Appendix J ATI FORM A & B PHARMOCOLOGY
Cholinesterase Inhibitors
* Neostigmine (Prostigmin)
ACTION: Prevent the enzyme cholinesterase (CHE) from inactivating acetycholine (ACh),
thereby increasing the amount of ACh available at receptor sites. Transmission of nerve
impulses is increased at all sites responding to ACh as a transmitter
Therapeutic Use (TU)
increases muscle strength by increasing ACh effects at motor neurons in Myasthenia Gravis
Causes reversal of nondepolarizing neuromuscular blocking agents (tubocurarine) following surgery
Side Effects/Adverse Effects
Increased GI motility and secretion, bradycardia & urinary Urgency due to excessive muscarinic
stimulation
* 1) If effects become intolerable notify primary care provider, Side effects can be treated
with ATROPINE
Cholinergic Crisis- excessive muscarinic stimulation and respiratory depression from neuromuscular
blockade
* Treat with Muscarinic effects with ATROPINE
* Provide resp. support through mechanical ventilation
Contraindications (CI) :
In clients with obstruction of GI and GU system
Pregnancy Risk Category C
Med food/ Interaction
Atropine : counteracts the effects of Neostigmine (Nursing interventions: ATROPINE is used to
treat NEOSTIGMINE TOXICITY……….if no recovery is noted apply mechanical ventilation
until full muscle function is regained)
Tubocurarine : Neostigmine reverses neuromuscular blockade after surgical procedures and
overdose
Succinylcholine (increase neuromuscular blockade) : Avoid concurrent use
Client Education : Start at low dosages and titrate until desired muscle function is achieved,
Encourage the client to keep track of self doasage administration, recognize signs of INADEQUATE
DOSING, such as difficulty swallowing and signs of overmedication, such as urinary urgency, Advise
the client to wear a medical alert bracelet Effectiveness : Decreased fatigued, improved muscle strength as demonstrated by chewing,
swallowing and performing hygiene
Neuromuscular blocking agent
Drug : Tubocuraine (non-depolarizing) & Succinycholine (Depolarizing)
Action: Neuromuscular blocking agents block Ach at the neuromuscular junction resulting in
muscle relaxation and hypotension. They d/n cross the blood-brain barrier so complete
paralysis can be achieved w/o loss of consciousness or decreased pain sensation
USE:
Used as adjuncts to general anesthesia to promote muscle relaxation
Used to control spontaneous respiratory movements in clients receiving mechanical ventilation
These Meds are used to diagnosis MYASTHENIA GRAVIS
Succinycholine is preferred for : Seizure contol during electroconvulsive therapy, endotracheal
tubation, endoscopy
S/E
Respiratory Arrest from paralyzed respiratory muscles (NI: monitor respirations and vitals
continuously, equipment ready for resuscitation)
Hypotension resulting from HISTAMINE RELEASE and GUANGLIONIC BLOCKADE,
Bradycardia and dysrhythmias
S/E of SUCCINYLCHOLINE (ANECTINE)
Malignant hyperthermia: 109.4 F (NI: Monitor vitals, stop med, ice or ice saline to cool the
client, Administer Dantrolene: decreases metabolic activity of the skeletal muscle)
Prolonged Apnea due to low Pseudocholinesterase (NI : Test clients blood and hold med if
pseudo levels are low)
HyperKalemia
Med/food Int
General anesthetics are often used concurrently in surgery
Aminoglycosides, tetracyclines : increase effects of neuromuscular blockade
Neostigimine & Prostigmin) and other Cholinesterase inhibitors : decrease the effects of nondepolarizing neuromuscular blockers, such as Tubucurarine; increase the effects of
depolarizing neuromuscular blockers, such as Succinylcholine
Education: Continous Cardiac and respiratory monitoring (have life support equipment handy)
Effectiveness: Muscle relaxation during surgery, absence of seizures in EC Therapy, Successful
Endotracheal intubation, No spontaneous respiratory movements
Classification : Adrenergic Agonist
Drug : Epinephrine (Adrenaline) other drugs Dopamine and Dobutamine
Action : Catecholamine adrenergic agonists c/n be taken by the oral route, d/n cross the blood
brain barrier and the duration is short
Receptors
Alpha1 : Activation of receptors in arterioles of skin, viscera ad mucous membranes, and
veins lead to vasoconstriction
Beta1 : Heart stimulation leads to increased HR. increased Myocardial contractility, increased
rate of conduction through the AV node, Activation of receptors in the kidney lead to release of
rennin
Beta2 : Activation of receptors in the arterioles of the heart, lungs, and skeletal muscles
leading to vasodilation, Bronchial stimulation leads to bronchodilation, activation of receptors
in the uterine smooth muscles causes relaxation, activation of receptors in the liver causes
glycogenesis, activation of skeletal muscles leads to muscle contraction
Dopamine : activation of receptors in the kidney cause the renal blood vessels to dilate
Estrogen acting on Alpha1
VASOCONSTRICTION
TU: Increases B/P, decreases congestation of nasal mucosa, Manages superficial bleeding, slows
absorption of local anesthetics
Estrogen acting on Beta 1
Increases HR, Myocardial contractility, rate of conduction through the AV
Tx: AV Block and Cardiac Arrest
Estrogen acting on Beta2
Bronchodilation
Tx : Asthma
S/E :
Hypertensive crisis : Due to Vasoconstriction of Alpha 1 receptors (NI: Continuous Cardiac
monitor).Dysrhythmias : Do to activating Beta1 receptors which increases the workload of the
heart and the oxygen demand of the heart
Contraindications- Pregnancy Risk C, In clients with Tachydysrhythmias and v.Fib
Med/Food Int- Avoid use of MAOI’s in clients receiving Epinephrine.Tricylic Antidepressants
increase the effects of epinephrine, may need to lower epinephrine dosage.General Anesthetics
and epi can cause Dsyrhythmias so monitor ECG and notify primary care provider for signs of
chest pain, increased HR
Phentolamine Treats Epinephrine Toxicity
Propranolol treats Chest Pain and dysrhythmias
Education- Must be administered IV by continuous infusion, continuous ECG monitoring
Effectiveness- urine output greater than 30ml/hr, improved mental status, systolic blood
pressure maintained at greater than equal to 90mm hg
Classification : Alpha Adrenergic Blockers (Sympatholytics)
Drug : PRAZOSIN (MINIPRESS)
Action: Venous and arterial dilation. Smooth muscle relaxation of the prostatic capsule
and bladder neck
TU: Tx: HTN
Doxazosin mesylate (Cardura) may be used to decrease symptoms of benign prostatic
hypertrophy (BPH) (e.g urgency, frequency, dysuria)
S/E
First-Dose Orthostatic Hypotension (NI: first dose may be given at night, monitor
blood pressure for 2hr after the initiation of tx, instruct clients to avoid activity for the first 1224hr, encourage pt. to change positions slowly)
Contraindications (CI) : Pregnancy risk C. CI in clients with hypersensitivity to
medication
Med/Food Int
Anti-hypertensive Medications
NSAID’s and Clonidine decrease Anit-HTN effects
Effectiviness
*decrease in b/p, reduction in benign prostatic hypertrophy symptoms Classification : Centrally Acting Alpha2 Agonists
Drug : Clonidine (Catapres)
Action :
Act in the CNS to decrease sympathethic outflow. This results in a decrease of norepinephrine
(NE) released from sympathetic nerves, thereby decreasing the amount of NE that is available
to stimulate the adrenergic receptors (both alpha and beta receptors) of the heart and peripheral
vascular system
decreases sympathetic outflow to myocardium, results in bradycardia and decrease cardiac
output (CO)
decreases in synmpathetic outflow to peripheral vasculature results in, vasodilation, which leads to
decrease blood pressure
S/E
Drowsiness and Sedation
Dry Mouth (encourage the client to chew gum or hard candy, symptoms resolves in 2 to 4 weeks)
Rebound HTN: Discontinue CLONIDINE gradually over the course of 2 to 4 days
Med & Food Int
Antihypertensive Meds (may have hypotensive additive effects)
Prazosin, MAOI’s and Tricyclic Antidepressants (May counteract anti-hypertensive effects)
Alcohol : CNS Depressants
Education- Pregnancy must be ruled out before treatment is begun
Administer Twice a day in divided doses
Transdermal patches applied every seven days
Effectiveness- decreased blood pressure, absence of pain
Classification : Adrenergic Neuron-Blocking Agents
Drug: Reserpine
Action- Depletion of NE from postganglionic symphathetic neurons which decreases the
activation of alpha and beta adrenergic receptors…………..This slows HR and Reduces
Cardiac Output
TU: Tx HTN and Can be, but is less commonly used to treat Psychotic States
S/ESevere Depression (NI: educate about signs of depression such as early morning insomnia,
decreased appetite, change in mood
Cardiovascular Effects : Bradycardia, orthostatic hypotension, nasal congestion ((due to depletion of
Noreepinephrine (NE))………Bradycardia caused by decreased activation at the beta1
receptors, hypotension and nasal congestion caused by dec. activation at alpha receptors
GI Effects : Increase secretion of gastric acid causing Ulcer Formation
CI: Patients who have a hx of Depression Classification : Beta Adrenergic Blockers (Sympatholytics)
Drugs : Propranolol and Metoprolol
Action : decrease HR, Myocardial contractility (inotropic), rate of conduction through the
AV.Metoprolol blocks at Beta1 receptor, Propranolol (Inderal) blocks at Beta 2 receptor
TU: Angina Pectoris, HTN, Cardiac Dysrhythmias, MI, Heart Failure,
Other uses : hyperthyroidism, migraine headache, stage fright, glaucoma
S/E of Metoprolol (lopressor): Bradycardia (Administer Atropine and Isoproterenol)
Decrease In Cardiac output (Metoprolol may take like 1 to 3 months for effects to work) AV
Block (D/n administer beta-blocker) Orthostatic hypotensive, rebound myocardium
excitation (use of beta blockers shouldn’t be abruptly stopped, discontinue over 1 to 2 weeks)
S/E of Propranolol (Inderal) : Bronchoconstriction (Avoid in asthmatic clients),
Glycogenolysis is inhibited (Contraindicated in Diabetic pt.s treat diabetic pt.s with Beta1
agent)
Contraindications
Beta adrenergic blockers are contraindicated in clients with AV block and Sinus BradyCardia
Non-Selective beta-adrenergic blockers are contraindicated in clients with asthma, bronchospasms
and heart Failure
Use cardioselective Beta-adrenergic blockers cautiously in clients with heart failure, asthma,
bronchospasm, diabetes, hx of allergies and depression
MED and Food Int
CCB’s (Verapamil &Diltiazem (Cardizem) : intensifies the effects of betablockers………monitor closely
Antihypertensive Meds : Increases Hypotensive effects……monitor b/p
Insulin- prevents glycogenolysis: may need to adjust dosage of insulin when using Propranolol
(Inderal)
Education- Self monitor HR and B/p, D/N crush or chew extended release tablets, avoid
sudden changes in position
Effectiveness- Absence of chest pain, cardiac dysrhythmias, normal b/p, control of signs of
HF
Classification : Muscarinic Agonists
Drug : Bethanechol (Urecholine)
Action : Binds reversibly to muscarinic cholinergic receptors and causes activation, the
principal structures affected by muscarinic activation are the heart, exocrine glands, smooth
muscles, and eye
At the heart : Causes Bradycardia
At Exocrine Glands : Causes increase sweat, salivation, bronchial secretions, and secretion of
gastric acid
In the Smooth muscles of the lung and GI Tract : Promote contraction
In the bladder : contracts the detrusor muscle and relaxs the trigone and sphincter causeing
BlADDER EMPTYING
TU : Tx for Urinary Retention in post opt and post pardum pt. NOT urinary retention caused by
physiological obstruction…..b/c it cam cause injury due to increased pressure
S/E : Hypotension and bradycardia. Excessive salivation ,increased sec. of gastric acid,
abdominal cramps and diarrhea
CI : Patients with low blood pressure, gastric ulcers, intestinal obstruction (can rupture the
bladder) patients with asthma (it causes bronchoconstriciton), hyperthyroid patients (Can cause
dysrhythmias)
Classification : Muscarinic Antagonists (Anticholinergic Drugs)
Drug: Atropine
Action : completely block the action of acetylcholine at muscarinic receptors. Exerts it’s
influence primarily on the heart, exocrine glands, smooth muscles, and eye, just like the
muscarinc agonist
At the heart : increase HR
Exocrine Glands : decrease secretion of salivation, bronchial glands, sweat glands and
decreases gastric secretions
Smooth muscles: Atropine causes relaxation of the bronchi, decreased tone of the urinary
bladder detrusor and decreased tone and motility of the GI
Eye : Dilates the pupil (mydriasis) focuses the lens for far vision (cycloplegia)
CNS: can cause mild excitation at therapeutic doses, Toxic doses can causes delirium &
hallucinations
TU:Helps during eye examinations for disorders of the eye. Tx Bradycardia. Tx : diverticulitis
by decreasing tone and motility in the smooth muscles of the intestine. Used to Reverse
Muscarinic Poisioning, Can treat Peptic Ulcers disease, Asthma (by bronchodilating)
S/E : Xerostomia (Dry Mouth), Blurred Vision (paralyze ciliary muscle focus on far objects
causes blurred vision) photophobia (paralysis of iris sphincter prevents constriction of the
pupil) (NI: where glasses 4photophobia-when unable to adapt to bright light)
Urinary Retention and Constipation (blockade of muscarinic receptors increase the pressure
w/in bladder and increases the tone of the urinary sphincter and trigone)
Anhidrosis (absence of sweat), Tachycardia, Asthma(cause thickening and drying of bronchial
secretions
Drug Interactions : Anti-histamines, phenothiazines, antipsychotics, tricyclic
antidepressants…have anticholinergic effects and can enhance the effects of Atropine
Note : Anti-cholinergic means blockade at Muscarinic Receptors-not blockade at all cholinergic
receptors Classification : Ganglinic Blocking Agents
Drugs : Mecamylamine
Action : Blocks transmission through the ganglia of the ANS by completing with Ach for
binding to nicotinic receptors
TU : Are used ONLY to decrease blood pressure, treats primary HTN in selected patients, only
used when b/p c/n be reduced by all other medications
S/E :
Antimuscarinic effects (dry mouth, blurred vision, photophobia, urinary retention,
constipation, tachycardia, anhidrosis)
Orthostatic hypotension (by dilating veins causes pooling of blood decreasing blood return to
the heart, reducing CO and subsequent fall in b/p)
CNS Effects ( tremor convulsions, and mental aberrationds)
Central Nervous System Drugs
Drugs for Parkinson’s disease
Dopaminergic Drugs:
Anti-Parkinson’s Medications
Dopaminergics: Levodopa (increases dopamine [DA] synthesis)
-levodopa plus carbidopa (Sinemet)
-Carbidopa (blocks levodopa destruction)
Dopamine agonists: pramipexole (Mirapex)
Centrally acting anticholinergics: Benztropine (Cogentin)
Dopamine releaser (Antiviral): Amantadine (Symmetrel)
Classification:
Dopaminergics:
Medications: Levodopa (Dopar, Larodopa), levodopa plus carbidopa (Sinemet)
Actions:
-Levodopa crosses the blood brain barrier and is taken up by dopaminergic nerve terminals and
converted to dopamine (DA). This newly synthesized DA is released into the synaptic space and
causes stimulation of DA receptors
- Carbidopa does not possess any therapeutic effects, but is used to augment levodopa.
Carbidopa inhibits conversion of levodopa to DA in the intestine and periphery, and thereby allows for
increase amounts of levodopa to reach the CNS
Dopamine agonists:
Medications: Pramipexole (Mirapex), Ropinirole (Requip), bromocrptine (Parlodel)
Actions:
-Act directly on DA receptors
Centrally Acting Anticholinergics:
Medications: Benztropine (Cogentin), Trihexyphenidyl (Artane)
Actions: These medications block acetylcholine at muscarnic receptors, which assists in maintaining
the balance between dopamine and acetylcholine in the brain.
Dopamine releaser (Antiviral):
Medications: Amantadine (Symmetrel)
Actions: Antiviral stimulate DA release, prevent dopamine reuptake, and may block cholinergic and
glutamate receptors
Therapeutic Uses:
- These medications do not halt the progression of Parkinson’s disease (PD): however, they do
offer symptomatic relief from dyskinesias (e.g., bradykinesis, resting tremors, and muscle
rigidity).
- Levodopa may be used as a first-line medication for PD treatment
- Pramipexole (Mirapex) is used as monotherapy in early-stage PD, and used in conjunction with
levodopa in late- stage PD. It is used often in younger clients who are more able to tolerate
daytime drowsiness and postural hypotension
Side/Adverse Effects: Nursing Interventions and Client Education
Dopaminergics: levodopa- usually dose dependant
- N&V, drowsiness
o Administer in small doses at the start of treatment and with food
- Dyskinesias (e.g.), head bobbing, tics, grimacing, tremors)
o Decrease dosage of medication, but the decrease may result in resumption of PD
symptoms
- Orthostatic hypotension
o Monitor the clients b/p
o Instruct the client about signs of postural hypotension
- Cardiovascular effects from beta1 stimulation (e.g., tachycardia, palpitations, irregular
heartbeat)
o Monitor the clients vital signs
o Use cautiously in clients with cardiovascular disorders
o Monitor ECG
-
-
-
Psychosis (e.g., visual hallucinations, nightmares)
o Administer antipsychotic medications such as clozapine (Clozaril) if symptoms occur.
Discoloration of sweat and urine
o Advise the client that this is a harmless side effect
Activation of malignant melanoma
o Avoid use of medication in clients with skin lesions that have not been diagnosed
Dopamine Agonists: Pramipexole (Mirapex)
Sleep attacks
Daytime sleepiness
o Advise the client to avoid the use of other CNS depressants such as alcohol
Orthostatic hypotension
Psychosis
Dyskinesisas
Nausea
Centrally acting anticholinergics: benztropine (Cogentin)
N&V
Atropine-like effects (e.g., dry mouth, blurred vision, mydriasis, urinary retention, constipation)
o Advise the client to chew sugarless gum, eat foods high in fiber, and increase water
intake to at least 8 to 10 glasses of water/day
antihistamine effects (e.g. sedation, drowsiness)
Antiviral: amatadine (Symmetrel)
CNS effects (e.g., confusion, dizziness, restlessness)
Atropine-like effects\
Discoloration of skin, also called livido, reticularis
o Advise the client that discoloration of the skin will subside when the medication is
discontinued
Levodopa plus cardidopa (Sinemet)
- Abnormal movements, psychiatric disorders
Contraindications/Precautions
Levodopa
- Pregnancy Risk Category C
- Contraindicated in clients with malignant melanoma
- Do not use w/in 2 weeks of MAOI use
- Use cautiously in clients with heart disease and psychiatric disorders
Pramipexole (Mirapex)
- Pregnancy Risk Category C
- Use cautiously in clients with liver and kidney impairment
Anticholinergic agents
- Contraindicated in clients with narrow-angle glaucoma
- Use cautiously in older adults, the very young, clients with enlarged prostate glands, and a
history of urinary retention
Medication/Food Interactions
-
Dopaminergics: levodopa
Proteins interfere with levodopa absorption and transport across the blood-brain barrier. High
protein meal decrease therapeutic effects.
o Proteins trigger an “off episode”
-
-
-
-
o Advise the client to eat protein in several portions during the day
Conventional-antipsychotic agents (e.g., chlorpromazine [Compazine], haloperidol [Haldol]
decrease therapeutic effects.
o Avoid use with levodopa
o To treat levodopa-induced psychosis, use the atypical antipsychotic clozapine (Clozaril)
Pyridoxine decrease therapeutic effects
o Advise client to avoid vitamin preparations that contain pyridoxine
MAOIs cause hypertension
o Avoid concurrent use
Carbidopa, dopamine agonists, anticholinergics, COMT inhibitors, and dopamine
releasers increase therapeutic effects
o These medications can be used concurrently to increase the beneficial effects of
levodopa
Dopamine agonists: pramipexole (Mirapex)
Levodopa- concurrent use has beneficial and harmful interactions. Use with levodopa can
decrease motor control fluctuations and allow for lower dosage of levodopa. Concurrent use
can also increase the risk of orthostatic hypotension and dyskinesias
Levodopa plus carbidopa (Sinemet)
Beneficial interactions include allowing for lower dosage of levodopa, decrease cardiovascular
responses to dopamine in the periphery, and decrease nausea.
Cholinesterase Inhibitors
Prototype Medication: Neostigime (Prostigmin)
Action: Prevent the enzyme cholinesterase (ChE) from inactivating acetylcholine (Ach), thereby
increasing the amount of Ach available at receptor sites. Transmission of nerve impulses is increased
at all sites responding to Ach as a transmitter.
Therapeutic Uses:
- Neostigmine (Prostigmin) increase muscle strength by increasing Ach effects at motor neurons
in myasthenia gravis
- Neostigmine causes reversal of nondepolarizing neuromuscular blocking agents (tubocurarine)
following surgery
Side/Adverse Effects:
- Excessive muscarine stimulation as evidenced by increased GI motility, increased GI
secretions, bradycardia, and urinary urgency
o Side effects may be treated with atropine
- Cholinergic crisis –excessive muscarnic stimulation and respiratory depression from
neuromuscular blockade
o Muscarinic effects can be treated with atropine
o Provide respiratory support through mechanical ventilation and oxygen
Contraindications/Precautions
- Pregnancy Risk Category C
- Contraindicated in clients with obstruction of GI and GU system
- Use cautiously in clients with seizure disorders, hyperthyroidism, peptic ulcer disease, asthma,
bradycardia, and hypotension.
Medication/Food Interactions
Atropine-counteracts the effects of neostigmine
- Used to treat neostigmine toxicity
-
Monitor the client closely and provide mechanical ventilation until the client has regained full
muscle function
Turocurarine:
- Neostigmine reverses neuromuscular blockade after surgical procedures and overdose.
- Monitor the client for return of respiratory function. Support respiratory function as necessary.
If used to treat overdose, provide mechanical ventilation until the client has regained full
muscle function
Succinylcholine: increase blockade
- Avoid concurrent use
Drugs for Epilepsy (Antiepileptics) AEDs
Select Prototype Medications:
Barbiturates: Phenobarbital (Luminal)
Hydantoins: phenytoin (Dilantin)
Benzodiazepines: diazepam (Valium)
Lorazepam (Ativan)
Carbamazepine (Tegretol)
Ethosuximide (Zarontin)
Valproic acid (Depakote)
Gabapentin (Neurontin)
Action: AEDs control seizure disorders by various mechanism, which include
- Slowing the entrance of sodium and calcium back into the neuron and, thus extending the time
it takes for the nerve to return to its active state
- Suppressing neuronal firing, which decreases seizure activity and prevents propagation of
seizure activity into other areas of the brain
- Potentiating the inhibitory effects of gamma butyric acid (GABA) and thereby suppressing
seizure activity.
Therapeutic Uses
- Treatment of generalized seizures
o Tonic clonic ( Grand mal)
o Absence seizures (Petit mal)
o Atonic seizures
o Myoclonic seizures
o Status epilepticus
o Febrile seizures
- Treatment of partial seizures
o Simple partial
o Complex partial
- Complete eradication of seizure activity
Medications/ Therapeutic Uses
Phenobarbital (Luminal)
- Used for partial seizures and generalized tonic-clonic seizures
- Not effective against absence seizures
Phenytoin (Dilantin)
- Is effective against all major forms of epilepsy except absence seizures
- Use IV route for status epilepticus
- Antidysrhythmic
Carbamazepine (Tegretol)
-
Used for the treatment of partial (simple and complex) seizures, tonic-clonic seizures, bipolar
disorder and trigeminal and glossopharyngeal neuralgias
Ethosuximide (Zarontin)
- Only indicated for absence seizures
Valproic acid (Depakote)
- Used for partial, generalized and absence seizures, bipolar disorder and migraine headaches.
Gabapentin (Neurontin)
- Used a single agent for control of partial seizures. The medication is also used for neuropathic
pain and the prevention of migraine headaches.
Diazepam (Valium)
- Status epilepticus
Side/Adverse Effects: Nursing Interventions and Client Education
Barbiturates: Phenobarbital (Luminal)
- CNS effects in adults manifest as drowsiness, sedation, confusion, and anxiety; in children,
CNS effects manifest as irritability and hyperactivity
- Toxicity (e.g., nystagmus, ataxia, respiratory depression, coma, pinpoint pupils, hypotension,
death)
o Stop medication. Administer oxygen and maintain respiratory function with ventilatory
support
o Monitor clients vital signs
Hydantoins: phenytoin (Dilantin)
- CNS effects (e.g., nystagmus, sedation, ataxia, double vision)
- Gingival hyperplasia- softening and overgrowth of gum tissue resulting in tenderness and
bleeding gums
o Advise the client to maintain good oral hygiene
- Skin rash
o Stop medication
- Teratogenic (e.g. cleft palate, heart defects)
o Avoid use in pregnancy
- Cardiovascular effects (e.g. dysrhythmias, hypotension)
o Administer at slow IV rate and in dilute solution to prevent adverse CV effects
- Endocrine and other effects (e.g., coarsening of facial features, hirsutism, and interference with
vitamin D metabolism)
o Encourage the client to consume adequate amounts of calcium and vitamin D
Carbamazepine (Tegretol)
- Cognitive function is minimally affected, but CNS effects can occur
o Administer in low doses initially and then gradually increase dose
o Administer dose at bedtime
- Blood dyscrasias (e.g., leucopenia, anemia, thrombocytopenia)
o Obtain the clients baseline CBC and platelets. Perform ongoing monitoring of CBC and
platelets
o Observe the client for signs of bruising and bleeding gums
- Teratogenesis
- Hyo-osmolarity – promotes secretion of ADH which inhibits water excretion by the kidneys,
and places the client with heart failure at risk for fluid overload
o Monitor serum sodium periodically.
o Monitor the client for edema, decrease urine output and hypertension.
- Skin disorders (e.g., dermatitis, rash, Stevenson-Johnson syndrome
o Treat mild reactions with anti-inflammatory or antihistamine medications
o Medications should be discontinued if there is a severe reaction
Ethosuximide (Zarontin)
- Gastrointestinal effects N&V
- CNS effects
Valproic acid (Depakote)
- Gastrointestinal effects
- Hepatoxicity (e.g., anorexia, abdominal pain, jaundice)
o Medication should be prescribed in lowest effective dose
- Pancreatits as evidenced by nausea, vomiting, and abdominal pain
o Monitor amylase level
o Medication should be discontinued if pancreatitis develops
- Thrombocytopenia
o Monitor platelet count
o Advise client to observe for signs of bruising
Gabapentin (Neurotin)
- CNS effects
- Respiratory depression
o Monitor client’s vital signs
o Have resuscitation equipment ready
o Administer oxygen\
- Anterograde amnesia
o Monitor clients memory loss
- Teratogenic (e.g., cleft palate, heart defects)
Contraindication/Precautions
Barbiturates- contraindicated in clients with intermittent porphyria
Phenytoin contraindicated in clients with sinus bradycardia, sinoatrial blocks, second- and third degree
AV block, or stokes-Adam syndrome
Carbamazepine- contraindicated in clients with bone marrow suppression or with bleeding disorders
Valproic Acid- contraindicated in clients with liver disorders.
Medication/Food interactions
Phenytoin (Dilantin)
- Oral contraceptives, warfarin (Coumadin), and glucocorticoids- phenytoin causes a
decrease effects of these medications due to the stimulation of hepatic drug-metabolizing
enzymes
o Advise the client to increase dose of oral contraceptives
- Alcohol, diazepam (valium), cimetidine (tagamet), and valproic acid increase phenytoin
levels.
- Carbamazepine (Tegretol), Phenobarbital, and chronic alcohol use decrease phenytoin
levels.
- CNS depressants (e.g., barbiturates, alcohol)
o Additive CNS depressant effects can occur with concurrent use
Carbamazepine (Tergretol)
- Oral contraceptives and warfarin (Coumadin) – carbamazepine causes decrease in the
effects of these medications due to stimulation of hepatic drug-metabolizing enzymes
- Grapefruit juice –inhibits metabolism, and thus increase carbamazepine levels
- Phenytoin and phenobarbital- decrease the effects of carbamazepine
Valproic acid (Depakote)
- Phenytoin and Phenobarbital –concurrent use with valproic acid increase the levels of these
medications
Drugs for migraines:
Nonsteroidal Anti-inflammatory drugs
aspirin (Ecotrin):
Action:
Prevents platelets from clumping together by inhibiting enzymes and factors that normally lead to
arterial clotting
Uses:



Primary prevention of acute MI
Prevention of reinfarction in clients following acute MI
Prevention of stroke
Side effects:
GI effects such as bleeding, hemorrhagic stoke
Interactions:
Nsaids, heparin, warfarin
Local Anesthetics
Ester-type Local anesthetics: procaine (Novocain)
Amide-type Local anesthetics: lidocaine (Xylocaine)
Action:
Decrease pain by blocking conduction of pain impulses in a circumscribed area. Loss of consciousness
does not occur
Use:
 Dental procedures
 Minor surgical procedures
 Labor and delivery
 Diagnostic procedures
Side effects:
CNS excitation (seizures, followed by resp. depression, leading to unconsciousness), Hypotensiins,
cardio suppression aeb bradycardia, heart block, and cardiac arrest, allergic rxn’s, spinal headache and
urinary retention
General Anesthetics
Inhalation Anesthetics: halothane (Fluothane)
Action:
Produces loss of consciousness, loss of all sensations, relaxation of muscles, and memory loss
Uses:
 Anesthesia for surgery
 Diagnostic procedures
 Cardiological procedures
 Relief of pain
 Muscle relaxation
Side effects:
Hypotension, respiratory and cardiac depression, malignant hyperthermia, hepatotoxicity
Interactions: CNS depressants (barbiturates, benzodiazepines, alcohol), CNS stimulants
(amphetamines, cocaine), Opioid analgesics (morphine), succinylcholine
Intravenous Anesthetics: thiopental (Pentothal)
Action:
Produce loss of consciousness and elimination of response to painful stimuli
Uses:
 Adjunct to inhalation anesthetics
 Induction and maintenance of anesthesia
 Amnesia
Side effects:
Respiratory and cardiovascular depression (hypotension)
Interactions:
CNS depressants (barbiturates, benzodiazepines, alcohol), CNS stimulants (amphetamines, cocaine),
Opioid analgesics (morphine),
Opioid (narcotic) Analgesics and Antagonists
Pure Opioid Agonists: Morphine sulfate
Action:
Act on mu receptors and to lesser degree on kappa receptors. Activation of mu receptors produces
analgesia, respiratory depression, euphoria, and sedation.
Uses:
 Relief of moderate to sever pain
 Sedation
 Reduction of bowel motility
Side effects:
Respiratory depression, constipation, orthostatic hypotension, urinary retention, coughs suppression,
sedation
Interactions:
CNS depressants (barbiturates, benzodiazepines, Phenobarbital, alcohol), anticholinergic agents
(antihistamines and tricyclic depressants, MAIO’s, antihypertensive
Agonist-Antagonist Opioid: pentazocine (Talwin)
Action:
Compared to pure opioid agonists, these have a low potential for abuse causing little euphoria and less
respiratory depression
Uses:
 Relieve mild to moderate pain, not severe pain
Side effects:
Abstinence syndrome (cramping, hypertension, vomiting)
Pure Opiod Antagonists: naloxone (Narcan)
Action:
Interfere with the action of opioids by competing for opioid receptors. Opioid antagonists have no
effect in the absence of opioids.
Uses:
 Treatment of opioid overdose
 Reversal of effects of opioids, such as respiratory depression

Reversal of respiratory depression in an infant
Side effects:
Tachycardia and tachypnea, abstinence syndrome (cramping, hypertension, vomiting)
Antipsychotic drugs
Traditional antipsychotic: chlorpromazine (Thorazine), haloperidol (Haldol)
Actions:
Dopamine, acetylcholine, histamines, and norepinephrine receptors in the brain and periphery are
blocked.
Uses:
 Schizophrenia
 Bipolar disorders
 Tourette’s syndrome
 Delusional disorders
 Schizoaffective disorder
 Dementia and other organic mental syndromes
 Huntington’s chorea
Side effects:
Early extrapyramidal symptoms: acute dystonia (severe spasms of the tongue, neck, face, and back),
parkinsonism tremors, akathisia (inability to stand still or sit). Late extrapyramidal symptoms: (tardive
dyskinesia). Neuroleptic malignant syndrome ( sudden high grade fever, blood pressure fluctuations,
dysrhythmias), anticholinergic effects.
Interactions:
Anticholinergic agents, CNS depressants (barbiturates, benzodiazepines, Phenobarbital, alcohol),
Levodopa
Atypical Antipsychotics: clozapine (Clozaril)
Action:
Block serotonin and dopamine receptors
Uses:
 Severe schizophrenia
 Psychosis induced by levodopa therapy
Side effects:
Agranulocytosis, seizures, new onset diabetes, weight gain, inflammation of the heart muscles
Interactions:
Immunosuppressive medications
Antidepressants:
Tyicyclic Antidepressants: imipramine (Tofranil)
Action:
Block reuptake of norepinephrine and serotonin
Uses:
 Depression
 Bipolar disorders
Side effects:
Orthostatic hypotension, anticholinergic effects, cardiac toxicity, sedation
Interactions:
MAOI’s, antihistamines, epinephrine, ephedrine, alcohol, benzodiazepines, opioids
Selective Serotonin Reuptake Inhibitors: fluoxetine (Prozac)
Action:
Block reuptake of serotonin
Uses:
 Major depression
 OCD
 Bulimia nervosa
 PMDD
 Panic disorders
 PTSD
Side effects:
Sexual dysfunction, weight gain, serotonin syndrome (mental confusion, agitation, anxiety),
withdrawal syndrome, hyponatremia, rash
Interactions:
MAIO’s, Coumadin, tricyclic antidepressnats and lithium, NSAID’s and anticoagulants
Monoamine Oxidase Inhibitors: phenelzine (Nardil)
Action:
Block MAO-A in the brain thereby increasing the amount of norepinephrine and serotonin available
for transmission
Uses:
 Atypical depression
 Bulimia nervosa
 OCD
Side effects:
CNS stimulation, orthostatic hypotension, hypertensive crisis
Interactions:
Ephedrine, amphetamine, tricylic antidepressants, SSRI’s antihypertensices, Demerol, Tyramine rich
foods
Atypical Antidepressants: bupropion HCL (Wellbutrin)
Action:
Inhibit dopamine uptake
Uses:
 Treatment of depression
 Aid to quit smoking
Side effects:
Headache, dry mouth, constipation, increase heart rate, nausea, restlessness, weight loss, seizures
Interactions:
MAOI’s
Drugs for Bipolar Disorder
Lithium carbonate, carbamazepine (Tegrertol), valproic acid (Depakote)
Action:
Produces neurochemical changes in the brain including serotonin receptor blockade
Uses:
 Treatment of bipolar (they control episodes of acute mania, and help to prevent the return of
mania or depression)
 Alcoholism
 Bulimia
 Schizophrenia
Side effects:
GI effects, tremors, polyuria, renal toxicity, goiter and hypothyroidism, teratogenesis
Interactions:
Diuretics, NSAID’s, anticholinergics
CLASS: Adrenergic Agonists
PRO: epinephrine and dopamine (catecholamine)
ACTION: vasoconstriction (up BP), bronchodialation, increase heart rate
SE: hypertensive crisis, dysrythmias
CONTRA: tachydysrhythmia and ventricular fibrillation
IINTERACT: MAOIS and general anesthetics
INTERVENTIONS: IV only and ECG monitoring
CLASS: Alpha Adrenergic Blockers
PRO: prazosin (minipress)
ACTION: dilate arteries and veins
USES: hypertension
SE: orthostatic hypertension (first dose at night, change position slow)
INTERACT: antihypertensive meds (hypotension), NSAIDS counteract the effects
INTERVENTIONS: take with food and first dose at night
CLASS: centrally acting alpha2 agonist
PRO: clonidine (catapres)
ACTION: lower sympathetic outflow, lower nowepinephrine, lower BP
USE: hypertension
SE: drowsiness (will diminish), dry mouth (resolves in 2-4 wks)
INTERACT: antihypertensive meds (hypotension), prazosin (counteract effects), alcohol
INTERVENTIONS: take large dose at night to lower drowsiness, transdermal patches changed every 7d
CLASS: beta adrenergic blockers (beta blockers)
PRO: metoprolol (lopressor), propranolol (inderal)
ACTION: lower HR, lower myocardial contractility, lower conduction through AV node
USE: angina pectoris, hypertension, dysrythmias, MI, heart failure
SE: bradycardia, lower cardiac output (1-3 months for beneficial effects), bronchoconstriction (avoid
asthma pt)
INTERACT: pt with AV block and sinus bradycardia, calcium channel blockers (intensifies), insulin
INTERVENTIONS: avoid sudden position changes
CLASS: ACE inhibitors
PRO: captopril, enalapril
ACTION: block production of angiotensin II, vasodilation (arteries), excrete NA, retain K
USES: heart failure, hypertension, MI
SE: 1st dose orthostatic hypotension (stop med for 2-3 days if taking diuretic), cough, hyperkalemia
CONTRA: 2nd and 3rd trimester pregnancy
INTERACT: diuretics (stop med for 2-3 d), K supplements, lithium (can up lithium levels), NSAIDS
(decrease andtihypertensive effect)
INTERVENTIONS: captopril taken 1h before meals
CLASS: ARB’s
PRO: losartan
ACTION: blocks action of angiotensin II, vasodialation, excrete NA, retain K
USES: reduce hypertension
SE: angioedema
CONTRA: 2nd and 3rd trimester pregnancy
INTERACT: antihypertensive med (additive effect)
INTERVENTIONS: take with or w/o food
*(ARB’s not as effective as ACE inhibitors because they only block the action and not the production of
angiotensin II)
CLASS: Calcium Channel Blockers
PRO: verapamil (affect heart and vessels)
ACTION: blocks vasodilation in arteries, lower contraction force, lower HR, slower AV conduction
USES: angina pectoris, hypertension, cardiac dysrythmias
SE: Orthostatic hypertension, peripheral edema, constipation
INTERVENTIONS: weigh daily, prescribe diuretic for edema, up fluid intake and fiber, IV admin over 2-3 min
CONTRA: cautiously use digoxin, beta blockers, and grapefruit juice
PRO: nifedipine (affect only vessels)
ACTION: blocks vasodilation in arteries
USES: angina pectoris, hypertension, cardiac dysrythmias
SE: reflex tachycardia, peripheral edema
INTERVENTIONS: administer beta blocker if tachy, prescribe diuretic for edema, IV admin over 2-3 min
CONTRA: cautiously use digoxin, beta blockers, and grapefruit juice
CLASS: organic nitrates
PRO: nitroglycerine
ACTION: lower cardiac O2 demand, dilating veins and decreasing preload
USES: angina, periop (control BP or produce hypotension), heart failure
SE: headache (take aspirin), tolerance
CONTRA: traumatic head injury (increase intracranial pressure)
INTERACT: alcohol, cautiously use with CCB, beta blockers, diuretics, Viagra (hypotension)
INTERVENTIONS: angina attack 1) take rapid-acting 2) wait 5 min 3) can take 2 more doses at 5 min intervals if
unrelieved
CLASS: cardiac glycosides
PRO: digoxin
ACTION: increase force of contraction, decrease HR
USE: heart failure, dysrhythmias (A Fib)
SE: dysrhythmias if toxic
INTERACT: thiazide diuretics, ACE and ARB, dopamine
INTERVENTIONS: take same time daily, avoid OTC drugs, do not take potassium-sparing diuretics, treat
dysryhthmias with lidocaine, trear bradycardia with atropine
CLASS: antidysrythmic meds
PRO: Sodium Channel Blockers 1A (procainamide)
ACTION: decrease electrical conduction, decrease rate of repolorization
USE: Afib, Aflutter
SE: lupus, cardiotoxicity
INTERACT: antichollinergics
PRO: Sodium Channel Blockers 1B (lidocaine)
ACTION: decrease electrical conduction, increase rate of repolorization
USE: short term dysrhythmias
SE: CNS effects, resp. arrest
INTERACT: cimetidine, beta blockers phenytoin
INTERVENTIONS: do not crush
INTERVENTIONS: never administer with epinephrine, administrations is usually loading dose followed by
maintenance dose of 1-4 mg
CLASS: statins
PRO: Lipitor, lovastatin
ACTION: increase LDL receptors to remove greater amt of LDL, increase HDL
USES: hypercholesterolemia
SE: hepatotoxicity (up in serum tranaminase), myopathy
CONTRA: pregnancy
INTERACT: fibrates (up myopathy), grapefruit juice
INTERVENTION: lovastatin take with evening meal, increase med dose if taking erythromycin
CLASS: bile-acid sequestrants
PRO: cholestyramine (questran)
ACTION: increase LDL receptors to remove more LDL
USES: use adjunct with HMG CoA reductase inhibitors (atorvastatin)
SE: so systemic effects, constipation
INTERACT: digoxin, warfarin, thiazide (all interfere with absorption)
INTERVENTION: take other med 1hr before or 4hr after
CLASS: loop diuretics
PRO: furosemide (lasix)
ACTION: block reabsorption of Na, Cl, and H2O in loop of henle
USE: pulmonary edema, conditions not responsive to other diuretics, renal impairment
SE: dehydration, hypotension, ototoxicity, hypokalemia
CONTRA: diabetes (cautious)
INTERACT: digoxin, antihypertensives, lithium, NSAIDS
INTERVENTION: weigh in morning, avoid administering late in day
CLASS: thiazide diuretics
PRO: hydochlorothizaide
ACTION: block reabsorption of Na, Cl, and H2O in early distal convoluted tubule
USE: essential hypertension, edema, liver and kidney disease
SE: dehydration, hypokalemia, hyperglycemia
CONTRA: lower kidney function
INTERACT: digoxin, lithium
INTERVENTION: monitor K levels, eat foods high in K
CLASS: potassium-sparing diuretics
PRO: spironolactone
ACTION: block aldosterone, potassium retension, Na and H20 secretion
USES: combined with other diuretics for K sparing effects, heart failure
SE: hyperkalemia
INTERACT: ACE and K+ supplements (hyperkalemia)
INTERVENTION: only given orally, avoid K+ salt substitutes
Gastrointestinal Drugs: Start on p. 891 in Lehne
Drugs for Peptic Ulcer Disease
An example antibiotic regiment for H pylori would include:
Omeprazole + Amoxicillin + Clarithromycin for 10 days-remember that none is effective
alone and a multi-drug regiment is to prevent development of resistance to H pylori. Other
options listed in p. 894
H2 Receptor Antagonists-Cimetidine [Tagamet], Ranitidine hydrochloride [Zantac]
Action: blocks receptor H2 receptor sites in PARIETAL cells lining the stomach
Therapeutic Use: GERD
Sides/Adverse Effects: Decreased libido and impotence (keep away from your partner)
Contraindications/Precautions: Pregnancy Cat. B. Careful with older folks can cause
antiadrenergic effects like impotence and CNS effects like confusion.
Interactions: Increases the levels of Warfarin and Phenytoin (anticonvulsant).
Interventions/Education: remember the drugs ending in –tidine can be administed IV in
acute situations. Also eat 6 small meals.
Proton Pump Inhibitor Omeprazole [Prilosec]
Action: reduce gastric acid secretion by irreversibly inhibiting the enzymes that produces
gastric acid so it stays in the system for a few weeks. They also reduce basal and stimulated
acid production.
Therapeutic Use: Ulcers, GERD, and hypersecretory conditions like Zollinger-Ellison
syndrome.
Sides/Adverse Effects: Insignificant with short term use.
Contraindications/Precautions: Preg C. Caution in children and women who are
breastfeeding. Increase risk for pneumonia.
Interactions: delayed absorption of ampicillin, digoxin, iron and ketocanazole
Interventions/Education: Do not crush, crew or break sustained-release capsules.
Mucosal Protectants Sucralfate [Carafate]
Action: uses acidic environment of stomach and duodenum into a viscous substance that
adheres to an ulcer and protects from further injury.
Therapeutic Use: Acute duodenal ulcers and maintained therapy.
Sides/Adverse Effects: increase dietary fiber to decrease constipation.
Contraindications/Precautions: Preg B and contraindicated in those with hypersensitivity
Interactions: May interfere with absorption of phenytoin, digoxin, warfarin and
ciprofloxacin so spread out meds by 2h.
Interventions/Education: empty stomach 1h before meals
Antacids Aluminum hydroxide gel [Amphojel]
Action: neutralize gastric acid and inactivate pepsin—mucosal protection may come into
play by stimulating the production of prostaglandins.
Therapeutic Use: PUD by promoting healing and relieving pain. Symptomatic relief for
GERD.
Sides/Adverse Effects: Can cause constipation. Can lead to hypophosphatemia.
Contraindications/Precautions: Preg Cat. C. DO not administer to clients with perforation
or obstruction
Interactions: Al binds with warfarin and tetracycline which interferes with absorption
Interventions/Education: Chew it up real good and drink 8oz of H20 or milk.
Drugs for NSAID-- Induced Ulcers
Misoprostol
Action: works on the GI tract to decrease acid secretion, increase the secretion of
bicarbonate and protective mucous and promote vasodilatation to maintain submucosal
blood flow.
Therapeutic Use: to prevent gastric ulcers in clients using NSAID long-term
Sides/Adverse Effects: Diarrhea and abdominal pain—notify provider the dose may need
to be reduced.
Contraindications/Precautions: remember this drugs causes contractions of the uterus
which could lead to spontaneous abortion.
Interactions: NONE it’s a miracle!!!
Interventions/Education: Besides ensuring contraception use teach client to take with
meals and at bedtime.
LAXATIVES
Surfactants Docusate Sodium [Colace]
Action: lower surface tension of the stool to allow penetration of H20
Therapeutic Use: short term use r/t pregnancy or opoid use. To relieve painful elimination
(hemorrhoids)., prevent straining, decrease risk of fetal impaction of immobile, promote
peristalsis due to aging
*other info below
Stimulant Laxatives Bisacodyl [dulcolax]
Action: stimulate intestinal peristalsis-act on the colon by reducing water and electrolyte
absorption and increasing the secretion of water and ions into the intestine.
Therapeutic Use: prior to surgery, short term treatment caused by high opoid use.
Sides/Adverse Effects: discourage clients from using suppositories on a regular basis as it
may cause burning and can lead to proctitis.
*other below
Osmotic Laxatives-magnesium hydroxide [Milk of Mag]
Action: Osmotic lax draw H2O into the mass of stool stretching musculature and
stimulating peristalsis
Therapeutic Use: used in clients to prevent painful elimination, prep for surgery of
diagnostic test, evacuate bowel after ingestion of poison or antihelminthic to rid body of
dead parasites.
Sides/Adverse Effects: Can lead to accumulation of toxic level of Mg (avoid in folks with
renal dysfunction). Osmotics can also cause dehydration.
*General Information for this group:
Sides/Adverse Effects: GI irritation-do not crush or chew enteric-coated tablets.
Contraindications/Precautions: Contraindicated in clients with fecal impaction, bowel
obstruction, and acute surgical abdomen to prevent perforation-also in clients with nausea,
cramping and abdominal pain. Warn clients with heart disease to avoid laxatives that
contain sodium.
Interactions: Milk and antacids can destroy enteric coating of bisacodyl.
Interventions/Education: Obtain a complete history of laxative use and provide teaching as
appropriate. Teach client that chronic laxative use can lead to fluid and electrolyte
imbalances. Promote fiber food so that normal bowel function may be resumed.
Anitemetics
Serotonin Antagonists Ondansetron [Zofran]
Action: blocks serotonin receptors in the chemoreceptor trigger zone (CTZ)
and antagonizing the serotonin receptors on the afferent vagal neurons that
travel from the upper GI tract to CTZ
Therapeutic Use: Sides/Adverse Effects: prevents emesis related to chemo, radiation
therapy and postoperative recovery
Sides/Adverse: Headache, diarrhea, dizziness
*see below
Dopamine Antagonists Prochlorperazine [Compazine]
Action: Anitemetic effects result from blockade of dopamine receptors in the CTZ.
Therapeutic Use: prevents emesis r/t chemo, opoid and postoperative recovery
Sides/Adverse Effects: EPS Extrapyramidal symptoms i.e. restlessness, anxiety, spasms of
the neck and face—treat with an anticholinergic like benadryl
*See below
Cannabinoids; dronabinol [Marinol]
Action: unknown
Therapeutic Use: Control vomiting and nausea(CINV) in chemo
Sides/Adverse Effects: Potential for dissociation, dysphoria
Contraindications/Precautions: avoid using in clients with mental health disorders
* See Below
*General information for this group:
*General Contraindications/Precautions- Use cautiously with children and older adults due
to EPS sides.
Interactions: CNS depressants such as opoid medications can intensity CNS depression of
antiemetics; antihypertensives concurrent use can intensify hypotensive effects of
antiemetics; anticholinergics like antihistamines concurrent use can intensify
anticholinergic effects of antiemetics.
Nursing Interventions: Antiemetics prevent or treat nausea and vomiting from various
causes match with cause. Using a combination allows for lower dosage and decrease the
risk of side effects i.e. EPS system.
Drugs for Adrenal insufficiency (Not in ATI-found in pharm)
Hydrocortisone (a glucocorticoid)
Prototype glucocorticoids
Key function replacement therapy used for acute adrenal
insufficiency/nonendocrine applications used to treat a broad spectrum of nonendocrine
disorders.
Adverse Effects When taken in large doses to treat nonendocrine disorders,
glucocorticoids are highly toxic. High dose therapy include adrenal suppression and
productive cushing syndrome.
Fludrocortisone (mineralocorticoid)
Prototype mineralocorticoid
Key function treats addison’s disease, primary hypoaldosteronism, and
congenital adrenal hyperplasia. (In most cases used with glucocorticoid)
Adverse Effects When dosage is too high, salt and water are retained in excess,
while excessive amounts of potassium are lost. Expansion of blood volume,
hypertension, edema, cardiac enlargement, hypokalemia.
Intervention monitor weight gain, elevation of b/p, and hypokalemia.
Women’s Health
Estrogen (ATI pg 488-490)
Prototype Conjugated equine estrogens (Premarin)
Estradiol (Estrace)
Action: estrogens are hormones needed for growth and maturation of the female
reproductive tract and secondary sex characteristics. Estrogens block bone resorption
and reduce low density lipoprotein levels. At high levels, estrogens suppress the release
of follicle stimulating hormone needed for conception.
Uses: contraception, relief of potmenopausal symptoms (hot flashes, mood
changes), prevention of postmenopausal osteoporosis, treatment of dysfunctional
uterine bleeding and endometriosis, treatment of prostate cancer.
Side Effects: Endometrail and ovarian cancers occur when prolonged estrogen is
the only potmenopausal therapy, potential risk for estrogen-dependent breast cancer,
embolic events, impotence, and decrease libido in males
Nursing interventions: Give the client progestins alson with estrogen, instruct
the client to report persistent vaginal bleeding, encourage regular self-breast exams and
mammograms, discourage smoking, monitor pain, swelling, warmth of legs for emboli
(make sure pt takes the med at the same time each day)
Interaction: estrogens can decrease the effectiveness of warfarin. (monitor INR)
Use of phenytoin with estrogen can increase the risk of toxicity (monitor signs of
toxicity)
Contraceptive Agents (ATI pg 493-494)
Combination Oral Contraceptives
Ethinyl Estradiol/norethindrone
Progestin-Only Oral Contraceptives
Norethindrone
Long-Acting Contraceptives
Subdermal progestin implant (Norplant)
Depot medroxyprogesterone acetate
Drugs for Emergency Contraception
Leveonorgestrel alone
Ethinyl estradiol/levonorgestrel (the Yuzpe Regimen)
PROTOTYPE: OVCON 35 (Necon 1/35, ortho-novum)
Action: Oral contraceptives decrease fertility by inhibiting ovulation, thickening
cervical mucus, and making the lining of the endometrium less favorable for
implantation.
Uses: Oral contraceptives are used to prevent pregnancy.
Side Effects: Thromboembolic events, hypertension, breakthrough or abnormal
uterine bleeding, cervical cancer
Nursing Interventions: Discourage smoking, report warmth, edema, etc, may be
emboli, monitor b/p, evaluate pt for possibility of pregnancy if two or more periods
missed, routine pap smear.
Interactions: Carbamazephine, Phenobarbital, phenytoin, rifampin, tetracyclines,
and ampicillin-oral contraceptive effectiveness decreases with concurrent use of these
medications (Use additional contraceptive measures). Warfarin and oral
hypoglycemics-oral contraceptives decrease the effects of these meds(check INR)
Drugs for infertility(NOT FOUND IN ATI)
Drugs for controlled ovarian stimulation
Clomiphene
Menotropins
Human chorionic gonadotropin
Drugs for hyperporlactinemia
Cabergoline (dopamine agonist)
Uterine Stimulatns and Relaxants
Uterine Stimulatns (Oxytocics) (ATI pg 481-483)
Prototype Oxytocin (Pitocin, Syntocinon)
Other med (Methylergonovine (Methergine)
Action: Uterine stimulants increases the strength, frequency, and length of
uterine contractions.
Uses: Induction of labor, enhancement of labor, delivery of afterbirth, to control
postpartum bleeding, fetal stress testing, intranasal promotion of milk let down.
Side Effects: Uterine rupture, hypertensive
Nursing intervention: Monitor the length, strength, and duration of contractions,
have magnesium sulfate on standby to relax the myometrium, monitor the pt for
symptoms of hypertension (headache, nausea, vomiting)
Interactions: vasopressors-can lead to hypertension (avoid use of oxytocin and
vasopressors, monitor b/p)
Uterine Relaxants (Tocolytics)
Prototype terbutaline sulfate (brethine)
Magnesium sulfate
Action: Terbutaline selectively activates beta2 adrenergic receptors, resulting in
uterine smooth muscle relaxation.
Uses: IV or SC terbutaline can be used for up to 48 hr to delay preterm labor.
Side Effects: tachycardia, palpitations, chest pain, tremors, anxiety, headache.
Nursing Interventions: Monitor the pt for these beta1 side effects, intervene
based on tolerance and physiological impact, monitor the pt for beta2 skeletal muscle
stimulant side effects.
CAUTION: Lactation enters breast milk
Interactions: adrenergic agonists-concurrent use can cause additive effects,
MAOIs-concurrent use can lead to hypertension, Beta blockers-concurrent use can blunt
effect (monitor for tachycardia, tremors, b/p)
***Terbutaline should be administered IV or SC due to high first pass effect
with oral administration.
MEN’S HEALTH
Androgens
Prototype Testosterone enanthate (Delatestryl)
Action: Androgens are a hormone needed for growth and maturation of male sex
organs and secondary sex characteristics. This hormone promotes skeletal muscle
growth in sexually mature males.
Uses: Androgens are used for treatment of hypogonadism in androgen deficient
men, treat delayed puberty, treat androgen-responsive breast cancer.
Side Effects: Hepatotoxicity, Cardiovascular risk high LDL, lower HDL, edema,
virilism effects, males- acne, facial hair, gynecomastia, impotence, priapism, femalesdeeper voice, unusual hair growth, clitoral enlargement, menstrual irreg, acne.
Hyercalcemia
Nursing interventions: Liver function test, check cholesterol levels, edema, low
sodium diet, hypercalcemia
Interactions: Warfarin, oral hypoglycemic, and glucocorticoids-androgen effects
on metabolism can increase med levels of these meds. Heaptotoxic drugs can increase
the risk of liver damage. (monitor INR, signs of bleeding, infection, liver function)
***Instruct pt to report weight fain of more than 2 pounds in a week.
Drugs for Erectile Dysfunction
Prototype sildenafil (Viagra)
Action: augments the effects of nitric oxide released during sexual stimulation
resulting in enhanced blood flow to corpus cavernosum and penile erection.
Uses: treat erectile dysfunction
Side effects: MI, sudden death, priapism
Nursing Interventions: Monitor pt risk factors and history with regard to
cardiovascular health, notify dr if erection lasts more than 4 hr.
**Do not take with Nitroglycerine
Interaction: Organic nitrates (nitroglycerin)-can lead to fatal hypotension,
Ketoconazole, erythromycin, grapefruit juice-inhibit metabolism of sildenafil thereby
increases plasma level of med
**Instruct pt to take 1 hr before sexual activity and limit use to once a day
Drugs for Benign Prostatic Hyperplasia (NOT IN ATI)
Drugs for IBS
Alosetron (Lotronex)
Only approved for treating women with severe, diarrhea-predominant IBS that has lasted for 6 or
more months. Causes selective blockade of type 3 serotonin receptors, which are found
primarily on neurons that innervate the viscera. It decreases abdominal pain, increases
colonic transit time, reduces intestinal secretions, and increases absorption of H2O and Na.
Side Effects—Most common complication is constipation, which can be complicated by
impaction, bowel obstruction, and perforation. Can also cause ischemic colitis (intestinal
damage secondary to reduced blood flow).
Drug Interactions—No known adverse interactions with other drugs.
Drugs for Bacterial Infections
Penicillin G (Bicillin LA)
Destroys bacteria by weakening the bacterial cell wall. Med of choice for gram-positive cocci, such
as streptococcus pneumonia, meningitis.
Side Effects—Allergies/anaphylaxis, renal impairment, hyperkalemia/dysrhythmias with high
doses of penicillin G.
Interventions—interview client for prior allergy, observe client for 30 min following
administration of parenteral penicillin. Monitor client’s kidney function and I&O. Monitor
client’s cardiac status and electrolyte levels.
Drug Interactions—
Aminoglycosides—penicillin inactivates aminoglcyosides when missed in the same IV solution. Oral
contraceptives
Apicillin—decreases oral contraceptive efficacy.
Cephalosporins (use cautiously in pts with renal impairment)
Cephalothin—Not in ATI,Pharm,Mosby’s drug book.
Cephalosporins are similar to penicillins, they destroy the bacterial cell wall.
Side Effects—allergic/hypersensitivity/anaphylaxis. Bleeding tendencies, Thrombophlebitis,
Cross allergy to penicillin.
Interventions—If signs of allergy appear, stop immediately, observe for signs of bleeding, if
bleeding administer parenteral vitamin K and stop cephalosporin, to avoid thrombophlebitis
rotate injection sites and administer slowly over 3-5min. Also assess patient for allergy to
penicillin.
Drug Interactions—
Disulfiram reaction (intolerance to alcohol) occurs with combined use of some cephalosporins with
alcohol, but not cephalotin.
Probenecid delays renal excretion
Other
Imipenem (Primaxin) (use cautiously in pts with renal impairment)
Destroys bacterial cell walls causing destruction of micro-organisms.
Primarily used with other antibiotics for broad spectrum with serious infections.
Side Effects—Allergy/hypersensitivity, GI symptoms(nausea,vomiting,diarrhea), Suprainfection
Interventions—Monitor the patient for signs of allergic reactions. Observe client for any GI signs,
notify primary caretaker, and watch I&O. For suprainfection, monitor patient for signs of
colitis (e.g., diarrhea, oral thrush, vaginal yeast infection) and intervene accordingly.
Drug Interactions—None listed.
Vancomycin (Vancocin) (use cautiously in pts with renal impairment)
Destroys bacterial cell walls.
Primarily used for serious infections caused by MRSA. Also used in antibiotic-associated
pseudomembranous colitis.
Side Effects—Ototoxicity, Infusion reaction (e.g., rashes, flushing, tachycardia, hypotension), and
Thrombophlebitis.
Interventions—Assess client for signs of hearing loss, obtain a baseline hearing test prior to
administration, tell pt. to inform care provider if hearing loss occurs. To avoid infusion
reactions, infuse vancomycin slowly over 60 min. To avoid thrombophlebitis, rotate injection
sites and monitor infusion site for redness, swelling, and inflammation.
Drug Interactions—None listed.
Bacteriostatic Inhibitors of Protein Synthesis
Tetracyclines
Tetracycline Hydrochloride (Sumycin)
Broad-spectrum antibiotics that inhibit micro-organism growth by preventing protein synthesis
(bacteriostatic).
Medication of choice topically and orally for acne vulgaris.
Side Effects—GI discomfort (cramping, nausea, vomiting, diarrhea, esophageal ulceration),
Yellow/brown tooth discoloration and/or hypoplasia of teeth enamel can occur,
Hepatotoxicity, Photosensitivity, Suprainfection of the bowel. Should be avoided by pregnant
women.
Interventions—Monitor client for signs of GI upset. To avoid tooth discoloration and enamel
problems, avoid giving to children under 8 years of age. To avoid hepatotoxicity, avoid giving
high doses via IV. For photosensitivity, avoid long exposure to sun. For suprainfection,
monitor GI system.
Drug Interactions—
Milk products, calcium supplements, iron supplements, magnesium-containing
laxatives, and most antacids. Tetracyclines should be taken on an empty stomach with
water. Give 1 hour before and 2 hours after meals and/or supplements containing
calcium/magnesium.
Oral contraceptives. Instruct the pt to report signs of reduced levels, such as breakthrough
bleeding. Dose of oral contraceptive may need to be increased.
Macrolides
Erythromycin (E-Mycin)
Slows the growth of micro-organisms by inhibiting protein synthesis.
Used primarily to treat infections in patients with a penicillin allergy.
Side Effects—GI discomfort (nausea, vomiting, epigastric pain), Thrombophlebitis.
Interventions—To avoid GI discomfort, administer with meals. To avoid thrombophlebitis,
administer slowly and in a dilute solution
Drug Interactions—
Antihistamines, theophylline (asthma med), carbamazepine (anticonvulsant), and
warfarin—concurrent use with these meds could result in toxicity so avoid use
of these with erythromycin.
Oxazolidinomes
Linezolid (Zyvox)
Works well against MRSA and vancomycin-resistant enterococci (VRE). Inhibits bacterial protein
synthesis
Side Effects—Generally well tolerated. Most common side effects are diarrhea, nausea, and
headache. Can cause myelosuppression, manifesting as anemia, leucopenia,
thrombocytopenia, or pancytopenia.
Interventions—Monitor for GI upset signs, and if pt. is receiving Linezolid for more than 2 weeks,
CBC should be done weekly.
Drug Interactions—
Linezolid is a weak inhibitor of monoamine oxidase (MAO), and hence poses a risk for hypertensive
crisis. Can also cause hypertensive crisis in conjunction with foods high in tyramine.
Glycylcylines
Tigecycline (Tygacil)
A tetracycline derivative designed to overcome resistant bacteria. Active against a broad spectrum
of bacteria, including many resistant strains.
Side Effects—Because it is a tetracycline derivative, side effects are very similar to those of
tetracyclines. Most common side effects were nausea and vomiting. Should be avoided by
pregnant women.
Interventions-- Monitor client for signs of GI upset. To avoid tooth discoloration and enamel
problems, avoid giving to children under 8 years of age. To avoid hepatotoxicity, avoid giving
high doses via IV. For photosensitivity, avoid long exposure to sun. For suprainfection,
monitor GI system.
Drug Interactions—Minimal interactions, can delay the clearance of warfarin so coagulation
should be monitored.
Others
Clyndamycin (Cleocin)
Inhibits bacterial protein synthesis. Effective against most anaerobic bacteria and most grampositive aerobes.
Side Effects—Antibiotic-associated pseudomembranous colitis (AAPMC). This is the most severe
toxicity. The cause is suprainfection of the bowel with C.difficile. AAPMC is characterized by
profuse, watery diarrhea (10-20 stools /day), abdominal pain, fever, and leukocytosis. Stools
often contain mucous or blood.
Interventions—Watch for signs of AAPMC, or other GI problems. If AAPMC is present, vigorous
replacement therapy with fluids and electrolytes is usually indicated. Drugs that decrease
bowel motility should NOT be used because they may worsen the symptoms.
Drug Interactions—The site at which clyndamycin binds overlaps the binding sites for
erythromycin and chloramphenicol. As a result, concurrent use of these with clyndamycin is not
suggested.
Drugs for Bacterial Infections
Class: Aminoglycosides (Bactericidal Inhibitors of Protein Synthesis)
Pro Drug- Gentamicin
Uses: Medication of choice for aerobic gram negative bacilli ( escherichia coli, pneumoniae, etc)
Side Effects: Ototoxicity (discontinue if this occurs), Nephrotoxicity (Monitor BUN, Creatinine and
I&O.
Do not mix Aminoglycosides with penicillins in the same IV solution.
Class: Fluoroquinolones
Pro Drug- Ciprofloxacin
Uses: A broad spectrum antimicrobial, can be used on gram positive or negative bacteria. Medication
of choice for clients who have inhaled anthrax.
Side Effects: GI discomfort, Achilles tendon rupture ( observe for swelling, redness or pain and to
report to primary care provider and stop med).
Do not give to children < 18, Warfarin levels can be increased with Ciprofloxacin, Do not use dairy
products, antacids or salts until 1 hr before or 2 hrs after med is administeed.
Class: Cyclic Lipopeptides
Pro Drug- Daptomycin
Uses: Can kill all gram positive bacterias.
No need to monitor plasma level, Only side effect may be muscle injury due to IV. Does not have any
significant interactions. Can be used for MRSA
Class: Sulfonamides and Trimethoprim
Pro Drug- Trimethoprim/Sulfamethoxazole (Bactrim)
Drug- Sulfisoxazole
Drug- Trimethoprim
Uses: inhibit bacterial growth by preventing synthesis of folic acid, med of choice for UTI’s.
Side Effects: Do not administer to patients allergic to sulfa, thiazide diuretics, loop diuretics. Can cause
crystalluria so increase fluid intake, photosensitivity, if sore throat or pallor notify provider.
Drugs for TB
Pro Drug- Isoniazid (INH)
Drug- Rifampin
Drug- Pyrazinamide
Drug- Ethambutol
Uses: Inhibits growth of mycobacteria, indicated for latent TB. INH daily for 6 months.
Side Effects: Peripheral neuropathy (give 50-200mg of vitamin B6 daily), Hepatotoxcity
Interacts with Phenytoin and levels may need to be adjusted, Avoid alcohol. Take on an empty
stomach.
Drugs for Funal Infections
Pro Drug- Polyene Macrolides (Amphotericin B)
Drug- Azoles (Itraconazole)
Drug- Echinocandins (Caspofungin)
Uses: Used for systemic fungal infections, Azoles are used for superficial fungal infections.
Side Effects: Infusion reactions (pretreat with diphenhydramine), Nephrotoxicty (monitor I&O, BUN),
Hypokalemia
Give 1 Liter of saline on day of amphotericin infusion. Contraindicated in renal failure patients. Avoid
use with antimicrobials such as aminoglycosides.
Viral Infections
Drugs for Cytomegalovirus Infection
Action: prevents the reproduction of viral DNA
Uses:
- medication of choice for herpes simplex virus, varicella zoster virus, and
cytomegalovirus
- Ganciclovir is treatment choice for CMV retinitis in immunocompromised pts with
HIV, and transplant pts at risk for CMV infection
Pro drug: acyclovir (Zovirax)
SE:
- phlebitis and inflammation at site of injection
- Nephrotoxicity
- mild discomfort
Contraindications:
- should be used cautiously in pts with renal impairment, dehydration, and pts taking
nephrotoxic meds
Interventions:
- administer slowly over 1 hr
- ensure adequate hydration during infusion and 2 hr after to minimize nephrotoxicity
Other: Ganciclovir (Cytovene), ribavirin (Rebetol)
SE:
- granulocytopenia and thrombocytopenia
- reproductive toxicity
Contraindications:
- pregnancy
- pts with neutrophils count <500/mm3
Interventions:
- obtain baseline CBC and platelet count and monitor
- if neutrophils count is <500/mm3, stop treatment, cell counts improve within 3-5
days
- advise women to avoid pregnancy during coarse of therapy and for 90 days after end
of therapy
- inform men of risk for sterility
Education:
- use rubber gloves for topical administration to avoid transfer of virus to other parts of
body
- acyclovir diminishes symptoms but does not cure virus
- refrain from sexual activity when lesions are present
- pts with healed lesions should continue to use protection during sexual activity to
prevent transmission of virus
Childhood Immunizations
Hepatitis B: doses given at birth, 1-2 mo, and 6-18 mo
~ SE: local reaction (anorexia, soreness, fatigue), anaphylaxis
~ Contraindicated in pts with a prior history of anaphylactic reaction and/or and allergy to
Baker’s yeast
Diptheria and tetanus toxoids and pertussis vaccine (DTaP): doses at 2, 4, 6, 15-18mo, and at 4-6
years
~ SE: encephalopathy (fever, irritability, persistent crying that can’t be consoled),
seizures, and/or local reaction at site of injection
~ Contraindicated in children with: severe febrile illness, history of prior anaphylactic
reaction to DTaP, occurrence of encephalopathy 7 days after administration of
DTaP immunization
Tetanus and diphtheria toxoids and pertussis vaccine (Tdap): 11-12 years
Tetanus and diphtheria (Td) booster: every 10 years following DTaP
Haemphilus influenza Type B (Hib): doses at 2, 4, 6, and 12-15 mo
Inactivated poliovirus vaccine (IPV): doses at 2, 4, 6-18mo, and 4-6 years
~ SE: vaccine associated paralytic poliomyelitis and/or local reaction
Measles, Mumps, Rubella vaccine (MMR): doses at 12-15 mo and at 4-6 years
~SE: local reactions (fever, rash, swollen glands), anaphylaxis
~ Contraindicated in:
- pregnant women and children who are allergic to eggs, gelatin, and neomycin
- history of thrombocytopenia
- immunocompromised children
- pts with advanced HIV
- pts who just received blood products or immunoglobulins
Varicella vaccine: single dose at 12-18 mo or 2 doses administered 4 wks apart after age 13
~ SE: varicella like rash
~ Contraindicated for:
- women who are pregnant
- clients with cancer
- pts with history of allergy to neomycin and/or gelatin
- immunocompromised pts
- children with congenital immunodeficiency
- pts taking immunosuppressive meds
Pneumococcal conjugate vaccine (PCV): doses at 2, 4, 6, and 12-15 mo
~SE: mild local reaction, fever
Hepatitis A: 2 doses 6 mo apart after 12 mo
Influenza vaccine: annually beginning at 6 mo (Oct thru Nov is ideal time)
~ SE: Guillain-Barre syndrome, local reaction, fever
~ Contraindicated in pts with:
- acute febrile illness
- hypersensitivity to eggs
Meningococcal vaccine (MCV4): dose at age 11-12
~ SE: mild local reaction
Uses: prevention of childhood of infectious diseases and their complications
Action: Immunizations produce antibodies that provide active immunity. May take
months to have an effect but confer long-lasting protection against infectious
diseases.
Nursing interventions:
~ in infants and young children, IM vaccinations are given in the vastus lateralis
muscle
~ for older children, adolescents, and adults, vaccinations are given in the deltoid
muscle
~ avoid administering aspirin to children to treat fever following immunization
due to the risk of the development of Reye syndrome
Adult Immunizations
Influenza Vaccine: given one dose annually after age 50 (earlier if specific risk factors such as
chronic disease)
Pneumococcal polysaccharide vaccine (PPV): one dose at age 65, and revaccinated every 6-8 years
after initial vaccination
Meningococcal vaccine: students entering college and living in college dormitories if not
previously immunized
Tetanus diphtheria (Td) booster: every 10 years
Action: Prevent infectious diseases through the production of antibodies that provide
active immunity
Uses: prevention of infectious diseases and their complications
Side effects: local reaction (redness, swelling, pain) at injection site, low grade fever,
risk of systemic allergic reaction (urticaria, anaphylaxis), small risk of GuillainBarre syndrome
Contraindications/precautions:
~ acute febrile illness- don’t give until symptoms resolve
~ hypersensitivity to eggs
Nursing Interventions:
~ administer IM deep in the deltoid muscle
~ have emergency meds and equipment on standby in case of the occurrence of an
allergic reaction
Anticancer Drugs
Alkylating Agents
- Nitrogen mustards: cyclophosphamide (Cytoxan, Neosar)
Platinum compounds:
- cisplatin (Platinol AQ)
Antimetabolites
- Folic acid analog: methotrexate (Rheumatrex, Trexall)
- Pyrimidine analog: cytarabine (Cytosar-U)
- Purine analogs: mercaptopurine (Purinethol)
Antitumor Antibiotics:
- doxorubicin (Adriamycin, Rubex)
Mitotic Inhibitors:
- vincristine (Oncovin)
- paclitaxel (Taxol, Onxol)
Topoisoomerase Inhibitors:
- topotecan (Hycamtin)
- irinotecan (Camptosar)
Cytotoxic Medications:
- asparaginase (Elspar)
- hydroxyurea (Hydrea)
- procarbazine (Matulane)
Breast Cancer: antiestrogen:
- tamoxifen (Nolvadex)
Prostate Cancer:
- leuprolide (Lupron)
Progestins:
- megestrol acetate (Megace)
Action: Destroy cancer cells, as well as healthy cells, by preventing the replication of DNA
Uses: Used in the treatment of a variety of cancers
Side Effects:
- Bone marrow suppression
~ monitor CBC
~ assess for bruising and bleeding gums
~ instruct pt to avoid crowds and contact with infectious individuals
- GI discomfort
- Alopecia
~ advise that hair loss will occur 7-10 days after beginning of treatment and will
last for a maximum of 2 mo after last administration of chemo agent
- Muscositis (GI tract)
~ assess for mouth sores
- Reproductive toxicity such as congenital abnormalities, amenorrhea, menopausal
symptoms and atrophy of vaginal epithelium, and sterility in males
~ advise females against becoming pregnant while taking meds
~ advise male clients to consider sperm banking prior to treatment
- Hyperuricemia
~ monitor kidney function, BUN, and creatinine
~ increase fluid intake and monitor I&O
~ administer allopurinol if uric acid level is elevated
Nursing interventions:
- dosage of agents should be individualized