Pharmacology HESI Review
Cardiac Drugs/Diuretics

Digoxin – positive inotrope (increases force of contraction); negative chronotrope (decreases heart rate).
How do you assess for this? (Always take AP for a full minute!)

Client with long hx of daily digoxin and furosemide (Lasix) use; creates a high risk for dig toxicity
(Lasix can cause hypokalemia, which can lead to dig toxicity)

Digoxin toxicity – know normal digoxin level (0.5 – 2 ng/mL); serum potassium (K+) level (3.5 to 5.0
mEq/L); low potassium or magnesium levels may increase risk for digoxin toxicity; S/S of dig toxicity
include anorexia, bradycardia, headache, dizziness, confusion, nausea, and visual disturbances
(blurred vision, yellow vision, and/or halo vision); hold digoxin if AP less than 60.

Labetalol (beta blocker) for HTN: Notify prescriber for low pulse rate and do not give med; SE is
weight gain (fluid retention) – pulmonary assessment (which is…). Remember monitoring weight is one
of the best indicators of fluid gain or loss – 1 kg (2.2 lb) = 1,000 mL fluid gain or loss in 24 hrs.

Nitroglycerin transdermal patch for treating chest pain (angina) – remove at night to allow 8 hours
without patch (can produce tolerance in 24 hours); may use SL nitro when wearing patch if patient
having chest pain

Why wear gloves when applying nitroglycerin paste or patch? (severe vasodilation, ↓BP, intense HA
[may give acetaminophen for HA])

Angina – for chest pain, if VS OK, leave nitro patch on and administer PRN SL nitro

Pt. in CCU/ICU on nitro drip; becomes hypotensive, decrease rate of nitro drip

Calcium channel blockers – dipine (like amlopidine) and verapamil (Calan) and diltiazem (Cardizem). –
dipine affect vessels only (vasodilation). SE: dizziness, facial flushing, hypotension, edema. Verapamil
(Calan) and diltiazem (Cardizem) also affect heart. Monitor BP, HR (↓). Constipation is SE. Avoid
grapefruit juice.

Aliskiren (Tekturna) – (direct renin inhibitor for HTN); teach don’t take if pregnant (stop drug if become
pregnant); don’t take with high fat meal. May increase K+, so don’t take with other drugs that ↑ K+.

Furosemide (Lasix) – loop diuretic; rapid acting; used for rapid diuresis in emergencies (pulmonary
edema); may produce hypokalemia (assess for muscle cramps, muscle weakness). Hypotension, F/E
abnormalities, dehydration. SE: dizziness, HA, tinnitus, N/V/D, ↓ K+, hyperglycemia, ototoxicity with
aminoglycosides (-mycin drugs).

May need potassium supplement. Foods containing potassium: dried fruits, fish, leafy veggies, squash,
beans, meats, nuts, bananas, potatoes, dairy products.

IV potassium (KCl) – assess overall condition of the veins. Use large vein, like antecubital (AC) vein
when administering potassium. Venous access is important because IV potassium can irritate the vein.
Have patient notify nurse immediately if burning at site. IV K+ extravasation can cause necrosis of
tissues. Calculate and set the rate as ordered, know anticipated duration of therapy, know restrictions
imposed by patient’s history. Don’t give IV push; infuse at a rate no greater than 20 mEq/hr;
concentration no greater than 40 mEq/L. Always use infusion pump. Assess IV site every hour.

Antihypertensives and low potassium (K+); hypokalemia. Antihypertensive effects are more pronounced
in the elderly.

Osmitrol (Mannitol) – osmotic diuretic; effectiveness determined by ↓ ICP. NOT used for peripheral
edema; used to treat pt. with closed head injury; effective response is decreased ICP
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
Spironolactone (Aldactone), amiloride (Midamor); triamterene (Dyrenium) – potassium-sparing
diuretic (can cause ↑K+). Blocks receptors for aldosterone. Inhibits sodium and water reabsorption.
Take in a.m. (diuretics in the morning if possible); avoid salt substitutes, ACE inhibitors, ARBs. Often
taken with other (thiazide) diuretics to treat edema, hypertension, heart failure. Can be taken with
other meds that lower K+.

Lab value for atorvastatin (Lipitor) – HDL should increase; LDL and total cholesterol decrease. Other
statin drugs include rosuvastatin (Crestor), fluvastatin, lovastatin, simvastatin, pravastatin. LFTs
routinely and CK for any c/o of muscle pain. How do you evaluate effectiveness?
Adrenergics/SNS Drugs & Adrenergic Blockers

Remember: alpha 1 stimulation – vasoconstriction; beta 1 (one heart), beta 2 (two lungs)

Mydriatics – agents used to produce dilation of pupils for eye exams and ocular surgery

Tamsulosin (Flomax) – alpha1 adrenergic blocker; ↓ smooth muscle contraction of prostate capsule and
bladder neck. Used for treating sx of BPH. Alpha 1 blockers –zosin – antihypertensives.

Effects of dopaminergic activation – causes dilation of the renal vasculature; this effect is exploited in the
treatment of shock; by dilating renal blood vessels, we can improve renal perfusion and can thereby
reduce the risk of renal failure. Dopamine itself is the only drug available that can activate dopamine
receptors. It should be noted that when dopamine is given to treat shock, the drug also enhances cardiac
performance (because it actives beta1 receptors in the heart.)

Catecholamines (epinephrine, norepinephrine, dopamine, dobutamine, etc.) must be watched carefully
for extravasation! The FDA has this to say about treating dopamine extravasation:
To prevent sloughing and necrosis in ischemic areas, the area should be infiltrated as soon as possible
with 10 to 15 mL of saline solution containing 5 to 10 mg of Regitine (brand of phentolamine), an
adrenergic blocking agent. A syringe with a fine hypodermic needle should be used, and the solution
liberally infiltrated throughout the ischemic area. Sympathetic blockade with phentolamine causes
immediate and conspicuous local hyperemic changes if the area is infiltrated within 12 hours. Therefore,
phentolamine should be given as soon as possible after the extravastation is noted.

Epi-Pen (Epinephrine Auto Injector). Single dose of epinephrine that can be injected (IM) into the
middle of the outer thigh (even through clothes). Seek emergency medical treatment immediately.
SE: increase in heart rate, stronger or irregular heartbeat, sweating, nausea or vomiting, difficulty
breathing, paleness, dizziness, weakness, shakiness, headache, apprehension, nervousness or anxiety.
These side effects may go away if patient rests.

Remember that many decongestants and bronchodilators have sympathomimetic effects (adrenergic
effects). SE include ↑ HR, nervousness, insomnia, etc. Bronchodilators that stimulate β2 receptors can
also stimulate β1 if dose is high enough (loses selectivity). Don’t forget cardiac assessment.
Drugs Affecting Coagulation

Anticoagulants and geriatrics (elderly) – risky either way.

Patient discharged on warfarin (Coumadin) – teach how to avoid bleeding: soft toothbrush, electric razor,
don’t go without shoes, etc. Teaching – maintain vitamin K foods (greens- spinach, mustard greens,
swiss chard, etc.) in diet (don’t increase or decrease); PT/INR monitoring; avoid activities that may
cause bleeding.

Pentoxifylline (Trental) for intermittent claudication (like cilastozal [Pletal]) – treats ischemic pain.
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
Prasugrel (Effient) is an antiplatelet like clopidogrel (Plavix). Watch for S/S bleeding. Used primarily
after interventional radiologic procedures (like coronary stents) and for patients who do not respond to
clopidogrel.

Clopidogrel (Plavix) – antiplatelet; notify health care provider of drug regimen prior to surgery;
may need to hold any anticoagulants/antiplatelet drugs

Enoxaparin (Lovenox) – low molecular weight heparin; 1st line therapy for treatment and prevention of
DVT. SubQ in “love” handles. No routine lab to monitor, but watch CBC d/t thrombocytopenia.

Remember that heparin sodium for injection is not same as hep-lock solution. They are NOT
interchangeable. Concentration of hep-lock solution is either 10 units/mL or 100 units/mL. Heparin for
injection is 10,000 units/mL or 20,000 units/mL or even 50,000 units/mL.

Heparin is high-alert medication – requires another nurse to check dosage.

New potent, oral anticoagulants – dabigatran (Pradaxa), apixaban (Eliquis), rivaroxaban (Xarelto); do not
require monitoring of labs; ↑ risk of bleeding (teach)
Opoiods/Analgesics/NSAIDs

MS Contin (morphine continued release) for chronic pain

Opioids (morphine, hydrocodone, oxycodone, hydromorphone [Dilaudid] codeine) can produce CNS
depression (be aware of safety for patients attempting to ambulate) and respiratory depression;
administer naloxone; (Narcan) reverses respiratory depression but also reverses analgesia; may need to
titrate dose and give repeated doses to prevent sudden withdrawal (repeat dose at 2-3 minute intervals)
(opioid double dose – be aware of LOC and RR). Remember naloxone has shorter half-life than opioids.
SE: constipation, pruritus, urinary retention, ↓ BP, ↓ HR.

Duragesic (transdermal fentanyl) – fentanyl patch. Opioid analgesic. Relief of moderate to severe chronic
pain, like cancer pain. Not for postop or short-term pain relief. Patch usually lasts 72 hours. Remove old
patch before applying new one. SE: CNS depression, confusion, sedation, weakness, dizziness,
restlessness; apnea, respiratory depression; anorexia, constipation, dry mouth, nausea, vomiting.
Considered one of safest opioid analgesics for patients with renal impairment. Avoid MAOIs. Avoid
grapefruit and grapefruit juice. Avoid other CNS depressants. Monitor RR!!! Notify MD if RR below 12.
Reverse effects with naloxone. Reverses respiratory depression but also reverses analgesia; may need to
titrate dose and give repeated doses to prevent sudden withdrawal

Epidural pump priority – monitor vital signs every 15 minutes; do not administer other sedatives; be sure
feeling/function has returned to lower extremities before returning pt. to floor. Label epidural tubing as
epidural only!

Tolerance and dependence – what are they? Assess for tolerance (patient not getting pain relief with
same dosage pt. has been receiving).

Acetaminophen (Tylenol) – Nonopioid analgesic. Not an NSAID (no anti-inflammatory properties).
Maximum daily dose 3,000 mg; 2,000 mg for elderly and those with liver disease. LT use can produce
nephrotoxicity. Overdose/frequent use can produce hepatotoxicity. Sx of hepatotoxicity include
jaundice, abdominal pain, clay-colored stools, dark urine.

Lorcet (hydrocodone and acetaminophen) Percocet (oxycodone & acetaminophen); Fioricet (butalbital &
acet.); Lorcet (hydrocodone & acet.); Ultracet (tramadol & acet.) – double dose (respiratory sedation and
too much Tylenol) – pay attention to drugs that may contain acetaminophen! Check LFTs.

Aspirin (ASA) – caution with PUD, children under 18 with recent viral illness (Reye’s syndrome),
interacts with other antiplatelets, anticoagulants, NSAIDs, etc. (bleeding)
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
Pregabalin (Lyrica) – nonopioid analgesic for peripheral neuropathy, postherpetic (shingles) neuralgia,
fibromyalgia. SE: suicidal thoughts, dizziness, drowsiness, edema, dry mouth, abdominal pain,
constipation.

Ketorolac (Toradol) NSAID (causes gastric irritation) should be given with meals or snack; also has
pain relief comparable to morphine but is NOT an opioid; postop pain (not used for chronic pain); do not
give for more than 5 days. SE same as other NSAIDs.

NSAID therapeutic uses – anti-inflammatory, analgesic (mild to moderate pain), antipyretic,
dysmenorrhea, treatment of RA, OA, GA; Aspirin also antiplatelet effects (prior stroke, MI);
contraindicated in renal impairment.

Ibuprofen (Advil) and other NSAIDs commonly taken with antacids to decrease GI distress.

Diclofenac (Zipsor) – NSAID; also can increase LFTs (hepatotoxicity). Like other NSAIDs, may
increase risk of stroke and MI. SE as other NSAIDs, including GI bleeding.

Medications for treatment of gout – NSAIDs first-line therapy; second-line agents include allopurinol,
colchicine, probenecid. Decrease uric acid. Colchicine – GI/GU bleeding (monitor CBC); probenecid –
don’t use with renal impairment; allopurinol – agranulocytosis, Stevens-Johnson syndrome (notify MD if
rash develops).
Respiratory Drugs

Albuterol (Proventil, Ventolin), levalbuterol (Xopenex), pirbuterol (Maxair), short-acting Beta2
agonists (SABA) – should be used during acute asthmatic episodes, not long term use; fluticasone is
glucocorticoid for prevention of acute asthma (not for acute episode); fluticasone is given BID

Albuterol (Proventil) – SA beta agonist. (See sympathomimetic/adrenergic effects). Assessment is for
improved breathing; open airway. Also may stimulate the heart – increased HR, nervousness, etc.

Topical/inhaled adrenergics (decongestants) use no longer than 3-5 days; can produce rebound
congestion.

Fluticasone and salmeterol (Advair) inhaler – use only BID (not more often; can ↑BP)

Tiotropium (Spiriva) – bronchodilator used in LT maintenance of COPD; given by inhaler; rinse mouth
after inhaler use

Pirbuterol (Maxair) inhaler – beta2 agonist (bronchodilator) used for treatment of asthma in pts. 12 and
older. Similar in effects to levalbuterol. Use cautiously in pts. with cardiovascular disorders, including
ischemic heart disease, hypertension, or cardiac arrhythmias, in patients with hyperthyroidism or diabetes
mellitus, and in patients who are unusually responsive to sympathomimetic amines or who have
convulsive disorders. Avoid use with beta blockers.

Bronchodilators should produce ease of breathing and decreased wheezing.

Teaching for use of inhaler with 2 puffs of same med; two different meds

Montelukast (Singulair) – indicated for treatment of asthma; can be given to patients 2 yrs and older;
administer orally at bedtime. SE: HA and dizziness. Leukotriene modifiers/inhibitors also include
zileuton (Zyflo), zafirlukast (Accolate). Check LFTs for these two.

Antihistamines (eg. diphenhydramine [Benadryl]) decrease nasopharyngeal secretions by blocking H1
receptors; use cautiously with elderly; major SE is sedation. Use cautiously with COPD, asthma,
pneumonia.
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
Theophylline (methylxanthine bronchodilator) – TheoDur, Theo-24, Uniphyl; indicated for treatment of
COPD. IV form (aminophylline) for status asthmaticus. Severe wheezing from bronchial constriction.
Avoid caffeinated beverages, as caffeine is a methylxanthine.
Adrenal Agents/Endocrine Drugs

Prednisone (Deltasone), prednisolone (Orapred, Pediapred), methylprednisolone (Solu-Medrol),
triamcinolone (Kenalog) – glucocorticoid; highest priority assessment is risk of infection (R/T
immunosuppression. Glucocorticoids (steroids). SE: Cushing syndrome (moon face, hump back,
hirsutism, weight gain, etc.). Increased risk of infection (immunosuppression); thin, fragile skin;
hyperglycemia; osteoporosis; steroid psychosis (euphoria); stunts bone growth in children.

LT use of steroids with asthma and COPD – SE of LT glucocorticoid use – see above. In addition,
adrenal insufficiency [which can be life-threatening]; be sure to taper steroids rather than
discontinuing abruptly (adrenal crisis); need stress dosing of steroids when hospitalized (be able to
identify glucocorticoids by their names, like prednisone –sone, -cort, -methasone, -nisolone).

Hypothyroidism treatment is replacement therapy (levothyroxine) – S/S of OD would be symptoms of
hyperthyroidism (increased metabolism) – tachycardia, weight loss, diarrhea, increased body temp and
intolerance to heat, perspiration, insomnia, etc. May even produce angina.

Radioactive iodine is given for thyroid gland ablation. Large capsules are odorless and tasteless. Can dry
up salivary glands. Excreted in urine, so force fluids. Pt. will be radioactive until removed from body.
Isolation. Double flush toilets, etc. Administered by the nuclear medicine physician.

Methimazole (Tapazole) or propylthiouracil (PTU) – for treatment of hyperthyroidism (Graves disease).
Take at same time every day with meal or snack. Avoid foods high in iodine (iodized salt; seafood). May
take 2 weeks to be effective. SE: hypothyroidism symptoms (sluggish, tired, weight gain, cold
intolerance, constipation). Take one hour apart from Lugol’s solution (potassium iodide) for treatment of
severe hyperthyroidism (thyroid storm/thyroid crisis).

Antidiuretic hormone (ADH) – prevents excess fluid loss. Pts. with diabetes insipidus have insufficient
ADH and produce large amounts of very dilute urine. Pt. on ADH should have decreased urine
output. Watch for fluid overload. Renal assessment. Drug may be Desmopressin or Vasopressin.
(DDAVP) – intranasal antidiuretic hormone (ADH) for treatment of diabetes insipidus caused by
deficiency of vasopressin (ADH); also controls bleeding in certain types of hemophilia and von
Willebrand’s disease; prevention of nocturnal enuresis (bedwetting). Check serum osmolality
(Fundamentals).

Only rapid (lispro [Humalog], aspart [Novolog], glulisine) and short-acting (regular) insulin can be given
IV; for emergencies. Rapid acting insulin: onset 5-10 minutes, peak 1 hour, duration 2-4 hours. Take
immediately before eating. Hypoglycemia can occur quickly if not consuming adequate calories
immediately after injection.

Regular insulin peaks in 2-3 hours (mid-morning when given before breakfast). Give 30-60 minutes
before meal. Pt. receiving Regular insulin at 7:30 a.m., be sure pt. eats breakfast

Insulin can ONLY be administered using an insulin (orange tip) syringe; always measured in units.

Lantus insulin has no peak – flat effect (lasts 24 hours)

Diabetic pt. on oral antidiabetic NPO prior to surgery; a.m. BS 250; call MD for sliding scale insulin
order. What about patient NPO who has hypoglycemia? May need IV glucose/dextrose.

Second generation sulfonylureas (glipizide [Glucotrol], glimepiride [Amaryl]) SE include hypoglycemia,
weight gain, skin rash, N/V/D.
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
Exenatide (Byetta) and liraglutide (Victoza) – incretin mimetic agent (antidiabetic) given subcutaneously
(NOT insulin). Only for type 2 DM. Cannot be used with insulin. Mimics the action of incretin which
promotes endogenous insulin secretion and promotes other mechanisms of glucose lowering. Used for
improved control of blood glucose. Take subQ injection within 60 minutes before morning and evening
meals. Teach to watch for signs of hypoglycemia: confusion, abdominal pain, sweating, hunger,
weakness, dizziness, headache, drowsiness, tremor, tachycardia, anxiety, irritability (especially when
combined with oral sulfonylureas).

Glucagon emergency kit – elevates blood sugar; it is used when a diabetic pt. becomes hypoglycemic and
becomes unconscious. It is a powder that is mixed with a packaged liquid (in the kit) and then
administered as an injection by someone else. Teach: Once the injection is given, the pt. should be
placed on their left side, as it is not uncommon for the pt. to vomit. The pt. should become conscious
within 15 minutes of injection. If not, a 2nd injection may be given. Go to ER.

Oxymetholone (Anadrol-50), oxandrolone (Oxandrin), nandrolone (Deca-Durabolin) – Anabolic
steroids – stimulate growth and development of male sex organs and 2ndary sex characteristics;
stimulate production of erythropoietin by the kidney. Administration of exogenous androgens inhibits the
release of endogenous androgens, which suppresses sperm production (leads to infertility) as well as can
cause shrinking of the testicles and gynecomastia.
Drugs Affecting the GI System

Cimetidine (Tagamet), ranitidine (Zantac) – H2 blocker to prevent irritation of stomach from too
much acid (PUD, GERD). First choice drugs for gastritis and duodenal ulcers. Antacids and smoking
decrease absorption. Drug-induced hepatitis with cimetidine and ranitidine, especially with elderly.
Timing: Take 30-60 minutes before meals. Take at least 1-2 hours before antacids (antacids decrease
absorption)

Lansoprazole (Prevacid) – Proton pump inhibitor (PPI), antacid for erosive esophagitis, PUD, ST
treatment for GERD; healing and risk reduction in NSAID-associated gastric ulcers

Esomeprazole (Nexium) – PPI for GERD, erosive esophagitis, Zollinger-Ellison syndrome; decrease
risk of gastric ulcer during continuous NSAID therapy

Drugs for PUD – take at least an hour apart from other drugs and antacids, except PPIs can be taken with
antacids. (Drug timing)

Misoprostol (Cytotec) – prostaglandin analog; prevents ulcers from LT NSAID use. Also produces
uterine contractions (pregnancy category X); used after delivery to expel products of conception (POC).

Sucralfate (Carafate) may delay absorption of PPIs. Should be taken on empty stomach; take other
drugs 2 hours before sucralfate. Typically taken before meals and at bedtime. Needs pH of 4 or less to
bind to ulcer.

Metoclopramide (Reglan) – prevention of chemotherapy-induced emesis; diabetic gastroparesis; SE
include drowsiness, EPS such as tremors (notify MD if tremors develop)

Xenical (Orlistat, Alli) – use for LT weight control; BMI of 30 or more; pt. has oily stool and flatulence;
ask pt. to describe dietary intake (SE are increased if greater than 30% fat in diet). Fiber laxatives like
Metamucil help decrease SE (binds to the fat).

Laxative use – Bulk-forming laxatives need to be given with plenty of fluid – can produce esophageal
and/or intestinal obstruction. Assess for last BM and characteristics, abdominal pain, fever, obstruction.
Assess dietary and fluid intake. Encourage fluids, fiber, and exercise as tolerated/indicated.
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
Lactulose (Chronulac) – for constipation and to lower serum ammonia levels in patients with liver
disease (cirrhosis) – hepatic encephalopathy (monitor ammonia levels 15-45 mg); effective if patient
having more frequent BMs OR if has improved mentation (less confusion) and decreased serum
ammonia levels.
Antibiotics/Antivirals/Antifungals, etc.

Azithromycin (Zithromax) – antibiotic for treatment of STDs such as gonorrhea and chlamydia.
Typically requires just one (1 g or 2 g dose). Male partner should be treated if woman has trichomonas
(any STI), even if asymptomatic. Hepatotoxicity – elevated liver enzymes.

Ciprofloxacin (Cipro) for UTI – Antacids decrease absorption of ciprofloxacin (Cipro); pt. with routine
use of milk of magnesia – do not take MOM within 2 hrs of taking Cipro. Teaching: Photosensitivity
(can cause severe sunburn). ↓ absorption with antacids. May cause tendon rupture in children ↓ 18.

Metronidazole (Flagyl) – Drug of choice for treating C. difficile. Take with food. Take around the
clock. Avoid alcohol & products containing alcohol (disulfiram-like reaction).

Gentamicin (Garamycin), neomycin, tobramycin (Nebcin) – aminoglycosides – given IV for several
days; what symptom is adverse effect? ↓ hearing (ototoxicity) and nephrotoxicity (check BUN and
creatinine)

Vancomycin – DOC for MRSA (severe staph infections that have become resistant to most antibiotics).
Acute care may require frequent monitoring of serum drug level for dose adjustment. Peak and trough
schedule. Trough usually just before the next dose. Risk of nephrotoxicity and ototoxicity.
Thrombophlebitis. Red man syndrome if infused too rapidly (flushing or rash of upper body, dyspnea,
itching, hypotension – can be lethal). IV infusions should be greater than 60 minutes.

Trimethoprim/sulfamethoxazole (Bactrim/Septra) – sulfonamide for treatment of UTI (high
concentrations of drug in kidneys). Drug known for sulfa allergy. Assess for rash.

Oral contraceptive pills (OCPs) have decreased efficacy while on antibiotics; use 2nd method of birth
control

Penicillins have cross-sensitivity to cephalosporins (structurally similar) – observe respiratory status for
first 30 minutes when administering for first time (watch for anaphylaxis if allergic to one or the othermay have cross-sensitivity); treat anaphylaxis with epinephrine

Patient wheezing after first dose of penicillin – what is treatment? epinephrine to open airway

Tetracycline teaching – do not administer to pregnant women and to children under age 8 (can cause
discoloration of permanent teeth and possibly retard fetal skeletal development in utero); interacts with
antacids, antidiarrheal drugs, calcium, and iron preparations (absorption of tetracycline is reduced); avoid
dairy products [milk, cheese, yogurt, ice cream]; photosensitivity (use sunscreen and protective
clothing); take medication around the clock (what does this mean?); instruct pt. to notify MD if diarrhea,
abdominal cramping, fever, watery or bloody stools occur and not to treat with antidiarrheal without
consulting health care provider (may have pseudomembranous colitis). OCPs ineffective.

Don’t take antibiotics for viral illnesses. Take entire prescription as ordered. Don’t take antibiotics if not
needed. Can produce drug resistant strains of organisms.

Rifampin is an antitubercular – treatment of TB; turns all body fluids red/orange/brown, including
tears, saliva, urine, etc. May turn soft contacts orange. Advise pt. in advance that this is a normal
response to the drug; drug has teratogenic properties that may decrease effectiveness of oral
contraceptives; counsel patient to use a nonhormonal form of contraception throughout therapy.
Hepatotoxic – check LFTs.
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
Isoniazid (INH) for TB; interacts with foods containing tyramine; can produce life-threatening
hypertensive crisis; know foods to avoid. Use 2nd form of birth control.

Oseltamivir (Tamiflu) – for treatment of influenza A and B; treatment should begin within 2 days of
onset of symptoms. Medication will ↓ duration of symptoms; may decrease flu sx in family members if
given before onset. Can be given with food to ↓ N/V.

Acyclovir (Zovirax) – antiviral for treatment of HSV-1 and HSV-2, varicella zoster virus (shingles) &
chickenpox. Patient’s with HSV-2 (genital herpes) should avoid sexual intercourse.

Flu vaccine. Typically given IM in the deltoid (upper arm) muscle. Recommended for everyone 6 months
and older every season. Does not contain flu virus. SE: Soreness, redness and swelling at the site of
injection; low grade fever; aches.

Superinfection – on antibiotics and normal flora destroyed (C. difficile colitis); yeast infections (vaginal,
oral thrush).

Fluconazole (Diflucan) – antifungal for vaginal candidiasis (yeast infection). Many antifungals can cause
liver injury (hepatotoxicity). Monitor LFTs.

Antifungal terbinafine (Lamisil) for treatment of superficial dermatologic infections (athlete’s foot) and
onychomycosis (nail fungus). Avoid alcohol. Monitor LFTs. Report nausea, upper stomach pain, itching,
loss of appetite, dark urine, clay-colored stools, jaundice.

How do you know if antibiotic is effective?
Neuropsychiatric & Antidepressant Agents

LT use of antidepressants can cause addiction. Patients experience withdrawal symptoms. Always gets
medication history – many drugs interact with antidepressants.

Benztropine (Cogentin) for Parkinson’s disease and treatment of extrapyramidal symptoms (EPS) also
called parkinsonism – anticholinergic; common SE include blurred vision, urinary retention (Parkinson’s
meds). How do you determine if medication was effective?

Levodopa-carbidopa (Sinemet) – stimulates dopamine production or increases sensitivity of dopamine
receptors; to treat Parkinson’s. Toxicity includes involuntary muscle twitching, facial grimacing,
spasmodic eye winking, exaggerated protrusion of tongue, etc. Notify prescriber. Do not consume high
protein meals with levodopa (can impair effects).

Lithium (Lithobid, Lithotabs) is a mood stabilizing drug used to treat pts with bipolar disorder. Lithium
has low therapeutic index. As a result, toxicity can occur at blood levels only slightly greater than
therapeutic levels; monitoring lithium levels is mandatory. Drug of choice for treating manic phases of
pts with BPD. Lithium levels must be kept below 1.5 mEq/L; levels greater than this can produce
significant toxicity. For initial therapy, levels should range from 0.8 to 1.4 mEq/L. Maintenance levels
are 0.5 to 1.5 mEq/L. Draw levels in the morning, 12 hours after evening dose. During maintenance
therapy, levels should be checked every 3 to 6 months. Maintain sodium 136-145 mEq/L – (↑Na
causes ↑ renal excretion, which will ↓ serum Lithium levels. Teach early sx of lithium toxicity;
diarrhea, nausea & vomiting, drowsiness, muscle weakness. Toxicity: life-threatening dysrhythmia,
coma, convulsions, death. Keep salt consistent in the diet; no diuretic.

Buspirone (BuSpar) – anxiolytic that does not produce CNS depression like benzodiazepines; indicated
for treatment of anxiety and is always given on a scheduled basis, not PRN. Only contraindication is
allergy. Onset of action is 2-3 weeks.
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
Antipsychotic drug haloperidol (Haldol) produces severe extrapyramidal symptoms (EPS) or
reactions to include tardive dyskinesia (TD). EPS are movement disorders resulting from effects of
antipsychotic drugs on the extrapyramidal motor system. The extrapyramidal system is the same
neuronal network whose malfunction is responsible for the movement disorders of Parkinson’s disease
(PD). Early reactions include acute dystonia, parkinsonism, akathisia; late reactions include tardive
dyskinesia (the most troubling EPS). TD is characterized by involuntary choreoathetoid (twisting writing,
worm-like) movements of the tongue and face. Pts. may also present with lip-smacking movements, and
their tongues may flick out in a “fly-catching” motion. One of the earliest manifestations of TD is slow
worm-like movement of the tongue. Involuntary movements that involve the tongue and mouth can
interfere with chewing, swallowing, and speaking. Eating difficulties can result in malnutrition and
weight loss. Notify MD if abnormal movements. (benztropine [Cogentin] is used to treat EPS; also
may see diphenhydramine [Benadryl] used for this).

Paroxetine (Paxil) – discharge teaching; selective serotonin reuptake inhibitors (Prozac, Zoloft, Paxil).
Assess and document neuromuscular and GI symptoms. May take 4-6 weeks to see therapeutic effects.
Take meds as prescribed. Carefully monitor patient for self-harm or suicide; obtain list of all other meds,
etc. See Patient Teaching Tips.
CNS Depressants

Don’t forget opioids, barbiturates (barbital), benzodiazepines (lam/pam), antiepileptics (AEDs), skeletal
muscle relaxants, etc.

Clonazepam (Klonopin) – anticonvulsant, benzodiazepine to treat panic disorder; SE include
drowsiness, CNS depression, dizziness, nightmares, dry mouth, constipation, weight gain; can produce
withdrawal phenomenon and hangover effect (antidote for benzodiazepines is flumazenil [Romazicon])

Lorazepam (Ativan) – drug of choice for treating alcoholic delirium tremens (DTs). After IV
administration, keep patient supine for 8 hours and observe closely. Used for anxiety and withdrawal
symptoms.

Phenytoin (Dilantin) used to treat seizures. Therapeutic plasma levels are 10 to 20 mcg/mL. At plasma
levels above 20 mcg/mL, toxicity can occur: nystagmus (continuous back-and-forth movements of the
eyes), ataxia (staggering gait), diplopia (double vision), and cognitive impairment. Suicidal thoughts.
EPS. Common side effects include gingival hyperplasia (excessive growth of gum tissue) – teach good
oral hygiene, including dental flossing and gum massage; measles-like rash; hirsutism; Stevens-Johnson
syndrome (SJS) or toxic epidermal necrolysis (TEN), especially in those of Asian descent with genetic
mutation HLA-B*1502.

Topiramate (Topamax) – phenytoin (Dilantin), valproic acid may ↓ effects of topiramate; topiramate may
↑ effects of phenytoin.

Lioresal (Baclofen) – muscle relaxant; CNS depressant; advise pt. to move carefully and slowly when
rising/walking; assess LOC; given intrathecally with Baclofen pump (use test dose 1st). SE: CNS
depression, drowsiness, dizziness, hypotension.

Cyclobenzaprine (Flexeril) – centrally acting muscle relaxant

Dantrolene (Dantrium) – direct acting muscle relaxant (does not produce CNS depression); also used to
treat malignant hyperthermia (severe genetic SE from general anesthesia)
CNS Stimulants & Antimigraine Drugs

Adderall (amphetamine/dextroamphetamine mixture – time of dosage is once in the morning and then
about 5 hours later; Adderall XR is given once daily in the morning (half dose is released immediately
and the remainder 4 hours later); for treatment of ADHD. Do NOT give at bedtime (insomnia).
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
Ergotamine (Ergomar), dihydroergotamine (D.H.E. 45, Migranal) – treatment of vascular headaches,
including migraine with or without aura, cluster headaches. Produces vasoconstriction of dilated blood
vessels. Used for migraine relief.

Sumatriptan (Imitrex) – serotonin receptor agonist (triptan) for relief of migraine headaches.
Contraindications: Don’t take within 24 hours of ergot alkaloids. Can cause coronary vasospasms.
Contraindicated in stroke (CVA).

Methylphenidate (Ritalin) – best if taken on empty stomach 30-45 minutes before eating; stimulant
which produces insomnia (don’t take at bedtime); schedule II drug

Atomoxetine (Straterra) – linked with increased suicidal thinking and behaviors in adolescents.
Herbals/Supplements

Review herbals (Echinacea topical can produce dermatitis/rash); page 16 of packet.

Feverfew is an herbal supplement used for its antiinflammatory properties; treatment of migraine HA,
menstrual cramps, inflammation, and fever

Herb gingko biloba – given to enhance mental alertness and improve memory; may increase risk of
bleeding with anticoagulants (warfarin, heparin), antiplatelets (aspirin, clopidogrel), and NSAIDs

St. John’s wort – herb used to treat depression and anxiety. May decrease benefits of immunosuppressant
drugs for patients with kidney transplants.

Glucosamine and chondroitin for osteoarthritis.

Mega vitamin C – 1,000 mg or more daily. Can be used for ascorbic acid deficiency. Excess doses can
lead to diarrhea and urinary stone formation. Foods high in ascorbic acid include citrus fruits, tomatoes,
strawberries, cantaloupe, and raw peppers. Abrupt withdrawal of megadoses of ascorbic acid may cause
rebound deficiency. (F.A. Davis Company, 2015)

Vitamin A deficiency can result from inadequate intake, fat malabsorption, or liver
disorders. Deficiency impairs immunity and hematopoiesis and causes rashes and typical ocular effects
(eg, xerophthalmia, night blindness). Diagnosis is based on typical ocular findings and low vitamin A
levels.
Drugs for ESRD and Osteoporosis

Vitamin D OD – causes increased serum calcium levels (excessive vitamin D intake leads to excessive
calcium absorption); normal serum Ca++ level is 8.4 – 10.5 mg/dL

Calcitonin (Miacalcin) nasal spray to decrease bone loss from osteoporosis; instruct pt. to alternate
nostrils each day when administering the nasal spray to decrease rhinitis

Kidney disease – calcium acetate (PhosLo) and calcium carbonate (TUMS) for management of
hypocalcemia and hyperphosphatemia in pts. on chronic renal dialysis (ESRD) or pts. with moderate to
severe renal insufficiency with secondary hyperparathyroidism. Shows desired effect when
↓phosphorus and ↑calcium levels seen. Know normal phosphorous/calcium levels: Calcium 8.4 – 10.5
mg/dL; phosphate 2.7 – 4.5 mg/dL. Inverse ratio of calcium & phosphorus.

Calcitriol (Rocaltrol, vitamin D3) – management of hypocalcemia in pts. on chronic renal dialysis or pts.
with moderate to severe renal insufficiency with secondary hyperparathyroidism; improved calcium
and phosphorous homeostasis in these pts.

Epoetin alfa (Epogen, Procrit) for patients with chronic kidney disease (CKD) increases RBC
production; treats anemia in patients with ESRD (CKD – chronic kidney disease) or from HIV or
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chemotherapy. Need normal iron levels. Monitor H&H. Monitor for signs of bleeding and/or clotting,
such as DVT. Teach diet high in iron. See Hematologic Agents.

Risedronate (Actonel), alendronate (Fosamax) – bisphosphonate (bone resorption inhibitor) used for
prevention and treatment of postmenopausal and corticosteroid-induced osteoporosis. Teaching: instruct
patient to take first thing in the morning with 8 ounces of water at least 30 minutes prior to other
medications, food, or beverages; caution pt. to remain upright for 30 minutes following dose to facilitate
passage to stomach and minimize risk of esophageal irritation (heartburn).

Ibandronate (Boniva) – same as above, except times are 60 minutes rather than 30.

Side Effects of bisphosphonates: HA, GI upset, joint pain, risk of esophageal burns if med becomes
lodged in esophagus (esophageal erosions have been noted); osteonecrosis of the jaw. Interactions
include: calcium supplements and antacids can interfere with absorption; space 1-2 hours apart.
Cholinergic/Anticholinesterase/Cholinesterase Inhibitors (all the same end result)

Pilocarpine (Isopto, Pilocar) is a topical muscarinic agonist (cholinergic) for glaucoma; produces
miosis (constriction of the pupil) and contraction of the ciliary muscle; side effects include decreased
visual acuity, local irritation, eye pain, brow ache; may produce bradycardia, bronchospasm,
hypotension, urinary urgency, diarrhea, hypersalivation, and sweating. Miotics (for treatment of
glaucoma) cause pupil constriction – reducing night vision; risk for injury.

Muscarinic agonists (cholinergic) drugs and renal; SLUDGE/DUMBBELLS (see packet)
o bethanechol (Urecholine) to treat urinary retention in postop and postpartum pts; relaxes the
trigone and sphincter muscles and increases voiding pressure (by contracting the detrusor muscle,
which composes the bladder wall)
o typical cholinergic SE as above; also causes miosis (pupillary constriction), which makes driving
at night dangerous
o cevimeline (Evoxac) like bethanechol but used to relieve xerostomia (dry mouth) in pts with
Sjögren’s syndrome

Donepezil (Aricept) may slow the progression of Alzheimer's disease over the next year (12 months);
improvement may be seen in quality of life and cognitive function; these improvements are only modest
and short-lasting. No evidence of marked improvement or significant delay of disease progression.

Patients with Alzheimers – safety is a potential problem; confusion; wandering; cognition.
Sundowning.

Edrophonium (Tensilon) – an anticholinesterase; enhances the effects of acetylcholine at the skeletal
muscle receptors; used in patients with myasthenia gravis; effective if improvement in pt. muscle
strength (e.g. opening of eyes, improved swallowing, etc.). NOTE: An anticholinesterase drug has
cholinergic effects!

Pyridostigmine (Mestinon) and neostigmine (Prostigmine) for myasthenia gravis; inhibits action of
cholinesterase (cholinergic drugs); improvement in eye opening (no ptosis), improved ease of
swallowing. Physostigmine (Antilirium), rivastigmine (Exelon) – for Alzheimer’s and Parkinson’s –
cholinergic medications. SE: SLUDGE/DUMBBELLS.
Anticholinergic (dry as a bone, red as a beet, mad as a hatter, hot as a hare – also treats bradycardia)

Transderm scopolamine (Transderm-Scop) – anticholinergic for motion sickness. Also dries secretions
and reduces nausea postoperatively. See above.
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
Atropine – antidote for cholinergic crisis (OD) and drug-induced bradycardia; also antidote for nerve gas
poisoning and organophosphate poisoning found in insecticides.

ABCDS of anticholinergic SE (atropine is anticholinergic – dry as a bone, red as a beet, mad as a hatter,
hot as a hare, blind as a bat):
Anorexia
Blurry vision
Constipation/Confusion
Dry mouth
Sedation/Stasis of urine

Oxybutynin (Ditropan) and tolterodine (Detrol) – urinary tract antispasmodics, treatment of overactive
bladder. Anticholinergic agents: constipation, dry mouth, urinary retention, mydriasis, tachycardia, HA,
insomnia, angina, overheating. KNOW anticholinergic SE!
Hormonal Agents

Androgen block – for prostate and testicular cancer (Lupron); decreases production of testosterone; SE
include decreased libido and gynecomastia. Work on the premise that tumors arising from tissue
influenced by the hormones estrogen and progesterone/androgen show regression (tumors shrink)
when treated with a drug which produces the opposite hormonal effect/environment. In men with prostate
cancer, estrogens act on the pituitary to suppress secretion of luteinizing hormone, which in turn
decreases testicular androgen secretion. Estrogen therapy causes feminization in men, manifested by
gynecomastia and impotence. Women may experience decreased libido and breast tenderness.

Medroxyprogesterone (Depo-Provera) – Adverse Effects: N/V, amenorrhea, spotting, edema, weight
gain or loss, rash, fever, insomnia, depression; most serious is liver dysfunction and thromboembolic
disorders such as PE.

Estrogen (Premarin) – hormone necessary to development and maintenance of female reproductive
system and 2ndary sex characteristics; hormone replacement therapy (HRT) for treating postmenopausal
symptoms. Adverse effects: most common is nausea; most serious is thromboembolic events;
photosensitivity; chloasma (brown spots on face, neck, and cheeks) (see Table 34-2, p. 548)
Drugs for Men’s Health

Sildenafil (Viagra), tadalafil (Cialis), and vardenafil (Levitra) – contraindicated with
nitrates/nitroglycerin (potent vasodilator) to include isosorbide dinitrate (Isordil) and isosorbide
mononitrate (Imdur).

Tamsulosin (Flomax) – alpha1 adrenergic blocker; ↓ smooth muscle contraction of prostate capsule and
bladder neck. Used for treating sx of BPH.

Oxymetholone (Anadrol-50), oxandrolone (Oxandrin), nandrolone (Deca-Durabolin) – Anabolic
steroids – stimulate growth and development of male sex organs and 2ndary sex characteristics;
stimulate production of erythropoietin by the kidney. Administration of exogenous androgens inhibits the
release of endogenous androgens, which suppresses sperm production (leads to infertility) as well as can
cause shrinking of the testicles and gynecomastia.
Drugs Affecting the Immune System

Don’t forget: glucocorticoids (steroid drugs) decrease the immune response – patient at increased risk of
infection.
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
Cyclosporine (Gengraf, Neoral, Sandimmune) – immunosuppressant drugs indicated for the prevention
of organ rejection (kidney, liver, heart transplants). Cyclosporine can cause nephrotoxicity and posttransplant diabetes mellitus. Avoid grapefruit juice.

Interferon – multiple sclerosis and other autoimmune disorders. Interferon beta medications make
flares happen less often. They might also slow down how quickly symptoms get worse and help people
have less physical disability over time. There are five types of interferon beta on the market in the U.S.
They’re FDA-approved for relapsing forms of MS: Avonex. Take once a week IM. People who start
taking it in the early stages of multiple sclerosis may be able to go longer before any physical disabilities
begin or get worse. Betaseron. SubQ injection taken every other day. SE of interferon meds and teaching
tips: Flu-like symptoms, such as fatigue, chills, fever, muscle aches, and sweating during the first weeks
of treatment. To keep those from slowing you down, it's best to take the shot at bedtime. You can take
pain and fever relievers, like acetaminophen or ibuprofen, before each injection and during the 24 hours
after one to help relieve these problems. Swelling, redness, and pain at the place where you get the shot.
If the spot gets hard, call your doctor. Don’t give yourself another shot into that site. Trouble with your
mood. You might feel sadness, anxiety, irritability, guilt, trouble concentrating, confusion, and have a
hard time sleeping or eating. Tell your doctor about these symptoms right away.
Hematologic Agents

Epoetin alfa (Epogen, Procrit) – increases RBC production; treats anemia in patients with ESRD (CKD
– chronic kidney disease) or from HIV or chemotherapy. Need normal iron levels. Monitor H&H.
Monitor for signs of bleeding and/or clotting, such as DVT. Teach diet high in iron.

Iron (Fe) [ferrous sulfate] administration – dilute oral liquid dosage forms and sip through a straw to
avoid discoloration of teeth; take oral iron supplements with meals or food to ↓GI upset. Take antacids
or milk products 1to 2 hours before or after oral dosage forms of iron. Instruct patient to remain upright
for 30 minutes to help minimize esophageal irritation. IM given via Z-track method. Vitamin C enhances
absorption.

Filgrastim (Neupogen) administered to increase the WBC count in neutropenic pts. - white blood cells
increase from 2,500/mm3 to 5,500/mm3 – means the desired effect is reached. Give before infection
develops. SE include fever, muscle aches, bone pain, and flushing. Give nonopioid or opioid
analgesic; stops when med D/C’d.
Pharmacologic Principles

Taking medications on an empty stomach (1 hour before or 2 hours after eating)

Timing for meds ordered after a meal – should be taken within 30-60 minutes after eating.

Peak and trough schedule – initially and then every 5 to 7 days; check peak levels 30 minutes after IV
infusion; check trough levels immediately before (less than 30 minutes) the next dose; elevated trough
signifies toxicity. Vancomycin and aminoglycosides.
Miscellaneous

Succinylcholine (Anectine) – depolarizing neuromuscular blocker (NMB) used during surgery may
cause ventricular tachycardia/dysrhythmias; added NMB action with vancomycin. Resp. status.

Medication adverse reaction – Nursing actions/responsibility?

Gastrectomy patient needs vitamin B12 (normally absorbed in stomach). May need B12 intramuscular
injections. Pernicious anemia. Lack of intrinsic factor (may be seen in elderly). Parenteral: Initial dose
1000 mcg intramuscularly once a day for 7 days. If there is clinical improvement and a reticulocyte
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response, 1000 mcg intramuscularly once every other day for 7 days, then once every 3 to 4 days for
another 2 to 3 weeks is recommended. Most patients require monthly injections of 100 to 1000 mcg
intramuscularly for life.

Isotretinoin (Accutane) – used for treatment of several nodulocystic acne; severe photosensitivity (avoid
sun); teratogenesis (preg. category X)
Dosage Calculations

1000 mcg equals 1 mg

Calculate dosage using mg/mL (liquid and tablet, parenteral). May ask in mL or tsp. Know that 5 mL = 1 tsp.

Always convert ounces to mL. 30 mL = 1 ounce.

Convert pounds to kg (1 kg = 2.2 lb). Divide pounds by 2.2 to get kg.

Calculate dosage using units/mL (such as heparin) or IM injection of penicillin ordered in units/mL

Calculate IV mL/hr

Calculate IV drip rates
mL to be infused x drop factor = gtt/min.
minutes
Order is for 3,000 mL D5/NS to be infused over 24 hours. Calculate drops per minute. Drop factor is 20.
1. First, find mL for one hour. 3,000 mL  24 hours = 125 mL.
2. Second, use formula above.
125 mL x 20 gtt/min. = 42 gtt/min.
60 min.
3. Remember to read instructions in the question about rounding or using whole number. Drops per
minute will ALWAYS be a whole number – there is no partial drop.

Calculate flow rate of X number of mEq/hr based upon total number of mEq in volume of fluid. Order is
“to infuse at a rate of…” or “administer at a rate of.” May be a secondary infusion. Can use the same
method of calculations with heparin. Can use formula method (D/H x Q)
Order is for 40 mEq KCl to be added to 1,000 mL 0.9% NaCl. Administer KCl at a rate of 3 mEq/hr.
3 mEq X 1,000 ml = ________ mL/hr
40 mEq
(3 x 1,000 = 3,000  40 mEq = 75 mL/hr.)
Order is for 7,000 units of heparin to be given subcutaneously. Available is 10,000 units/mL. Calculate
dosage.
7,000 units X 1 mL = 0.7 mL
10,000 units
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