Exam 3 Drugs Flashcards
Diuretic Side Effects
Prevent renal reabsorption of fluid –> diuresis & natriuresis –> decreased IV volume
“diuretic contraction”: increased concentration of blood content that are not excreted in urine
-Blood cells, glucose, uric acids, lipids
Electrolyte imbalance
- Low K, Mg, Na, Bicarb
- High Ca, BG, uric acid, LDL
Decreased BP –> orthostatic hypotension, dizziness, syncope, fall
- Poor renal perfusion –> AKI
- Tachycardia (reflex tachycardia)
- Hypovolemia: Assess daily weight & Assess edema (0-4+)
Diuretics Nursing
Assess ability to use the urinal/BSC in 30 minutes after taking
Adherence
-Build rapport to understand the root cause of non-adherence
Avoid taking potassium supplement while skipping the diuretic dose
-Hyperkalemia & fluid overload
Take diuretics earlier in the day rather than close to bedtime
Keep a long of BP & daily weight
Thiazide and Thiazide-Like
Thiazide
- Chlorothiazide (PO, IV)
- Hydrochlorothiazide= HCTZ (PO)
Thiazide-Like
-Metolazone: Give it an hour before Loop
-Oldest and cheapest; many brands
Category Class: Diuretic
Indication: Hypertension
Contraindication:
- Hypovolemia
- Pregnancy
- Lactation
- Anuria (oliguria)
Loop Diuretics
Furosemide, bumetanide
Strongest diuretics (high ceiling)
Renal Vasodilator
- All diuretics cause AKI due to loss of blood volume/lower BP (lower renal perfusion)
- All diuretics should be avoided in AKI, but if we must use diuretics, Loop diuretics are the safest
- The only diuretic that may be used in CKD
Category Class: Diuretic
Indication: Hypertension
Contraindication:
- Hypovolemia
- Pregnancy
- Lactation
- Anuria (oliguria)
Medication Administration: IV, PO, IM
Nursing Interventions:
-Dilute & very slowly IVP to avoid tinnitus (ototoxicity)
K-Sparing Diuretics
Spironolactone (PO)
Weakest diuretics
Category Class: Diuretic, Aldosterone Receptor Blocker
MOA:
-blocks the action of aldosterone –> K retention, water, Na, bicarb excretion
Indication:
-Hypertension
Secondary Indication:
- With other diuretics to balance potassium
- Treatment of post-adolescent acne (MOA: anti-adrogenic effect)
Contraindication:
- Hypovolemia
- Pregnancy
- Lactation
- Anuria (oliguria)
Adverse effects: Anti-androgenic effect
- Male: impotence, gynecomastia
- Female: deepened voice, irregular menstrual cycles
Monitor increased K
- Place on heart monitor (dysrhythmia)
- Bradycardia/cardiac arrest, peaked T (cardiac monitor)
Monitor for paresthesia, abd/muscle cramps, weakness, fatigue
Diet: Avoid high potassium foods
-Oranges, grapefruit, potatoes, bananas, dried fruits
Interactions:
-Avoid with ACEi and ARB
-lol
Medication: Propranolol, Metoprolol, Atenolol, Carvedilol, Labetalol
Category Class: Beta-blocker (sleepy chicken)
MOA:
- Decreased HR (negative chronotrope)
- Decreased excitability (negative dromotrope)
- Decrease BP
Indication:
- Angina/MI, dysrhythmia, HTN, HF
- Off label: Glaucoma, migraine
Contraindication:
- Bradycardia, hypotension
- Call provider & hold for HR <60 or SBP <90
- Asthma, COPD
Side effects, Adverse reactions:
Even selective beta-blockers may become nonselective at high dose (blocking beta 2 & bronchospasm)
-Monitor breath sounds (for worsening or new wheezing)
Bradycardia, hypotension, dysrhythmia (FALL)
- Monitor trend of HR, BP, cardiac rhythm
- Postural hypotension and FALL (lie down if feeling dizzy, avoid sudden changes of position)
Impotence, decreased libido (build rapport and discuss factors that may affect adherence)
Medication Administration: IV, PO
Nursing Interventions (monitoring): -Masks hypoglycemia symptoms (palpitation)- monitor DM patients BG for asymptomatic hypoglycemia
Patient Education:
- Avoid stopping abruptly, wean off over 1-2 weeks
- At home keep a log HR/BP and associated s/s
Methyldopa & Clonidine
Category Class: Alpha-2 Agonist (sleepy chicken)
MOA: Decrease sympathetic stimulation:
-Decrease HR & CO, vasodilated (decrease peripheral resistance)
Indication:
-Hypertension
Off label Indication:
- Clonidine: CA pain, ADHD, opioid withdrawal, migraine, menopause flushing
- Eye drops for glaucoma: brimonidine, apraclonidine
Contraindication:
- Pregnancy
- Lactation
Side effects, Adverse reactions:
- Na/water retention (use with diuretics & monitor daily weight & edema)
- Bradycardia
- Orthostatic hypotension, dizziness, FALL
- Impotence, decreased libido
Hydralazine
Medication Administration: IV, PO
MOA: Direct-acting vasodilator
Indication:
- Quick management of acute HTN
- Preeclampsia
Contraindication:
- RF
- Concurrently with sildenafil
Side effects, Adverse reactions:
- Less blood pressure in kidney –> fluid/Na retention (combine with diuretics)
- Increased permeability with arteriodilation (edema, nasal congestion, HA) combine with diuretics
- Orthostatic hypotension (fall)
- Tachycardia (reflex), patient reports palpitation
Alpha 1 Blockers
Medication:
- For HTN & BPH: Prazosin, terazosin, doxazosin
- For BPH only: Tamsulosin, silodosin
MOA: vasodilation (decrease peripheral resistance), relaxing prostate
Indication: Hypertension
Side effects, Adverse reactions:
- Orthostatic hypotension (Fall risk)
- Na/water retention (use with diuretics & monitor daily weight & edema)
- Tachycardia (reflex)
- Erectile dysfunction
ACE Inhibitors (-pril)
Medication: benzepril, captopril, lisinopril, enalapril, enalaprilat
MOA: angiotensin-converting enzyme inhibitor
- Prevent angiotensin II formation –> decrease peripheral resistance & afterload
- AKI & hyperkalemia
Indication:
- Hypertension
- HF
Contraindication:
-PAAK: pregnancy, allergy, AKI (helpful for CKD), K increase
Side effects, Adverse reactions:
- Increases bradykinin (inflammatory mediator) –> dry hacking cough, angioedema
- AKI, hyperkalemia (monitor K, dysrhythmia, paresthesia, weakness, cramps)
- Orthostatic hypotension, tachycardia (reflex), dizziness, fall (change position slowly, lie down if dizzy
Angiotensin Receptor Blocker (ARBs)
Medication: losartan, valsartan, telmisartan
MOA: Block the receptor site of angiotensin II
- Very similar to ACEi but not as effective
- Prevents vasoconstriction –> low BP
- AKI & hyperkalemia
- Tachycardia (reflex)
Indication:
- Hypertension
- HF
Contraindication:
-PAAK: pregnancy, allergy, AKI (helpful for CKD), K increase
Side effects, Adverse reactions:
- AKI, hyperkalemia (monitor K, dysrhythmia, paresthesia, weakness, cramps)
- Orthostatic hypotension, tachycardia (reflex), dizziness, fall (change position slowly, lie down if dizzy)
Amlodipine & Nifedipine
IV, PO
MOA: CCB
- Specific vasculature
- Systemic vasodilation –> decreased BP (Call the provider & hold for SBP < 90)
Indication:
- Hypertension
- Angina
Side effects, Adverse reactions:
- Peripheral edema (daily weight, I/O)
- Low BP –> tachycardia (reflex)
- Low BP –> fall
- Low BP –> monitor renal panel for AKI
Midodrine
MOA: alpha-1 agonist –> vasoconstriction
Contraindication: AKI
For people at risk of hypervolemia or on hemodialysis
Side effects, Adverse reactions:
- Urinary retention (BPH)
- Supine HTN (HTN associated with lying supine, check BP & administer while patient in supine position)
Medication Administration: PO, IV
Symptomatic Hypotension
Usually treated with:
- Crystalloid (NS)
- Colloid volume expander (albumin) if edematous
During hypovolemic shock (medical emergency)
- vasopressin (Pitressin)=ADH
- dobutamine (Dobutrex) (beta-1 agonist)
- emergency drugs, used for shock and cardiopulmonary resuscitation (discussed in Endocrine)
Digoxin
IV/PO
MOA:
- Positive inotrope (increased force & CO) better perfusion
- Negative chronotrope (decreased HR) lower workload
- Negative dromotrope (decreased conduction) less excitability
Indication:
- HF
- Dysrhythmia
Toxicity
- Monitor for bradycardia & hold for HR <60
- Yellow halos around objects, blurred, diplopia, dysrhythmias
- Narrow therapeutic window
Nursing Interventions:
- Monitor K level, hypokalemia –> dig toxicity
- K-wasting diuretics –> decrease K –> dig toxicity
- K-sparing diuretics, ACE, ARB –> increased K –> decreased effect of digoxin
Patient Education:
-checking HR, toxicity s/s, avoid sildenafil
Milrinone
IV gtt
MOA:
- Positive inotrope (inc force –> inc CO)
- Arteriodilator –> dec BP –> dec cardiac workload
Indication:
- For 48-72 hr. to manage acute exacerbation of HF
- End-stage HF unresponsive to other medications
Side effects:
- Dysrhythmias
- Low BP
Dopamine
MOA:
-Nonspecific adrenergic: inc HR, vasoconstriction
Indication:
-HF, hypotension, shock
IV gtt. Via pump in designated central IV line (extravasation)
Many SE:
- tachydysrhythmia
- MI
- N/V
- AKI
Nursing Interventions:
- Needs titration
- Hemodynamic monitoring (MAP, PP) & cardiac rhythm monitoring
- Tapering dose before stopping
Dobutamine
MOA:
-Beta1 agonist –> pos inotrope (inc force), pos chronotrope (inc HR)
Indication:
-HF, hypotension, shock
Adverse reactions:
- MI
- Tachydysrhythmias
- Tremors
IV gtt. Vis pump in designated peripheral IV
Nursing Interventions:
- Tapering dose before stopping
- Needs titrations
- Hemodynamic monitoring (MAP, PP) & cardiac rhythm monitoring
Epinephrine
Category Class: Nonselective adrenergic agonist- A1, B1, B2
MOA: increases BP & HR, opens airway
Indication:
- IM/SubQ: allergic reaction (anaphylaxis)
- IV: cardiac arrest, severe hypotension (shock)
- Aerosol: airway obstruction (bronchospasm)
Adverse reactions
- High risk for extravasation
- Antidote: phentolamine mesylate
Side effects
- Hypertension: pulmonary edema, dyspnea
- Tachycardia: dysrhythmias/palpitations
- Worsening prostate disease (BPH): urinary retention
- If it crosses BBB (large dose): tremors, restlessness, dizziness, fall
- Mydriasis: worsening glaucoma, photophobia
- Hypercoagulability: DVT, PE, CVA, MI
- Lower GI motility/secretions: poor absorption, N/V, constipation, xerostomia (dry mouth), hypoactive bowel sounds
- Blood shunting: acute kidney injury, ischemic bowel, cold skin
- Glycogenolysis: hyperglycemia particularly in DM
Atropine
Category Class: anticholinergic
Indication:
- IV: symptomatic bradycardia
- PO drop: to reduce saliva (pre-op, palliative)
- Ophthalmic drop: to produce mydriasis & cycloplegia (pre-op)
- IM: reversal for cholinergic OD (OD with MG drugs)
Contraindication:
- Glaucoma
- BPH
- MG
Side effects, Adverse reactions:
- Tachycardia
- Palpitations
- Nasal congestion
- Photophobia
- Blurred vision
- Dry mouth and skin
- Constipation
- Urinary retention
- Impotence
- Memory impairment
- Coma
Nitrates
MOA:
- coronary artery dilation: inc O2
- systemic vasodilation: dec BP —> dec workload of heart —> dec O2 demand
Contraindication:
- Glaucoma
- Traumatic brain injury
Side effects, Adverse reactions:
-Monitor for low BP, dizziness, faintness, HA, tachycardia, FALL
Nursing Interventions):
-Cardiac monitoring & VS (obtaining ECG and labs should not delay NTG administration)
Patient Education: When having angina
- Stop activity, lie down, rest
- Take NTG SL or translingual spray, chew an aspirin (at home patients don’t have morphine & O2)
- Call 911 if pain is not resolved with the first NTG and 5 min of rest and take the second SL
- Avoid taking > 3 SL NTG
Nitroglycerin
SL tab/translingual spray – 0.4 mg q5min
Monitor BP/HR before & q5min with SL dose
SL tablets must be kept in their own dark glass container
-Up to 6 months after opening or until expiration date if not opened
Spray lasts up to 2 years
Take SL dose prophylactically before strenuous activity (climbing a flight of stairs)
Causes severe throbbing HA
Isosorbide Mononitrate, Isosorbide Dinitrate
- PO
- Do not abruptly stop taking
- Keep a log of angina (frequency, intensity, duration, location, quality)
- Do not crush or chew
Nitropaste
- can cause tolerance => 8-12 hrs nitrate free periods per day, do not cut the patch
- Apply to hairless area of chest, back, abd
- Rotate side to avoid skin irritation; wipe off the old ointment when replacing
- Avoid touching the ointment
- FALL risk
IV Nitroglycerin
- Indication: acute severe angina, HF
- Continuous infusion (gtt.), special tubing from a glass vial
- FALL risk
Procainamide, Flecainide
Na channel blockers
Category Class: Class 1
Side effects:
-Dysrhythmia, bradycardia, hypotension, dizziness, syncope, fatigue, edema, impotence (Need to put patient on heart monitor)
- anticholinergic symptoms
- May cause Lupus symptoms (if joint pain contact provider)
- low blood cells (monitoring CBC)
- Dysrhythmia: (monitor cardiac rhythm, VS)
- paresthesia, seizure (precautions)
FALL risk
Medication Administration:
- Cardiac rhythm must always be monitored
- Anticoagulation is always part of plan of care
- Continuous IV infusion eventually switched to PO
- IV push always slow (2-3 minutes): Exception: adenosine with 1/2 life <10 sec, push very fast & flush quickly with NS
Patient Education:
- Keep a log of VS, side effects at home and report to cardiologist
- Encourage adherence
Interactions:
- Grapefruit juice
- Caffeine
- ETOH
- Tobacco
Amiodarone, Sotalol
K Channel Blockers
Category Class: Class III
Side effects, Adverse reactions:
-Dysrhythmia, bradycardia, hypotension, dizziness, syncope, fatigue, edema, impotence (need to put patient on a heart monitor)
FALL risk
Nursing Interventions (monitoring):
- monitor for HF, pulmonary edema (dyspnea, crackles breath sound, edema)
- monitor for brady-dysrhythmia (monitor cardiac rhythm, low HR, low BP)
- photophobia may progress to loss of vision
Medication Administration:
- Cardiac rhythm must always be monitored
- Anticoagulation is always part of plan of care
- Continuous IV infusion eventually switched to PO
- IV push always slow (2-3 minutes): Exception: adenosine with 1/2 life <10 sec, push very fast & flush quickly with NS
Patient Education:
- Keep a log of VS, side effects at home and report to cardiologist
- Encourage adherence
Interactions:
- Grapefruit juice
- Caffeine
- ETOH
- Tobacco
Diltiazem, Verapamil
Calcium Channel Blockers (CCBs)
Category Class:
- Nonspecific (vasculature & heart) no suffix
- Class IV
Indication: tachy-dysrhythmia
Side effects, Adverse reactions:
- Call the provider & hold for HR < 60 or SBP < 90
- Peripheral edema (daily weight, I/O)
- Dec BP –> FALL
- Dec BP –> monitor renal panel, I/O
- May cause ventricular dysrhythmia
Medication Administration:
-Cardiac rhythm must always be monitored
-Anticoagulation is always part of plan of care
-Continuous IV infusion eventually switched to PO
IV push always slow (2-3 minutes): Exception: adenosine with 1/2 life <10 sec, push very fast & flush quickly with NS
Patient Education:
- Keep a log of VS, side effects at home and report to cardiologist
- Encourage adherence
Interactions:
- Grapefruit juice
- Caffeine
- ETOH
- Tobacco
Heparin
IV/SubQ
-Measured in units
Category Class: Anticoagulant
MOA: Inhibits activation of vitamin K (factor X)
Indication:
-Prophylactic: patients at high risk for thromboembolism
-Therapeutic: prevents clot enlargement
while waiting for warfarin onset of action which is 3-5 days (therapeutic INR)
Adverse reactions:
-heparin-induced thrombocytopenia (HIT), bleeding with OD
Nursing Interventions :
- Onset of action: 20 minutes
- Duration of action 8 hrs
- Labs to monitor: aPTT, platelet count for thrombocytopenia (HIT)
- Antidote: FFP, protamine sulfate IV; or wait 6-8 hrs
Enoxaparin
Medication: Enoxaparin, Dalteparin, Fondaparinux
- Low-molecular-weight heparin (LMWHs)
- measured in mg
Category Class: Anticoagulant
Side effects:
-stinging for a few minutes after injection
SubQ
- avoid massaging the area
- prefilled syringes
Nursing Interventions:
- No lab to monitor
- Duration of action 12 hrs
- Antidote: FFP, protamine sulfate IV; or wait 12-24 hrs
Warfarin
Category Class: Anticoagulant
MOA:
-Inhibits activation of vitamin K (factor X)
Contraindication:
- Pregnancy (switch to heparin)
- Thrombocytopenia
- Chronic liver disease
- ETOH abuse
Side effects:
- Bleeding
- Antidote: phytonadione (Vitamin K) (PO, subQ, IM, IV), FFP transfusion
Nursing Interventions:
Frequent monitoring
-PT (normal 11-13.5 sec) (therapeutic 18-24 sec)
-INR (normal 0.8-1.1) (therapeutic 2-3)
-Takes 3-5 days for INR to reach therapeutic (bridging with heparin)
-Long ½ life => takes 5 days for INR to return to normal after discontinuing the drug
Patient Education:
- Consistent amount of green leafy vegetables in the diet
- frequent PT/INR monitoring; keep a diet/dose log
Interactions):
-avoid ETOH –> increase INR
Antiplatelet
PO: aspirin, clopidogrel
- takes the whole life of platelet to clear (7 days)
- CI: NEVER to children <19 years (risk of Reye’s syndrome) => NEVER while breastfeeding
IV: eptifibatide
-duration of action: antiplatelet effect lasts 4 hrs
MOA:
-prevents platelet aggregation
Indication:
-Prophylactic for patients at risk for thromboembolism
Contraindication:
- Pregnancy
- Hx. of bleeding disorder
- retinal/cerebral hemorrhage
- Thrombocytopenia
- PUD
- Aneurysm
- uncontrolled HTN
Adverse reactions:
-Hemorrhage: particularly GI bleed
Nursing Interventions:
- Take with food to minimize GI upset/ GIB
- for Hx. of GIB, PUD: Enteric-coated aspirin, don’t crush & Buffered aspirin (mixed with calcium carbonate)
- Reversal agent: platelet transfusion
Interactions):
- Avoid NSAIDs (increased risk of GI bleed)
- Avoid alcohol (increased risk of GI bleed)
Alteplase (tPA)
IV bolus followed by drip for 60 min, tapering dose
- Goal: resolution of symptoms (t1/2 :35 min), given in ICU, ED
- Avoid all AC & antiplatelet until thrombolytic effect is cleared (3hrs)
Category Class: Thrombolytics
MOA:
-dissolve the clots by fibrinolysis (naturally it takes 1-2 weeks)
Indication:
- within 4hrs of the onset of MI or ischemic CVA symptoms
- PE, DVT, restore patency of IV catheters
Contraindication:
- BP > 180/110
- hemorrhagic diseases (PUD), neoplasm, recent CNS trauma, aneurism
- recent CVA, AC use, thrombocytopenia, ASA, NSAIDs, pregnancy
Adverse reactions:
- bleeding, hemorrhagic CVA, spinal cord infarction
- N/V, fever, angioedema, anaphylactic shock, rhabdomyolysis, dysrhythmias, pulmonary edema
“Nadia & Vlad forgot about Anna’s rehearsal dinner present”
Nursing Interventions:
- Antidote: aminocaproic acid PO/IV, FFP, PRBC
- Monitor trend of VS and assessment (q 15 min)
- monitoring for: resolution of symptoms (CP, neurological deficit) & active bleeding, allergic reaction (hives, angioedema, & dyspnea, anaphylaxis)
- cardiac monitoring (risk of reperfusion dysrhythmia treated with beta-blockers)
- Avoid venipuncture/arterial sticks, injections (SubQ/IM) as possible: hold pressure for 30 min
Statins
Medication: Atorvastatin, Simvastatin, Rosuvastatin
PO
Indication: hyperlipidemia
MOA:
-inhibit cholesterol synthesis in the liver
Contraindication:
- Pregnancy
- Lactation
Adverse reactions:
- Liver failure: elevated LFT, check base line and q8wks
- Myopathy & cramps –> hold with muscle aches
- Rhabdomyolysis, check baseline CK & q8wks
Nursing Interventions:
- Abruptly stopping cause rebound effect and acute MI
- Grapefruit juice reduce statins level
- Take at night (cholesterol biosynthesis is higher at night)
- May cause cataract formation (annual eye exam)
Bile Acid Resins (sequestrants)
Medication: Cholestyramine, Colesevelam
Indication: hyperlipidemia
-Cholestyramine: antidiarrheal (adsorbent)
MOA:
- Bind bile acid and increase excretion of cholesterol & LDL
- Cholestyramine: coat the wall of GI tract, adsorb bacteria/toxins
Contraindication:
-abdominal pain = possible small bowel obstruction (SBO)
Antidiarrheal Contraindications:
- Using antidiarrheals > 2 days
- If fever with unknown etiology is present
- If the etiology of diarrhea is unknown
Side effects:
- constipation, SBO, flatulence, cramping –> Increase intake of high-fiber food, fluid, activity
- poor absorption of fat-soluble vitamins and many drugs –> Take 4 hours apart from other drugs & vitamins
Patient Education:
- Take 30 min before meal
- Take with at least 8 oz of water to avoid impaction of esophagus
Nicotinic Acid (B3)
Medication: Niacin
- Vitamin dose 25 mg/day (OTC)
- Anticholesterol dose 2500 mg/day (Rx)
PO
Indication: hyperlipidemia
MOA:
-inhibits breakdown of triglycerides to free fatty acids, synthesis of LDL and breakdown of HDL
Contraindication:
- Pregnancy
- Liver disease
- Gout
Side effects:
- flushing of face/neck, feeling warmth, paresthesia
- Hyperglycemia (caution with DM, monitor BG closely in DM patients)
Adverse reactions:
- Hepatotoxicity: LFT, avoid alcohol and acetaminophen
- Hyperuricemia => gout & RF (monitor renal panel, increase fluid, may need allopurinol)
Omega- 3 acid ethyl esterase
Medication:
- omega3 (Rx)
- fish oil (OTC)
MOA:
-Inhibits triglyceride production in the liver
Indication:
- preventive/treat hyperlipidemia
- Off label: HTN & rheumatoid arthritis (RA)
Side effects:
-GI distress (acidic), nausea, aftertaste, rash
Patient Education:
-Take with food
Bismuth Subsalicylate
OTC, liquid or chewable tablet
Category Class:
-Antiemetic, Antidiarrheal (Adsorbent)
MOA:
-Adsorbs bacteria/toxins that are causing nausea
Indication:
-Also used for diarrhea, indigestion
Contraindication:
- Contains salicylate: Not for <19 due to causing Reye’s syndrome & Avoid if allergic to ASA or NSAIDs
- Pregnancy (teratogenic)
Antidiarrheal Contraindications:
- Using antidiarrheals > 2 days
- If fever with unknown etiology is present
- If the etiology of diarrhea is unknown
Side effects:
- Slurred speech, hearing loss, vision problems
- AMS
- Muscle spasm
- Black discoloration of stools/tongue (harmless & temporary)
“stop having visions about my brother tom”
Interactions:
-decreased absorption of other drugs
Diphenhydramine
PO, IM, IV (OTC)
MOA:
-inhibit vestibular stimulation in the inner ear
(histamine)
Indication:
- Nausea, motion sickness
- Secondary: insomnia
Contraindication:
- Pregnancy
- Lactation
- Newborn
- Children
- Older adults
- Anticholinergic effects: retention, glaucoma, HTN, BPH, tachycardia
Side effects, Adverse reactions:
- Crossing BBB: CNS depressant- drowsiness, dizziness, fatigue, disturbed coordination, FALL
- Anticholinergic effects (PNS)
- Hangover effect
Nursing Interventions:
- Toxicity: excitation, hallucination, seizure
- Warn against combination medications (decongestant A1 agonist)
Assess
- Breathing (CNS depression –> respiratory depression –> shallow/diminished)
- VS (for anticholinergic effects)
- I/Os (for anticholinergic effects)
Patient Education:
-CNS depression: avoid driving or operating dangerous machinery
Interactions:
-Avoid other CNS depressants: ETOH, codeine
Promethazine
PO, IV
Category Class:
-1st Gen Antihistamine, Anticholinergic (CNS), Dopamine Antagonists
MOA:
- inhibit vestibular stimulation in the inner ear (histamine, Ach)
- Block dopaminergic receptors in the intestine and CTZ (dopamine)
Indication:
- Nausea, motion sickness, Ménière’s Disease, allergies
- Nausea associated with chemotherapy, opioids, anesthesia
- Secondary: insomnia
Contraindication:
- Pregnancy
- Lactation
- Newborn
- Children
- Older adults
- Anticholinergic effects: retention, glaucoma, HTN, BPH, tachycardia
Side effects, Adverse reactions:
- Crossing BBB: CNS depressant- drowsiness, dizziness, fatigue, disturbed coordination, FALL
- Anticholinergic effects (PNS)
- Hangover effect
- Is vesicant (causes blistering, tissue injury, damage to intima layer of veins) dilute IV form in a large-bore IV and very slow IV push, deep IM if you have to give IM
- Memory impairment: caution in older adults, chronic respiratory diseases
- CNS: seizure, EPS (high risk peds & geriatrics)
Nursing Interventions:
- Toxicity: excitation, hallucination, seizure
- Warn against combination medications (decongestant A1 agonist)
- Vesicant: ensure for IV patency
Assess
- Breathing (CNS depression –> respiratory depression –> shallow/diminished)
- VS (for anticholinergic effects)
- I/Os (for anticholinergic effects)
Patient Education:
-CNS depression: avoid driving or operating dangerous machinery
Interactions (with drugs/food/UV light):
- Avoid other CNS depressants/stimulants
- ETOH, codeine
Scopolamine
Patch, PO, IM, IV
Category Class: Anticholinergic (PNS)
MOA:
-inhibits vestibular stimulation in the inner ear (Ach)
Indication:
- Nausea
- Motion sickness
- Meniere’s Disease
- Allergies
Side effects, Adverse reactions:
- CNS depressant: drowsiness
- Memory impairment: caution in older adults, chronic respiratory diseases
Ondansetron
IM, IV, ODT
Category Class: Serotonin Antagonists
MOA:
-Blocks CTZ center in the brain & visceral stimulation (serotonin)
Overall, well tolerated (no risk of EPS)
-Drug of choice for most types of nausea associated with chemo, opioids, & anesthesia
Side effects
- Headache
- Diarrhea
- Dizziness
- Fatigue
Adverse reaction
-Dysrhythmia
“Frick Dan Had Diarrhea Daily”
Nursing Interventions:
-Monitor cardiac rhythm & avoid in Hx of dysrhythmia
Benzodiazepines
PO, IM, IV
Lorazepam (Ativan)
-Epilepsy
Midazolam (Versed)
-Pre-operative
Category Class: CNS depressant, Schedule IV
MOA:
-GABA stimulation
Indication:
Sedative (anxiolytic) –> preventing alcohol withdrawal symptoms (DTs)
Epilepsy (antiepileptic)
- Primarily prescribed for treating acute status epilepticus
- Must be administered IV to achieve the desired response
- Due to tolerance other anticonvulsants need to be given or dose adjustments within 6 months
- Spasms (centrally acting muscle relaxant)
- Insomnia (hypnotic)
- Anesthesia induction (sedative/hypnotic)
Midazolam & Lorazepam
- Most effective for chemotherapy related nausea
- Often part of anesthesia induction
Side effects:
- Lethargy
- Poor balance
- Respiratory suppression
- FALL
“lets play real football”
Overdose
- Flumazenil
- Protect airway and breathing (intubation/ventilation)
- Support BP
- If oral within the last hour gastric lavage
Glucocorticoids
IV: Methylprednisolone (Solu-Medrol)
PO: Dexamethasone
MOA: anti-inflammatory (similar to body’s cortisol, negative feedback)
Indication:
IV
-Acute exacerbation of inflammatory disorders (requires loading dose)
PO
- To wean from IV and to continue to wean
- End-stage disease for maintenance
Methylprednisolone & Dexamethasone
-Nausea associated with chemotherapy “premedication”
Side effects, Adverse reactions:
- Hyperglycemia (in diabetic patients)
- Leukocytosis (yet immunosuppressant)
- Immunosuppressant (anti-inflammatory mechanism- higher risk of infection)
- Water/Na retention (worsening of HF, edema, HTN) –> hypokalemia (dysrhythmia)
- Water/Na retention –> increased IOP (worsening of glaucoma)
- SubQ tissue loss with chronic use –> “paper skin” or “steroid skin”
- Adrenal suppression (never stop abruptly to avoid adrenal crisis) requires weaning
- Osteoporosis (take Vitamin D, Ca++, and exercise)
Nursing Interventions:
-Must always wean off
Dronabinol
PO
One of the active ingredients is marijuana
Category Class: Cannabinoids, Schedule III
MOA:
-unknown, affecting cerebral cortex
Indication:
- N/V secondary to chemotherapy (since 1985)
- Appetite stimulant for AIDS, failure to thrive
Contraindication: psychiatric disorders
Side effects: THC related
-Mood changes, euphoria, drowsiness, dizziness, HA, depersonalization, nightmares, confusion, incoordination, memory lapse, dry mouth, orthostatic hypotension, tachycardia, FALL
Ipecac Syrup
OTC
Category Class: Emetic
MOA:
-Stimulates CTZ and acts directly on gastric mucosa
Indication: may inducing vomiting only if
- If <60min after ingestion (before the substance leaves the stomach)
- If no antidote as available (contact Poison Control)
- If no risk of aspiration
- if ingested substance is not caustic/erosive to the mucous membrane
Nursing Interventions:
-Risk of abuse (anorexia nervosa patients)
Activated Charcoal
With or without sorbitol which is a sweet osmotic laxative
PO, via NG tube
MOA: adsorbent
Side effects, Adverse reactions:
- Constipation
- Bowel obstruction
Nursing Interventions:
-May be used with gastric lavage (if toxic ingestion <60min and if indicated)
Opiate Related Agents
Medication:
- Diphenoxylate with Atropine (OTC, Rx)
- Loperamide (OTC)
MOA:
-dec peristalsis by activating opioid receptors in the GI
Indication: Antidiarrheal
Contraindication:
- Atropine contraindicated in glaucoma/BPH (Added to discourage abuse since diphenoxylate is a synthetic opioid & Also for its anticholinergic effects on GI)
- Using antidiarrheals > 2 days
- If fever with unknown etiology is present
- If the etiology of diarrhea is unknown
Side effects, Adverse reactions:
- CNS & respiratory depression (Especially children, older adults, & polypharmacy)
- Physical dependence (short-term use only)
Interactions (with drugs/food/UV light):
- ETOH
- Other CNS depressants
Lactobacillus Acidophilus
PO
MOA:
- probiotic to replace GI normal flora
- Reduces colonization by pathogenic bacteria
Indication:
- prophylactic superinfection from antibiotic use (Administer at least 2hrs apart from antibiotics)
- IBS, UC, C.Diff infection
Contraindication:
-lactose intolerance
Antidiarrheal CI:
- Using antidiarrheals > 2 days
- If fever with unknown etiology is present
- If the etiology of diarrhea is unknown
Antidiarrheals Nursing Interventions
Assessment: BM consistency, frequency, & quantity; bowel sounds
Prior to administering antidiarrheal:
-Collect a stool sample to rule out C.diff, OB, C&S, O&P
Monitor VS trend for hypovolemia and shock (low BP, tachycardia)
Educate:
- only short term drugs (only for 48 hrs.)
- increase fluid intake (PO/IV)
Laxatives
Indications: therapeutic/prophylactic treatments for constipation associated with
- Opioid use
- Pregnancy
- Prevent painful BM with hemorrhoid or post episiotomy
- Prevent straining (with aneurysm, myocardial infarction)
- Evacuation of bowel (prep for colonoscopy, post-ingestion of poisons)
Contraindications:
with other enteral medication (separate at least for 2 hours)
abdominal pain/cramping, nausea, vomiting
- fecal impaction, bowel obstruction, ischemic bowel
- biliary obstruction, appendicitis, diverticulitis, GI bleed
Hyperosmolar Saline
Medication
- Polyethylene glycol (PEG): PO drink
- Polyethylene glycol (PEG) with electrolytes: PO drink
- Magnesium hydroxide, PO drink, also antacid
- Saline Enema
Category Class: Osmotic Laxatives
MOA:
-Pull more water into the intestine (osmotic effect)
Indication:
- Quick treatment, results within 2 hours
- Colonoscopy prep
Contraindication:
- Polyethylene glycol (PEG): using > 1 week
- RF: Requires renal function to excrete excess electrolytes
- Children < 2
Side effects, Adverse reactions:
- Hypermagnesemia: cardiac arrest (monitor serum Mg)
- Hypovolemia: monitor VS trends of low BP with tachycardia
Nursing Interventions:
-Monitor for abnormally high level of electrolytes
Bisacodyl, Senna, Castor Oil
Medication:
- bisacodyl: OTC PO, suppository
- senna: OTC PO
- castor oil: OTC PO
Category Class: Stimulant (irritants)
MOA:
-Increase peristalsis by irritating sensory nerve endings in intestinal mucosa
Quick treatment
- PO: 6-12 hours
- PR: 15-60 minutes
Side effects, Adverse reactions:
- Anorexia, N/V, cramps, weakness, reddish brown urine
- Dependence
- Suppository: Proctitis: inflammation of the rectum and anus, burning sensation
“Nadia & Vlad Can Always Wear Red Dresses”
Interactions:
-Avoid milk or antacid with PO form (at least 1 hour apart)
Soapsuds Enema
Castile is a mild soap
Category Class: Stimulant (irritants)
MOA:
- The suds irritate the bowels increasing the peristalsis
- The soap also works as an emollient
- The large volume water increases the water in stool
Indication:
-used when other medications are not effective
Emollients (Stool Softeners)
Medication:
- Docusate sodium
- Docusate sodium/senna
- Mineral oil enema
MOA:
- Lowers surface tension (works like surfactant) –> Promotes water penetration in the stool
- Emulsifies and lubricates feces for easier passage
- Maintenance: slow action
Indication: Constipation
Psyllium
Category Class: Bulk-forming
MOA:
Natural fibers (nonabsorbable) made from psyllium plant seed
-Identical to the action of dietary fiber
-Increase fecal bulk & soften fecal mass
Maintenance: results in 8-24 hours
Indication: Constipation
Patient Education:
- No dependence
- Drink plenty of water to prevent bowel obstruction
Antacids
Medication:
- Calcium-carbonate: chewable tab, suspension, gum
- Magnesium-hydroxide: suspension/tablet (osmotic laxative)
- Magnesium-hydroxide/aluminum-hydroxide: suspension, tab
MOA: Neutralize HCL acid –> dec pepsin activity
- Promote healing of ulcers, dec inflammation
- Antagonistic interaction with ETOH
Indication: PUD
Contraindication: Constipation or diarrhea
- Mg –> diarrhea
- Al –> constipation
Side effects, Adverse reactions: OD of electrolytes (Mg, CA, Al)
-Specially with history of RF
Patient Education:
- Take up to 7 doses/day (1 & 3 hrs after meals & at HS)
- Take other drugs at least 1 hr before or 4 hrs after antacids
- Monitor for diarrhea as a sign of infection (low acidity –> opportunistic infections)
- Chewable (must chew), suspension (must shake well)
- Take with 8 oz water, just enough to ensure the drug reaches stomach
H2 Receptor Blockers
Medication:
- Famotidine: IV, PO
- Cimetidine: IV, PO
- Nizatidine: PO
MOA:
- Reduce gastric acid by blocking H2 receptors on the stomach wall
- Promote healing of ulcer by reducing hydrochloric acid production
Indication: PUD
Contraindication: RF
Side effects, Adverse reactions:
B12 deficiency (take supplement)
Blocking androgen receptors
-Impotence, decreased libido, gynecomastia
CNS effects
- Lethargy, depression, confusion (take at bedtime)
- Caution: geriatric population
Low gastric acidity: may cause bacterial colonization (precautions)
RF
Nursing Interventions:
- Take right before meals: To decrease food-induced acid secretion
- Monitor I&Os: Monitor lab: renal panel, CMP
- Don’t take with antacids (lower absorption)- take separately 1-2 hours
- May cause toxicity with warfarin, phenytoin, theophylline, lidocaine
- Older adults need smaller dose due to less gastric acid
Proton Pump Inhibitors (PPI)
Medication:
- Pantoprazole: IV, PO
- Omeprazole: PO
MOA:
- Reduces gastric acid
- Oral peak effect: after several days
Indication: PUD
Side effects, Adverse reactions:
- Diarrhea, insomnia, dizziness, dry mouth, flatulence, liver failure, C-diff
- Long term use –> osteoporosis
Nursing Interventions:
- Take at least an hour before meal/drugs (to avoid poor digestion/absorption)
- Taper off to avoid rebound acid hypersecretion
Sucralfate
PO (tablet, oral suspension)
Category Class: Pepsin Inhibitors
MOA:
- Reacts with gastric acid and forms a thick paste
- Selectively adheres to the ulcer protecting it from acid and pepsin for up to 6 hours
Indication: PUD
Side effects:
-Constipation, hyperglycemia (sugar content of the drug)
Nursing Interventions:
- Given 30 minutes AC & HS (qid)
- Avoid taking with other drugs (At least 2 hours apart from other drugs to prevent poor absorption)
- Finish the course even if feeling better
- Increase activity, water, fiber to avoid constipation
