver disease o angle closure glaucoma, myasthenia gravis, thyrotoxicosis nursing care o establish baseline data and monitor
o

iv.

heart rate, blood pressure, respiratory rate, I & O residual urine, bowel pattern, nausea, flushing vision, increased intraocular pressure, eye pain o client teaching may crush tablets keep in airtight container give after meals to decrease GI upset include fluids, fiber, ambulation, and bowel ritual to prevent constipation type: monamine oxidase B inhibitor action: blocks breakdown of dopamine and may slow disease progression example: selegiline (Eldepryl 2.5-10 mg by mouth in 2 doses)

v.

use: Parkinsons disease for clients responding poorly to other therapy o adverse effects o incidence increases with severity of disease o dysrhythmias, severe hypertension, severe depression, hyperthermia, dysrhythmias, angina o restlessness, vertigo, mood changes, nightmares, confusion o orthostatic hypotension, extrapyramidal findings, anticholinergic effects o increased sweating, alopecia, rash, sexual dysfunction o nausea, weight loss, anorexia, xerostomia, rectal bleeding o active metabolites: amphetamine and methamphetamine contraindications: use with opioids or tricyclic antidepressants (fatal reaction) nursing care o establish baseline data and monitor client response to dosage, blood pressure, heart rate and EKG, mental status o limit dose to 10 mg/day o give with meals, avoid high-protein diet o avoid concurrent therapy with meperidine (Demerol) o client teaching report severe headache, severe hypertension, and unusual findings avoid foods with tyramine change positions slowly, ask for help getting up take only as directed, do not abruptly withdraw therapy type: catechol O-methyltransferase (COMT) inhibitor action: increases availability of dopamine by inhibiting COMT, may allow increased dosing of levodopa example o tolcapone (Tasmar 200-600 mg by mouth daily in 2-3 doses)

entacapone (Comtan 600 mg by mouth with each dose of levodopa) use: Parkinsons disease adverse effects o fatal liver failure, hemolytic anemia, leukopenia, agranulocytosis o dystonia, dyskinesia, confusion, psychosis o orthostatic hypotension, nausea, fatigue, headache, contraindication: advanced Parkinsons disease nursing care o establish baseline data and monitor LFT and CBC, blood pressure, bowel sounds, temperature o administer with levodopa o provide assistance for ambulation while initiating therapy o client teaching report nausea, vomiting, anorexia use barrier contraception sweat and urine may change color change positions slowly, ask for help before getting up take on empty stomach: 1 hour before or 2 hours after meals
o

3. General anesthetics

a. general i. action: CNS depression for invasive procedures and surgery; rapid distribution to brain and spinal cord resulting in rapid onset and short duration of action ii. uses: used in combination with local anesthetics, narcotics, anticholinergics, and neuromuscular blockers to achieve analgesia, unconsciousness, muscle relaxation, and amnesia during surgery iii. adverse effects hypotension, shock, dysrhythmias, respiratory depression, laryngospasm, bronchospasm, malignant hyperthermia lipophilia, headache, nausea, vomiting iv. contraindications history of malignant hyperthermia hepatic or renal failure, severe CV disease, hypotension, shock status asthmaticus, increased intracranial pressure, myasthenia gravis v. nursing care establish baseline data and monitor airway, vital signs, SaO2, level of consciousness verify preoperative evaluation of client by anesthesia provider and surgeon general anesthetics potentiate the effects of one another, used only by specially trained personnel have emergency equipment and drugs at the bedside including client teaching: preoperative instructions o do not eat or drink 6-8 hours before the procedure o take medication before procedure as directed by provider take oral medication with small sip of water o arrange chaperone for 24 hours after anesthesia

arrange for transportation home after procedure

b. parenteral anesthetic agents

type: barbiturates (See also: II.C.1.b.ii anticonvulsants: barbiturates) o examples pentobarbital (!high alert drug) (Pentothal 100-500 mg IV) methohexital (Brevital) o use: in combination with inhalation anesthetics for induction and maintenance of surgical anesthesia type: benzodiazepine (See also: III.D.3.a benzodiazepines) o example: midazolam hydrochloride (Versed 0.15-0.35 mg/kg IV slow IV bolus) o use: induction for general anesthesia; conscious sedation type: opioids (See also: III.A.2 opioids) type: propofol o action: o example: propofol (!high alert drug) (Diprivan 1.5-2.5 mg/kg IV for induction) o use: in combination with other anesthetic agents to induce and maintain surgical anesthesia o adverse effects (See also: II.C.1.b.i barbiturates i) excellent medium for bacterial growth, associated with serious infection lower risk of bronchospasm o nursing care administer immediately after removing from sterile packaging, do not use past expiration date decrease dose of propofol when combined with other agents versus decreasing other agents to propofol dose

c. inhalation anesthetics

type: stable anesthetic gases action: severe CNS depression to induce and maintain unconsciousness examples o nitrous oxide: weak gas, low toxicity, and short acting with strong analgesic properties) o cyclopropane: short acting, more likely to cause nausea and vomiting o ethylene: low toxicity, bitter aftertaste adverse effects o affinity for adipose tissue o postoperative nausea, vomiting, somnolence ii. type: volatile gases action: stabilizing effect on post-junctional membrane and acts synergistically with competitive blocking agents examples o halothane (Fluothane) o enflurane (Ethrane) o sevoflurane (Ultane) uses o significantly lower adverse effects with children adverse effects o hepatic toxicity, renal toxicity, dysrhythmias, prolonged respiratory depression, bradycardia, decreased A-V conduction o postoperative fever, nausea, vomiting o dose dependent hypotension nursing care o establish baseline data and monitor airway, vital signs o remain at bedside until client maintains airway and spontaneous respirations; collaborate for supplemental oxygen and ventilatory support o rapid onset and recovery o inhibited by aminoglycoside antibiotics, tetracyclines, calcium channel blockers d. perioperative emergency drugs i. type: hydantoin

i.

ii.

iii.

action: interferes with intracellular release of Ca++, slows catabolism in malignant hyperthermia example: dantrolene sodium (Dantrium 1mg/kg, may repeat up to total dose of 10 mg/kg) uses o prevention and treatment of malignant hyperthermia o reduce spasticity in neurological degenerative diseases, trauma adverse effects o seizures, hepatic injury, eosinophilia o dizziness, weakness, nausea o hypotension, angina, nasal congestion, anticholinergic effects contraindications: compromised pulmonary function, active hepatic disease, impaired ventricular function nursing care o establish baseline data and monitor body temperature, blood pressure, heart rate, EKG, I & O, LFTs, allergic reaction, severe weakness, CNS depression o screen clients for client or family history of malignant hyperthermia o client teaching 1. report lack of improvement or worsening of findings, abdominal pain, jaundice, dark urine or stool, rash, itching 2. take only as directed, do not double dose 3. avoid alcohol, CNS depressants; wear sunscreen type: anticholinergic agent action: block action of acetylcholine example: atropine (Atropine) (See also: II.C.2.iii anticholinergics) use: reduce respiratory secretions, reduce vagal tone type: opioid antagonist (See also: III.A.2.c opioid antagonists) action: competes with opioids for opioid receptors example: naloxone (Narcan) use: reverse opioid analgesics

type: cholinergic agent: anticholinesterase (See also: II.C.5.b.ii indirect cholinergic agents: edrophonium chloride) action: inhibits destruction of acetylcholine example: edrophonium chloride (Tensilon) use: antagonist of curare, diagnostic for myasthenia gravis v. type: benzodiazepine receptor antagonist (See also: benzodiazepines: nursing care II.D.3.a.vi) action: antagonizes the action of benzodiazepines on the CNS example: flumazenil (Romazicon) 2. Local anesthetic agents a. action: loss of sensation to a region of the body b. examples i. type: ester procaine hydrochloride (Novocaine) tetracaine (Pontocaine) ii. type: amines bupivacaine (Marcaine) lidocaine (Lidocaine) c. uses i. regional, spinal, epidural anesthesia ii. topical, infiltration, field block, nerve block anesthesia iii. used with epinephrine for topical hemostasis, chronic pain management d. adverse effects i. loss of sensation resulting in injury ii. systemic absorption leading to cardiopulmonary arrest headache, anxiety, blurred vision dysrhythmias, peripheral vasodilation e. contraindications: heart block, shock, plasma esterase deficiency f. nursing care i. keep emergency equipment at bedside ii. protect client from injury until complete return of sensation and function iii. client teaching ask for help before trying to get up effects of local agent and anticipated return of sensation and function 5. Therapeutic class: cholinergic agents a. type: direct-acting cholinergic agonists i. action: mimics the action as Ach by stimulating postsynaptic muscarinic receptors

iv.

ii. iii. iv.

v. vi.

example: bethanechol (Urecholine 25-50 mg 3 times daily by mouth) use: non-obstructive urinary obstruction, neurogenic bladder adverse effects hypotension, acute asthma, dyspnea, bronchoconstriction nausea, bloody diarrhea, eructation, vomiting, cramps, urinary and fecal incontinence dizziness, drowsiness, blurred vision flushing, increased sweating, increased salivation older clients especially sensitive to adverse effects contraindications: hyperthyroidism, Parkinsons disease, CAD, asthma, hypotension, peptic ulcer disease (PUD) nursing care establish baseline data and monitor blood pressure, heart rate and EKG, respiratory rate, breath sounds, SaO2, urine output, residual urine establish baseline data and monitor older clients closely for dysrhythmias and hypotension administration o increase dosage as tolerance occurs o avoid IM and IV administration because it may result in circulatory collapse, bloody diarrhea o may use in children > 8-years-old: give by subcutaneous injection client teaching o report cramping, bloody diarrhea, flushing o take on empty stomach: 1 hour before or 2 hours after meals o if dose is missed, take within 1 hour of next dose o change positions slowly and ask for help when getting up

b. type: indirect acting cholinergic agents (anticholinesterase

agent, cholinesterase inhibitors) i. action: reversibly inhibits action of cholinesterase, the enzyme that degrades acetylcholine at the synaptic clef to increase Ach concentrations and improve neuromuscular impulse transmission; cholinomimetic

ii.

iii.

iv.

examples treatment o neostigmine bromide (Prostigmin 45375 mg/day in divided doses by mouth, IM/IV0.5-2 mg every 1-3 hours) o pyridostigmine (Mestinon 60-180 mg 2-4 times daily by mouth, IV: use 1/3 of oral dose) o ambenonium chloride (Mytelase 1-2 grams IV, may repeat in hour; given with atropine IV) diagnosis o edrophonium chloride (Tensilon 2 mg rapid IV bolus) uses diagnosis and treatment of myasthenia gravis prevention of cholinesterase inhibitor poisoning (nerve gas) reverses non-depolarizing neuromuscular blocking agents (curarine) adverse effects cholinergic crisis and myasthenia crisis, chest tightness, bradycardia, hypotension, respiratory depression neurologic syndrome (Persian Gulf War syndrome) muscle twitching, nausea, vomiting, cramping increased salivation, lacrimation, urinary retention reverses therapeutic effect of phenothiazines, antihistamines, and tricyclic antidepressants peritonitis bradycardia, hypotension obstruction of GI or GU tract nursing care establish baseline data and monitor vital signs, bowel activity, muscular weakness (especially strength of eyelids and neck muscles) o monitor for weakness 1 hour after therapy: may indicate cholinergic crisis (overdose of cholinesterase inhibitor)

v.

vi.

monitor for weakness 3 hours after therapy: may indicate myasthenia crisis (underdose) carefully review drug label for correct dosage and concentration may increase the neuromuscular blockade of succinylcholine (depolarizing neuromuscular blocker) keep atropine, airway, oxygen, and Ambu bag at bedside client teaching o may take with food o instruct family on finding recognition o proper adjustments to dosage based on response to therapy: keep a record of dosages and response to therapy o may need to take medication during the night to maintain blood level c. type: centrally-acting cholinesterase inhibitors i. action: blocks cholinesterase activity at the synaptic cleft resulting in elevated Ach levels ii. examples:
o

iii.

uses: anti-Alzheimer's therapy; mild to moderate dementia

contraindication: concurrent use of NSAIDs nursing care establish baseline data and monitor o heart rate, EKG, LFTs, blood pressure, respiratory rate o mental status, bowel pattern, bowel sounds, bleeding keep atropine immediately available provide oral care, frequent sips of water give at bedtime, institute fall precautions client teaching o report excessive salivation, diarrhea, emesis, and frequent urination o apply artificial tears for dry eyes o instruct family on finding recognition o ask for help before getting up, change positions slowly e. type: cholinesterase reactivator action: restores response to neuromuscular stimulation by reactivating cholinesterase example: pralidoxime (Protopam 1-2 grams IV, may increase by 250 mg increments every 5 minutes) use o early treatment of organophosphate anticholinesterase poisoning o management of anticholinesterase (neostigmine, pyridostigmine, ambenonium) overdose e. type: N-methyl-D-aspartate (NMDA) glutamate-receptor antagonist

iv. v.

action: blocks NMDA receptors to reduce rate of clinical deterioration example: memantine (Namenda 10 mg by mouth twice daily) use: Alzheimers disease adverse effects: headache, dizziness