CHAPTER 1: INTRODUCTION TO DRUGS
1.

Pharmacology
o the study of the biologic effects of chemicals
o Pharmacotherapeutics
 deals with the uses of drugs to treat, prevent, and diagnose disease
 the effect of drugs on a client’s body

Pharmacoeconomics
o includes any costs involved in drug therapy

Pharmacodynamics
o how a drug affects the body

Pharmacokinetics
o how a drug acts on the body
o consider the phases so that the drug regimen can be made as effective as possible

Pharmacogenomics
o includes mapping of the human genome
o in the future, medical care and drug regimens may be personally designed based on a patient’s
unique genetic make-up
o describes predictable differences in the effects of drugs in people of particular cultural
backgrounds

Schedule I
o high abuse potential and no accepted medical use
o Are not prescribed

Schedule II
o high abuse potential because of severe dependence liability
o ex. hydromorphone, morphine

Schedule III
o lesser abuse potential than Schedule II drugs and have an accepted medical use

Schedule IV
o low abuse potential and limited dependence liability

Schedule V (C-V)
o Limited abuse potential, primarily including small amounts of narcotics (codeine) used as
antitussives or antidiarrheals
2.
3.

Preclinical Study
o Use of animals in the drug studies
o Not available to patients

Phase I Study
o Healthy human volunteers who are usually paid for their participations
o Usually healthy young men

Phase II Study
o Patients who are involved in the study have the disease the drug is intended to treat
o If a drug is removed from testing during this phase, it is due to unacceptable adverse effects

Phase III Study
o involve use of a drug in a vast clinical population/clinical market in which patients are asked to
record any symptoms they experience while taking the drug
o nurses help collect and analyze the information to be shared with the FDA
o monitor and observe patients for adverse effects
o When a large number of people begin using the drug in this phase, it is not unusual to identify
adverse effects that are not previously noted
o Placebo-controlled designs are used

Phase IV Study
o Manufacturer’s responsibility: Continue to monitor the drug’s effects while the drug is in
general use
o Continual evaluation of the drug

Once a drug becomes patented, the drug may not be manufactured by other companies until the
patent expires.
4.
5. PREGNANCY RISK CATEGORIES

Category A
o adequate studies in pregnant women have not demonstrated a risk to the fetus in the first
trimester or in later trimesters
o Safest to administer to a pregnant woman

Category B
o Animal studies have not demonstrated a risk to the fetus
o NO ADEQUATE STUDIES IN HUMANS

Category C
o Animal studies have shown an adverse effect to the fetus
o NO STUDIES IN HUMANS

Category D
o Evidence of human fetal risk,
but the potential benefits from the use of drugs in pregnant women may outweigh potential
risks

Category X
o Studies in both animals and humans demonstrate fetal abnormalities or adverse reactions
o The risk of use in a pregnant woman clearly outweighs any possible benefit

Aspects of pharmacology a nurse studies:
o Pharmacotherapeutic level (the effect/impact of drugs on the body)
o The body’s response to drugs
o Adverse and anticipated drug effects
o Expected and unexpected drug effects

Teratogenic Effects
o Adverse effects on the fetus
o Not a likely concern for an older adult

Toxic Effects
o When medication is taken in larger than recommended dosages caused by an increase in
serum drug levels

Adverse Effects
o Negative or unexpected effects

Therapeutic Effects
o Desired actions for which the medication is prescribed

Controlled Substances
o Controlled by the FDA (Food and Drug Administration) and DEA (Drug Enforcement Agency)
FDA
DEA
Determines abuse potential
- Enforces control
- Monitors controlled substances in all states

Drug Enforcement Agency Number
6.
7.
8.
9.
o Given to all physicians and pharmacists when they register with the DEA to prescribe and
dispense controlled substances
o Only needed when prescribing controlled substances
10.

Orphan Drugs
o Not financially viable for a drug company to produce because of:
 Lawsuits about adverse effects
 The drug is not prescribed, often seen in rare diagnoses

Prescription Drug Labels
o Brand name
o Generic name
o Drug concentration
o Expiration date

Package Inserts
o Contains most reliable information about a drug
o Prepared according to strict FDA regulations
o Contains a compilation of information called Physicia’s Desk Reference (PDR)

Synergistic Drug Reactions
o Can be fetal because the interaction occurs when drugs react with each other and produce an
effect that is greater than the sum of their separate actions
11.
12.
13.
CHAPTER 2 – DRUGS AND THE BODY
PHASES OF PHARMACOKINETICS:
 Absorption
o Refers to what happens when a drug is introduced to the body until it reaches the circulating
fluids and tissues / bloodstream

Distribution
o Movement of a drug to the body’s tissues
o Affected by lipid solubility and ionization and perfusion of reactive tissue

Metabolism (Biotransformation)
o The process by which drugs are changed into new, less active chemicals
o Most important site: liver

Excretion
o Removal of a drug from the body
o Important role by the kidney
o Other organs play a part:
 Skin
 Saliva
 Lungs
 Bile
 Feces
1.
- Antihypertensive Drugs
 Work to decrease blood pressure
 When a patient goes to a warmer climate, blood vessels dilate and the BP falls
 If a patient is taking an antihypertensive drug and moves to a warmer climate, there is a chance
the patient’s BP will drop too low, resulting in dizziness and feelings of weakness
 Do not accumulate in the body
2.

Agonists
o drugs that produce effects similar to those produced by naturally occurring neurotransmitters,
hormones, or other substances found in the body
o interacts directly with receptor sites that cause the same activity that a natural chemical
would cause at that site

Noncompetitive Antagonists
o Drugs that react with receptor sites preventing the reaction of another chemical with a
different receptor site

Drug-Enzyme interactions
o Interfere with enzyme systems that stimulate various chemical reactions

First-Pass Effect
o Involves drugs that are absorbed from the small intestine directly into the portal venous system
 Delivers the drug molecules to the liver
 After reaching the liver, enzymes break the drug into metabolites, which may become
active or be deactivated and readily excreted from the body
 Large percentage of the oral dose is usually destroyed and never reaches tissues
 Oral dosages account for the phenomenon to ensure an appropriate amount of the drug
in the body to provide a therapeutic action
 Only a portion of the medication taken only reaches the tissue

Passive Diffusion
3.
o Drugs are absorbed into the body

4.
Active Transport
o Process that uses energy to actively move a molecule across a cell membrane
o Involved in drug excretion in the kidney
ROUTES OF ADMINISTRATION

IM Injections
o Cold environmental temp  vasoconstriction of blood vessel and decrease absorption
o Hot environmental temp  vasodilation of blood vessels and increase absorption

Subcutaneous Injections
o Perfusion of blood to the subcutaneous tissue can cause alterations in absorption

Oral Medications
o Most frequently used route in clinical pratice
o Blood flow to the gastrointestinal tract can cause alterations in absorption

Sublingual & Buccal
o Condition/Integrity of mucous membranes can cause alterations in absorption
5.
Absorption
- Influenced by route of administration
- IV is the fastest
- Slower when given orally
Distribution - Impacted by:
 cardiovascular function
 drug’s lipid solubility
 ionization and perfusion of the reactive tissue
Metabolism - Impacted by liver function
Excretion
- Impacted by kidney function
6.

Antibiotic Treatment
o Can occur only when the infection is severe enough to alter the blood-brain barrier and allow
antibiotics to cross
o Lipid-soluble medications cross the blood-brain barrier more easily
 Most antibiotics are lipid soluble
o No matter where the infection originates, drugs must cross the blood-brain barrier to treat
central nervous system infections
7.
PROTEIN-BINDING
o In order for drugs to reach the cells where drugs can act, the drug must break away from the
protein-binding site and float freely
o Most drugs are bound (to some extent) to proteins in the blood to be carried into circulation
o The protein-drug complex is large and cannot enter into capillaries and then to tissues to react
 The drug must be freed from the protein’s binding site at the tissues
 Occurs without the introduction of another chemical or dissolving it in plasma
o When a drug is tightly bound to protein, the drug will have a long duration of action.
8.

Tetracycline
o Not absorbed from the GI tract if calcium or calcium products are present in the stomach
o Cannot be taken with iron products because a chemical reaction occurs, preventing absorption
o Can increase sun sensitivity
o If administered to a child,
 Stain the child’s permanent teeth

Promoting Optimal Drug Effectiveness
o Incorporate basic history and physical assessment factors into the plan of care
 So obvious problems can be identified and handled promptly
o Evaluate the effectiveness of drugs after they have been administered
o Modify the drug regimen to modify adverse or intolerable effects
o Examine factors known to influence specific drugs if they are to be effective

Cumulative Effect
o If a drug is taken in successive doses at intervals that are shorter than recommended
OR
o if the body is unable to eliminate a drug properly, the drug can accumulate in the body
 Leads to toxic levels and adverse effects
9.
10
o Drug is not properly eliminated, and more of the drug is administered, resulting in toxic levels

Drug Interactions
o When taken with other drugs, food, or complimentary alternative therapies

Cross-Tolerance
o Resistance to drugs within the same class

Tolerance
o Due to increased biotransformation of the drug
11.
o Increased resistance to its effects
o When tolerance occurs, the amount of the drug no longer causes the same reaction
 Increasingly larger doses are needed to achieve a therapeutic effect
12.

Kidney disease
o Slow excretion
o Extend a drug’s half life

Liver Disease
o Slow metabolism
o Extend a drug’s half-life

Cardiovascular Disease
o Slow distribution
o Extend a drug’s half-life
* IV medications eliminate the absorption step in the process
13.

Loading Dose – recommended for doses whose effects are needed quickly

Bioavailability
o portion of a dose of a drug that reaches the systemic circulation and is available to act on the
body cells
o Binders used in a generic drug may not be the same as those in the brand name
o A drug is 100% bioavailable when administered through intravenous routes

Critical Concentration
o Amount of drug needed to cause a desired therapeutic effect
o Must be present before a reaction occurs within the cells to bring about the desired therapeutic
effect

Half-Life
o Amount of time it takes for the amount of the drug to decrease to half the peak level it
previously achieved
o Take into account
 Rate of absorption
 Distribution to the tissues
 Excretion rate

Dynamic Equilibrium
o Obtained from the absorption of a drug from the following to have a critical concentration for
the desired length of time
o Involves the rate of several processes:

Absorption from Site of drug entry
 Muscle
 GI tract if taken orally
 Distribution to the active site
 Biotransformation (Metabolism) in the liver
 Excretion from the body
o Key elements in the nurse’s ability to determine:
 Amount of drug (dose)
 Frequency of dose repetition (scheduling)

Selective Toxicity
o Ability of a drug to attach only to those systems found in foreign cells
o The ability of a drug to attack only systems found in foreign cells
o Ex. Penicillin causing bacterial cell death without disrupting normal human cell functioning
BLOOD-BRAIN BARRIER
- drugs that are more lipid-soluble are more likely to
pass through the barrier and reach the central
nervous system
-
PLACENTAL BARRIER AND BREAST MILK
- Many drugs readily pass through the placenta and
affect the developing fetus in pregnant women
CHAPTER 3- TOXIC EFFECTS OF DRUGS
TYPES OF ADVERSE EFFECTS:
 Primary Action Adverse Effects
o Extension of the therapeutic actions
o Result of overdosage, essentially too much of the therapeutic effect
o Ex. A client taking anticoagulants who develops a GI bleed

Secondary Action
o Negative effects of the drug that occur even when the drug is in the therapeutic range
o Occur as a result of taking a medication but do not fall under therapeutic action
o Ex. A patient taking erythromycin and experiencing abdominal discomfort
o Ex. Patient taking antibiotic and experiencing nausea and diarrhea
o Ex. Client who is drowsy after taking an antihistamine

Hypersensitivity Reaction
o Excessive response to either the primary or secondary effects of a drug

Drug Allergy
o Formation of antibodies to a drug or drug protein
o Causes an immune response when the person is next exposed to the drug
o Does NOT occur at the first exposure to a drug
TYPES OF DRUG ALLERGIES
 Anaphylactic Reaction
o Involve an antibody that causes the release of histamine
o Histamines produce immediate reactions
o Can lead to respiratory distress and even to respiratory arrest
o Administer epinephrine
o Symptoms:
 Increased BP and HR
 Dilated pupils

Cytotoxic Reaction
o Antibodies circulate and attack antigens on cell sites, causing death of that cell
o Discontinue drug immediately as ordered

Serum Sickness
o To certain medications
o Injection proteins used to treat immune conditions
o Antiserum, the liquid part of the blood that contains antibodies that help protect against
infections or poisonous substances

Delayed Allergic Reaction
o Can occur several hours to days after exposure and involves antibodies bound to specific white
cells

Liver injury can be caused by the first-pass effect and can cause the skin to have a yellow appearance
o Most drugs are metabolized in the liver
o Liver damage causes jaundice

Dark red papules appearing on limbs = Stevens-Johnsons syndrome
o Potentially fatal erythema multiforme exudativum
1.
o Steven-Johnson Syndrome
 Example of organ and tissue damage caused by a drug
2.

Serum Potassium = 3.5 to 5.0 mEq/L
o Potassium is an important electrolyte in the action potential
o Needed for cell membrane stability
Hypokalemia
Hyperkalemia
- decrease in BP - higher than 5.0 mEq/L
and pulse
- oliguria: <1000 mL per day
- when K levels are too high, the cells of the heart become very irritable and
rhythm disturbances can occur (arrhythmias)
- prepare for a possible cardiac emergency
- most often found in patients with renal failure
3.

Macrolide Antibiotics
o Auditory nerve damage
 Can cause dizziness
 Ringing in the ears (tinnitus)
 Loss of balance and hearing
o Patient would be at high risk for injury due to falls

Antidiabetic Medications
o Decrease blood glucose levels
o If levels fall too low, symptoms of hypoglycemia can occur
 Confusion
 Lack of coordination

Chloroquine (Aralen)
o For rheumatoid arthritis
o Can cause ocular toxicity
 Blurring of vision
 Color vision changes
 Corneal damage
 Blindness

Antihistamines
o Can cause anticholinergic effects
 Decreased sweating
 Risk for heat stroke
o Educate patient to avoid the hottest part of the day to prevent dehydration and heat
prostration
4.
5.
6.
* Extreme restlessness = Parkinson-like syndrome
* Excessive thirst = hyperglycemia
* Hallucinations = drugs that affect neurologic functioning
7.

A patient with Parkinson’s disease taking an anticholinergic drug to decrease the tremors and drooling
caused by the disease process. A patient complains that he is having trouble voiding. This is a
secondary action of the drug.
o Sometimes the drug dosage can be adjusted so that the desired effect is achieved without
producing undesired secondary reaction.  but sometimes it is not possible

Ephedrine
o Bronchodilator used to treat asthma and relieve nasal congestion
 Breaks down stored glycogen
8.

Cause an elevation of blood glucose (hyperglycemia) by its effects on the SNS
9.

Teratogen
o a drug that can harm the fetus or embryo
o Consider the teratogenic properties of medications when caring for a woman of child-bearing
age including adolescents and young adult women

Carcinogens
o Chemicals that can cause cancer

Blood Dyscrasia (symptoms)
o Fever
o Chills
o Sore Throat
o Weakness
o Back pain
o Dark urine
o Decreased hematocrit (anemia)
o Low platelet count (thrombocytopenia)
o Low WBC count (leukopenia)
o Reduction of all cellular elements of the CBC (pancytopenia)

Anticholinergic Response
o Occur in response to drugs that block the parasympathetic nervous system

Second Action
o Adverse response that the drug causes in addition to the therapeutic effect

Immediate systemic reaction = anaphylactic reaction

Patient with benign prostatic hypertrophy prescribed with anticholinergic
o May develop urinary retention or even bladder paralysis
 Drug’s effects block the urinary sphincters
o Educate patient to empty the bladder before taking the drug
o Reduced dosage may be required to avoid potentially serious effects on the urinary system
o Hypotonia is more likely to occur
10.
11.
12.
13.
16.

Antipsychotic Drugs
o Affect the dopamine levels in the brain
o Cause a syndrome that resembles Parkinson’s disease
 Lack of activity
 Akinesia
 Muscular tremors
 Drooling
 Changes in gait
 Rigidity
 Extreme restlessness (akathisia)
 Spasms (dyskinesia)
o Liver damage
 Yellow discoloration of the skin and sclera (jaundice)

Poisoning
o Occurs when an overdose of a drug damages multiple body systems
o Leads to the potential for fatal tractions
 Respiratory distress
 Vomiting with blood
 Somnolent
 Electrocardiogram shows an arrhythmia

Ephedrine
o Treats asthma
o Breaks down stored glycogen  enters bloodstream as glucose
 Causes an increase in serum blood glucose, or blood sugar levels

Neuroleptic Malignant Syndrome
o Generalized syndrome that includes extrapyramidal symptoms
 Slowed reflexes
 Rigidity
 Involuntary movements
 Hyperthermia
 Autonomic disturbances (hypertension, fast heart rate)
 Fever
o Most often seen after administering general anesthesia or drugs with CNS effects
o Was once known as malignant hyperthermia
17.
18.
19.
------------------------------------------------------------------------------------------------------------------------------------------------- Types of Anticholinergics:
o Atropine
 Used preoperatively
20.

Anticholinergic Secondary Effects
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Dry mouth
Altered taste perception
Dysphagia
Heartburn
Constipation
Bloating
Paralytic Ileus
Urinary hesitancy and retention
Impotence
Blurred vision
Cycloplegia
Photophobia
Headache
Mental confusion
Nasal congestion
Palpitations
Decreased sweating
Dry skin
21.

Glucose
o Brain uses the greatest amount to function
o Hypoglycemia has the greatest impact on the brain
 Explains why hypoglycemia has many neurological signs and symptoms
 Fatigue
 Drowsiness
 Anxiety
 Headache
 Shaking
 Lack of coordination
 Numbness and tingling of the mouth, tongue, and/or lips
 Confusion
 In severe cases, seizures or coma
22.
Anaphylactic Shock
 Pruritus
 Nausea
 Patient is pale, sweating, coughing, and wheezing
23.

Nephrotoxicity
o Decrease in urine output
o Aminoglycosides
o Aspirin

Parkinsonian Symptoms
24.
o Caused by antipsychotic drugs
o Symptoms:
 Lack of activity
 Akinesia
 Muscular tremors
 Drooling
 Changes in gait
 Rigidity
 Jitters (Akarhisia)
 Spasms (Dyskinesia)
25.

Superinfection
o Fever
o Diarrhea
o Black or hairy tongue
o Swollen tongue (glossitis)
o Mucous membrane lesions
o Vaginal discharge with or without itching
o Joint pain
CHAPTER 4: THE NURSING PROCESS IN DRUG THERAPY
AND PATIENT SAFETY
1. Responsibility of the nurse related to drug therapy:
 Teaching the patient how to cope with therapy to ensure the best outcome
 Providing therapy as well as medications
 Evaluating the effectiveness of therapy
2. When reading the nurse handbook in relation to recommended dosage, the suggested dosage is based
on a 150-pound adult male.
3. The nurse would expect to an adjusted dosage in:
 Infants
 Neonates
 Older adults
 Based on the functional level of the liver and kidneys and responsiveness of other organs
4. As patients age, the body undergoes many normal changes that can affect drug therapy
 Decreased blood volume
 Decreased GI absorption
 Reduced blood flow to the muscles or skin
 Changes in receptor site responsiveness
5. The nurse admits a patient to the unit and learns the patient has recently been diagnosed with chronic
renal failure but has not informed the primary care provider of this diagnosis. What is the nurse’s first
priority?
 Call the admitting physician immediately.
i. The nurse does not breach confidentiality when sharing information that impact needed
care to the primary care provider.
6. Baseline data prior to initiating drug therapy includes:
 Education level
i. Allows the nurse to plan an effective teaching plan
 Allergies
 Drug use
7. Enzyme Cytochrome P-450 (CYP450)
 Metabolizes drugs in the liver
 Affects metabolism
 In neonates, the ability to metabolize drugs is very low due to the immaturity of the liver and
the resultant inability to break down drugs
CHAPTER 6: CHALLENGES TO EFFECTIVE DRUG THERAPY
2. According to CDC recommendations, the role of the nurse in preparing for the possibility of
bioterrorism is to remain current on recognition and treatment of infections caused by biological
weapons.
3. Herbal Remedies
 Ginseng
i. Decreases blood sugar levels
ii. If a patient uses this in combination with their oral antidiabetic agent, diet, and exercise,
the blood sugar could drop below therapeutic levels
 Kava
i. Liver toxicity
 Fish Oil
i. Decreased coronary artery disease
4. St. John’s Wart
 Can interact with oral contraceptives that alter drug metabolism, which can decease the
effectiveness of the contraceptive
 Can be a cause of concern for a patient taking digoxin
5. Amphetamine Abuse
 Hypertension
 Tachycardia
 Insomnia
6. Elation = abuse of cannabis
7. Off-label indications
 Include drugs used to treat psychiatric problems
 Most likely to be prescribed for pediatric and geriatric patients
 Nurse should be clear about
i. Intended use
ii. Why the drug is being given
iii. Potential for problems
8. Home Care Teachings
 Generic names of the medication
 OTC drugs that need to be avoided
 How to calculate safe dosages
9. Alternative Products
 Not controlled or tested by the FDA
 Advertising is not as restrictive or accurate as with classic drugs
 Strength of tablets may vary within the bottle depending on conditions
10. Ipecac is no longer effective
11. If the company states what the drug is used for, the following must also be included:
 Contraindications
 Adverse effects
 Precautions
12. Garlic with antidiabetic drugs  hypoglycemia
Stimulants
Amphetamines
Amyl nitrate
Methamphetamine
Methylphenidate
Depressant
Barbituates
Benzodiazepines
Gamma-hydroxybutyrate
Ketamine
Opioid
Fentanyl
Heroin
Morphine
Oxycontin
Hallucinogen
LSD
MDMA
PCP with weed
Peyote
13.
 Date rape drugs
o Rophynol
o Gamma-hydroxybutyrate
CHAPTER 16: ANTI-INFLAMMATORY, ANTIARTHRITIS, AND
RELATED AGENTS
1. Acetaminophen (Tylenol)
a. Evaluate hepatic function
i. Severe hepatotoxicity can occur from overuse
b. Therapeutic Action:
i. Acts on the hypothalamus to cause vasodilation and sweating to reduce fever
c. NOT an anti-inflammatory
d. Do not exceed recommended doses due to risk of life-threatening liver damage
e. Safely recommend for pregnant clients who has been experiencing frequent headaches
2. Anti-Inflammatory Agents
a. Have potential to decrease antihypertensive effects from beta blockers if taken at the same
time
b. Monitor patients closely and make appropriate dosage adjustments if needed
c. Drug interaction with beta blockers
d. Potential to irritate the gastric mucosa and increase the risk of bleeding
i. Encourage patients to check stool for bleeding
e. Take with a full glass of water
f. Anti-Inflammatory Metabolism
i. Affected by alcohol and crushing the tablets
3. Use of salicylates in Children
a. Aspirin and choline magnesium trisalicylate are the only meds recommended for children
i. Do not use when any risk of Reye’s syndrome exists
b. Give acetaminophen when:
i. 6-year-old child presents with a fever of 102.8F and diagnosed with the flu
c. Etanercept and penicillamine are given for severe rheumatoid arthritis therapy
4. Anakinra (Kineret)
a. Blocks the increased interleukin 1, which is responsible for the degradation of cartilage in
rheumatoid arthritis
b. Administered subcutaneously
5. Etanercept
a. Reacts with free-floating TNF released by active leukocytes in autoimmune inflammatory
disease to prevent the damage caused by TNF
b. Rheumatoid Arthritis
c. Administered subcutaneously
i. Rotate sites to avoid tissue damage
6. Hyaluronidase Derivatives (hylan G-F 20, sodium hyaluronate)
a. Have elastic and viscous properties
b. Injected directly into the joints of patients with severe rheumatoid arthritis of the knee
i. Cushion and lubricate the joint and relieve the pain associated with degenerative
arthritis
ii. Given weekly for 3-5 weeks
c. Sodium hyaluronate
i. treats rheumatoid arthritis when other traditional treatment has been ineffective, and
the condition starts to worsen
7. NSAID’s
a. Indicated for relief of the signs and symptoms of:
i. Rheumatoid arthritis and osteoarthritis
ii. Mild-moderate pain
iii. Primary dysmenorrhea
iv. Fever reduction
b. Inhibit synthesis of prostaglandins
c. Teaching plan:
i. Signs and symptoms of GI bleeding
d. Types of NSAID’s
i. Ibuprofen
ii. Ketorolac
8. Antimalarial Agents
a. Treatment of systemic lupus erythematosus
b. May cause:
i. Visual changes
ii. GI upset
iii. Rash
iv. Headaches
v. Photosensitivity
vi. Bleaching of hair
9. Xanthine oxidase inhibitors and uricosuric agents
a. Treatment of gout
10. Medications with reports of increased toxicity in older/geriatric patients:
a. Naproxen (Aleve)
b. Ketorolac
c. Ketoprofen
11. Indomethacin
a. Given IV
b. For premature infants to close a patent ductus arteriosus and avoid a surgical procedure
c. Anti-inflammatory effects
12. Gold-containing compounds / gold-salts
a. Adverse effects due to deposition in the tissues and effects at local level:
i. Stomatitis
ii. Glossitis
iii. Gingivitis
iv. Pharyngitis
v. Laryngitis
vi. Colitis
vii. Diarrhea
viii. Other GI inflammation
ix. 8th cranial nerve damage
b. Contraindicated in:
i. Antimalarials
ii. Cytotoxic Drugs
iii. Penicillamine
c. Contraindicated in the presence of:
i. Allergies to gold
ii. Severe diabetes mellitus
iii. CHF
iv. Severe debilitation
v. Renal or hepatic impairment
vi. Hypertension
vii. Blood dyscrasias
viii. Recent radiation treatment
ix. History of toxic levels of heavy metals
x. Pregnancy or lactation
13. Salicylate Therapy
a. Tinnitus
b. Contraindicated in:
i. Surgery for increased bleeding
14. Corticosteroid Therapy
a. Hirsutism
15. Lab results for blood clotting
a. Salicylates
b. NSAID’s
16. Chrysotherapy
a. treatment with gold salts, in which gold is taken up by macrophages, which inhibit phagocytosis
b. For patients who are unresponsive to conventional therapy
c. Can be toxic
17. Salicylism (Aspirin Toxicity)
a. Can occur with high dosage of aspirin
b. Adverse effects:
i. Dizziness
ii. Ringing in the ears
iii. Difficulty hearing
iv. Nausea and vomiting
v. Diarrhea
vi. Mental Confusion
vii. Lassitude
viii. Sweating
c. Acute Salicylate Toxicity
i. Hyperventilation
ii. Muscle spasms
iii. Agitation
18. Salicylate Toxicity:
a. 20-25 g in adults
b. 4 g in children
COX-1 INHIBITORS
- Present in all tissues
- Involved in many body functions including:
i. Blood clotting
ii. Protecting the stomach lining
iii. Maintaining sodium and water balance in the
kidney
COX-2 INHIBITORS
- Act only at the sites of trauma and injury to more
specifically block the inflammatory region
- May block some protective responses such as:
iv. Vasodilation
v. Inhibited platelet clumping
vi. ^^ Protective if vessel narrowing or blockage
occurs
vii. Blocking this effect could lead to
cardiovascular problems
Assess for:
viii. GI Effects
ix. Changes in bleeding time
x. Water retention
2. NSAID’s combined with loop diuretics
a. Potential for decreased diuretic effect
3. Lithium combined with ibuprofen
a. Potential for lithium toxicity
4. Ibuprofen (Motrin)
a. Cause irritation to the GI mucosa and block platelet clumping  result in bleeding
b. Assess for patients for blood loss due to dysmenorrhea
c. Overuse may lead to GI irritation
d. Properties:
i. Anti-inflammatory
ii. Analgesic
iii. Antipyretic
5. Auranofin (Ridaura)
a. Prescribed when more usual anti-inflammatory therapies are ineffective, and the patient’s
condition worsens despite weeks or months of standard pharmacologic treatment
b. Gold-compound
c. Treatment for rheumatoid arthritis
d. Given through oral route
6. Naproxen (Naprosyn)
a. Effective in treating:
i. Muscle pain
ii. Arthritis
iii. Dysmennorhea
b. Approved for pediatric use
c. Has antipyretic properties
7. Aspirin
a. Decreases risk of myocardial infarction in patients with unstable angina or previous myocardial
infarction
b. Swallow with milk or food
c. Effected exerted:
i. Analgesic
ii. Antipyretic
iii. Anti-inflammatory
d. Given one a day to inhibit platelet aggregation
8. Analgesics
a. Treatment of pain
9. Celecoxib
a. Causes the least gastrointestinal distress
b. Associated with increased risk of:
i. Cardiovascular thrombosis
ii. Myocardial infarction
iii. Stroke
c. Appropriate for:
i. 56-year-old client diagnosed with osteoarthritis and reports joint pain and stiffness
d. Contraindicated in clients with allergies to sulfonamides
e. Acts on COX-2 enzyme
10. Meloxicam
a. Treated for arthritis
11. Salicylates
a. Pain
b. Fever
c. Inflammation
Balsalazide (Colazal)
Sodium thiosalicylate
Choline magnesium triasalicylate (Tricosal)
Salasate (Aregesic)
Local anti-inflammatory effects to patients
with ulcerative colitis
Acute gout, muscular pain, rheumatic fever
Pain, fever, inflammation
Pain, fever inflammation
CHAPTER 25: MUSCLE RELAXANTS
1. The movement of calcium contributes to the process of muscle contraction and relaxation.
a. Released from the sarcoplasmic reticulum, which leads to the binding of calcium with
troponintropomyosin  contraction of the muscle fiber
b. Calcium pump moves calcium back into the sarcoplasmic reticulum  relaxation
2. Muscle spasticity
a. Results from damage to motor neurons within the CNS
3. Chlorzoxazone (Paraflex)
a. Urine may be discolored while using the drug
b. Will turn orange to purple-red when metabolized and excreted
c. Causes constipation
d. Onset is usually within an hour after the drug has been taken
e. Report immediately for yellow discoloration of the skin  liver damage or dysfunction
4. Methocarbamol (Robaxin)
a. Drug of choice for a child that needs to be treated for tetanus
b. Signs of tetanus
i. Patient stepped on a rusty nail
ii. Signs of muscle rigidity and contractions
5. Baclofen (Lioresal)
a. Used for treatment of muscle spasticity for neuromuscular diseases such as multiple sclerosis
b. Achieves skeletal muscle relaxation
c. Available for oral and intrathecal forms
d. Can be administered via a delivery pump for the treatment of central spasticity
e. Taper drug slowly over 1-2 weeks to prevent the development of psychoses and hallucinations
f. Giving baclofen with carisoprodol would risk toxicity
g. Primary adverse effect: CNS depression
i. If the patient receives too much medication, or reaches toxic levels, respiratory rate will
decline as a result of excessive CNS depression
ii. Monitor for respiratory status
6. Drugs for painful, acute musculoskeletal conditions
a. Cyclobenzaprine
b. Metaxalone
c. Orphenadrine
7. Datrolene (Dantrium)
a. If combined with estrogen, the incidence of hepatocellular toxicity is increased
b. Avoid this combination
c. Highest risk: 65-year-old woman who is on hormone replacement therapy
d. Contraindicated in:
i. Spasticity that contributes to locomotion
ii. Upright position
iii. Increased function (would be lost if spasticity was blocked)
iv. Active hepatic disease (interferes with metabolism)
v. Lactation
1. Drug may cross into the breast milk and cause adverse effects to the infant
e. Directly affects peripheral muscle contraction
i. DRUG OF CHOICE to manage spasticity associated with neuromuscular diseases
f. Crosses the placenta and is found to be embryotoxic in animal studies
g. Children prescribed should be screened for CNS and GI toxicity
h. Monitor for:
i. Drowsiness
ii. Weakness
iii. Fatigue
iv. Diarrhea
v. Hepatitis
vi. Myalgia
vii. Tachycardia
viii. Transient BP changes
ix. Rash
x. Urinary frequency
i.
Periodically discontinue drug for 2-4 days to monitor therapeutic effectiveness
j.
Indications include:
i. control of clinical spasticity resulting from upper motor neuron disorders
ii. prevent or attenuate the development of malignant hyperthermia
k. Most serious adverse effect: hepatitis
8. Tizanidine (Zanaflex)
a. Associated with hypotension
i. Safety risk for patient taking an antihypertensive drug
b. Common adverse effects:
i. Constipation
ii. Dry mouth
iii. Fatigue
9. Botulinum toxin types A and B
a. Bind directly to the receptor sites of motor nerve terminals and inhibit the release of
acetylcholine, leading to local muscle paralysis
b. Injected locally to paralyze and prevent the contractions of specific muscle groups
i. Effect is temporary
c. Smooth wrinkles in the area, but does not cause muscle death
d. Do not inject into area with an active infection because of the risk of exacerbation of the
infection
i. If the patient has adult acne, hold the injection and consult the health care provider
1. Expectation: the medication would be held until the acne resolves
e. Adverse effects:
i. Headache
ii. Respiratory infections
iii. Flu-like syndrome
iv. Droopy eyelids in severe cases
10.
Spastic
Atonic
Flaccid
Tonus
Sustained muscle contraction
Soft and flabby muscle tone
Limp muscle without tone
Maintenance of some of the muscle fibers in a contracted state
11. Muscle spasms:
a. Result from injury to the musculoskeletal system
i. Overstretching a muscle
ii. Wrenching a joint
iii. Tearing a tendon or ligament
12. Centrally Acting Skeletal Muscle Relaxants
a. Adverse Effects:
i. Transient drowsiness
ii. Dizziness
iii. Weakness
iv. Fatigue
v. Constipation
vi. Headache
vii. Insomnia
viii. Hypotension
ix. Nausea
x. Urinary Frequency
13. Patient receiving intrathecal baclofen and another patient receiving dantrolene
a. Acute pain related to GI effects of the drug
b. Risk for injury related to CSN effects
c. Disturbed thought processes related to CNS effects
14. Diazepam (Valium)
a. Muscle relaxant (treats muscle spasm)
b. Anxiolytic (reduces anxiety)
15. Carisoprodol
a. Drug of choice for an older adult or patient with hepatic or renal impairment
b. Common adverse reactions:
i. Drowsiness
16. Orphenadrine (Banflex)
a. Only can be given parenterally
i. IV or intramuscularly
17. Cyclobenzaprine (Flexeril)
a. Norma daily dose: 10 mg orally TID
b. Maximum of 60 mg per day
c. Assess for drowsiness
i. Nursing diagnosis: risk for injury related to CNS depression
d. Produces an anticholinergic response
CHAPTER 26: NARCOTICS, NARCOTIC ANTAGONISTS, AND
ANTIMIGRAINE AGENTS


Analgesia = relief from pain
Analgesic = painkillers
1. Codeine
a. Correct dose: 15-60mg every 4-6 hours
b. Used for analgesic and antitussive effects
c. Mild-to-moderate pain
d. Used to relieve coughing
2. Triptans
a. Class of selective serotonin receptor blockers that cause vasoconstriction
b. Can cause:
i. Dizziness
ii. Feelings of strangeness
iii. Vertigo
c. Adverse effects are fewer than those associated with ergot therapy
3. Sumatriptan (Imitrex)
a. Used for the treatment of acute migraine attacks and cluster headaches in adults
b. Binds to serotonin receptors to cause vasoconstrictive effects on cranial blood vessels
4. Zolmitriptan
a. Administered orally only
5. Ergot Derivatives
a. Cause constriction of cranial blood vessels
b. Decrease pulsation of cranial arteries
c. Reduce hyper perfusion of the basilar artery vascular bed
6. Ergot Drugs
a. Do not combine with beta blockers
i. Increases risk for peripheral ischemia and gangrene
7. A-delta and C fibers
a. generate nerve impulses that produce pain sensations
8. A-fibers
a. transmit sensations associated with touch and temperature
9. Mu-receptors
a. pain-blocking receptors
10. Sigma-receptors
a. cause papillary dilations
b. May be responsible for hallucinations, dysphoria, and psychoses that occur with narcotic use
11. Eletriptan
a. Can take another dose in 2 hours if the headache is not relieved
b. Do NOT combine with ergot drugs  due to vasoconstriction caused by both
12. Naloxone
a. Drug of choice for treatment of opioid overdose
b. Works within 1 to 2 minutes to reverse opioid induced respiratory depression
c. Contraindicated in those who:
i. Are pregnant
ii. Infants of opioid-dependent mothers
iii. Mothers breastfeeding an infant
d. Abrupt reversal of opioid-induced respiratory depression may cause vomiting
13. Butorphanol
a. Morphinan-type synthetic opioid analgesic
b. Nasal spray
i. Repeat dose may be administered within 60-90 minutes
14. Buprenorphine (Buprenex)
a. Narcotic-agonist-antagonist
b. Would suppress respirations
15. Nalbuphine Hydrochloride (Nubain)
a. Synthetic opioid used commercially as an analgesic
b. Depress respirations
16. A strong narcotic analgesic (morphine sulfate 8mg IV q 1hr) would not be indicated for chronic
osteoarthritis pain
17. Morphine
a. OPIOID-ANALGESIC PROTOTYPE DRUG / NARCOTIC ANALGESIC
b. Common adverse effects:
i. Dizziness
ii. Drowsiness
iii. Visual changes
c. Oral morphine
i. Peak activity: 60 minutes
ii. Duration of action: 5-7 hours
d. Hold morphine if the client is taking a monoamine oxidase (MAO) inhibitor
e. If the nurse suspects the patient is developing a cold after administration,
i. Monitor for pneumonia
1. Respiratory depression is a common effect of morphine
2. Can cause retained secretions and put the patient at risk for pneumonia
18. Narcotics that have an established pediatric dose:
a. Morphine
b. Meperidine
c. Hydrocodone
d. Codeine
e. Fentanyl
19. Pentazocine
a. Administer cautiously to patients with known heart disease
i. Drug may cause cardiac stimulation including:
1. Arrhythmias
2. Hypertension
3. Increased myocardial oxygen consumption
a. Can lead to angina, myocardial infarction, or CHF
b. Appropriate nursing diagnosis: impaired gas exchange related to respiratory depression
c. Causes constipation  slows down Gi tract
20. Narcotic-Agonists-Antagonists
a. Relief of moderate to severe pain
b. Relief of pain during labor and delivery
c. Adjuncts to general anesthesia
d. Monitor for adverse effects:
i. CNS changes
ii. GI depression
iii. Respiratory depression
iv. Arrhythmias
v. Hypertension
21. Administering narcotics to older adults:
a. Priority assessments:
i. CNS effects
ii. GI effects
iii. Cardiovascular effects
22. Methylanatrexone (Relistor)
a. Only given subcutaneous injection once a day
23. Gate Control Theory
a. Nurses could help block pain by back massage
24. Patient in Labor
a. Medications used for analgesia
i. Morphine
ii. Meperidine
iii. Oxymorphone
b. Monitor mother closely for adverse reactions
c. If the drug is used during a prolonged labor, monitor newborn infant for opioid effects
i. Give naloxone only if the newborn displays opioid effects
25. Codeine
a. mild-to-moderate pain
26. Hydrocodone
a. moderate pain
27. Opium
a. moderate pain and treatment of diarrhea
28. Hydromorphone
a. moderate-to-severe pain
29. Methadone
a. Used for detoxification and temporary maintenance of narcotic addiction
30. Oxymorphone
a. Relief of moderate to severe pain
b. Preoperative medication
c. Obstetrical analgesia
31. Tramadol
a. Relief of moderate to moderately severe pain
b. Limit in clients with a history of addiction
32. Acute Narcotic Abstinence Syndrome
a. Nausea & Vomiting
b. Sweating
c. Tachycardia
d. Hypertension
e. Tremulousness
f. Feelings of anxiety
33. Reversal of Opioid Effects
a. 0.1-0.2 mg given IV and then repeated every 2-3 minutes
b. If the patient has overdosed, the dose would be: 0.4-2mg every 2-3 minutes
34. Oxycodone (Oxycontin)
a. Tablet provides around-the-clock pain management and should not be crushed, chewed, or
broken  drug is released slowly over time
b. Relief of moderate to severe pain
35. Opioids
a. Produce hypotension due to the effect on the vasomotor center
36. Opioid Antagonists
a. Produce withdrawal symptoms in patients who are physically dependent on opioids
b. Adverse reactions
i. Nausea and vomiting
ii. Sweating
iii. Increased BP
iv. Tachycardia
v. Tremors
c. Primary goal of therapy: return to a normal respiratory rate, rhythm, and depth