Pharmacology Bullet

Review
Nursing Board 2005
 Drug classification

Pharmacodynamic
s

Pharmacokinetics Nursing process

applied to
pharmacology
 Diuretics Comparison
Diuretic class Major site of action Special Side effect
(s)
1. Carbonic Proximal tubule Acidosis
anhydrase
inhibitor
2. Thiazide and Proximal tubule Hyperuricemia
thiazide like Hypokalemia
3. Loop diuretics Loop of Henle Hypokalemia
Ototoxicity
4. Potassium Distal tubule Hyperkalemia
sparing
5. Osmotic Glomerulus Hypovolemia &
diuretic hypotension
 Diuretics Comparison
Diuretic class Special Uses
1. Carbonic Mountain sickness
anhydrase inhibitor
Meniere’s disease
2. Thiazide and Nephrolithiasis due to calcium stones
thiazide like Hypocalcemia
3. Loop diuretics Hypercalcemia

4. Potassium CHF taking digoxin

sparing
5. Osmotic diuretic Increased ICP
LITHIUM TOXICITY
 Thiazides
Prototype: Hydrochlorothiazide

 1. Bendroflumethiazide
 2. Benthiazide
 3. Chlorothiazide (Diuril)
 4. Hydroflumethiazide
 5. Methylclothiazide
 6. Trichlormethiazide
 Thiazide-like
 1. Indapamide
 2. Quinethazone
 3. Metolazone
 4. Chlorthalidone
 Thiazides
Pharmacodynamics
 These drugs BLOCK the chloride pump

 This will keep the Chloride and Sodium in the

distal tubule to be excreted into the urine
 Potassium is also

flushed out!!
 Thiazide
 Special Pharmacodynamics: Side effects
 Hypokalemia
 DECREASED calcium excretion hypercalcemia

 DECREASED uric acid secretion hyperuricemia

 Hyperglycemia
 Loop Diuretics
Prototype: Furosemide

 1. Bumetanide
 2. Ethacrynic acid
 3. Torsemide
 Loop Diuretics
Pharmacodynamics
 High-ceiling diuretics

 BLOCK the chloride pump in the ascending

loop of Henle
 SODIUM and CHLORIDE reabsorption is
prevented
 Potassium is also excreted together with Na
and Cl
Loop Diuretics
 Loop Diuretics
 Special Pharmacodynamics: side-effects
 Hypokalemia
 Bicarbonate is lost in the urine

 INCREASED calcium excretion Hypocalcemia

 Ototoxicity- due to the electrolyte imbalances

 Potassium sparing diuretics
Prototype: Spironolactone

 1. Amiloride
 2. Triamterene
 Potassium sparing diuretics
Pharmacodynamics
 Spironolactone is an ALDOSTERONE
antagonist
 Triamterene and Amiloride BLOCK the
potassium secretion in the distal tubule
 Diuretic effect is achieved by the sodium loss
to offset potassium retention
Potassium sparing diuretics
 Potassium sparing diuretics
Pharmacokinetics: Side effects
 HYPERkalemia!
 Avoid high potassium foods:
 Bananas
 Potatoes
 Spinach
 Broccoli
 Nuts
 Prunes
 Tomatoes
 Oranges
 Peaches
 Osmotic Diuretics
Prototype: Mannitol

 1. Glycerin
 2. Isosorbide
 3. Urea
 Osmotic Diuretics
Pharmacodynamics
 Mannitol is a sugar not well absorbed in the
nephron osmotic pull of water diuresis
 Osmotic Diuretics
Pharmacokinetics: side effects
 Sudden hypovolemia

Important for the nurse to warm the solution to

allow the crystals to DISSOLVE in the bottle!
 Carbonic Anhydrase Inhibitors
Prototype: Acetazolamide

 1. Methazolamide
 Carbonic Anhydrase Inhibitors
Pharmacodynamics
 Carbonic Anhydrase forms sodium
bicarbonate
 BLOCK of the enzyme results to slow
movement of hydrogen and bicarbonate
into the tubules
 plus sodium is lost in the urine
 Carbonic Anhydrase Inhibitors
Pharmacokinetics: side effects
 Metabolic ACIDOSIS happens when bicarbonate
is lost
 Hypokalemia
 The Nursing Process and the
diuretics
ASSESSMENT
 Assess the REASON why the drug is given:

______
______
______
______
 The Nursing Process and the
diuretics
ASSESSMENT
 The nurse must elicit history of allergy to the
drugs
 Allergy to sulfonamides may contraindicate the
use of thiazides
 Assess fluid and electrolyte balance
 Assess other conditions like gout, diabetes,
pregnancy and lactation
 The Nursing Process and the
diuretics
ASSESSMENT
 Physical assessment
 Vital signs
 Special electrolyte and laboratory examination

 Assess symptom of body weakness which may

indicate hypokalemia
 The Nursing Process and the
diuretics
Nursing Diagnosis
 Fluid volume deficit related to diuretic effect
 Alteration in urinary pattern

 Potential for injury (ototoxocity, hypotension)

 Knowledge deficit
 The Nursing Process and the
diuretics
IMPLEMENTATION
 Administer IV drug slowly
 Safety precaution for dizziness/hypotension
 Provide potassium RICH foods for most
diuretics, with the exception of spironolactone
 Provide skin care, oral care and urinary care
 The Nursing Process and the
diuretics
IMPLEMENTATION
 Monitor DAILY WEIGHT- to evaluate the
effectiveness of the therapy
 Monitor urine output, cardiac rhythm. Serum
electrolytes
 ADMINISTER in the MORNING!

 Administer with FOOD!

 The Nursing Process and the
diuretics
EVALUATION: for effectiveness of therapy
Weight loss
Increased urine output
Resolution of edema
Decreased congestion
Normal BP
The ANXIOLYTICS AND HYPNOTICS

These drugs are used to change the

individual’s responses to the
environment.
The ANXIOLYTICS AND HYPNOTICS

The medications that can prevent the

feelings of tension and fear are called
ANXIOLYTICS.
– Anti-anxiety drugs
The ANXIOLYTICS AND HYPNOTICS

The drugs that can calm individuals

making them unaware of the
environment are called SEDATIVES.
The ANXIOLYTICS AND HYPNOTICS

The drugs that can induce sleep are

called HYPNOTICS.
The ANXIOLYTICS AND HYPNOTICS

The drugs in this class are the

– BENZODIAZEPINES
– BARBITURATES
 Use of The Drugs
Clinical indications for the use of the
anxiolytics, sedatives and hypnotics
1. Prevention of anxiety
2. Formation of sedative state
3. Induction of sleep
 The BENZODIAZEPINES
The benzodiazepines are the most frequently
used anxiolytic drugs.

These agents prevent anxiety states without

causing much sedation, with less physical
dependence than other agents.
 The BENZODIAZEPINES
The following are the benzodiazepines
Alprazolam (Xanax)
Chlordiazepoxide (Librium)
clonazepam
clorazepate
Diazepam (Valium)
estazolam
flurazepam
lorazepam
midazolam
oxazepam
quazepam
temazepam
triazolam
 The BENZODIAZEPINES
Special uses
Diazepam Status epilepticus
(Valium)
Chlordiazepoxide Alcohol
(Librium) withdrawal
Alprazolam Panic attack
(Xanax)
 The BENZODIAZEPINES

The Mechanism of Action of the Benzodiazepines

These agents act on the Limbic system

and the RAS (reticular activating system)
to make the GABA ( Gamma-
aminobutyric acid) more effective
causing interference with neuron firing.
 The BENZODIAZEPINES
The Mechanism of Action of the Benzodiazepines

The GABA is an inhibitory

neurotransmitter.
This will result to an anxiolytic
effect at lower doses than
required for sedation/hypnosis.
 The BENZODIAZEPINES

These agents are indicated for the treatment

of
1. anxiety disorders
2. alcohol withdrawal
3. hyperexcitability, and agitation
4. pre-operative relief of anxiety and
tension and in induction of balanced
anesthesia.
 The BENZODIAZEPINES
Pharmacodynamics: The adverse effects
CNS effects= sedation, drowsiness,
depression, lethargy, blurred vision
GIT= dry mouth, constipation, nausea,
vomiting
CVS= Hypotension or hypertension,
arrhythmias, palpitations, and respiratory
difficulties.
Hematologic= blood dyscrasias and
anemia
GU= urinary retention, hesitancy, loss of
libido and sexual functions changes.
 The BENZODIAZEPINES
Nursing Considerations:
Maintain patients on bed for at
least 3 hours after drug
administration.
Instruct to avoid hazardous
activities like driving and machine
operation.
Instruct to avoid consuming
ALCOHOL while taking the drug.
 The BENZODIAZEPINES
Nursing Considerations:
Provide comfort measures to help
patients tolerate drug effects-
– instruct to urinate before taking
drug
– give high fiber foods
– use side-rails and assistance with
ambulation.
Have available FLUMAZENIL as an
antidote for benzodiazepine
overdose.
 The BARBITURATES
These are also anxiolytics and
hypnotics with a greater likelihood of
producing sedation, with increase
risk of addiction and dependence.
 The BARBITURATES
The following are the barbiturates
amobarbital
aprobarbital
butabarbital
mephobarbital
pentobarbital
Phenobarbital
secobarbital
 The BARBITURATES
The Mechanism of Action of the
Barbiturates
They depress the motor output from the
brain.
The results of their MOA are sedation,
hypnosis and anesthesia, and if extreme,
coma.
 The BARBITURATES
Clinical indications of the Barbiturates
1. Relief of anxiety manifestations
2. For sedation
3. For patients with insomnia
4. For pre-anesthesia
5. seizures/epilepsy
6. The rapid acting barbiturates are also
used for the treatment of acute manic
reactions and status epilepticus
 The BARBITURATES
Pharmacodynamics: The Adverse effects
CNS= CNS depression, somnolence,
vertigo, lethargy, ataxia, paradoxical
excitement, anxiety and hallucinations.
GIT= nausea, vomiting,
constipation/diarrhea and epigastric pain
CVS= bradycardia, Hypotension and
syncope.
Respi= serious hypoventilation, respiratory
depression and laryngospasms
Others= hypersensitivity and Stevens-
Johnson syndrome.
 The BARBITURATES
Nursing Considerations
Provide stand-by life support facilities
in cases of severe respiratory
depression or hypersensitivity reaction.
Taper the drug gradually after long-term
therapy to avoid withdrawal syndrome.
Provide comfort measures including
small frequent meals, access to
bathroom facilities, high-fiber foods,
environmental control, safety
precaution and skin care.
 The CNS stimulants
These are drugs used to treat certain
disorders
1. exogenous obesity
2. attention-deficit hyperactivity
disorders (ADHD)
3. narcolepsy
 The CNS stimulants
What is unusual is the ability of
the CNS stimulants to CALM
hyperactive children, which
allows them to focus on one
activity for a longer period.
 The CNS stimulants
The following are the CNS stimulants:
1. Methylphenidate (Ritalin)= most
commonly used for ADHD
2. Dextroamphetamine= a CNS stimulant
that is used for short tem therapy for
obesity.
3. Modafinil= used for narcolepsy
4. Pemoline= used for ADHD
 The CNS stimulants
The Mechanism of Action

These agents act as to stimulate the

cortical and reticular activating system
(RAS) of the brain.
This is by releasing neurotransmitters
from the nerve cells leading to increased
stimulation of the post-synaptic neurons.
 The CNS stimulants
The paradoxical effect of calming
hyperexcitability through CNS
stimulation seen in ADHD is believed to
be related to the increased stimulation of
an IMMATURE Reticular Activating
System leading to the ability to be more
selective in response to incoming
stimuli.
 The CNS stimulants
Pharmacodynamics: Adverse effects of the CNS
stimulants
CNS= nervousness, insomnia, dizziness,
headache, and blurred vision
GIT= anorexia, nausea and weight loss
CVS= hypertension, tachycardia arrhythmias, and
angina
Others= rashes, physical/psychological
dependence.
 The CNS stimulants
Implementation
The nurse must ensure that the drug is only given to
the indicated conditions
Administer the drug before 6 pm to reduce the
effect of insomnia
BEST given AFTER meals to prevent the effect
of anorexia
Consult with school personnel to monitor the patient
under therapy
Provide safety measures such as side-rails and
assisted ambulation
 The CNS stimulants
Evaluation
Evaluate the effectiveness of the drug:
1. Calming effect in the patient with ADHD
2. Alertness for patients with narcolepsy
 The Anti-epileptics

These agents, also called anticonvulsants,

are used to treat epileptic conditions.
Hydantoins, Barbiturates,
benzodiazepines, Succinimides and many
others are given to a specific type of
seizure.
 Anti-epileptics
Agents for treating TONIC-CLONIC SEIZURES
1. Hydantoins
– Phenytoin
– Ethotoin
– Fosphenytoin
– Mephenytoin
2. Benzodiazepines
– Diazepam
– Clonazepam
– Clorazepate
3. Barbiturates
– Phenobarbital
 Anti-epileptics
Agents for treating ABSENCE SEIZURES
1. Succinimides
a. Ethosuximide
b. Methsuximide
c. Phensuximide
2. Valproic Acid
3. Zosinamide
 Anti-epileptics
Agents for treating Partial FOCAL SEIZURES
1. Carbamazepine
2. Gabapentin
3.Lamotrigine
4. Tiagabine
5. Topiramate
 The hydantoins
These agents are utilized for general seizures
because they can depress the central
nervous system.
They affect the entire brain and reduce the
chance of sudden electrical outburst that
causes seizures.
These agents generally are less sedating than
other anti-epileptics.
 The hydantoins
Mechanism of Action of the Hydantoins
These agents STABILIZE the nerve cell
membrane throughout the brain reducing
and limiting the excitability and
conduction through nerve pathways.
 The hydantoins
Clinical Indications of the hydantoins
1. Tonic-clonic seizures
2. Status epilepticus
3. For the prevention of seizures in
neurosurgery
4. For muscle relaxation.
 The hydantoins
Contraindications and Precautions
Hydantoins are NOT given to pregnant
patient because it can cause fetal
hydantoin syndrome.
 The hydantoins
Pharmacodynamics: Adverse effects of the
Hydantoins
CNS effects- depression, confusion,
drowsiness, lethargy, fatigue
GIT- GI upset, constipation, dry mouth,
GINGIVAL HYPERPLASIA , severe liver toxicity
which are all related to cellular toxicity.
SKIN- hirsutism and coarsening of the facial
skin
Bone Marrow depression
 The hydantoins
Implementation
Administer the drug with food to alleviate
GI irritation
Discontinue the drug at any sign of
hypersensitivity reaction, severe liver
dysfunction and severe skin rashes.
Provide meticulous mouth oral care
Rule out pregnancy and advise women to
use contraceptive measures to prevent
pregnancy.
 Drugs affecting GI secretions
There are five types of drugs that affect
gastric acid secretions and are useful for the
treatment of peptic ulcer.
1. Histamine (H2) receptor
antagonist/blockers
2. Antacids
3. Proton pump inhibitors
4. Mucosal protectants
5. Prostaglandin analogs
 Drugs affecting secretions:
anti ulcer
Anti-ulcer drugs Prototype

Histamine (H2) receptor Cimetidine

antagonist/blockers
Antacids AlOH and MgOH

Proton pump inhibitors Omeprazole

Mucosal protectants Sucralfate

Prostaglandin analog Misoprostol

 General indication of the drugs
affecting gastric acid secretion
► Peptic ulcer
► Gastritis
► Patient on NPO to prevent stress ulcer
 General time of administration of the
drugs affecting gastric acid secretion
Anti-ulcer drugs Prototype Best time to give

Histamine (H2) Cimetidine With FOOD or ONE

receptor hour after ANTACID
antagonist/blockers
Antacids AlOH and MgOH Usually after meals

Proton pump Omeprazole BEFORE MEALS

inhibitors
Mucosal Sucralfate BEFORE MEALS
protectants
Prostaglandin Misoprostol WITH MEALS
analog
 Pharmacology of Anti-ulcer
drugs
Drug Mechanism of Action

Antacids- AlOH, MgOH Neutralize Gastric ACIDITY

H2-Blockers- “tidine” Block Histamine receptor

Cimetidine, Ranitidine causing decreased secretion
and acidity

Proton pump inhibitors- Inhibit Proton Pump in parietal

“Prazoles” cell decreasing secretion and
Omeprazole, pantoprazole acidity
Pharmacology of Anti-ulcer drugs
Drug Mechanism of Action

Anti-cholinergic- Prophanteline Blocks VAGUS nerve, decreases

Bromide secretion

Sucralfate (Carafate) Coats the mucosal lining

Misoprostol (Cytotec) Prostaglandin Analogue, causes

secretion of MUCUS
 Pharmacodynamics
Histamine (H2) receptor blockers
►These drugs BLOCK the release of
hydrochloric acid in the stomach
in response to gastrin
 Drugs affecting GI secretions

Antacids
►These drugs interact with the
gastric acids at the chemical
level to neutralize them
 Drugs affecting GI secretions

Proton pump inhibitors

►These drugs suppress the
secretion of hydrochloric acid
into the lumen of the stomach
 Drugs affecting GI secretions

Mucosal protectants
►These are agents that coat any
injured area in the stomach to
prevent further injury from
acid
 Drugs affecting GI secretions
Prostaglandin analogs
►These are agents that inhibit the
secretion of gastrin and
►increase the secretion of mucus
lining of the stomach, providing
a buffer.
 The H2 Blockers- “tidines”
Prototype: Cimetidine

► 1. Ranitidine
► 2. Famotidine
► 3. Nizatidine
 The H2 Blockers- “tidines”
Pharmacodynamics: Drug Action
► The H2 blockers are antagonists at the
receptors in the parietal cells of the
stomach.
► The blockage results to inhibition of the
hormone gastrin.
► There will be decreased production of
gastric acid from the parietal cells.
► Also, the chief cells will secrete less
pepsinogen.
 The H2 Blockers- “tidines”
Therapeutic use of the H2 blockers
► Short-term treatment of active duodenal ulcer or
benign gastric ulcer
► Treatment of hypersecretory conditions like the
Zollinger-Ellison syndrome
► Prevention of stress-induced ulcers and acute GI
bleeding
► Treatment of erosive GERD (reflux disease)
► Relief of Symptoms of heart burn and acid
indigestion
 The H2 Blockers- “tidines”
Precautions and Contraindications
► Any known allergy is a clear contraindication
to the use of the agents. Conditions such as
pregnancy, lactation, renal dysfunction and
hepatic dysfunction should warrant cautious
use.
► Nizatidine can be used in hepatic
dysfunction.
 The H2 Blockers- “tidines”
Pharmocodynamics- Side effects and adverse effects
► GIT= diarrhea or constipation
► CNS= Dizziness, headache, drowsiness, confusion
and hallucinations
► Cardio= arrhythmias, HYPOTENSION (related to
H2 receptor blockage in the heart)
► Cimetidine= TREMORS, Gynecomastia and
impotence in males
 The H2 Blockers- “tidines”
Drug-drug Interactions
► Cimetidine, Famotidine, Ranitidine
are metabolized in the liver- they can
cause slowing of excretion of other
drugs leading to their increased
concentration.
 The H2 Blockers- “tidines”
Drug-drug Interactions
► These drugs can interact with
CIMETIDINE anticoagulants,
phenytoin, alcohol, antidepressants.
 The H2 Blockers- “tidines”
Nursing considerations:
►Administer the drug WITH meals at
BEDTIME to ensure therapeutic level
►One hour after Antacids
►Stress the importance of the
continued use for the length of time
prescribed
 The H2 Blockers- “tidines”
Nursing considerations:
►Monitor the cardiovascular status
especially if the drugs are given IV
►Warn patient of the potential
problems of increased drug
concentration if the H2 blockers are
used with other drugs or OTC drugs.
Advise consultation first!
 The H2 Blockers- “tidines”
Nursing considerations:
► Provide comfort measures like
analgesics for headache, assistance
with ambulation and safety measures
► Warn the patients taking cimetidine
that drowsiness may pose a hazard if
driving or operating delicate machines.
 The H2 Blockers- “tidines”
Nursing considerations:
► Provide health teaching as to the dose,
frequency, comfort measures to initiate
when side-effects are intolerable
Evaluate the effectiveness:
► Relief of symptoms of ulcer, heart burn and
GERD
 The Antacids

► These are drugs or inorganic chemicals that

have been used for years to neutralize acid in
the stomach. The following are the common
antacids that can be bought OTC:
► Aluminum salts (hydroxide)
► Calcium salts (carbonate)
► Magnesium salts (milk of magnesia)
► Sodium bicarbonate
► Magaldrate (aluminum and magnesium
combination)
 The Antacids
Pharmacodynamics: drug action
► These agents act to neutralize the acidic pH
in the stomach.
► They do not affect the rate of gastric acid
secretion.
 The Antacids
Pharmacodynamics: drug action
► The administration of antacid may cause an
acid rebound.
► Neutralizing the stomach content to an
alkaline level stimulates gastrin production
to cause an increase in acid production and
return the stomach to its normal acidic
state.
 The Antacids
Therapeutic Indications
► Symptomatic relief of upset stomach
associated with hyperacidity
► Hyperacidic conditions like peptic ulcer,
gastritis, esophagitis and hiatal hernia
► Special use of AMPHOGEL (aluminum
hydroxide): to BIND phosphate
 The Antacids
Precautions of Antacid Use
► Known allergy is a clear contraindication.
Caution should be instituted if used in
electrolyte imbalances, GI obstruction and
renal dysfunction.
► Sodium bicarbonate is rarely used because
of potential systemic absorption
 The Antacids
Pharmacokinetics
► These agents are taken orally and act
locally in the stomach
 The Antacids
Pharmacodynamics: Effects of drugs
1. GIT= rebound acidity; alkalosis may occur.
► Calcium salts may lead to hypercalcemia
► Magnesium salts can cause DIARRHEA
► Aluminum salts may cause
CONSTIPATION and
hypophosphatemia by binding with
phosphates in the GIT.
2. Fluid retention due to the high sodium
content of the antacids.
 The Antacids
Nursing Considerations:
► Administer the antacids apart from any
other medications by ONE hour before
or TWO hours after- to ensure adequate
absorption of the other medications
► Tell the patient to CHEW the tablet
thoroughly before swallowing. Follow it
with one glass of water
► Regularly monitor for manifestations of
acid-base imbalances as well as electrolyte
imbalances
 The Antacids
Nursing Considerations:
► Provide comfort measures to alleviate
constipation associated with aluminum and
diarrhea associated with magnesium salts.

► Monitor for the side-effects, effectiveness of

the comfort measures, patient’s response to
the medication and the effectiveness of the
health teachings
 The Antacids
Nursing Considerations:
► Evaluate for effectiveness:
Decreased symptoms of ulcer and
pyrosis
Decreased Phosphate level (amphogel)
 The PPI
These are the newer agents for ulcer
treatment
► The “prazoles”
Prototype: Omeprazole
► Lanisoprazole
► Esomeprazole
► Pantoprazole
 The PPI
Pharmacodynamics: drug action
► They act at specific secretory surface
receptors to prevent the final step of acid
production and thus decrease the level of
acid in the stomach.

► The “pump” in the parietal cell is the H-K

ATPase enzyme system on the secretory
surface of the gastric parietal cells
 The PPI
Clinical use of the PPIs
► Short-term treatment of active duodenal
ulcers, GERD, erosive esophagitis and
benign gastric ulcer.
► Long-term- maintenance therapy for
healing of erosive disorders.
 The PPI
Clinical use of the PPIs.
Precautions with the use of the PPIs
► Known allergy is a clear contraindication.
Caution if patient is pregnant
 The PPI
Pharmacodynamics: Adverse effects
► CNS- dizziness, headache, asthenia (loss
of strength), vertigo, insomnia, apathy
► GIT- diarrhea, abdominal pain, nausea,
vomiting, dry mouth and tongue atrophy
► Respi- cough, stuffy nose, hoarseness and
epistaxis.
 The PPI
Nursing considerations:
► Administer the drug BEFORE meals. Ensure
that patient does not open, chew or crush
the drug.
► Provide safety measures if CNS dysfunction
happens.
► Arrange for a medical follow-up if symptoms
are NOT resolved after 4-8 weeks of
therapy.
 The PPI
Nursing considerations:
► Provide health teaching as to drug name,
dosages and frequency, safety measures to
handle common problems.
► Monitor patient response to the drug, the
effectiveness of the teaching plan and the
measures to employ
 The PPI
Nursing considerations:
Evaluate for effectiveness of the drug
► Healing of peptic ulcer
► Decreased symptoms of ulcer
 The Mucosal Protectant
Sucralfate
► This is given to protect the eroded ulcer
sites in the GIT from further damage by
acid and digestive enzymes
 Sucralfate
Pharmacodynamics: Action of drug
► It forms an ulcer-adherent complex at
duodenal ulcer sites, protecting the sites
against acid, pepsin and bile.
► This action prevents further breakdown of
proteins in the area and promotes healing.
 Sucralfate
Clinical use of sucralfate
► Short and long term management of
duodenal ulcer.
► NSAIDs induced gastritis
► Prevention of stress ulcer
► Treatment of oral and esophageal ulcers
due to radiation, chemotherapy or
sclerotherapy.
 Sucralfate
Precautions on the use of Sucralfate
► This agent should NOT be given to any
person with known allergy to the drug,
and to those patients with renal
failure/dialysis because of build-up of
aluminum may occur if used with
aluminum containing products.
 The Mucosal Protectant
Pharmacodynamics: Side-effects & adverse
reactions
► Primarily GIT= CONSTIPATION,
occasionally diarrhea, nausea,
indigestion, gastric discomfort, and
dry mouth may also occur
► CNS= dizziness, drowsiness, vertigo
► Others= rash and back pain
 The Mucosal Protectant
Drug-drug interactions
► If used with aluminum salts= high risk
of accumulation of aluminum and
toxicity.
► If used with phenytoin, fluoroquinolones
and penicillamines- decreased levels of
these drugs when taken with sucralfate
 The Mucosal Protectant
Nursing Considerations
► Administer drug ON AN EMPTY stomach, 1
hour before meals , or 2 hour after meals
and at BEDTIME
► Monitor for side-effects like constipation and GI
upset
► Encourage intake of high-fiber foods and
increased fluid intake
► Administer antacids BETWEEN doses of
sucralfate, NOT WITHIN 30 minutes of
sucralfate dose
 The Mucosal Protectant
Nursing Considerations
► Provide comfort measures if CNS effects
occur
► Provide health teaching as to drug name,
dosages and frequency, safety measures to
handle common problems.
► Monitor patient response to the drug, the
effectiveness of the teaching plan and the
measures employed
 The Mucosal Protectant
Nursing Considerations
► Evaluate effectiveness of therapy
Healing of ulcer
No formation of ulcer
 Prostaglandin analogue
Misoprostol
► This agent is a synthetic prostaglandin E1
analog that is employed to protect the lining
of the mucosa of the stomach
 Prostaglandin analogue
Misoprostol: Pharmacodynamics
► Being a prostaglandin analog, it inhibits
gastric acid secretion to some degree
► It INCREASES mucus production in the
stomach lining.
 Prostaglandin analogue
Misoprostol: Clinical use
► NSAIDs-induced gastric ulcers
► Duodenal ulcers unresponsive to H2
antagonists.
 Prostaglandin analogue
Precautions of Misoprostol Use
► This drug is CONTRAINDICATED during pregnancy
because it is an abortifacient.
► Women should be advised to have a negative
pregnancy test within 2 weeks of beginning
therapy and should begin the drug on the
second or third day of the next menstrual
cycle.
► They should be instructed in the use of
contraceptives during therapy.
 Prostaglandin analogue
Pharmacodynamic effects: drug reactions
► GIT= Nausea, diarrhea, abdominal pain,
flatulence, vomiting, dyspepsia
► GU effects= miscarriages, excessive
uterine CRAMPING and bleeding,
spotting, hypermenorrhea and menstrual
disorders.
 Prostaglandin analogue
Nursing Considerations
► Administer to patients at risk for NSAIDs-induced
ulcers during the full course of NSAIDs therapy
► Administer four times daily with meals and at
bedtime
► Obtain pregnancy test within 2 weeks of beginning
therapy. Begin the therapy on second or third day
of menstrual period to ensure that the woman is
not pregnant
 Prostaglandin analogue
Nursing Considerations
► Provide patient with both written and oral
information regarding the associated risks of
pregnancy
► Provide health teaching as to drug name,
dosages and frequency, safety measures to
handle common problems.
► Monitor patient response to the drug, the
effectiveness of the teaching plan and the
measures to employ
 Laxatives
Type Prototype Action

Chemical Bisacodyl (Dulcolax) Direct stimulation of the

stimulants GIT nerves
Irritant laxatives
Mechanical (bulk) Lactulose Increased fluid content of
stimulants the fecal material
causing stimulation of
the local reflex
Lubricants Docusate Lubricating the intestinal
material to promote
passage through the GIT
 Laxatives
► Generally used to INCREASE the passage of
the colonic contents
► The general classifications is as follows:
1. Chemical stimulants
2. Mechanical stimulants
3. Lubricants
 Therapeutic Indications of the
Laxatives
► SHORT term relief of Constipation
► Prevention of straining in conditions like
CHF, post-MI, post partum, post-op
► Preparation for diagnostic examination
► Removal of poison or toxins
► Adjunct in anti-helminthic therapy
 Contraindications in Laxative use
► ACUTE abdominal disorders
 Appendicitis
 Diverticulitis
 Ulcerative colitis
 Chemical Stimulant Cathartics
Prototype: Bisacodyl
Irritant laxatives:
► 1. Castor oil
► 2. Senna
► 3. Cascara
► 4. Phenolphthalein
 Chemical Stimulant Cathartics
Pharmacodynamics
► These agents DIRECTLY stimulate the nerve
plexus in the intestinal wall
► The result is INCREASED movement or
motility of the colon
 Mechanical Stimulant Cathartics
► Prototype: LACTULOSE (Cephulac)
Bulk-forming laxatives
► 1. Magnesium (citrate, hydroxide, sulfate)
► 2. Psyllium
► 3. Polycarbophil
 Mechanical Stimulant Cathartics
Pharmacodynamics
► These agents are rapid-acting laxatives that
INCREASE the GI motility by
 Increasing the fluids in the colonic material
 Stimulating the local stretch receptors
 Activating local defection reflex
 Lubricants
► Prototype: Docusate

► 1. Glycerin
► 2. Mineral oil
 Lubricants
Pharmacodynamics
► Docusate increases the admixture of fat and
water producing a softer stool
► Glycerin
► Mineral oil forms a slippery coat on the
colonic contents
 Pharmacokinetics:
Common Side-effects of the Laxatives
► Diarrhea
► Abdominal cramping
► Nausea
► Fluid and electrolyte imbalance
► Sympathetic reactions- sweating,
palpitations, flushing and fainting
► CATHARTIC dependence
 The Nursing Process and Laxative

ASSESSMENT
► Nursing History- elicit allergy to any
laxatives, elicit history of conditions like
diverticulitis and ulcerative colitis
► Physical Examination- abdominal
assessment
► Laboratory Test: fecalysis, electrolyte levels
 The Nursing Process and Laxative

NURSING DIAGNOSIS
► Alteration in bowel pattern
► Alteration in comfort: pain
► Knowledge deficit
 The Nursing Process and Laxative

IMPLEMENTATION
1. Emphasize that it is use on a SHORT term
basis
2. Provide comfort and safety measures like
ready access to the bathroom, side-rails
3. Administer with a full glass of water
 The Nursing Process and Laxative

IMPLEMENTATION
4. Encourage fluid intake, high fiber diet and
daily exercise
5. DO NOT administer if acute abdominal
condition like appendicitis is present
6. Advise to change position slowly an avoid
hazardous activities because of potential
dizziness
 The Nursing Process and Laxative

EVALUATION of drug effectiveness

1. Evaluate relief of GI symptoms, absence of
staining and increased evacuation of GI
tract
2. For Lactulose: decreased ammonia
 The Anti-diarrheals
► These are agents used to calm the irritation
of the GIT for the symptomatic relief of
diarrhea
► General Classifications
1. Local anti-motility
2. Local reflex inhibition
3. Central action on the CNS
 The Anti-diarrheals
Type Prototype Action

Local reflex inhibitor Bismuth subsalicylate Locally coats the

lining of the GIT to
soothe irritation that
may stimulate the
reflex
Local anti-motility Loperamide Directly inhibits the
intestinal muscle
activity to SLOW
peristalsis
Central acting agent Opium derivatives Stops GIT spasm by
(paregoric) CNS action
 Clinical Indications of drug use
► Relief of symptoms of acute and chronic
diarrhea
► Reduction of fecal volume discharges from
ileostomies
► Prevention and treatment of traveler's
diarrhea
 Contraindications of anti-diarrheal
Use
► Poisoning
► Drug allergy
► GI obstruction
► Acute abdominal conditions
 Pharmacokinetics: Side effects
► Constipation
► Nausea,vomiting
► Abdominal distention and discomfort
► TOXIC MEGACOLON
 Nursing process and anti-diarrheals

ASSESSMENT
► Nursing History – Elicit history of drug
allergy, conditions like poisoning, GI
obstruction and acute abdominal conditions
► Physical Examination- Abdominal
examination
► Laboratory test- electrolyte levels
 Nursing process and anti-diarrheals

NURSING DIAGNOSIS
► Alteration in bowel pattern
► Alteration in comfort: pain
 Nursing process and anti-diarrheals

IMPLEMENTATION
1. Monitor patient response within 48 hours.
Discontinue drug use if no effect
2. Provide comfort measures for pain
3. Provide teaching
 Nursing process and anti-diarrheals

EVALUATION
1. Monitor effectiveness of drug- RELIEF of
diarrhea
2. Monitor adverse effects, effectiveness of
pain measures and effectiveness of
teaching plan
 Emetics and Anti-emetics
Emetic Agent
► Syrup of Ipecac

Anti-emetics
► 1. Phenothiazines
► 2. Non-phenothiazines
► 3. Anticholinergics/Antihistamines
► 4. Serotonin receptor Blockers
► 5. Miscellaneous
 EMETIC
► Prototype: Ipecac Syrup
 EMETIC
Pharmacodynamics
► Ipecac syrup irritates the GI mucosa locally,
resulting to stimulation of the vomiting
center
► It acts within 20 minutes
 EMETIC
Clinical Use of ipecac
► To induce vomiting as a treatment for drug
overdose and certain poisonings
 EMETIC
Contraindications of Ipecac use
► Ingestion of CORROSIVE chemicals
► Ingestion of petroleum products
► Unconscious and convulsing patient
 EMETIC
Pharmacokinetics: side effects of Ipecac
► Nausea
► Diarrhea
► GI upset
► Mild CNS depression
► CARDIOTOXICITY if large amounts are
absorbed in the body
Nursing process and the EMETIC
ASSESSMENT
► Nursing History- elicit the exact nature of
poisoning
► Physical Examination- CNS status and
abdominal exam
Nursing process and the EMETIC
IMPLEMENTATION
1. Administer to conscious patient only
2. Administer ipecac as soon as possible
3. Administer with a large amount of water
4. Vomiting should occur within 20 minutes
of the first dose. Repeat the dose and
expect vomiting to occur with 20 minutes
Nursing process and the EMETIC
IMPLEMENTATION
5. Provide comfort measures like ready access
to bathroom, assistance with ambulation
6. Offer support
Nursing process and the EMETIC
EVALUATION
1. Evaluate patient response within 20
minutes of drug ingestion
2. Monitor for adverse effects
3. Evaluate effectiveness of comfort
measures and teaching plan
 ANTI-EMETICS
► These are agents used to manage nausea
and vomiting
► They act either locally or centrally
 ANTIEMETICS
Anti-emetic types Common examples

Phenothiazines Prochlorperazine, promethazine

Non-phenothiazines Metoclopramide (Reglan)

Anticholinergics and Antihistaminics Meclizine, buclizine

Serotonin Receptor blockers “setron”- dolasetron

Miscellaneous Dronabinol, hydroxyzine

 ANTIEMETICS
Types Pharmacodynamics

Phenothiazines Centrally block the vomiting

center in the medulla
Non-phenothiazine Reduces the responsiveness
of the nerve cell in the
medulla
Anticholinergics Block the transmission of the
impulses to the medulla
Serotonin receptor blockers Centrally and locally inhibits
the serotonin receptors
Miscellaneous Act in the CNS , either in the
medulla or in the cortex
 ANTIEMETICS
Types Clinical Use

Phenothiazines N/V associated with

anesthesia, intractable
hiccups
Non-phenothiazine N/V associated with
chemical stimulation
Anticholinergics N/V associated with motion
sickness
Serotonin-receptor Blockers N/V associated with chemotherapy

Miscellaneous N/V associated with chemotherapy

 ANTIEMETICS
Contraindications
► 1. Severe CNS depression
► 2. Severe liver dysfunction
 ANTIEMETICS
Pharmacokinetics: Side-effects
1. PHOTHOSENSITIVITY
2. Drowsiness, dizziness, weakness
and tremors and DEHYDRATON
3. Phenothiazines= autonomic anti-
cholinergic effects like dry mouth, nasal
congestion and urinary retention
 Nursing Process and the
ANTIEMETICS
ASSESSMENT
► Nursing History- elicit allergy, impaired
hepatic function and CNS depression
► Physical Examination- CNS status and
abdominal examination
► Laboratory test- Liver function studies
 Nursing Process and the
ANTIEMETICS
NURSING DIAGNOSIS
1. Alteration in comfort: pain
2. High risk for injury
3. Knowledge deficit
 Nursing Process and the
ANTIEMETICS
IMPLEMENTATION
1. Assess patient’s intake of other drugs that
may cause dangerous drug interaction
2. Emphasize that this is given on a short
term basis
 Nursing Process and the
ANTIEMETICS
IMPLEMENTATION
3. Provide comfort and safety measures
 Advise to change position slowly
 Avoid hazardous activities
 Provide mouth care and ice chips
 Monitor for dehydration and offer fluids
if it occurs
 Nursing Process and the
ANTIEMETICS
IMPLEMENTATION
4. Protect from sun exposure
 Sunscreens
 Protective covering
5. Provide health teaching
 Nursing Process and the
ANTIEMETICS
EVALUATION
1. Monitor for the drug effectiveness
• Relief of nausea and vomiting
2. Monitor for adverse effects
3. Evaluate effectiveness of comfort measures
and teaching plan
Pharmacology of the
Selected Endocrine
Drugs
Nursing Review
 Endocrine Medications
Anti-diuretic hormones
Enhance re-absorption of water in the
kidneys

Used in DI
1. Desmopressin and Lypressin
intranasally
2. Pitressin IM
 Endocrine Medications
Anti-diuretic hormones
SIDE-effects
Flushing and headache
Water intoxication
 Thyroid Medications

Thyroid hormones
These products are used to treat
the manifestations of
hypothyroidism
Replace hormonal deficit in the
treatment of HYPOTHYROIDSM
 Thyroid Medications

Thyroid hormones
Levothyroxine (Synthroid)
Liothyroxine (Cytomel)
Thyroid dessicated
Liotrix (Thyrolar)
 Thyroid Medications

Thyroid hormones: Actions

Increase the metabolic rate
Increase O2 consumption
Increase HR, RR, BP
 Thyroid Medications
Thyroid hormones
Side-effects
1. Nausea and Vomiting
2. Signs of increased metabolism=
tachycardia, hypertension,
cardiac arrhythmias, anxiety,
headache
 Thyroid Medications
Thyroid hormones : Nursing responsibility

1. Monitor weight, VS
2. Instruct client to take daily
medication the same time each
morning WITHOUT FOOD
Monitor blood tests to check the
activity of thyroid
 Thyroid Medications

Thyroid hormones: Nursing responsibility

3. Advise to report palpitation,

tachycardia, and chest pain
4. Instruct to avoid foods that
inhibit thyroid secretions like
cabbage, spinach and radishes
 ANTI-Thyroid Medications

ANTI-THYROID medications
The thyroid becomes
oversaturated with iodine and
stop producing thyroid
hormone
 ANTI-Thyroid Medications

ANTI-THYROID medications
Drugs used to BLOCK the
thyroid hormones and treat
hyperthyroidism
Inhibit the synthesis of thyroid
hormones
 ANTI-Thyroid Medications
ANTI-THYROID medications
1. Methimazole (Tapazole)
2. PTU (prophylthiouracil)
3. Iodine solution- SSKI and
Lugol’s solution
 ANTI-Thyroid Medications
ANTI-THYROID medications
Side-effects of thionamides
 N/V, drowsiness, lethargy,
bradycardia, skin rash
 GI complaints

 AGRANULOCYTOSIS

Most important to monitor

 ANTI-Thyroid Medications
ANTI-THYROID medications
Side-effects of Iodine solutions
 Most common adverse effects is
HYPOTHYROIDISM
 Iodism= metallic taste, burning in

the mouth, sore teeth and gums,

diarrhea, stomach upset
 ANTI-Thyroid Medications
ANTI-THYROID medications
Nursing responsibilities
1. Monitor VS, T3 and T4,
weight
2. The medications WITH
MEALS to avoid gastric upset
 ANTI-Thyroid Medications
ANTI-THYROID medications Nursing
responsibilities
3. Instruct to report SORE THROAT
or unexplained FEVER
4. Monitor for signs of
hypothyroidism.
 Instruct not to stop abrupt medication
 ANTI-Thyroid Medications
ANTI-THYROID medications
Lugol’s Solution
Used to decrease the vascularity of the
thyroid (in preparation for thyroid surgery)
T3 and T4 production diminishes
Given per orem, can be diluted with juice
Use straw to decrease staining
Monitor iodism (metallic taste, burning in
mouth)
 STEROIDS
Replaces the steroids in
the body
Interfere with the release
of inflammatory factors
and immune responses
 STEROIDS
Cortisol, cortisone,
betamethasone, and
hydrocortisone
Dexamethasone= long
acting
 STEROIDS
These drugs enter the
cells and bind to
receptors
They inhibit the enzyme
phospholipase
 STEROIDS
Corticosteroids are used topically
and locally to achieve the desired
anti-inflammatory effects at a
particular site
 STEROIDS
Steroid Clinical use

Dexamethasone Use to induce the

formation of lung
surfactant
Other steroids Use for the treatment of
immune-related
diseases, control of
asthma and allergic
symptoms
 STEROIDS
Side-effects
 HYPERglycemia

 Increased susceptibility to

infection
(immunosuppression)
 Hypokalemia

 Edema and Hypertension

 Peptic ulceration
 STEROIDS
Side-effects
 If high doses- osteoporosis,

growth retardation, peptic

ulcer, hypertension,
cataract, mood changes,
hirsutism, and fragile skin
 STEROIDS
Nursing responsibilities
1. Monitor VS, electrolytes,
glucose
2. Monitor weight edema
and I/O. Encourage
Potassium supplements
 STEROIDS
Nursing responsibilities
3. Protect patient from infection
4. Handle patient gently
5. Instruct to take meds WITH
MEALS to prevent gastric ulcer
formation
 STEROIDS
Nursing responsibilities
6. Caution the patient NOT to
abruptly stop the drug
7. Drug is tapered to allow the
adrenal gland to secrete
endogenous hormones
 STEROIDS
Evaluation:
The drugs are effective if there
is:
1. Relief of signs and
symptoms of inflammation
2. Return of adrenal function to
normal
 The cardiac glycosides
 These are agents extracted from the
foxglove plant. They are available in
oral and parenteral preparations. The
following are the cardiac glycosides:
 Digoxin (Lanoxin)
 Digitoxin (Crystodigin)
 Ouabain
 The cardiac glycosides
Pharmacodynamics: the Mechanism of
action
 They increase the level of
CALCIUM inside the cell by inhibiting
the Sodium-Potassium pump.
 More calcium will accumulate inside
the cell during cellular depolarization.
 The cardiac glycosides
 Positive inotropic Effect- the
myocardium will contract forcefully
– Increased cardiac output
– Increased blood flow to the body organs like
the kidney and liver
 Negative chronotropic effect- the heart
rate is slowed due to decreased rate of
cellular repolarization
– Bradycardia
 Decreased conduction velocity
through the AV node
 The cardiac glycosides
Clinical Use of the cardiac glycosides
 Treatment of congestive heart failure
 Treatment of dysrhythmias like atrial
flutter, atrial fibrillation and
paroxysmal atrial tachycardia
 The cardiac glycosides
Contraindications and Precautions
 Contraindicated in the presence of allergy
to any cardiac glycoside.
 They are NOT given to patients with
ventricular dysrhythmias, heart block or
sick sinus syndrome, aortic stenosis, acute
MI, electrolyte imbalances
(HYPOKALEMIA, HYPOMAGNESEMIA
and HYPERCALCEMIA) and renal failure
(may cause accumulation of drug)
 The cardiac glycosides
Pharmacodynamics: the Adverse Effects of the
Cardiac glycosides
 CNS- Headache, weakness , seizures and
drowsiness
 CVS- arrhythmias
 If digitalis toxicity is developing- the nurse must
assess the following adverse effects: Anorexia,
nausea and vomiting, visual changes-
YELLOW halo around an object, and
palpitations or very slow heart rate
 The cardiac glycosides
Remember= NAVDA and hypokalemia
 The cardiac glycosides
Drug-Drug Interactions
 If taken with potassium-losing
diuretics like furosemide- can
INCREASE the risk of toxicity and
arrhythmias. Potassium replacement
must be given.
 The cardiac glycosides
Implementation
 Administer the initial rapid digitalization
and loading dose as ordered intravenously
 Monitor the APICAL pulse rate for ONE
full minute before administering the drug.
Withhold the drug if
– Less than 60 in adults
– Less than 90 in infants
– More than 110 in adults
 Retake pulse in one hour, if pulses remain
abnormal, refer!
 The cardiac glycosides
Implementation
 Check the spelling of the drug- DIGOXIN is
different from DIGITOXIN!
 Check the dosage preparation and the
level of digitalis in the blood. (Therapeutic
level is 0.5 to 2.0 nanograms/mL)
 Administer intravenous drug VERY slow IV
over 5 minutes to avoid arrhythmias. Do
NOT administer intramuscularly because it
can cause severe pain
 The cardiac glycosides
Implementation
 Administer the drug without food if possible
to avoid delayed absorption. Weight patient
daily to determine fluid retention
 Maintain emergency equipment and drugs=
Potassium salts, Lidocaine for arrhythmias,
phenytoin for seizures, atropine for bradycardia.
 Provide comfort measures- small, frequent
meals, adequate lighting, comfortable position,
rest periods and safety precautions
 The cardiac glycosides
Implementation
 Provide health teaching- drug name, action,
dosage and side effects. Advise the patient to
report any of the following: Visual changes,
rapid weight gain, unusually low heart
rate, persistent nausea, vomiting and
anorexia
 Monitor serum potassium level
 The cardiac glycosides
Evaluation
Evaluate effectiveness of the drug:
Increased urine output
Normal heart rate in arrhythmia
 The Antianginal drugs

 In the treatment of angina, three agents

are commonly employed-
– Organic nitrates
– Beta-blockers and
– Calcium-channel blockers.
 The benefits of the drugs lie in their
different mode of action.
 The Antianginal drugs
 The nitrates can cause vasodilatation
of the veins and to some extent,
coronary artery
 The Antianginal drugs

 Beta-blockers will decrease the heart

rate
 The Antianginal drugs
 Calcium-channel blockers will
decrease force of contraction leading
to a decreased myocardial workload
and demand.
 They can also produce vasodilation
 The Organic nitrates
 These agents are simple nitric and nitrous
acid esters of alcohols. Being alcohol, they
differ in their volatility. The following are
the nitrates commonly used:
 Nitroglycerin- A moderately volatile
nitrate
 Isosorbide Dinitrate (Isordil) or
mononitrate
 Amyl nitrate- an extremely volatile nitrate
 The Organic nitrates
Nitroglycerin
 This agent is supplied in oral, spray,
transdermal and ointment preparations.
 The Organic nitrates
Pharmacodynamics: the mechanism of
action
 Nitroglycerin relaxes the smooth
muscles in the vascular system
by its conversion to nitric oxide,
a chemical mediator in the body
that relaxes smooth muscles.
The Organic nitrates
Administered nitrates

Increased nitrates in the blood

increased formation of nitric oxide

increased cGMP formation

increased dephosphorylation of myosin

Vascular smooth muscle relaxation

vasodilatation
 The Organic nitrates
Pharmacokinetics- absorption to excretion
 It can be given orally, parenterally and
topically.
 The onset of action of nitroglycerin is
more than 1 hour.
 Because significant first-pass hepatic
effect, Nitroglycerin is given
SUBLINGUALY.
 The Organic nitrates
Pharmacodynamics: Side effects and adverse
effects
 HEADACHE is the most common
effect of nitroglycerin.
 CVS- postural Hypotension, facial flushing,
tachycardia
 TOLERANCE- the tolerance to the actions
of nitrates develop rapidly. This can be
managed by providing a day of abstinence.
 The Nitrates
Implementation
 Monitor vital signs, especially watchful for
hypotensive episodes
 Advise patient to remain supine or sit on a
chair when taking the nitroglycerin for the
first time. Emphasize that he should
change his position slowly or rise from bed
slowly to avoid orthostatic Hypotension
 Offer sips of water before giving
sublingual nitroglycerin because dryness
may inhibit drug absorption
 The Nitrates
Implementation
 Apply nitroglycerin ointment to the
designated mark on paper.
 The nurse should remove any excess
ointment on the skin from the previous
dose.
 She should NEVER USE her bare fingers
because the drug can be absorbed, utilize
gloves or tongue blades instead.
 The Nitrates
Implementation
 Apply nitroglycerin patch to an area with
few hairs. Never touch the medication
portion.
 The patch and the ointment should NOT
be applied near the area for defibrillation
because explosion and skin burns may
result
 The Nitrates
IMPLEMENTATION
 Emphasize that tolerance to the
nitroglycerin can occur.
 If the medication cannot relieve the pain,
report to the hospital immediately.
 The Nitrates
IMPLEMENTATION
 Provide client health teaching- the sublingual
nitroglycerin tablet is USED if chest pain occurs
 The dose may be repeated if pain is
unrelieved within 5 minutes.
 Repeat the medication administration if
the pain has not yet subsided.
 DO NOT give more than 3 tablets!!! If chest
pain persists for more than 15 minutes,
hospital consult should be done
immediately.
 The Nitrates
IMPLEMENTATION
 Instruct the client to avoid alcohol while
taking nitroglycerin to avoid potentiating
the hypotensive effect of the medication
 If beta blockers and calcium-channel
blockers are given, instruct the patients to
consult the physician before discontinuing
the medication
 The Nitrates
IMPLEMENTATION
 Other components of health teaching for
home self-administration:
– If taking Sublingual Nitroglycerin, the patient
should be instructed to place the tablet
under the tongue for quick absorption.
– A burning sensation/biting/stinging sensation
may indicate that the tablet is FRESH!
– Store the tablet in a dark container, keep it
away from heat and direct sunlight to avoid
lessening the potency
 The Nitrates
IMPLEMENTATION
 Other components of health teaching for home
self-administration:
– HEADACHES are common in the initial period of
nitroglycerin therapy. Advise patient to take
PARACETAMOL for relief
– The nitroglycerin patch is applied once a day,
usually in the morning. The sites should be
rotated, in the chest, arms and thighs avoiding
hairy areas.
 The Nitrates
IMPLEMENTATION
 Other components of health teaching for
home self-administration:
– Position supine with elevated legs to manage
Hypotension.
– Nitroglycerin tablet can be taken
prophylactically in situations where chest
pain is anticipated- Sex, exercise, etc..
– If patient is taking beta blockers, instruct how
to obtain heart rate in a minute
 Drugs for Shock
Dopamine
 This is a sympathomimetic drug often
used to treat Hypotension in shock states
that are not caused by Hypovolemia.
 This drug is an immediate precursor of
nor-epinephrine, occurs naturally in the
CNS basal ganglia where it functions as a
neurotransmitter.
 Drugs for Shock
Dopamine
 Pharmacodynamics: It can activate the
alpha and beta adrenergic receptor
depending upon the concentration. It
stimulates receptors to cause cardiac
stimulation and renal vasodilation.
 The dose range is 1-20 micrograms/kg/min
 Drugs for Shock
Dopamine
 Pharmacokinetics: Dopamine is
administered IV, excreted in the urine.
 At low dose (1-2 micrograms),
dopamine DILATES the renal and
mesenteric blood vessels producing an
increase output (dopaminergic effect)
 Drugs for Shock
Dopamine
 At moderate dose of 2-10 micrograms,
dopamine enhance cardiac output by
increasing heart rate (beta 1-adrenergic
effect) and elevates blood pressure
through peripheral vasoconstriction (alpha
adrenergic effect)
 Drugs for Shock
Dopamine
 At higher doses of more than 10
micrograms- vasoconstriction of all
vessels will predominate that can lead to
diminished tissue perfusion
 Drugs for Shock
Dopamine
 Dopamine is indicated to treat Hypotension, to
increase heart rate and to increase urine output
(given less than 5 mg/kg/min)
 The nurse typically prepares the dopamine drip-
dopamine (at a concentration of 400-800 mg) is
mixed in 250 mL D5W and administered as drip
via an infusion pump for precise dosage
administration.
 Sodium bicarbonate will inactivate the dopamine
 Drugs for Shock
Dopamine
 Pharmacodynamics: side effects-
Tachycardia
hypertension
ectopic beats, angina, dysrhythmias,
myocardial ischemia, nausea and
vomiting.
 Drugs for Shock
Dopamine: Nursing consideration
– Check the IV site hourly for signs of drug
infiltration of dopamine, which can cause
tissue necrosis.
– Phentolamine should be infiltrated in
multiple areas to reduce tissue damage.
– Drug is effective if Urine output is increased
and BP is increased
 Antihypertensive drugs
The Drugs employed to control hypertension
can be classified as:
 Diuretics
 Beta-blockers
 Alpha adrenergic blockers
 Calcium channel blockers
 Angiotensin-converting enzyme inhibitors
 Angiotensin II receptor blockers
 Peripheral vasodilators
 Common Drugs in HPN
IN Evaluating the effectiveness of these
drugs is simply to monitor the BP if it
becomes NORMAL
 Anti-hypertensive drugs
Class Prototype MOA Side effects

Diuretics Furosemide Decreases blood Hypokalemia

volume
Beta-blocker Propranolol Blocks B1 receptor Bradycardia,
in the heart hypoglycemia
ACE Captopril Prevents A1 to AII Headache, Cough,
Inhibitors conversion flushing
Ca channel Nifedipine Blocks Ca entry Headache, flushing,
blockers into cell reflex tachycardia
Vasodilator Nitroglycerin Dilates veins and HEADACHE
arteries
Alpha Prazozin Blocks alpha Urination
blockers receptor in BV
causing
vasodilatation
Central alpha Clonidine Stimulates CNS Depression
agonist alpha 2 receptor
 Anticoagulants
HEPARIN WARFARIN
Parenteral (SQ and IV) Oral
Action is to enhance natural Action is to INHIBIT Vitamin-K
anti-thrombin III in the blood dependent clotting factors
(10,9,7,2)
Acts within minutes Acts within days
Monitor for aPTT Monitor for PT and INR
Large molecule, can be given to Small molecule CANNOT be
pregnant given to pregnant
Antidote: Protamine Antidote: Vit. K
sulfate
SE: bleeding, decreased SE: Bleeding
platelets
 The antianemics: Iron
preparations and Epoetin

Iron preparations
 Iron is important for hemoglobin formation.

The iron preparations are:

 Ferrous sulfate
 Ferrous fumarate
 Ferrous gluconate
 The antianemics: Iron
preparations and Epoetin
Side-effects:
GIT- constipation (usually), diarrhea,
vomiting, epigastric pain, gastric
ulceration and darkening of stools.
 Liquid preparation can stain the
teeth, and injectable iron can cause
tissue discoloration
 Other- dizziness
 The antianemics: Iron
preparations and Epoetin
Drug-Drug interaction
 Tetracyclines combine with iron preparations
and render the iron unabsorbable.
 Antacids and cimetidine- decrease iron
absorption and effects
 Foods can impair iron absorption but they
should be taken with iron to reduce GI
discomfort.
 Milk containing foods, coffee, tea and eggs
are NOT given with iron because they delay
iron absorption.
 The antianemics: Iron
preparations and Epoetin
Implementation
 Encourage the patient to eat iron-rich foods like liver, lean meat,
egg yolk, dried beans, green leafy vegetables.
 Administer iron preparations orally with foods to decrease GI
discomfort.
 If increased absorption is necessary, administer IN BETWEEN
meals with full glass of water or juice.
 It is best to offer citrus juices because the vitamin C
content can increase iron absorption.
 Instruct the patient to swallow the whole tablet and remain
upright for 30 minutes to prevent esophageal corrosion from
reflux.
 DO NOT administer iron together with or within 1 hour of
ingesting tetracyclines, antacids, milk and milk-containing
products.
 Advise clients to increase fluid intake and consume fiber rich
foods if constipation becomes a problem.
 The antianemics: Iron
preparations and Epoetin
Implementation
 Emphasize that the therapeutic effect of iron
therapy may not be apparent until several
weeks.
 If injecting a parenteral iron preparation, inject
DEEP IM utilizing the Z-track method to avoid
leakage into the subcutaneous tissues and skin .
 Offer straw if giving liquid iron preparation to
avoid staining the teeth.
 To prevent undue alarm, instruct the patient
that the stools may turn black or dark green.
This is a harmless occurrence.
 The antianemics: Iron
preparations and Epoetin
Evaluation
 The nurse evaluates the effectiveness of the
drug therapy by determining that the client is
not fatigued, with absence of pallor, and with
hemoglobin results within desired range.
 Erythropoietin
The mechanism of action of epoetin
alfa
(Epogen)
 This drug acts like the natural glycoprotein
erythropoietin to stimulate the production
of RBC in the bone marrow.
 Erythropoietin
Clinical indications
 It is given SUBCUTANEOUSLY or
INTRAVENOUSLY for the treatment of
anemia associated with renal failure or for
patients on dialysis.
 It is also used in patients for blood
transfusion to decrease the need for blood
in surgical patients.
 Erythropoietin
Pharmacodynamics: the adverse
effects of epoetin alfa
 CNS- headache, fatigue, asthenia,
dizziness and seizures- these are due to
the cellular response to the glycoprotein.
 GIT- nausea, vomiting and diarrhea
 CVS- hypertension, edema and chest pain
due to increase RBC number
 Erythropoietin
Implementation
 Administer the drug SC or IV usually 3 times per week.
 Monitor the IV access line if given IV. Do not mix with
other solutions
 Determine periodically the level of hematocrit and iron
stores during therapy. If patient does not respond to the
drug, reevaluate the cause of anemia.
 Maintain seizure precaution on stand by as seizure can
occur.
 Provide comfort measures like small frequent feedings
and pain medications for headache.
 Provide thorough health teaching: need for lifetime
injection
 Erythropoietin

Evaluation
 Monitor patient response to the drug=
increased hemoglobin
 Psychotrophic drugs
• Drugs that can:
1. Stimulate the release of neurotransmitters
2. Block the receptor/activity of the
neurotransmitter= like dopamine
3. Stimulate the receptors in the CNS
4. Prevents the breakdown of the
neurotransmitters or the re-uptake
mechanism
 Anti-Psychotics/Neuroleptics
• Drugs used to treat PSYCHOSES

• MAIN ACTION: Blockage of the

DOPAMINE receptor in the CNS
 Anti-Psychotics/Neuroleptics
Class Prototype Others

Phenothiazines Chlorpromazine Thioridazine,

Fluphenazine,
Perphenazine
Butyrophenones Haloperidol droperidol

Thioxanthines Chlorprothixene thirothixene

Dibenzoxapine Molindone

Diphenylbutlypiperidine Pimozide

Atypical drugs Clozapine Olanzapine

Risperidone quetiapine
 Anti-Psychotics/Neuroleptics
Desired Effects
1 Reduced hallucination and illusions
2 CNS sedation and emotional slowing
3 Decreased ambivalence, reduced delusion
4 Reduced agitation resulting to calmness
5 Relief of emotional turmoil
6 Reduced flattening of affect
 Anti-Psychotics/Neuroleptics

Common SE Nursing Interventions

Anticholinergic effects Sugarless gum, bed rest
Photosensitivity Sunglasses, sunscreen, avoid
sun
Postural hypotension Change position slowly, lie
prone for 1 hour after drug
intake, monitor BP
Agranulocytosis Instruct to report sore throat
and fever, monitor WBC
Seizure Monitor EEG
Sedation Safety, no machine operation
 Anti-Psychotics/Neuroleptics
Extra-Pyramidal Syndrome Nursing Intervention
Parkinsonism-Tremor, rigidity, Avoid abrupt withdrawal, give anti-
bradikinesia EPS drugs like Cogentin
Dystonia- torticollis, contraction Remain with client, administer anti-
of face and tongue EPS
Akathisia= motor restlessness Verbalize understanding of the
condition, administer anti-EPS
Tardive Dyskinesia= No treatment except discontinue
irreversible drooling, tongue drug
movement and shuffling gait
Neuroleptic Malignant Notify physician, prepare to
syndrome= elevated temp, administer dantrolene
treme muscle rigidity
Review Outline
 Adrenergic Agonists
 Adrenergic Antagonists
 Cholinergic Agonists
 Cholinergic Antagonists
Comparison of the Sympathetic and
Parasympathetic Nervous system
Characteristics Sympathetic Parasympathetic
CNS origin Thoraco-lumbar spinal Cranio-Sacral spinal
cord cord
Pre-ganglionic neuron Short axon Long axon
Pre-ganglionic NTA Acetylcholine Acetylcholine
Ganglia location Next to spinal cord Near target organ
Post-ganglionic Long axon Short axon
neuron
Post-ganglionic NTA Epi and NE Acetylcholine
Enzyme for NTA MAO, COMT Acetylcholine-
ESTERASE
General response Fight or flight Rest and Digest
The autonomic drugs
 Pharmacologic use depends on their
EFFECTS on the body

 They can STIMULATE= agonists OR

mimetics

 They can DECREASE THE RESPONSE=

antagonists OR blockers
The autonomic drugs
They can STIMULATE= agonists OR mimetics
 DIRECT STIMULATION by binding with
receptors

 INDIRECT STIMULATION by blocking the

enzymes that degrade the neurotransmitters
or increasing the release of neurotransmitters
The autonomic drugs
They can DECREASE THE RESPONSE=
antagonists OR blockers

 DIRECT blockage by removing the

neurotransmitter or competing with the
neurotransmitter
 Binding with the receptor and NO
RESPONSE will happen
The autonomic
Theydrugs
can be

NON-SELECTIVE when they stimulate or

block many receptors

SELECTIVE when they stimulate or block

specific receptors

SPECIFIC when only ONE type of receptor is

stimulated or blocked
The autonomic drugs: Pharmacologic use
depends on their EFFECTS on the body
Effect on the body Therapeutic use

Increases BP Used for SHOCK where

there is LOW BP

Decreases BP and heart Used for

rate HYPERTENSION and
Tachycardia
The Adrenergic AGONISTS
 Also called SYMPATHOMIMETIC agents

 These drugs MIMIC the effects of the

sympathetic nervous system
The Adrenergic AGONISTS
 They usually stimulate DIRECTLY the
receptors of the adrenergic system
The Adrenergic AGONISTS
 Alpha and Beta agonists (non-selective)
 Prototype: Epinephrine

 Alpha Agonists (Selective)

 Prototype: Phenylephrine

 Beta Agonists (Selective)

 Prototype: Isoproterenol
The Adrenergic AGONISTS
 Alpha and Beta agonists (non-selective)
Pharmacodynamics:
These agents stimulate ALL types of
adrenergic receptors in the body by direct
interaction or by releasing
neurotransmitters from the nerve cells
The Adrenergic AGONISTS
 Alpha and Beta agonists
 Prototype: Epinephrine
1. Ephedrine
2. Epinephrine
3. Metaraminol
4. Norepinephrine
5. Dobutamine (sometimes a B1 specific)
6. Dopamine
The Adrenergic AGONISTS
Alpha and Beta agonists: Clinical Use
 1. Dopamine- used in shock

 2. Epinephrine- drug of choice of anaphylaxis,

Status asthmaticus
 3. Norepinephrine- used in shock

 4. Dobutamine- used in CHF

 5. Ephedrine- used in shock, asthma and

rhinitis
The Adrenergic AGONISTS
 Alpha and Beta agonists: Desirable effects
 Increased myocardial contractility
 Bronchial DILATATION
 Vasoconstriction
 Increased blood pressure
 Decreased intraocular pressure
 Pupillary dilatation
The Adrenergic AGONISTS
 Alpha and Beta agonists:
Contraindications
 Pheochromocytoma
 Tachyarrhythmias
 With halogenated anesthesia- increased
sensitivity to adrenergic drugs
The Adrenergic AGONISTS
 Alpha and Beta agonists: Adverse effects
 Sympathetic stimulation effects
CVS- hypertension, tachycardia, palpitations
Respi- tachypnea
GI- nausea, vomiting
Others- sweating, headache, piloerection
The Adrenergic AGONISTS
Alpha and Beta agonists: Nursing
considerations
1. Monitor patient response to the drug

2. Emphasize to avoid the use with MAOIs and

TCA
3. Maintain phentolamine (alpha blocker) to
manage extravasation of IV drug
4. Usually given IV
The Adrenergic AGONISTS
Alpha and Beta agonists: Nursing
considerations
Determine effectiveness of the drug:
Increased BP in shock
Relief of anaphylaxis and asthma attack
Relief of nasal congestion
The Adrenergic AGONISTS
Alpha Agonists (selective)

Prototype: phenylephrine
clonidine (alpha-2 specific)
The Adrenergic AGONISTS
Alpha Agonists Pharmacodynamics:

These agents bind primarily to the alpha

receptors in the body
Clonidine
Stimulating the ALPHA-2 receptor causes
decreased sympathetic outflow from the
CNS/ decreased release of NE
The Adrenergic AGONISTS
Alpha Agonists: Clinical use

1. Phenylephrine- vasoconstricting drug,

used topically to decrease the symptoms of
rhinitis
2. Clonidine- for hypertension
The Adrenergic AGONISTS
Alpha Agonists: Contraindication
1. Allergy to drug

2. Caution in the following conditions:

• Hyperthyroidism-aggravation of symptoms
• Diabetes- increased glucose levels
• Tachyarrhythmias- possible additive effect
The Adrenergic AGONISTS
Alpha Agonists: Adverse effects
CNS- anxiety, depression, fatigue
CVS- palpitations
GI- nausea, vomiting and anorexia
GU- oliguria, dysuria
The Adrenergic AGONISTS
Alpha Agonists: Nursing considerations
1. DO NOT discontinue drug abruptly to
prevent rebound effect
2. Maintain phentolamine if giving IV drug
3. Provide comfort measures- rest, quiet
environment, analgesics
The Adrenergic AGONISTS
Alpha Agonists: Nursing considerations
Evaluate effectiveness:
Decreased BP
Decreased Nasal congestion
The Adrenergic AGONISTS
Beta Agonists (Selective): ANTI-ASTHMA
DRUGS

Prototype: isoproterenol (B1 and B2)

salbutamol (Ventolin)= B2 specific
1. Ritodrine (B2 specific)

2. “terol”- albuterol, salmeterol, bitolterol

3. Terbutaline (B2)
The Adrenergic AGONISTS
Beta Agonists Pharmacodynamics

These agents bind to the BETA receptors

causing the sympathetic manifestations
and effects
The Adrenergic AGONISTS
Beta Agonists Clinical use
1. Asthma- due to the bronchodilation!

2. Preterm labor- ritodrine is given to relax

the uterine muscles
3. Shock= To increase BP
The Adrenergic AGONISTS
Beta Agonists Adverse effects
CNS- restlessness, headache, anxiety , tremors
CVS- tachycardia, angina, palpitations
GI- nausea, vomiting and anorexia
Others- pupilary dilation, rash, sweating,
pulmonary edema
The Adrenergic AGONISTS
Beta Agonists Nursing considerations
1. Monitor VS when giving the drug
2. Remind mothers to lie on the left side during
ritodrine administration
3. Maintain a beta blocker on stand by
4. Provide comfort- quiet environment, rest,
analgesics.
5. Prevent over-hydration to avoid pulmonary
edema
The Adrenergic AGONISTS
Beta Agonists Nursing considerations
 These are given usually inhalational for
asthma attack
 Instruct on how to use inhalers and
nebulizers
Evaluate effectiveness:
Normal RR
Clear breath sounds
The Adrenergic ANTAGONISTS
 These are called adrenergic blockers

 They can be Alpha Blockers (selective)

Beta Blockers (selective)
Both Alpha & Beta Blockers
(non-selective)
The Adrenergic ANTAGONISTS
The alpha blockers (selective)

Prototype: Phentolamine
Phenoxybenzamine
“zosin”- prazosin, doxazosin,
terazosin- these are alpha 1 blockers
The Adrenergic ANTAGONISTS
The alpha blockers: Pharmacodynamics
These agents have affinity for the ALPHA
receptors

Blocking the alpha receptors will cause:

Vasodilation
Sphincter relaxation in the bladder
The Adrenergic ANTAGONISTS
The alpha blockers: Clinical use
1. Phenoxybenzamine- used in
pheochromocytoma
2. Phentolamine- also used in
pheochomocytoma
3. “zosin” drugs- are used to decrease blood
pressure and to relax the urinary
sphincter in BPH!
The Adrenergic ANTAGONISTS
The alpha blockers: Contraindications

1. Myocardial infarction
2. Allergy
The Adrenergic ANTAGONISTS
The alpha blockers: Adverse Effects
CVS- hypotension, reflex tachycardia,
flushing
CNS- dizziness, weakness, fatigue, drowsiness
Others- nasal congestion, reddened eyes,
priapism
The Adrenergic ANTAGONISTS
The alpha blockers: nursing consideration
1. Monitor heart rate and BP
2. Caution to change position slowly
3. Advise to avoid hazardous activities
4. Provide supportive measures like quiet
environment, rest and analgesics
5. Monitor response to the drug- improvement
of blood pressure readings and urination
The Adrenergic ANTAGONISTS
The Beta blockers
These are agents used to treat
cardiovascular problems- Hypertension,
CHF, angina
Blocking beta receptor will cause
decreased heart rate
decreased BP
The Adrenergic ANTAGONISTS
The Beta blocker or The “olol”s
They can be beta 1 blockers, beta 2 blockers or
Both
Prototype of non-selective: propranOLOL (beta 1
and 2)
carteOLOL
nadOLOL
penbutOLOL
sotaLOL
The Adrenergic ANTAGONISTS
The Beta blocker or The “olol”s
They can be beta 1 blockers, beta 2 blockers
or Both
Prototype of B1 selective: atenOLOL
acebutOLOL
betaxOLOL
esmOLOL
metoprOLOL
The Adrenergic ANTAGONISTS
The Beta blockers: pharmacodynamics
These agents block the beta receptors of
the sympathetic system. The selective B1
antagonists block the B1 receptors,
especially in the heart and the kidney
The Adrenergic ANTAGONISTS
The Beta blockers: Clinical use
1. Hypertension

2. Angina and MI

3. Cardiac arrhythmias

4. Migraine headache

5. HYPERTHYROIDISM
 The Adrenergic ANTAGONISTS
The Beta blockers: Clinical use

Hypertension to decrease BP
Angina and MI to decrease cardiac workload

Cardiac tachyarrhythmias to terminate arrhythmias

Migraine headache to cause vasoconstriction in

the cranial vessels
HYPERTHYROIDISM to decrease the tachycardia
The Adrenergic ANTAGONISTS
The Beta blockers: contraindications
1. Allergy

2. Heart blocks

3. Bradycardia

4. COPD

5. Precaution in DM
The Adrenergic ANTAGONISTS
The Beta blockers: Adverse effects
CVS- bradycardia, hypotension, heart block
CNS- fatigue, dizziness, depression
Respi- bronchospasm, pulmonary edema
GI- nausea, vomiting, diarrhea, hypoglycemia
GU- decreased libido, impotence, dysuria
The Adrenergic ANTAGONISTS
The Beta blockers: nursing considerations
1. Emphasize NOT to stop abruptly the drug
intake
2. Give with FOODS to improve absorption

3. Provide comfort measures

 Adequate rest periods
 Avoidance of hazardous activities
 Change position slowly
The Adrenergic ANTAGONISTS
The Beta blockers: nursing considerations
Evaluate effectiveness:
Decreased BP in hypertension
Decreased HR in hyperthyroidism
Decreased PAIN angina
The Cholinergic Agonists
 These are also called
parasympathomimetic agents

 Their action mimics the parasympathetic

nervous system
The Cholinergic Agonists
 These agents INCREASE the activity of
acetylcholine in the acetylcholine receptors
 DIRECTLY by occupying the receptor
 INDIRECTLY by blocking the enzyme that
degrades the acetylcholine, preventing it
from breakdown - the enzyme:
acetylcholinESTERASE
The Cholinergic Agonists
 Direct acting cholinergic agonists
Prototype: BetaneCHOL
CarbaCHOL
Pilocarpine
 Indirect acting cholinergics
Prototype: Pyridostigmine
Neostigmine
Endrophonium (Tensilon)
The Cholinergic Agonists
Direct acting cholinergic agonists
Pharmacodynamics
 They are similar to acetylcholine and
directly act on the acetylcholine
receptors
The Cholinergic Agonists
Direct acting cholinergic agonists
Parasympathetic stimulation will cause:
DUMBELS
urination
miosis (pupil constriction)
The Cholinergic Agonists
Direct acting cholinergic agonists: Clinical use
1. Post operative and post partum urinary
retention and to treat neurogenic bladder
2. Relief of increased intraocular pressure of
glaucoma by inducing miosis
The Cholinergic Agonists
Direct acting cholinergic agonists: Clinical use
1. The drugs INCREASE the bladder tone,
RELAX the GI and urinary sphincters
2. The topical agent (pilocarpine) topically
causes pupilary constriction to reduce IOP
The Cholinergic Agonists
Direct acting cholinergic agonists:
Contraindications
1. Bradycardia

2. Hypotension

3. Asthma
The Cholinergic Agonists
Direct acting cholinergic agonists: Adverse
effects (DUMBELS)
CVS- bradycardia, heart block, hypotension
GIT- nausea, vomiting, diarrhea, increased
salivation, lacrimation
GUT- sense of urgency, sphincter relaxation
Others- increased sweating, headache, miosis
The Cholinergic Agonists
Direct acting cholinergic agonists: nursing
considerations
1. Assure proper administration of
ophthalmic preparations
2. Administer on EMPTY stomach

3. Provide safety precautions- because of poor

visual acuity
4. Promote cool environment, maintain access
to the bathroom (urination)
The Cholinergic Agonists: evaluate
effectiveness
Drug effectiveness

Pilocarpine Decreased IOP in

glaucoma

Betanechol/Carbachol Urination/ relief of bladder

distention
The Cholinergic Agonists
Indirect acting cholinergic agonists
Pharmacodynamics
These agents DO NOT react directly with
the receptors but REACT chemically with
the enzyme= acetylcholinesterase
The Cholinergic Agonists
Indirect acting cholinergic agonists
Pharmacodynamics
The acetylcholine breakdown is prevented
so that the effect of acetylcholine is
prolonged!= increased muscle contraction

They are used IN myasthenia gravis

The Cholinergic Agonists
Indirect acting cholinergic agonists
Clinical use
1. Myasthenia gravis
 Physostigmine, pyridostigmine, Neostigmine,
and endrophonium
2. Alzheimer's disease
 Tacrine and Donepezil
The Cholinergic Agonists
Indirect acting cholinergic agonists
Adverse effects
GI- nausea, vomiting, cramps, diarrhea,
increased salivation, involuntary defection
CVS- bradycardia, heart block, hypotension
GU- urinary urgency
Others- blurred vision, miosis, headache,
dizziness
The Cholinergic Agonists
Indirect acting cholinergic agonists
Nursing considerations
1. Administer IV drug slowly

2. Administer with foods BUT better BEFORE

meals
3. Maintain atropine sulfate as antidote

4. Discontinue the drug if excessive salivation,

diarrhea, vomiting become problematic
The Cholinergic Agonists
Indirect acting cholinergic agonists
Nursing considerations
Evaluate effectiveness
Decreased muscle weakness
Decreased dysphagia, ptosis
Increased muscular activity
The ANTI-cholinergics
 These are drugs that BLOCK the effect of
acetylcholine
 They are also called parasympatholytic
agents
 In effect, the sympathetic system becomes
unopposed!!!
The ANTI-cholinergics
 Anticholinergics:
Prototype: Atropine
dicyclomine
glycopyrrolate
propantheline
scopolamine
The ANTI-cholinergics
Anticholinergics: pharmacodynamics
These agents work by BLOCKING or
COMPETING with acetylcholine for the
acetylcholine receptors

BEST taken BEFORE MEALS

Atropine
 Depresses salivation
 Decreases bronchial secretions
 Mydriasis
 Cyclopedia
 Inhibits vagal response in the heart
 Reverses cholinergic toxicity
 Atropine
effects Clinical use
Depresses salivation Used as pre-op med
Decreases bronchial Used as pre-op med
secretions
Mydriasis Used in cataract surgery
Cyclopledia Used in cataract surgery
Inhibits vagal response in Used in BRADYCARDIA
the heart and heart block
Constipation Used in partly to control diarrhea
(in Lomotil)
Reverses cholinergic Used in Cholinergic and
Organophosphate poisoning
Scopolamine
 Decreases nausea and vomiting associated
with motion sickness
Anticholinergic
 Contraindications of anticholinergic

1. Known allergy
2. Glaucoma
3. Bladder obstruction (like PBH)
Anticholinergic
Adverse effects: anticholinergic effects
CNS- blurred vision, pupil DILATION,
photophobia, cycloplegia and increased
Intraocular pressure
GI- dry mouth, constipation, bloatedness
CVS- tachycardia, palpitations
GU- urinary retention
Others- decreased sweating, flushing
Anticholinergic
Nursing considerations
1. Provide comfort measures
 Frequent mouth care
 Provide increased fluids
 Protect eyes form lights
 Advise to avoid hazardous activities
 Provide high-fiber diet and laxative
 Avoid extremes of temperature
 Instruct to void before administering the drug
Anticholinergic
Nursing considerations
2. Monitor for toxicity:
3. Ensure adequate hydration to prevent
hyperpyrexia
Evaluate effectiveness of drug:
Increased HR in heart block
Decreased secretions in pre-op patients
Relief of motion sickness (scopolamine)