NURS - 343 PHARMACOLOGY EXAM 1
Week Topic
questions
# of exam
Pharmacologic principles
Nursing process and drug therapy
Medication errors
Over-the-counter medications
Herbal supplements
Chronic neurologic medications
Analgesics
Medication math
5-10
2-8
2-8
2-5
2-8
10-20
4-12
5
PHARMACOLOGIC PRINCIPLES
Chapter 1
PHARMACOKINETICS AND ROUTES OF ADMINISTRATION
I.
II.
III.
I.
II.
III.
Drug
A. Any chemical that affects the physiologic processes of a living organism
Pharmacology
A. Study or science of drugs
Drug Names
A. Chemical name: name of the med that reflects its chemical composition and molecular
structure.
B. Generic name: official or nonproprietary name the USANC gives a medication.
1. Ex. Ibuprofen
C. Trade name: brand or proprietary name the company that manufactures the
medication gives it.
1. Ex. Advil and Motrin
Pharmaceutics: The study of how various drug forms influence the way in which the drug
affects the body
Pharmacokinetics: How the meds travel through the body
Phases of Pharmacokinetics
A. Absorption: transmission of meds from the location of administration to the
bloodstream. The most common routes are enteral and parenteral. Rate determines
how soon the meds will take effect. Amount determines the intensity of meds. Route
affects the rate and amount of absorption.
1. Oral →
BARRIERS: Meds must pass through the layer of epithelial cells that line the GI
tract.
2. Sublingual or buccal →
BARRIERS: swallowing before the meds are completely dissolved can cause the
gastric pH to inactivate the medication
3. Other mucous membranes (rectal, vaginal) →
BARRIERS: presence of stool in the rectum or infectious material in the vagina
limits tissue contact. Or the sphincters are not working properly and the
patient is not able to hold in the medication.
4. Inhalation (mouth or nose) →
BARRIERS: Inspiratory effort. Some patients have COPD and they are unable to
get a deep enough breath. Sometimes patients do not use the inhaler the
correct way.
5. Intradermal or topical →
BARRIERS: Close proximity of epidermal cells; lipid soluble meds can be slower
processed bc it’s fat that is being absorbed.
6. Subcutaneous or intramuscular →
BARRIERS: Capillary walls have large spaces between cells.
7. Intravenous →
BARRIERS: No barriers
B. Distribution: transportation of medications to sites of action by bodily fluids.
1. Circulation: poor blood flow can restrict med distribution such as those with
peripheral vascular or cardiac disease
2. Permeability of the cell membrane: meds must be able to pass through tissues
and membranes to reach its target area
3.
IV.
V.
Plasma protein binding: meds compete for protein binding sites within the
bloodstream specifically albumin. This determines how much of the meds will
leave and travel to the target tissues.
C. Metabolism: changes meds into less active or inactive forms by the action of enzymes.
Occurs in the liver but also the kidneys, lungs, intestines and blood.
Factors influencing the rate of medication metabolism →
1. Age: Hepatic medication metabolism declines with age. Older adults usually
get smaller doses of meds because it can stay in their body for a longer period
of time.
2. Increase in some med-metabolizing enzymes
3. First-pass effect: liver inactivates some meds on their first pass through and
can require for the meds to be distribute in a nonenteral route such as IV
4. Similar metabolic pathways:
5. Nutritional Status
D. Excretion: elimination of the meds from the body primarily through the kidneys. Also
takes place through the liver, lungs, intestines and exocrine glands (breast milk).
Kidney dysfunction can lead to an increase in the duration and intensity of a
medication’s response so it is important to monitor BUN and creatinine levels.
Medication Responses: Maintains it at a minimum effective concentration
A. Therapeutic Index: Meds with a high therapeutic index (TI) have a wise safety
medication therefore it doesn’t need for routine serum medication-level monitoring.
However, those meds with a low TI require close monitoring. Nurses should consider
the route of administration when monitoring for peak levels. For trough level, obtain a
blood sample.
B. Half Life: the time for the meds in the body to drop to 50%
1. Short half life → med leaves the body quickly (4-8hrs), short intervals
2. Long half life → med leaved the body more slowly, over 24 hrs. Risk of med
accumulation and toxicity. Long intervals w/o loss of therapeutic effects, longer
time to reach a steady state.
C. Pharmacodynamics: interactions between meds and target cells, body systems, and
organs to produce effects.
1. Agonist → binds to receptor. (ex. Morphine binds to a receptor that activates it
to produce analgesia, sedation and constipation.
2. Antagonists → blocks the usual receptor activity. (ex. Losartan which is an
angiotensin II blocker, it blocks the angiotensin II receptor on blood vessels
which prevents vasoconstriction.
3. Partial agonists → acts as both. (ex. Nalbuphine acts as antagonists at mu
receptors and an agonist at kappa receptors causing analgesia with minimal
respiratory depression at low doses.
Routes of Administration
A. Oral or Enteral: tablets, capsules, liquids, suspensions, elixirs, lozenges (most common
route)
1. Read Nursing actions on page 5
B. Sublingual and Buccal: under the tongue or between the cheek and gum, directly
enters the bloodstream and bypass the liver.
1. Read Nursing actions on page 5
C. Liquids, Suspensions, and Elixirs:
1. Read Nursing actions on page 5
D. Transdermal: med in a skin patch for absorption through the skin, producing systemic
effects
1. Read Nursing actions on page 5
E. Topical: painless and limited adverse effects
1. Read Nursing actions on page 5
F. Instillation (drops, ointments, sprays): used for eyes, ears, and nose
1. Read Nursing actions on page 5
G. Inhalation: administered through metered dose inhalers (MDI) or dry powder inhalers
(DPI)
1. Read Nursing actions on page
H. Nasogastric and Gastrostomy tubes
1. Read Nursing actions on page
I. Suppositories
1. Read Nursing actions on page
J. Parenteral
1. Read Nursing actions on page
K. Intradermal
1. Read Nursing actions on page
L. Subcutaneous and Intramuscular
1. Read Nursing actions on page
M. Z-track
1. Read Nursing actions on page
N. Intravenous
1. Read Nursing actions on page
O. Epidural
1. Read Nursing actions on page
6
6
6
6
6
6
6
6
6
CHAPTER 2
SAFE MEDICATION ADMINISTRATION & ERROR REDUCTION
➔
➔
➔
➔
➔
➔
➔
➔
➔
Medication category/Class
◆ Meds have a pharmacological action, therapeutic use, body system target, chemical
makeup, and classification for use during pregnancy.
Mechanism of Action
◆ How meds produce their therapeutic effect.
Therapeutic effect
◆ Expected effect (physiological response) for which the nurse administers a medication
to a specific pt. One medication can have more than one therapeutic effect.
● Ex: one pt. Receives acetaminophen to lower fever, another pt. Receives it to
relieve pain.
Side effects
◆ Expected and predictable effects that result at therapeutic dosages.
● Ex: morphine for pain relief usually results in constipation.
Adverse effects
◆ Undesirable, inadvertent unexpected and potentially dangerous responses to
medications. Some are immediate, while others take weeks and months to develop.
Toxic effects
◆ Meds can have specific risks and manifestations of toxicity.
◆ Developed after taking med for a lengthy period of time → or when toxic amounts build
up due to faculty metabolism or excretion.
Medication interactions
◆ Meds can interact with each other resulting in beneficial or harmful effects.
Precautions/ Contraindications
◆ Conditions (diseases, age, pregnancy, lactation) that make it risky or completely
unsafe for pts. To take specific medications.
Preparation, dosage, administration
◆ Important to know any specific considerations for preparation, safe dosages, dosage
calculations, and how to administer the med.
Medication Category and Classification
➔ Nomenclature
◆ Chemical, generic, trade names
➔ Considerations
◆ Uncontrolled substances: require monitoring by provider, but do not generally pose
risks of abuse and addiction. (ex. antibiotics)
◆ Controlled substances: potential for abuse & dependence and have a schedule
classification.
● Ex: schedule 1 → heroin (no medical use)
● Schedule 2-5 → legitimate applications
○ Phenobarbital (Luminal): epilepsy med.- schedule 4
○
➔
Morphine → schedule 2 (greater risk than phenobarb for abuse and
dependence)
Medication Prescriptions
◆ Each facility has written policies for medication prescriptions, including which providers
may write, receive, and transcribe medication prescriptions.
◆ Types of medication prescriptions
● Routine or standard prescriptions
○ Give on a regular schedule with or without a termination date or a
specific number of doses.
○ No termination date until provider discontinues or discharges pt.
○ Provider must re-prescribe some meds, like opioids & antibiotics, within
a specific amount of time or they will automatically discontinue.
● Single or one-time prescriptions
○ For administration once at a specific time or as soon as possible.
○ Common for preoperative or pre-procedural meds.
● Stat prescriptions
○ Only admin once and immediately during an emergency when a pt’s
condition changes suddenly
● PRN prescriptions
○ (pro re nata) prescription specifies at what dosage, frequency, and
under what conditions a nurse may administer the med.
○ Nurse uses clinical judgement to determine the need for the PRN med
● Standing prescriptions
○ Providers write standing prescriptions for specific circumstances or for
specific units.
◆ Ex: critical care unit has standing prescriptions for treating pts.
who have asystole → or heparin protocol.
◆
Components of a Medication
● Pt.’s full name
● date/time of prescription
● Strength and dosage of the medication
● Route of administration
● Time and frequency of administration: exact times or number of times per day
(according to facility’s policy or specific qualities of the medication)
● Quantity to dispense and the number of refills
● Signature of the prescribing provider.
◆
Communicating medication prescriptions
● Origin of medication prescriptions: providers or nurses who take verbal or
telephone prescriptions from a provider write medication prescriptions on the
pt.’s medical record. → facility’s policy specifies how much time the provider
has to sign the prescription. → nurse transcribe med prescrip. Onto the MAR.
● Taking a telephone prescription: if possible, have second nurse listen on an
extension or speaker in private area → make sure it is correct and complete by
reading back pt. Name, name of med, dosage, time of admin, frequency, and
route. → correct spelling (b as in boy) → remind provider to verify prescription
& sign it w/i the amount of time (facility policy) → enter prescription in pt’s
health record.
◆
Medication reconciliation
● Joint commision requires policies and procedures for med reconciliation.
● Nurse compile list of pt meds, dose, and freq → then compare with new med
prescrip. And reconcile it with provider to resolve any discrepancies.
●
Process takes place at admission, when transferring pt between units or
facilities, and @ discharge.
Pre-assessment for Medication Therapy
➔ Nurse obtain following info before initiating medication therapy → & update if necessary.
◆ Health History
● Age
● Health probs & current reason for seeking care
● All meds currently taking (prescrip. & nonprescrip.): name, dose, route, & freq
of each.
● Any adverse or side effects possibly from med therapy, and therapeutic effects
● Use of herbal or natural products for medicinal purposes
● Use of caffeine, tobacco, alcohol, & street drugs.
● Pt’s understanding of the purpose of the meds along with their beliefs,
feelings, and concerns.
● All medication and food allergies.
◆ Physical Examination
● Provides baseline for evaluating therapeutic effects of medication therapy and
for detecting possible side & adverse effects.
Rights of Safe Medication Administration.
➔ Right patient
◆ 2 identifiers
➔ Right medication
◆ correctly interpret med prescription, verifying completeness and clarity.
➔ Right dose
◆ calculate correct med dose → check drug reference to ensure dose is w/i usual range →
have another nurse check calculations. (some med dosage require a second verifier or
witness)
➔ Right time
◆ administer med on time to maintain a consistent therapeutic blood level.
➔ Right route
◆ most common is oral, topical, subq, IM, and IV. → additional, sublingual, buccal,
intradermal, transdermal, epidural, inhalation, nasal, ophthalmic, otic, rectal, vaginal,
intraosseous (into bone), and via enteral tubes.
➔ Right documentation
◆ record med, dose, route, time, and pt. Response → document after administration.
➔ Right education
◆ inform pt of med→ purpose, what to expect, how to take it, what to report.
➔ Right to refuse
◆ explain consequences, inform the provider, and document the refusal.
➔ Right assessment
◆ collect any data before and after administering any medication.
➔ Right evaluation
◆ follow up to verify therapeutic, side, and adverse effects.
Medication Error Prevention
➔ Using the nursing process to prevent medication errors
◆ Assessment
● Be knowledgeable about the medication administered
● Obtain info about medical diagnoses and conditions that affect medication
administration, such as the ability to swallow, allergies, heart, liver, and kidney
disorders.
● Determine if medication prescription is complete, including the name of pt.,
date & time, name of med, dosage, route of admin., time of admin. Or freq.,
and signature of prescribing provider.
●
◆
◆
◆
Error-Prone abbreviation list: abbre. That have caused a high number of med
errors.
● Confused medication name list: sound- alike and look- alike med names.
● High-alert medication list: nurse administers them in error, high risk of
significant harm to pt.
● Question provider if unclear or refuse admin. If seems unsafe for patient.
Planning
● Identify outcomes for medication
● Set priorities (which meds to give first or before specific treatments or
procedures)
Implementation
● Avoid distractions.
● Check label, read directions, check expiration, double check with a colleague.
● Do not admin. Medications that someone else prepared.
● Omit or delay a dose when a pt question the size or appearance of the meds
● Use verbal prescrip. Only for emergencies
● Nursing students may not accept verbal or telephone orders
● Communicate clearly.
● Another nurse should witness the discarding of controlled substances
Evaluation
● Evaluate pt. response to med., and document.
● Use knowledge of therapeutic effect, common side and adverse effects of
meds to compare expected outcomes with actual findings.
● Report all errors, and implement corrective measures immediately.
○ Incident report, usually w/i 24 hrs. → report include: pt identification,
name and dose of med, time and place of incident, accurate &
objective account of event, who you notified, actions taken, and your
signature. (or who completed report)
○ NOT INCLUDED IN PT. MEDICAL RECORD.
Chapter 5
ADVERSE EFFECTS, INTERACTIONS, AND CONTRAINDICATIONS
Side effects occur when the med is given at a therapeutic dose. Adverse effects are undesired,
inadvertent and unexpected severe responses to the meds. Providers will discontinue the meds
immediately. Interactions can occur when more than one meds is given or it can interact with foods, or
herbal medicines.
I.
Adverse Medication Effects
A. Central Nervous System
1. CNS excitement or CNS depression
B. Anticholinergic
1. effects that are result of muscarinic receptor blockade; most are seen in eyes,
smooth muscle, exocrine glands, and the heart.
C. Cardiovascular
1. involve blood vessels and the heart; antihypertensives can cause orthostatic
hypotension
D. Gastrointestinal (GI)
1. irritation of GI tract, stimulation of the vomiting center results in adverse
effects
E. Hematologic
1. relatively common and potentially life threatening with some groups of meds
F. Toxicity
1. can be life threatening; caused by excessive dose but can also occur at
therapeutic dose levels.
2. Hepatotoxicity: Can occur with many meds. Damaged to liver cells can impair
metabolism of many meds and cause accumulation of meds in the body.
3. Nephrotoxicity: primarily the result of certain antimicrobial agents and NSAIDs
G. Allergic Reactions
1. When an individual develops an immune response to a medication
2. Anaphylactic Reaction
a) Life threatening, immediate allergic reaction that causes respiratory
distress, severe bronchospasm, laryngeal edema, a quick drop in BP,
as well as cardiovascular collapse.
H. Extrapyramidal Symptoms (EPSs)
1. Abnormal body movements that can include involuntary fine motor tremors,
rigidity, uncontrollable restlessness and acute dystonias
I.
Immunosuppression
1. Decreased or absent immune response
II.
Interactions
A. Drug-Drug Interactions
1. Increased therapeutic effects
2. Increased adverse effects
a) Can take two meds that have the same side/adverse effect
3. Decreased therapeutic effects
a) One med can increase the metabolism or block the effects of the other
meds
4. Decreased side/adverse effects
a) One med can be given to counteract the side effect of the other med
5. Increased serum levels, leading to toxicity
a) One med can decrease the metabolism of the other med which
increases the serum level and can lead to toxicity
B. Medication-Food Interactions
1. food can alter med absorption and can contain substances that react with
certain meds
III.
Contraindications and Precautions
Some meds are contraindicated to pt’s such as penicillin as they might be allergic to it.
Precautions should be taken for a client who is more likely to have an adverse reaction than
another.
➔ Ex. Morphine depresses respiratory function, so it should be use with caution to those
pts who have asthma or impaired respiratory functions.
Chapter 6
INDIVIDUAL CONSIDERATIONS OF MEDICATION ADMINISTRATION
I.
II.
III.
Factors affecting medication dosages and responses
A. Body weight
1. greater body mass require larger doses.
B. Age
1. smaller doses for kids and older adults primarily bc of liver and kidney
functions
C. Gender
1. women differs from men bc of body fat and hormones
D. Genetics
1. missing enzymes can alter metabolism of certain meds.
E. Biorhythmic cycles
1. Ex. hypnotic meds work better when given at usual sleeping times.
F. Tolerance
1. Meds taken too much by a patient can reduce their response to it; which is
called pharmacodynamic tolerance. Cross tolerance -- to a chemically similar
medication.
G. Accumulation
1. inability to metabolize the med can cause accumulation and toxicity.
H. Psychological factors
1. emotional state and expectations can influence the effects of a med
I. Diet
1. inadequate nutrition can affect protein building response of meds
J. Medical problems: read pg 41.
Pharmacology and Children
A. Amount of medications differ from adults and children.
Pharmacology and Older Adults (65+ years)
A. Read page 42
IV.
Pharmacology and Pregnancy and Lactation
A. Read page 42
ATI: CHAPTER 30
VITAMINS, MINERALS, and SUPPLEMENTS
★ Iron preparations
Oral:
➔
➔
➔
ferrous sulfate **
ferrous gluconate
ferrous fumarate
Parenteral:
➔ Iron dextran **
➔ Ferumoxytol
➔ Iron sucrose
➔ Sodium-ferric gluconate complex (SFGC)
PURPOSE
➔ Needed for RBC development and O2 transport to cells.
➔ Iron is poorly absorbed by the body, so relatively large amounts must be ingested orally to
increase Hgb and Hct (hematocrit) levels.
Therapeutic uses:
Iron prep are used to treat and prevent iron-deficiency anemia.
➔ Ferumoxytol: limited to pt who have chronic kidney disease, regardless if on dialysis or
receiving erythropoietin.
◆ Two doses over 3-8 days compared to SFGC and iron sucrose, 3-10 doses over several
weeks.
➔ SFGC: long-term hemodialysis and are deficient in iron.
➔
Iron Sucrose: pt w/ chronic kidney disease, are receiving erythropoietin, and are
hemodialysis- or peritoneal dialysis- dependent; and pt who have chronic kidney disease, are
not receiving erythropoietin, and are not dialysis- dependent.
*Parenteral form should only be used in clients who are unable to take oral medications*
COMPLICATIONS
➔
➔
➔
➔
➔
➔
GI distress (nausea, constipation, heartburn)
◆ If intolerable, admin. med with food, but this greatly reduces absorption
◆ Monitor pt’s bowel pattern
Teeth staining (liquid form)
◆ Dilute liquid iron with water or juice drink with a straw, and rinse mouth after
swallowing
Staining to skin and other tissues (IM injection)
◆ Use Z-track → avoid route if possible
Anaphylaxis
◆ Risk with parenteral admin of iron dextran
◆ Triggered by dextran in iron dextran, not by iron
◆ Minimal with SFGC, iron sucrose, and ferumoxytol
Hypotension
◆ Can progress to circulatory collapse with parenteral admin. → monitor vitals when
admin parenteral iron
Fatal iron toxicity in children
◆ Can occur when an overdose of iron (2-10 g) ingested.
● Toxicity -- severe GI symptoms, shock, acidosis, and liver and heart failure
● Deferoxamine, given parenterally used to treat toxicity.
● Avoid using oral and parenteral iron concurrently.
CONTRAINDICATIONS / PRECAUTIONS
➔ Pts who have previous hypersensitivity to iron, anemias other than iron-deficiency anemia
➔ Oral prep should be used with caution in pts. who have peptic ulcer disease, regional enteritis,
ulcerative colitis, and severe liver disease.
★
★
★
Concurrent administration of antacids or tetracyclines reduces absorption of iron
○ Separate use at least 2 hrs
Caffeine and dairy products can interfere with absorption
Food reduces absorption but reduces gastric distress
NURSING ADMINISTRATION
➔ Take iron on empty stomach, 1 hr before meals- stomach acid increases absorption
➔ Take with food if GI effects occur
➔ Space doses at equal intervals throughout day to efficiently increase RBC production
➔ Anticipate harmless dark green or black color stool
➔ Dilute liquid iron w/ H2O or juice, drink with straw, and rinse mouth after swallowing.
➔ Increase H2O and fiber intake (unless contraindicated) and to maintain an exercise program to
counter constipation effects.
➔ Therapy can last 1-2 months.
◆ Dietary intake will be sufficient after Hgb has returned to therapeutic level.
➔ Encourage concurrent intake of appropriate quantities of foods high in iron (liver, egg yolks,
muscle meats, yeast, grains, green leafy veggies)
NURSING EVALUATION OF MEDICATION EFFECTIVENESS
➔
➔
➔
Increased reticulocyte (immature RBC) count is expected at least 1 week after beginning iron
therapy.
Increase in Hgb of 2 g/dL is expected 1 month after beginning therapy.
Fatigue and pallor (skin/ mucous membrane) should subside, also pt. Reports increased energy
level.
★ Vitamin B12/ Cyanocobalamin
➔
➔
Vitamin B12
Intranasal cyanocobalamin
PURPOSE
➔ Vitamin B12 is necessary to convert folic acid from its inactive form to its active
form
◆ all cells rely on folic acid for DNA production
➔ Vitamin B12 deficiency can result in megaloblastic (macrocytic) anemia and cause
dysrhythmias and heart failure if not corrected.
◆ This vitamin is administered to prevent or correct deficiency.
◆ Damage to rapidly multiplying cells can affect the skin and mucous membranes→ GI
disturbances.
◆ Deficiency of this vitamin can result in neurologic damage, which includes numbness
and tingling of extremities and CNS damage caused by demyelination of neurons.
➔ V-B12 deficiency affects all blood cells produced in the bone marrow.
◆ Loss of erythrocytes→ heart failure, cerebral vascular insufficiency, and hypoxia.
◆ Loss of leukocytes→ leads to infections.
◆ Loss of thrombocytes→ bleeding and hemorrhage.
➔ Loss of intrinsic factor within the cells of the stomach causes an inability to absorb VB12,
making it necessary to administer parenteral or intranasal V-B12 or high doses of oral B12 for
the rest of the patient’s life
COMPLICATIONS
➔ Hypokalemia: Secondary to the increased RBC production effects of vitamin B12.
◆
Monitor potassium levels- potassium deficiency→ muscle weakness, irregular cardiac
rhythm) → which then require potassium supplements
CONTRAINDICATIONS / PRECAUTIONS
➔ B12 deficiency should not be treated with only folic acid
➔ If folic acid is used for patient who has B12 deficiency, ensure dosage of B12 is adequate
◆ Treatment with folic acid alone can reverse the hematologic effects of the deficiency
but can allow neurologic damage to process
➔ Oral and intranasal cyanocobalamin are pregnancy risk category A
➔ Parenteral cyanocobalamin is pregnancy risk category C
INTERACTIONS
➔ Masks manifestations of B12 deficiency with concurrent administration of folic acid.
NURSING ADMINISTRATION
➔ Obtain baseline vitamin B12, Hgb, Hct, RBC, reticulocyte count, and folate levels. (MONITOR
PERIODICALLY)
➔ Monitor manifestations of B12 deficiency→ beefy red tongue, pallor, neuropathy.
➔ Cyanocobalamin is admin. Intranasally, orally, IM, or subq.
◆ Injections are painful & reserved for pts who have significant reduced ability to absorb
vitamin B12→ lack of intrinsic factor (pernicious anemia), enteritis, and partial removal
of the stomach.
➔ Pts who have malabsorption syndrome can use intranasal or parenteral preparations.
➔ Intranasal cyanocobalamin should be admin. 1 hr before or after eating hot foods, which can
cause the medication to be removed from nasal passages w/o being absorbed→ b/c of
increased nasal secretions.
➔ Pts. with irreversible malabsorption syndrome (parietal cell atrophy or total gastrectomy) will
need lifelong treatment, usually parenterally.
◆ Encourage concurrent intake of quantities of foods high in vitamin B12, such as dairy
products
◆ Perform schilling test to determine vitamin B12 absorption in the gastrointestinal tract.
◆ Measurement of plasma B12 levels helps determine the need for therapy.
◆ Monitor blood counts and vitamin B12 levels every 3-6 months.
★ Folic Acid
PURPOSE
➔ Folic acid is essential in the production of DNA & erythropoiesis (RBC, WBC, and
platelets)
➔ Therapeutic Uses
◆ Treatment of megaloblastic (macrocytic) anemia secondary to folic acid deficiency
◆ Prevention of neural tube defects can occur early during pregnancy (thus needed for
all women of childbearing age who might become pregnant)
◆ Treatment of malabsorption syndrome→ sprue
◆ Supplement for alcohol use disorder
CONTRAINDICATIONS / PRECAUTIONS
➔ Avoid indiscriminate use of folic acid to reduce the risk of masking manifestations of vitamin
B12 deficiency.
INTERACTIONS
➔ Folic acid levels are decreased by methotrexate and sulfonamides.
◆ Avoid concurrent use of these medications
➔ Folic acid can decrease phenytoin serum levels b/c of increased metabolism.
◆ Monitor serum phenytoin levels.
NURSING ADMINISTRATION
➔ Assess for manifestations of megaloblastic anemia
◆ Pallor, easy fatigability,palpitations, paresthesias ((burn or prickling sensation)) of
hands or feet
➔ Obtain baseline folic acid, Hgb and Hct levels, and RBC and reticulocyte counts. (MONITOR
PERIODICALLY)
➔ Folic acid deficiency→ increase intake of food sources of folic acid, liver, green leafy, citrus
fruits, and dried peas and beans.
NURSING EVALUATION OF MEDICATION EFFECTIVENESS
➔ Depending on therapeutic intent:
◆ Folate level w/i expected reference range
◆ Return of RBC, reticulocyte count, Hgb and Hct to levels w/i expected reference range.
◆ Improvement of anemia findings such as absence of pallor, dyspnea, easy fatigability
● Absence of neural tube defects in newborns.
★ Potassium Supplements
➔
➔
➔
➔
Potassium
Potassium
Potassium
Potassium
Chloride
gluconate
phosphate
bicarbonate
PURPOSE
➔ Potassium is essential for conducting nerve impulses, maintaining electrical excitability of
muscle, and regulation of acid/base balance.
◆ Treating hypokalemia (potassium less than 3.5 mEq/L)
◆ Pts. receiving diuretics resulting in potassium loss, such as furosemide
◆ Pts. who had potassium loss due to excessive or prolonged vomiting, diarrhea,
excessive use of laxatives, intestinal drainage, & GI fistula.
COMPLICATIONS
➔ Local GI ulceration and GI distress
◆ Nausea, vomiting, diarrhea, abdominal discomfort, and esophagitis with oral
administration.
● Instruct to take med with meals or at least 8 oz of water to minimize GI
discomfort and prevent ulceration.
● Teach not to dissolve the tablet in the mouth b/c oral ulceration will develop.
➔ Hyperkalemia (potassium more than 5.0 mEq/L)
◆ Rarely occurs with oral administration.
◆ Monitor pts. Receiving IV potassium for manifestations of hyperkalemia, such as
bradycardia, ECG changes, vomiting, confusion, anxiety, dyspnea, weakness,
numbness, and tingling.
◆ Severe hyperkalemia can require treatment→ calcium salt, glucose and insulin,
sodium bicarbonate, sodium polystyrene sulfonate, peritoneal dialysis, or
hemodialysis.
CONTRAINDICATIONS / PRECAUTIONS
➔ Contraindicated for pts. who have severe kidney disease or hypoaldosteronism.
INTERACTIONS
➔ Concurrent use of potassium-sparing diuretics, such as spironolactone, or ACE inhibitors
(lisinopril) increases the risk of hyperkalemia
NURSING ADMINISTRATION
➔ Oral Formulation
◆ Mix powdered formulation in at least 120 ml (4 oz) of liquid.
◆ Advise pts. to take potassium chloride with a meal or at least 8 oz of water to reduce
the risk of adverse GI effect.
◆ Instruct not to crush extended-release tablets
◆ Instruct pts to notify provider if they have difficulty swallowing pills→ there is
medication in powdered form (sustained- release tablet)
➔ IV Administration
◆ NEVER administer IV bolus→ rapid IV infusion can result in fatal hyperkalemia. → use IV
infusion pump to control rate.
◆ Dilute potassium and give no more than 40 mEq/L of IV solution to prevent vein
irritation. → infuse slowly no faster than 10 mEq/L
◆ Cardiac monitoring is indicated for serum potassium levels outside of expected range.
● ECG changes→ prolonged PR interval and peaked T-waves, can indicate
potassium toxicity.
● Infuse potassium through large bore needle.
○ Assess IV site→ irritation, phlebitis, and infiltration.
◆ Discontinue IV if infiltration occurs.
● Monitor I&O → at least 30 mL/hr.
NURSING EVALUATION OF MEDICATION EFFECTIVENESS
➔ Depending on therapeutic intent, effectiveness is evidenced by serum potassium level w/i the
expected reference range (3.5 to 5.0 mEq/L)
★ Magnesium Sulfate
◆
◆
Parenteral: magnesium sulfate
Oral: Magnesium hydroxide, magnesium oxide, magnesium citrate
● Magnesium hydroxide and magnesium oxide act as antacids when
administered in a low dose, and all three act as laxatives.
PURPOSE
➔ Magnesium activates many intracellular enzymes, binds the messenger RNA to ribosomes, and
plays a role in regulating skeletal muscle contractility and blood coagulation.
➔ Therapeutic uses
◆ Magnesium supplements are used for pts. Who have hypomagnesemia (magn level
less than 1.3 mEq/L)
◆ Oral preparations of magnesium sulfate are used to prevent or treat low magnesium
levels and as laxatives
◆ Parenteral magnesium is used for pts. Who have severe hypomagnesemia.
◆ IV magnesium sulfate is used to stop preterm labor and as an anticonvulsant during
labor and delivery.
COMPLICATIONS
➔
➔
Muscle weakness, flaccid paralysis, painful muscle contractions, suppression of AV conduction
through the heart, respiratory depression
◆ Nurse considerations
● IV administration requires careful monitoring of cardiac and neuromuscular
status.
● Monitor serum magnesium levels.
● Avoid admin. With neuromuscular blocking agents, which can potentiate
respiratory depression and apnea.
● Iv calcium available to reverse the effects of magnesium.
Diarrhea
◆ Monitor electrolyte levels for electrolyte loss from diarrhea.
◆ Monitor I&O, observe for manifestations of dehydration.
CONTRAINDICATIONS / PRECAUTIONS
➔ Magnesium is pregnancy risk Category A.
➔ Contraindicated in pts. Who have Av block, rectal bleeding, nausea, vomiting, and abdominal
pain.
➔ Be cautious with pts who have renal and/or cardiac disease
INTERACTIONS
➔ Magnesium sulfate can decrease the absorption of tetracyclines and digoxin.
➔ Monitor therapeutic effect to determine if absorption has been affected.
NURSING ADMINISTRATION
➔ Monitor serum magnesium, calcium, and phosphorus
➔ Monitor BP, heart rate, and respiratory rate when given IV.
➔ Assess for depressed or absent deep tendon reflexes as a manifestation of toxicity.
➔ Calcium gluconate is given for magnesium sulfate toxicity.
◆ ** always have injectable calcium gluconate
➔ Teach pts. About dietary sources of magnesium (whole grain cereals, nuts, legumes, green
leafy veggies, bananana)
NURSING EVALUATION OF MEDICATION EFFECTIVENESS
➔ Effectiveness is evidenced by serum magnesium levels w/i range (1.3-2.1 mEq/L)
ATI: Chapter 30
HERBAL SUPPLEMENTS
➔
➔
➔
★
Widely used but less tested and regulated than conventional medications.
Dosages are less precise than for more regulated medications.
Supplements are regulated by the FDA for manufacturing devoid of impurities, and accurate
labeling.
ALOE VERA
➔ Topical anti-inflammatory, analgesic, and cathartic
➔ Soothes pain, heals burns, softens skin, laxative.
Adverse effects and Precautions
➔
➔
➔
➔
Skin prep
◆ possible hypersensitivity
Laxative
◆ possible fluid and electrolyte imbalance
Increases menstrual flow when taken during menses
Avoid in pts. who have kidney disorders.
Interactions
➔ Interacts with digoxin, diuretics, corticosteroids and antidysrhythmics.
Nursing administrations
➔ Teach to recognize manifestations of fluid and electrolyte imbalance if using as a laxative.
★
BLACK
➔
➔
➔
COHOSH
Acts as estrogen substitute
Mechanism of action is unknown
Treats manifestations of menopause
Adverse effects and precautions
➔ GI distress, lightheadedness, headache, rash, weight gain
➔ Avoid during pregnancy, especially first 2 trimesters
➔ Limit use to no longer than 6 months→ b/c no info on long term effects
Interactions
➔ Increases effects of antihypertensive meds
➔ Can increase effects of estrogen meds
➔ Increases hypoglycemia in pts taking insulin or diabetes med
Nursing administration
➔ Question pts with antihypertensive, insulin, hypoglycemic agents, or pregnant with possible
use of black cohosh
★
ECHINACEA
➔ Stimulates immune system
➔ Decreases inflammation
➔ Topically heals skin disorders, wounds, and burns
➔ Possibly treats viruses (common cold, herpes simplex)
➔ Used to increase T-lymphocyte, tumor necrosis factor, and interferon production
Adverse effects
➔ Bitter taste
➔ Mild Gi symptoms or fever can occur
➔ Allergic reactions → especially to ragweed or others in the daisy family.
Interactions
➔ With chronic use (more than 6 months)
➔
Can decrease positive effects of medications for tuberculosis, HIV, or cancer.
Nursing Administration
➔ Echinacea is available in many forms→ dried roots, plants, extracts, and teas.
➔ Question pts→ with tuberculosis, cancer, HIV, lupus erythematosus, and rheumatoid arthritis
about concurrent use.
★
FEVERFEW
➔ Can block platelet aggregation, factor that causes migraine, and decrease the number and
severity of migraine headaches (does not treat existing migraine)
Adverse effects and precautions
➔ Mild Gi symptoms
➔ Post-feverfew syndrome can occur→ causing agitation, tiredness, inability to sleep, headache,
& joint discomfort.
➔ ** allergic reaction in pts. → ragweed or echinacea
Interactions
➔ Can increase risk of bleeding in pts. Taking NSAIDs, heparin, and warfarin
➔ Discontinue 2 weeks before elective surgery.
★
GARLIC
➔ crushed→ forms enzyme allicin
➔ Blocks LDL cholesterol and raises HDL cholesterol, lower triglycerides
➔ Suppresses platelet aggregation and disrupts coagulation
➔ Acts as vasodilator (can lower blood pressure)
Adverse effects
➔ GI symptoms
Interactions
➔ Risk of bleeding taking NSAIDs, warfarin, and heparin.
➔ Decreases levels of saquinavir (med for HIV treatment) and cyclosporine
★
GINGER ROOT
➔ Relieved vertigo and nausea
➔ Increases intestinal motility
➔ Increases gastric mucous production
➔ Decreases GI spasms
➔ Produces an anti-inflammatory effect
➔ Suppresses platelet aggregation
➔ Used to treat morning sickness, motion sickness, nausea from surgery.
➔ Can decrease pain and stiffness of rheumatoid arthritis
Adverse and precautions
➔ Cautious with pregnant b/c high doses can cause uterine contractions
➔ Adverse effect: unknown, potential CNS depression and cardiac dysrhythmias w/ very large
overdose.
Interactions
➔ Interact with medication that interfere with coagulation (NSAIDs, Warfarin, heparin)
➔ Can increase hypoglycemic effects of diabetes meds.
★
GINKGO BILOBA
➔
➔
➔
➔
Promotes vasodilation: decreases leg pain caused from occlusive arterial disorders
Decreases platelet aggregation: can decrease risk of thrombosis
Decreases bronchospasm
Increases blood flow to the brain: thought to improve memory→ studies don’t prove
effectiveness.
Adverse effects and precautions
➔ Mild GI upset, headache, lightheadedness, can be decreased by reducing dose.
➔ Caution with pts → seizure.
Interactions
➔ Can interact with meds that lower the seizure threshold→ antihistamines, antidepressants, and
antipsychotics.
➔ Can interfere with coagulation
Nursing administration
➔ Question: history of antidepressants (imipramine)- decrease in seizure threshold.
★
GLUCOSAMINE
➔ Stimulates cells to make cartilage and synovial fluid
➔ Suppresses inflammation of the joints and cartilage degradation.
➔ Treats osteoarthritis of knee, hip, and wrist.
Adverse and precautions
➔ Mild GI upset (nausea, heartburn)
➔ Caution: shellfish allergy
Interactions
➔ Caution: antiplatelets or anticoagulant meds
★
KAVA
➔
➔
➔
➔
➔
*CAUSES LIVER INJURY
Possibly acts on gamma-aminobutyric acid (GABA) receptors in CNS
Promotes sleep
Decreases anxiety
Promotes muscle relaxation without affecting concentration
Adverse & precautions
➔ Chronic use: causes dry, flaky skin and jaundice
➔ Chronic use & large doses= liver damage or liver failure.
Interactions
➔ Can cause sedation when taken with CNS depressants.
Nursing admin.
➔ Question: CNS depressant- alcohol → or liver condition with current use.
★
MA HUANG
➔ **CAN CAUSE HYPERTENSION, TACHY, STROKE, MI
➔ Stimulates the CNS
➔ Suppresses appetite
➔ Used for weight loss
➔ Constricts arterioles: increases heart rate and BP
➔ Bronchodilation: treats colds, flu, and allergies.
Adverse & precautions
➔ Contains ephedrine- can stimulate cardiovascular system→ high doses can cause DEATH from
hypertension and dysrhythmias.
➔ Stimulation of CNS can cause euphoria→ high doses= psychosis
Interactions
➔ CNS stimulant to potentiate their effect.
➔ Severe hypertension when taken with monoamine oxidase inhibitor antidepressants
➔ Interact with antihypertensive meds, decreasing effects.
➔ More than 10 mg/dose are forbidden to be sold in the U.S
★
ST. JOHN’S WORT
➔ Affects serotonin, producing antidepressant effects: used for mild depression.
➔ Used orally as analgesic & inflammation
➔ Applied topically
Adverse effects
➔ Mild effect- dry mouth, lightheadedness, constipation, GI symptoms
➔ Skin rash when exposed to sunlight.
Interactions
➔ Serotonin syndrome when combined with antidepressants, amphetamine, and cocaine.
➔ Decreases effectiveness of oral contraceptives, cyclosporine, warfarin, digoxin, calciumchannel blockers, steroids, HIV protease inhibitors, and some anticancer meds.
★
SAW PALMETTO
➔ Can decrease prostate symptoms of hyperplasia
Adverse & precautions
➔ Few adverse- can cause mild GI effects
Interactions
➔ Possible additive effects with finasteride
➔ Can interact with antiplatelet and anticoagulant meds
➔ Pregnancy risk category X
★
VALERIAN
➔ Increases GABA to prevent insomnia (similar to benzodiazepines)
➔ Reduces anxiety-related restlessness
➔ Drowsiness effect increases over time
Adverse effects and precautions
➔ Cause drowsiness, lightheadedness, depression
➔ Risk of physical dependence.
➔ Caution: mental health → avoid women pregnant and lactating.
Interactions
➔ Not known is it potentiates effects of CNS depressants.
➔ Warn about drowsiness when operating motor vehicles and other equipments.
Antiepileptics (AEDs)
➢ Control seizure disorders -- slowing entrance of sodium and calcium back into the
neuron, thus extending the time it takes for the nerve to return to its active state and
slows the frequency of neuron firing; suppress neuronal firing; enhance the inhibitory
effects of gamma butyric acid (GABA)
MEDICATIONS
Phenobarbital
(Barbiturates)
Complications
● CNS effects: Drowsiness, Sedation,
depression (adults); Confusion and
Precautions
● Not recommended
during pregnancy due
Interactions
● Decreased effectiveness of oral
contraceptives
Anxiety (Older adults); Irritability and
hyperactivity (Kids)
● Toxicity: Nystagmus, ataxia, respiratory
depression, coma, pinpoint pupils,
hypotension, and death
to increased risk of
fetus developing
malformations
● Decrease synthesis of Vitamin K and
D
● Decrease effectiveness of warfarin
Primidone
(Barbiturates)
● CNS effects: Drowsiness, Sedation,
depression (adults); Confusion and
Anxiety (Older adults); Irritability and
hyperactivity (Kids)
● Toxicity: Nystagmus, ataxia, respiratory
depression, coma, pinpoint pupils,
hypotension, and death
● Not recommended
during pregnancy due
to increased risk of
fetus developing
malformations
● Decreased effectiveness of oral
contraceptives
● Pregnancy -- D
● Teratogenic: Cleft
palate, heart defects
and developmental
deficiencies
● Phenytoin causes a decrease in
the effects of oral
contraceptives. Warfarin, and
glucocorticoids due to
stimulation of hepatic
medication-metabolizing
enzyme
● Decrease synthesis of Vitamin K and
D
● Decrease effectiveness of warfarin
Phenytoin
(Hydantoins)
● CNS effects: Nystagmus, Sedation,
Ataxia, Double Vision, and Cognitive
Impairment
● Gingival Hyperplasia: Softening and
overgrowth of gum tissue, tenderness and
bleeding gums
● Skin Rash
● Alcohol(used acutely),
diazepam, cimetidine, and
valproic acid increases
phenytoin levels
● Cardiovascular effects: dysrhythmias,
hypotension
● Endocrine and other effects:
Coarsening of facial features, hirsutism,
and interference with Vitamin D
metabolism
● Carbamazepine, phenobarbital
and chronic alcohol use
decrease phenytoin levels
● Additive CNS depressant effects
can occur with concurrent use of
CNS depressants such as
barbiturates and alcohol)
● Interference with Vitamin Kdependent clotting factors causing
bleeding in newborns
Carbamazepine
● CNS effects: Nystagmus, Double Vision,
Vertigo, Staggering Gait, and Headache.
Cognitive function is minimally affected
● Blood dyscrasias: Leukopenia, Anemia,
Thrombocytopenia
● Pregnancy -- D
● Birth defects: Spina
Bifida, Neural Tube
defect and delays in
growth
● Carbamazepine causes a
decrease in the effects of oral
contraceptives and warfarin due
to stimulation of hepatic
medication-metabolizing
enzymes
● Hypo-osmolarity: Promotes secretion of
ADH -- inhibits water secretion which risk
pt for fluid overload.
● Grapefruit juice inhibits
metabolism and thus increases
carbamazepine levels
● Skin Disorders: Dermatitis, rash and
Stevens-Johnson syndrome
● Phenytoin and phenobarbital
decrease effects of
carbamazepine
Valproic Acid
● GI effect: Nausea, Vomiting, Indigestion
● Hepatotoxicity: Anorexia, Abdominal
pain, Jaundice
● Pregnancy -- D
● Teratogenic: Cleft
palate, heart defects
● Concurrent use of valproic acid
increases levels of phenytoin
and phenobarbital
● Pancreatitis
● Thrombocytopenia
● CNS effects from hyperammonemia:
Vomiting, Lethargy, Impaired Cognitive
Alertness
Ethosuximide
● GI effects: Nausea, Vomiting
***
● CNS effects: Sleepiness,
Lightheadedness, fatigue
** Only used for absence seizures **
Lamotrigine
● CNS effects: Dizziness, Somnolence,
aphasia, double or blurred vision,
headache, nausea, or vomiting and
depression
● Pregnancy -- C
● Teratogenic: Cleft
palate, heart defects
are low risk
● Aseptic Meningitis: headache, fever,
stiff neck, nausea, vomiting, rash,
sensitivity to light
● Skin Disorders: Stevens-Johnson
syndrome and Toxic Epidermal Necrolysis
Levetiracetam
● CNS effects: Dizziness, asthenia,
agitation, anxiety, depression, suicidal
ideation
***
Topiramate
● CNS effects: Somnolence, dizziness,
ataxia, nervousness, diplopia, confusion,
impaired cognitive function
● Pregnancy -- D
● Teratogenic: Cleft lip,
Cleft palate and heart
defects
● Phenytoin and carbamazepine
can decrease topiramate level.
Topiramate can increase
phenytoin levels.
● Pregnancy -- D
● Teratogenic: Cleft
palate, heart defects
● Decreases oral contraceptive
levels
● Phenytoin levels increase when
administered with
oxcarbazepine
● Depresses CNS if alcohol is
consumed
● Reduced sweating and increased
body temp
● Metabolic acidosis
● Angle-closure glaucoma
Oxcarbazepine
● CNS effects: Dizziness, drowsiness,
double vision, nystagmus, headache,
nausea, vomiting and ataxia
● Skin disorders: Stevens-Johnson
syndrome and Toxic Epidermal Necrolysis
● Hyponatremia: Nausea, drowsiness,
headache, and confusion
● Multiorgan hypersensitivity
reactions: Fever and rash with
lymphadenopathy, hepatorenal
syndrome, hematologic abnormalities
Gabapentin
● CNS effects: Somnolence, dizziness,
ataxia, fatigue, nystagmus, and
peripheral edema diminish in time
Pregabalin
● CNS effects: Somnolence, dizziness,
adverse cognitive effect and headache
● Weight gain, Peripheral Edema and
Dry mouth
● Hypersensitivity reactions
(angioedema)
● Pregnancy -- C
● Birth defects: Skeletal
and Visceral
Malformations
● Benzodiazepines, alcohol, and
opioids intensify CNS effects
Anti-Parkinson’s Disease
Medication Name
Purpose
Adverse Effects
Levodopa (Dopamine synthetic)
- Most effective for PD
treatment. Beneficial effect
end at end of year 5.
- Nausea and vomiting, drowsiness
- “Wearing off” time occur at
end of dose cycle or high
dose level→ last minutes to
hours
- Orthostatic Hypotension
Cardiovascular effects from beta,
stimulation.
- Dyskinesias: head bobbing, tics, tremors
- Psychosis: visual hallucinations
- Discoloration of sweat and urine
- Activation of malignant melanoma
Carbidopa (Dopamine synthetic)
- Most effective for PD
treatment. Beneficial effect at
end of year 5.
- Nausea and vomiting, drowsiness
- “Wearing off” time occur at
end of dose cycle or high
dose level→ last minutes to
hours
- Orthostatic Hypotension:
Cardiovascular effects from beta,
stimulation.
- Dyskinesias: head bobbing, tics, tremors
- Psychosis: visual hallucinations
- Discoloration of sweat and urine
- Activation of malignant melanoma
Pramipexole (Dopamine agonist)
- Admin. as monotherapy in
early stage PD
- sudden inability to stay awake
- daytime sleepiness
- Conjunction with
levodopa/carbidopa in late
stage PD to allow for lower
dosage of
levodopa/carbidopa.
- orthostatic hypotension
- psychosis
- Impulse control disorder
- Admin more often in younger
patients→ better tolerate
daytime drowsiness and
postural hypotension
- dyskinesias
- Nausea
Ropinirole (Dopamine agonist)
- Admin. As monotherapy in
early stage PD
- sudden inability to stay awake
- daytime sleepiness
- Conjunction with
levodopa/carbidopa in late
stage PD to allow for lower
dosage of
levodopa/carbidopa.
- orthostatic hypotension
- psychosis
- Impulse control disorder
- Admin. more often in younger
patients→ better tolerate
daytime drowsiness and
postural hypotension
Apomorphine (Dopamine agonist)
- Admin. as monotherapy in
early stage PD
- dyskinesias
- Nausea
- sudden inability to stay awake
- daytime sleepiness
- conjunction with
levodopa/carbidopa in late
stage PD to allow for lower
dosage of
levodopa/carbidopa.
- orthostatic hypotension
- psychosis
- Impulse control disorder
- Admin. more often in younger
patients→ better tolerate
daytime drowsiness and
postural hypotension
Bromocriptine: (Dopamine agonist)
- Ergot derivative, poorly
tolerated and has high
incidence of valvular heart
injury. → admin. Less freq.
- dyskinesias
- Nausea
- sudden inability to stay awake
- daytime sleepiness
- orthostatic hypotension
- psychosis
- Impulse control disorder
- dyskinesias
- Nausea
Dopamine releaser
- Amantadine releases
dopamine where it is stored
in the neurons, prevents
dopamine reuptake, and can
block cholinergic and
glutamate receptors.
- CNS effects: confusion, dizziness,
restlessness
- Atropine-like effects: dry mouth,
blurred vision, mydriasis (dilated pupils),
GU retention, constipation.
Entacapone & tolcapone: (COMT
inhibitors)
- Beneficial with
levodopa/carbidopa to inhibit
metabolism of levodopa in
the intestines and peripheral
tissues.
- Same as for pramipexole when
administered w/ levodopa/carbidopa
- GI: vomiting, diarrhea, constipation
- Discoloration of urine: yellow-orange
- Rhabdomyolysis: muscle pain, tendon
weakness.
- Liver failure.
Selegiline: (MAO-B)
- Can preserve dopamine
produced from levodopa, and
prolong the effects of
levodopa but only 1-2 years.
- Insomnia (selegiline)
- Hypertensive crisis triggered from foods
containing tyramine→ cheese,
avocado, choco.
- hypertensive crisis death from some
meds.
- nausea, diarrhea
Rasagiline: (MAO-B)
- Preserves dopamine in the
brain and is NOT converted
into amphetamine or
methamphetamine like
selegiline does.
- Insomnia (selegiline)
- hypertensive crisis triggered from foods
containing tyramine→ cheese,
avocado, choco.
- hypertensive crisis death from some
meds.
- nausea, diarrhea
Benztropine & Trihexyphenidyl:
(Anticholinergics)
- Antagonist diminish
cholinergic effects (neuron
excitability) due to decreased
dopamine
- Nausea, vomiting
- Atropine-like effects: dry mouth, blurry
vision mydriasis, GU retention,
constipation.
- Antihistamine effects: (sedation /
drowsiness)
Chapter 35
NONOPIOID ANALGESICS
★ Nonsteroidal anti-inflammatory drugs
First generation NSAIDs (COX-1 and COX-2 inhibitors)
➔ Aspirin
➔ Ibuprofen
➔ Naproxen
➔ Indomethacin
➔ Diclofenac
➔ Ketorolac
➔ Meloxicam
Second generation NSAIDs (selective COX-2 inhibitor)
➔ Celecoxib
PURPOSE
Inhibition of cyclooxygenase:
➔ Inhibition of COX-1 can result in decreased platelet aggregation and kidney damage
➔ Inhibition of COX-2 results in decreased inflammation, fever, and pain, and does not decrease
platelet aggregation
Therapeutic Uses:
➔ Inflammation suppression
➔ Analgesia for mild and moderate pain, such as with osteoarthritis and rheumatoid arthritis
➔ Fever reduction
➔ Dysmenorrhea
➔ (Aspirin) -- Inhibition of platelet aggregation, which protects against ischemic stroke and MI
COMPLICATIONS
➔
➔
➔
➔
➔
Gastrointestinal discomfort
◆ Dyspepsia, abdominal pain, heartburn, nausea
● Damage to gastric mucosa -- GI bleed and perforation
● Increased risk in those who smoke or have alcohol disorder / history of peptic
ulcers or previous inability to tolerate NSAIDs
● Take med with food or 8oz of milk
● Black or dark colored stools and severe abdominal pain
● Use prophylaxis agents 00 misoprostol
Impaired kidney function
◆ Decreased urine output, weight gain from fluid retention, increased BUN, and
creatinine levels
Increased risk of heart attack and stroke
◆ With nonaspirin NSAIDs
● Use smallest effective dose w/ pt who has cardiovascular disease
Salicylism (can occur with aspirin)
◆ Tinnitus, sweating, headache, dizziness and respiratory alkalosis
Reye syndrome (rare but serious complications)
◆
➔
Occurs when aspirin is used for fever reduction in children and adolescents who have a
viral illness such as chickenpox or influenza
Aspirin toxicity
◆ Progresses from the mild findings in salicylism to sweating, high fever, acidosis,
dehydration, electrolyte imbalances, coma and respiratory depression
● Medical emergency
● Give activated charcoal to decrease absorption
● Hemodialysis can be indicated
● Cool the pt. With tepid water
● Give IV fluids to correct dehydration and electrolyte imbalance
● Reverse acidosis and promote salicylate excretion with bicarbonate
● Perform gastric lavage
CONTRAINDICATIONS / PRECAUTIONS
First generation NSAIDs
➔ Pregnancy D
➔ Peptic ulcer disease
➔ Bleeding disorders -- hemophilia and vitamin K deficiency
➔ Hypersensitivity to aspirin and other NSAIDs
➔ Children and adolescents who have chickenpox or influenza
➔ Ketorolac -- contraindicated in clients who have advanced kidney disease. Use
should be no longer than 5 days bc of risk for kidney damage
Use cautiously:
➔ Older pts
➔ Smokers
➔ Pts who have Helicobacter pylori, hypovolemia, asthma, chronic urticaria, bleeding
disorders, or a history of alcohol use disorder
➔ Pts who is taking anticoagulants glucocorticoids, ACE inhibitors and ARBs
Second generation NSAIDs
➔ Used cautiously in pts who have cardiovascular disease
➔ Celecoxib -- suppresses inflammation, relieved pain, decreased fever, and protects
against colorectal cancer
◆ It’s a COX-2 inhibitor; last choice meds for chronic pain bc it increases the risk of MI
and stroke due to secondary suppression of vasodilation (dilation of blood vessels)
INTERACTIONS
➔
➔
➔
➔
➔
➔
Anticoagulants such as heparin and warfarin increases the risk of bleeding
Glucocorticoids increase the risk of gastric bleeding
◆ Take antiulcer prophylaxis -- misoprostol -- to decrease the risk for gastric ulcer
Alcohol increases the risk of bleeding
Ibuprofen decreases the antiplatelet effects of low dose aspirin used to prevent MI
Ketorolac and concurrent use of other NSAIDs increase the risk of known adverse effects
OTC interactions
NURSING ADMINISTRATION
➔
➔
➔
➔
Stop aspirin 1 week before an elective surgery or expected date of childbirth
Take it with food or milk
Ketorolac -- used for short term treatment of moderate to severe pain
◆ Admin. Parenterally then switched to oral doses
◆ Should not be used longer than 5 days
Admin. IV Ibuprofen as na infusion over 30 min.
◆ Pt. should be hydrated before infusion to prevent kidney damage
★ Acetaminophen
PURPOSE
Expected Pharmacological Action:
➔ Slows the production of prostaglandins in the CNS
Therapeutic Uses:
➔ Analgesic (relief of pain) effect
➔ Antipyretic (reduction of fever) effects
COMPLICATIONS
Adverse effects are rare at therapeutic dosages
➔
Acute toxicity
◆ Results in liver damage w. Early manifestations of nausea, vomiting, diarrhea,
sweating, and abdominal discomfort progressing to hepatic failure, coma, and death
● Don’t exceed 4g/day
● Undernourished pts should limit to 3 g/day
● Alcoholics should limit to 2 g/day
● Administer the antidote -- acetylcysteine
CONTRAINDICATIONS / PRECAUTIONS
➔
Use cautious: pts who consume three or more alcoholic drinks per day and those taking
warfarin
INTERACTIONS
➔
➔
Alcohol increases the risk of liver damage
Acetaminophen slows the metabolism of warfarin, leading to increased levels of warfarin. This
places the pts at risk for bleeding
◆ Monitor prothrombin time and INR levels and adjust dosages of warfarin accordingly
NURSING ADMINISTRATION
➔
➔
Keep a running total of your intake -- should not exceed 4g/day
Administer the antidote to prevent liver damage -- admin via duodenal tube to prevent emesis
and subsequent aspiration
Chapter 36
OPIOID AGONISTS AND ANTAGONISTS
★ Opioid agonists
Select prototype medication:
➔ Morphine -- Oral, Subcu, IM, IV, epidural, intrathecal
Other Medications:
➔ Fentanyl -- IV, IM, transmucosal, transdermal
➔ Meperidine -- Oral, subcu, IM, IV
➔ Methadone -- Oral, subcu, IM
➔ Codeine -- Oral, subcu, IM, IV
➔ Oxycodone -- Oral, rectal
➔ Hydromorphone -- Oral, subcu, IM, IV
PURPOSE
Expected Pharmacological Action:
➔ Opioid agonists and other morphine like medications (fentanyl), act on the mu receptors and to
a lesser degree on kappa receptors. Activation of mu receptors produces analgesia, respiratory
depression, euphoria, and sedation, whereas kappa receptor activation produces analgesia,
sedation, and decreased GI motility. Activation of mu receptors can also be linked to physical
dependence
Therapeutic Uses:
➔ Relief of moderate to severe pain (postop, MI, following childbirth, cancer)
➔ Sedation
➔ Reduction of bowel motility
➔ Cough suppression (codeine)
COMPLICATIONS
➔
➔
➔
➔
➔
➔
Respiratory depression
◆ Monitor vital signs
◆ Stop if respiratory rate is less than 12/min
◆ Have naloxone and resuscitation equipment available
◆ Avoid use of opioids with CNS depressant meds (barbiturates, benzodiazepines,
consumption of alcohol)
Constipation
◆ Increase fluid/fiber intake
◆ Admin laxative
Orthostatic hypotension
Urinary retention
◆ Void every 4 hr
◆ Monitor I and O
◆ Assess the bladder for distension every 4-6 hr
◆ Meds w/ anticholinergic properties can increase symptoms
Cough suppression
◆ Cough at regular intervals to prevent accumulation of secretions in the airway
◆ Auscultate the lungs for crackles and instruct clients to increase intake of fluid to
liquefy secretions
Sedation
➔
➔
➔
Biliary colic
◆ Avoid morphine -- give meperidine instead
Nausea/vomiting
◆ Admin an antiemetic
Opioid overdose triad
◆ Coma, respiratory depression and pinpoint pupils
● Monitor vital signs
● Provide mechanical ventilation
● Admin. Naloxone, an opioid antagonist that reverses respiratory depression
and other overdose manifestation
CONTRAINDICATIONS / PRECAUTIONS
➔
➔
➔
➔
Morphine is contraindicated after biliary surgery
Morphine is contraindicated for premature infants during and after delivery bc of respiratory
depressant effects
Meperidine is contraindicated for pts who have kidney failure bc of the accumulation of
normeperidine, which can result in seizures and neurotoxicity
Use cautiously:
◆ Pts who has asthma, emphysema, head injuries, infants, older adult (resp. depression)
◆ Pts who are pregnant (risk of physical dependence of fetus)
◆ Pts in labor (resp. Depression in the newborn and inhibition of labor by decreasing
uterine contractions)
◆ Pts who are extremely obese (risk for adverse effects bc metabolism is at a slower
rate)
◆ Pts who have inflammatory bowel disease (risk of megacolon or paralytic ileus)
◆ Pts who have an enlarged prostate (risk of acute urinary retention)
◆ Pts who have hepatic or renal disease
INTERACTIONS
➔
➔
➔
➔
➔
CNS depressants have additive CNS depression action
Anticholinergic agents, antihistamines, and tricyclic antidepressants have additive
anticholinergic effects
◆ Increase fluid and fiber intake to prevent constipation
Meperidine can interact w/ MAOIs and cause hyperpyrexic coma, characterized by excitation,
seizures and respiratory depression
Antihypertensives have additive hypotensive effects
Additional meds such as amphetamines, clonidine and dextromethorphan can increase opioidinduced analgesia
NURSING ADMINISTRATION
➔
➔
➔
➔
➔
➔
➔
Assess pain level
Take vital signs for a baseline. If resp. Rate is less than 12/min notify provider and withhold the
med
Double check opioid doses w/ another nurse
Admin. IV opioids slowly over 4 to 5 min. Have naloxone and resuscitation equipment
Warn pts not to increase dosage w/o consulting provider
Cancer pts -- admin meds on a fixed schedule
Opioids should be withdrawn slowly and dosage should be tapered over a period of 3 days
◆ Closely monitor pt.
◆ Controlled analgesia (PCA) Dose lockout interval 4 hr limit.
◆ When switching from PCA to oral dose make sure pt receives adequate PCA dosing
until onset of oral med takes place
➔
First admin of transdermal fentanyl patch will take several hours to achieve the desired
therapeutic effect. Admin. Short acting opioids prior to onset of therapeutic effects and for
breakthrough pain.
Chapter 37
ADJUVANT MEDICATIONS FOR PAIN
Select
➔
➔
➔
➔
➔
➔
➔
Prototype Medications:
Tricyclic antidepressants: amitriptyline (oral)
Anticonvulsants: Carbamazepine and gabapentin (oral)
CNS stimulants: Methylphenidate (oral and transdermal)
Antihistamines: Hydroxyzine (oral and IM)
Glucocorticoids: Dexamethasone (oral, IV and IM)
Bisphosphonates: Etidronate (oral)
NSAIDs: Ibuprofen (oral and IV)
Other Medications:
➔ Tricyclic antidepressants: Imipramine (oral)
➔ Anticonvulsants: Phenytoin (oral and IV)
➔ CNS stimulants: Dextroamphetamine (oral)
➔ Glucocorticoids: Prednisone (oral)
➔ Bisphosphonates: Pamidronate (IV)
➔ NSAIDs: Ketorolac (oral, IM, IV, intranasal)
PURPOSE
Expected Pharmacological Action
➔ Adjuvant medications for pain enhance the effects of opioids
Therapeutic Uses
➔ These medications are used in combination with opioids and cannot be used as substitute for
opioids
➔ Tricyclic antidepressants
◆ Used to treat depression, fibromyalgia syndrome, and neuropathic pain, such as
cramping, aching, burning, darting, and sharp stabbing pain
➔ Anticonvulsants
◆ Used to relieve neuropathic pain and neuralgia
➔ CNS stimulants
◆ Augment (increases) analgesia and decrease sedation
➔ Antihistamines
◆ Decrease anxiety, prevent insomnia, and relieve nausea and vomiting
➔ Glucocorticoids
◆ Improve appetite and decrease pain from intracranial pressure, spinal cord
compression and rheumatoid arthritis
➔ Bisphosphonates
◆ Manage hypercalcemia and bone pain
➔ NSAIDs
◆ Used to treat inflammation and fever and relieve mild to moderate pain and
dysmenorrhea
COMPLICATIONS
➔
Tricyclic antidepressants: amitriptyline
◆
◆
◆
Orthostatic hypotension
● Withhold meds and notify provider about the low BP
Sedation
Anticholinergic effects
● Dry mouth, urinary retention, constipation, and blurred vision
○ Increase fluid/fiber intake
○ Suck on sugarless candy
○ Admin. Laxative -- bisacodyl
○ Void every 4 hr -- monitor I&O
➔
Anticonvulsants: Carbamazepine and gabapentin
◆ Bone marrow suppression
● Monitor blood count including platelets
● Look for symptoms -- bruising, bleeding, fever, or sore throat
◆ Gastrointestinal distress
● Nausea, vomiting, diarrhea, and constipation
○ Take meds with food
◆ Drowsiness
◆ Rash
● Withhold the meds
➔
CNS stimulants: Methylphenidate
◆ Weight loss
◆ Insomnia
● Take the last dose of the day no later than 4 pm
● Decrease caffeine intake
➔
Antihistamines: Hydroxyzine
◆ Sedation
● Reduce dosage in older adults
◆ Dry mouth
➔
Glucocorticoids: Dexamethasone
◆ Adrenal insufficiency
● Hypotension, dehydration, infection, weakness, lethargy, vomiting, diarrhea
assoc. With prolonged use
◆ Osteoporosis
● Take calcium supplements, vitamin D or a bisphosphonate
◆ Fluid and Electrolyte disturbances
● Hypokalemia, and sodium and water retention
○ Monitor potassium levels and admin potassium supplements
○ Restrict sodium intake
◆ Glucose intolerance
◆ Peptic ulcer disease
● Take with meals
● Check stools for occult blood -- black, tarry stools
● Encourage the use of antiulcer meds
➔
Bisphosphonates: Etidronate (oral)
◆ Transient flu-like manifestations (pamidronate)
◆ Abdominal cramps, nausea, diarrhea, esophagitis (etidronate)
● Admin. Med with a full glass of water and sit or stand upright for 30 to 60 min
after taking
● Wait 2 hr before ingesting food for a better absorption of the meds
◆ Venous irritation at injection site (pamidronate)
◆ Hypocalcemia
● Monitor calcium, magnesium, potassium, and phosphate levels. Report
numbness/tingling around the mouth, spasms, or seizures to provider.
● Take supplemental calcium and vitamin D
➔
NSAIDs: Ibuprofen (oral and IV)
◆ Bone marrow suppression
● Monitor CBC including platelets
◆ Gastrointestinal distress
● Abdominal pain, ulceration, nausea, vomiting and diarrhea or constipation
○ Take with food, milk, or antacid
○ Monitor for GI bleeding
◆ MI or stroke
● Monitor cardiac and neurological status
CONTRAINDICATIONS / PRECAUTIONS
➔
Tricyclic antidepressants: amitriptyline
◆ Recovering from an MI and within 14 days of taking MAOI
◆ Use caution in pts with seizure disorder, urinary retention, prostatic hyperplasia, angleclosure glaucoma, hyperthyroidism and liver or kidney disease
➔
Anticonvulsants: Carbamazepine and gabapentin
◆ Pts who have bone marrow suppression and within 14 days of taking a MAOI
◆ Avoid use in pregnancy
➔
CNS stimulants: Methylphenidate
◆ Pts who took MAOI within 14 days
◆ Use caution in pts who have →
● Hypertension
● Agitation or tics
● History of substance use disorder
➔
Antihistamines: Hydroxyzine
◆ Pts who have acute asthma should not take hydroxyzine
◆ Pts who are in the first trimester of pregnancy or breastfeeding should not take this
◆ Use caution w/ older adults and those in the second or third trimester of pregnancy
➔
Glucocorticoids: Dexamethasone
◆ Pts who have fungal infection, seizure disorders, ulcerative colitis or coagulopathy
◆ Use caution w/ pts who have hypertension, hypothyroidism, diabetes mellitus,
osteoporosis or liver disease
Bisphosphonates: Etidronate
◆ Pts who have achalasia, esophageal structure or osteomalacia
NSAIDs: Ibuprofen
◆ Pts who have a history of bronchospasms w/ aspirin or other NSAIDs and those who
have severe kidney/hepatic disease
◆ Use caution w/ clients who have bleeding, GI, or cardiac disorders
◆ Use caution with older adults
➔
➔
INTERACTIONS
➔
Tricyclic antidepressants: amitriptyline
◆ Barbiturates, CNS depressants, antihistamines, OTC, sleep aids, and alcohol can cause
additive CNS depression
➔
Anticonvulsants: Carbamazepine and gabapentin
◆ Carbamazepine causes a decrease in the effects of oral contraceptives and warfarin
◆ Carbamazepine can result in CNS toxicity with lithium and fatal reaction with MAOIs
◆ Grapefruit juice inhibits metabolism and thus increases carbamazepine levels
◆
◆
Phenytoin and phenobarbital decrease the effects of carbamazepine
CNS depression occurs with gabapentin and all other CNS depressants such as alcohol,
sedatives and antihistamines
➔
CNS stimulants: Methylphenidate
◆ Alkalizing meds can cause increase in reabsorption
◆ Acidifying meds can increase excretion of amphetamine
◆ Insulin and oral antidiabetic meds can decrease glucose level
◆ Methylphenidate decreases the effect of antihypertensiveness
◆ MAOIs can cause severe hypertension
◆ Caffeine can increase stimulant effect
◆ OTC medications with sympathomimetic action can lead to increased CNS stimulation
➔
Antihistamines: Hydroxyzine
◆ Barbiturates, CNS depressants and alcohol can cause additive CNS depression
➔
Glucocorticoids: Dexamethasone (oral, IV and IM)
◆ Glucocorticoids promote hyperglycemia, thereby counteracting the effects of insulin
and oral hypoglycemics
● Dose of hypoglycemic meds might need to be increased
◆ Concurrent use of salicylates and NSAIDs can increase the risk for GI bleed
◆ Bc of the risk of hypokalemia, there is an increased risk of dysrhythmias caused by
digoxin
◆ Diuretics that promote potassium loss increase the risk for hypokalemia
◆ Glucocorticoids decrease the antibody response to vaccines and increase the risk of
infection from love virus vaccines
● Pts should not receive immunization
➔
Bisphosphonates: Etidronate
◆ Decreased absorption with calcium or iron supplements and high calcium foods
● Take etidronate on an empty stomach 2 hr before meals with an 8oz glass of
water
NSAIDs: Ibuprofen
◆ NSAIDs can reduce effectiveness of antihypertensives, furosemide, thiazide diuretics
and oral antidiabetic meds
◆ Aspirin, corticosteroids, alcohol, and tobacco can increase GI effects
◆ NSAIDs can increase levels of oral anticoagulants and lithium
◆ There is an increased risk of bleeding with the use of other NSAIDs, thrombolytics,
antiplatelets, anticoagulants, and salicylates
➔
NURSING ADMINISTRATION
➔
➔
➔
➔
Assessment of pain
Pt should receive pain management plan
Pt who have cancer should be encouraged to voice fears and concern about cancer, cancer
pain, and pain treatment
Advice pt that pain meds should be given on a fixed schedule around the clock and not as
needed