Pharmacology Medications

A patient has been taking an oral corticosteroid to treat inflammation of the respiratory tract. The patient questions the nurse who is administering a dose of insulin. The nurse should respond: "Your healthcare provider wants you to take this to prevent diabetes." "Your pancreas is no longer functioning and you need insulin." "Your respiratory tract inflammation has caused you to be diabetic." "Corticosteroids frequently cause your blood sugar increase."

"Corticosteroids frequently cause your blood sugar increase." Rationale: Corticosteroids do cause an increase in blood sugar, requiring insulin to lower the blood sugar level. Giving an injection of insulin will not prevent diabetes. There is no indication that the patient's pancreas is not functioning and corticosteroids do not cause pancreatic failure. Respiratory tract inflammation does not cause diabetes.

The nurse is teaching an adult patient recently diagnosed with diabetes about the condition. Which statement made by the patient indicates a need for further teaching? "I'll inject my insulin at a 90-degree angle." "I'll store my insulin in the refrigerator when I'm not using it." "I'll keep some hard candy with me in case my blood sugar gets low." "If I get the flu and vomit, I won't take any insulin since I can't eat."

"If I get the flu and vomit, I won't take any insulin since I can't eat." Rationale: The patient seems to think that if he or she is not eating, then insulin will not be needed, which is incorrect. The nurse should provide further education to increase the patient's understanding of blood glucose levels and the need for cells to rely on other sources for glucose, like muscle and fat.

The nurse is teaching a patient about a glucocorticoid medication to treat an adrenal disorder. Which statement made by the patient indicates a need for further teaching? "I take my medications with breakfast." "I'll be careful not to be in crowds of people." "My prescription ran out, but I'll refill it next week." "I'll follow up with my healthcare provider in 1 week."

"My prescription ran out, but I'll refill it next week." Rationale: It is very important to not abruptly stop corticosteroid medications, which may result in adrenal insufficiency. The medication must be slowly decreased in increments to allow the body to adjust to the levels.

•The nurse is teaching a patient about the use of a prescribed proton pump inhibitor to decrease the symptoms of GERD. Which statement made by the patient indicates a need for further teaching?

"This medication will coat my stomach so it doesn't hurt so much."

In which patient would you not use a laxative?

A patient with sudden abdominal pain of unknown cause

Steroid Taper

Abrupt discontinuation of therapy may result in adrenal insufficiency Symptoms: Fever, malaise, fatigue, weakness, dizziness, fainting, anorexia, nausea, hypotension, dyspnea, hypoglycemia, muscle and joint pain Gradual withdrawal of steroid use prevents symptoms of adrenal insufficiency and allows adrenal glands to start functioning again

Which reaction to a magnesium sulfate infusion indicates that the drug must be withheld? Absent patellar reflex Urine output of 50 mL/hr Hyperactive biceps reflexes Respiratory rate of 18

Absent patellar reflex Rationale: Reflexes must be monitored hourly during magnesium sulfate infusions, and if the reflex is absent, the drug should be held until the reflexes return. Urine should be a minimum of 30 mL/hr and respirations at least 16. The patient must be monitored very carefully during the infusion.

Coating Agents Drug: Sucralfate (Carafate)

Action: Adheres to craters of an ulcer, protecting it from acids, pepsin, and bile salts •Use: Treatment of duodenal ulcers; for patients who cannot tolerate other therapies •Common adverse effects: Constipation, dry mouth, dizziness •Implementation: •Shake well if the suspension •Administer 30-60 minutes before meals •Antacids 30 minutes before or after (if ordered)

Drug Class: Mineralocorticoids Drug: Fludrocortisone (Florinef) Only drug with true mineralocorticoid effects

Action: Affects fluid and electrolyte balance, causing sodium and water retention Uses: Treatment of adrenal insufficiency, Addison's disease Therapeutic outcomes: Control of blood pressure, restoration of fluid and electrolyte balance Adverse effects: Sodium accumulation, potassium depletion Used in combination with glucocorticoids

Drug Class: Angiotensin II Blockers (ARBs)

Action: Bind to angiotensin II receptor sites and block the vasoconstrictor from binding to receptor sites in target organs Uses: Alone or in combination with other antihypertensives to reduce blood pressure: African Americans may not respond well to therapy with an ARB only Common adverse effects: Dyspepsia, cramps, diarrhea; headache; orthostatic hypotension Serious adverse effects Hyperkalemia, more common in patients with renal impairment or DM Monitor potassium levels Discourage potassium or dietary supplements Can cause birth defects

Other Antithyroid Medications Drugs: Propylthiouracil (PTU, Propacil), methimazole (Tapazole)

Action: Block synthesis of T3 and T4 Uses: Long-term treatment for hyperthyroidism, presurgical treatment Common and serious adverse effects: Purpuric, maculopapular rash; headache; nephrotoxicity; hepatotoxicity; bone marrow suppression; lymph node enlargement Will not destroy T3 and T4 already produced; a few days to 3 weeks before symptoms improve. Drug interactions; warfarin dosage may have to be increased; digoxin dosage may have to be decreased.

Drug Class: Anticholinergic Agents for Overactive Bladder Syndrome Oxybutin/Ditropan XL, solifenacin/Vesicare, tolterodine/Detrol

Action: Block the cholinergic receptors of the bladder, causing relaxation Use: Reduce urgency and frequency of bladder contractions in patients with overactive bladder (OAB) Common adverse effects: Dry mouth, urinary hesitancy, retention, constipation, bloating, blurred vision Serious adverse effect: Intensification of any of the above symptoms Contraindications: narrow-angle glaucoma, myasthenia gravis, gastric retention, ulcerative colitis, urinary retention due to prostate disorder. Drug interactions with fluoxitine, erythromycin, clarithromycin, miconazole, vinblastine, ritonavir and others

Drug Class: Sodium-Glucose Cotransporter 2 Inhibitors -glifozin

Action: Block the secretion of the SGLT2 protein, dropping glucose reabsorption from 90% to less than 10% Uses: Treatment of hyperglycemia in type 2 diabetes; used as adjuncts to exercise Common and serious adverse effects: Hypotension, increases in low-density lipoprotein cholesterol, hypoglycemia, glycosuria, genitourinary tract infections, increased urination, antihypertensive agents

Drug Class: Antihypoglycemic Agents Drug: Glucagon

Action: Breaks down stored glycogen to glucose aids in converting amino acids to glucose (gluconeogenesis). Use: Treatment of hypoglycemic reactions Administered Subcut, IM, IV Common and serious adverse effects: Nausea, vomiting Administer SC, IM, or IV. Should respond in 5 to 20 minutes; if not, 1 to 2 additional doses Need glycogen for action (won't work with adrenal insufficiency, chronic hypoglycemia, starvation)

Drug Class: Uterine Stimulants Drug: Misoprostol (Cytotec)

Action: Causes uterine contractions in pregnancy Uses: Cervical ripening agent, induces labor, treatment of serious postpartum hemorrhage Common adverse effects: Nausea, vomiting, diarrhea, fever Serious adverse effect: Orthostatic hypotension

Drug Class: Thrombin Inhibitor Drug: Dabigatran (Pradaxa)

Action: Direct thrombin inhibitor, prevents the conversion of fibrinogen to fibrin Use: Reduces risk of stroke with nonvalvular atrial fibrillation Premedication assessments: Bleeding; monitor labs; pregnancy Safety alert Capsules must be swallowed whole and are sensitive to moisture The bottle must be used within 30 days Adverse effects: Bleeding

Other Uterine Stimulants Drugs: Ergonovine (Ergotrate Maleate), methylergonovine (Methergine)

Action: Directly stimulate uterine contractions Uses: Control bleeding and maintain uterine firmness in postpartum patients Common adverse effects: Nausea, vomiting, abdominal cramping Serious adverse effect: Hypertension Use with caution in patients with eclampsia or preexisting hypertension.

Drug Class: Androgens testosterone

Action: Dominant male sex hormone Uses: Treat hypogonadism, eunuchism, androgen deficiency, and palliation of breast cancer in postmenopausal women with certain types of cancer (suppress cancer cells) Common adverse effect: Gastric irritation (take with food) Serious adverse effects: Electrolyte imbalance, edema; hypercalcemia; masculinization; hepatotoxicity Use gloves when applying topical Andorgel/testosterone gel Apply to shoulders, arms, abdomen and allow to air dry before dressing

Saline Laxatives Lubiprostone (Amitiza) Magnesium citrate (Citrate of Magnesia) Magnesium hydroxide (Dulcolax Liquid, Phillip's Milk of Magnesia) Sodium phosphates (Fleet Phospho-Soda) enema

Action: Draw water into the intestine from surrounding tissues, distending the bowel, causing peristalsis •Usually act within 1 to 3 hours and up to 6 hours for sodium phosphates. •Use: Relieve acute constipation •Continuous use may alter electrolyte balance and cause dehydration.

Drug Class: Intravaginal Hormonal Contraceptives Drugs: Etonogestrel-ethinyl estradiol vaginal ring (NuvaRing), segestrone-ethinyl estradiol vaginal ring (Annovera)

Action: Estrogen and progestin inhibit ovulation Use: Plastic ring dosage form inserted into vagina Common adverse effects: Nausea, weight gain, spotting, depression, mood changes, headaches, insomnia, fatigue, lack of energy Serious adverse effects: Leg pain, chest pain, shortness of breath Teach patient correct insertion technique 3 weeks in/1 week out Teach what to do if ring falls out or forget to change ring

Drug: Phytonadione Vitamin K

Action: Fat-soluble vitamin K for the production of blood clotting factors Use: Administered prophylactically to protect against hemorrhagic disease of the newborn Newborns are often deficient in vitamin K and clotting factors (referred to as vitamin K bleeding deficiency). 0There is no premedication assessment required Serious adverse effects: Bruising, hemorrhage Give IM in lateral aspect of the thigh (never IV)

Drug Class: Anticoagulants Drug: Heparin

Action: In the presence of heparin, antithrombin III neutralizes thrombin; factors IXa, Xa, XI, and XII; and plasmin Uses: Treat deep vein thrombosis, pulmonary embolism, cerebral embolism Can be given subcutaneously, IV push, IV infusion Dosages vary depending on route Monitor aPTT, platelets, hematocrit Do not give if platelets < 100, 000 Antidote for heparin is protamine sulfate.

Drug Class: Bisphosphonates Drugs: Alendronate, risedronate, and zoledronic acid

Action: Inhibit bone resorption by actions on osteoclasts Uses: Treatment and prevention of osteoporosis in postmenopausal women Common adverse effects include headaches, abdominal pain, gastroesophageal reflux disease, dyspepsia, constipation, diarrhea, dysphagia, gastritis, gastric ulcers, musculoskeletal pain, nephrotoxicity, osteonecrosis of the jaw, and atypical femoral fractures.

Dopamine Antagonists Drugs: Phenothiazines (promethazine/Phenergan)

Action: Inhibit dopamine receptors that are part of the pathway to the vomiting center Use: Treat mild to moderate nausea and vomiting associated with anesthesia, surgery, radiation therapy, cancer chemotherapy Because these drugs inhibit dopamine receptors, watch for extrapyramidal symptoms of dystonia, parkinsonism, and tardive dyskinesia. Side effects: sedation/sleepiness, loss of gag reflex, orthostatic hypotension Stop if rash develops

Drug Class: Calcium Channel Blockers

Action: Inhibit movement of calcium ions across cell membranes Uses: Ideal for first- or second-line drug therapy for hypertension; Effective in African-American patients Serious adverse effects: Hypotension and syncope; edema Effective for African American and elderly patients

Drug Class: Alpha-Glucosidase Inhibitor Agents Drugs: Acarbose (Precose), miglitol (Glyset)

Action: Inhibit pancreatic alpha amylase and GI alpha glucoside hydrolase enzymes used in the digestion of sugars Use: Effective in patients with type 2 diabetes mellitus Common adverse effects: Abdominal cramps, diarrhea, flatulence Serious adverse effects: Hypoglycemia (except Acarbose), hepatotoxicity

Drug Class: Anticoagulants Drug: Warfarin (Coumadin)

Action: Inhibits activity of vitamin K, which activates certain clotting factors Uses: Treatment/prophylaxis of DVT, embolization from atrial fibrillation or heart valve replacement, pulmonary embolism Target INR of 2 to 3 for patients with atrial fibrillation, stroke, MI, and DVT INR of 2.5 to 3.5 for patients with mechanical heart valve device

Drug Class: Transdermal Contraceptives Drug: Norelgestromin-ethinyl estradiol transdermal system (Ortho Evra)

Action: Inhibits ovulation Use: Estrogen and progestin hormones are in patch form Common adverse effects: Nausea, weight gain, depression Serious adverse effects: Vaginal discharge, breakthrough bleeding, blurred vision, severe headaches, dizziness, leg pain, chest pain, shortness of breath, acute abdominal pain Increased risk of blood clots Implementation: 3 weeks on/1 week off

Drug Class: Other Urinary Antibacterial Agents Drug: Nitrofurantoin (Furadantin, Macrodantin, Macrobid)

Action: Interfere with several bacterial enzyme systems Use: Treat UTIs Common adverse effects: Nausea, vomiting, anorexia, urine discoloration Serious adverse effects: Dyspnea, chills, fever, rash, pruritus, neuropathies, secondary infection Do not administer to infants <1 month old Urine may turn rust-brown to yellow.

Drug Class: Dipeptidyl Peptidase-4 Inhibitors -gliptin Drug: Sitagliptin (Januvia)

Action: Prolong life of active GLP-1 and GIP incretin hormones Use: Used alone or in combination with other therapies to reduce elevated fasting and postprandial hyperglycemia in type 2 diabetes mellitus Common adverse effects: Nausea, abdominal pain, diarrhea, headache, mm weakness Serious adverse effects: Hypoglycemia, upper respiratory infection, pancreatitis Beware of drug interactions with sitagliptin

Drug Class: Class III Antidysrhythmic Agents Drugs: Amiodarone hydrochloride (Cordarone, Pacerone)

Action: Prolongs the action potential of atrial and ventricular tissue by increasing the refractory period Uses: Treat life-threatening supraventricular tachycardia, atrial fibrillation, atrial flutter Poses a significant risk to patients. Must be hospitalized during the loading dose Numerous drug interactions May cause exacerbation of preexisting dysrhythmia or induce others Serious adverse effects CNS: Fatigue, tremors, involuntary movements, sleep disturbances, numbness and tingling, dizziness, ataxia, and confusion Respiratory: Pulmonary interstitial pneumonitis, exertional dyspnea, cough GI: Nausea/vomiting, constipation, abdominal pain, anorexia Thyroid disorders, hepatotoxicity, dysrhythmias Visual: Pigmentations in the cornea, corneal microdeposits Integumentary: Photosensitivity, blue-gray skin coloration

Drug Class: Direct Vasodilators

Action: Relax arterial smooth muscle, reducing peripheral vascular resistance Uses: Treatment of stage 2 hypertension, renal disease hypertension, toxemia of pregnancy Common adverse effects: Dizziness, numbness, tingling in legs; orthostatic hypotension, palpitations, tachycardia; nasal congestion; hair growth Serious adverse effects: Fever, chills, joint and muscle pain, skin eruptions; gynecomastia

Drug Class: Thyroid Replacement Hormones levothyroxine

Action: Replace deficient T3 and T4 hormones Use: Return patient to normal thyroid state Common and serious adverse effects: Signs of hyperthyroidism; hyperglycemia Drug interactions Warfarin, digoxin, estrogens, cholestyramine Need increased dosage of anticoagulants, decreased dose of digoxin May need hypoglycemic agent dose adjustments

Drug Class: Opiate Antagonists Drugs Naloxone (Narcan)** Naltrexone (Revia)

Action: Reverse respiratory depression, sedation, hypotension associated with opiate agonists and opiate partial agonists Use: Treat respiratory depression from excessive doses of opiate agonists or opiate partial agonists; drug of choice Not effective in CNS depression from tranquilizers or sedative-hypnotics. The most common adverse effects are rare: Nausea, vomiting, chills, myalgia, dysphoria, abdominal cramps, joint pain, mental depression, apathy.

Drug Class: Phosphodiesterase Inhibitors -afil Sildenafil/Viagra, tadalafil/Cialis

Action: Selective inhibitors of PDE-5 enzyme Uses: Treatment of male erectile dysfunction; pulmonary arterial hypertension Common adverse effects: Headache, flushing of the face and neck, color vision impairment Serious adverse effects: Hypotension, dizziness, angina, loss of vision, sustained erection Nitrates are contraindicated because they can potentially cause hypotension and dysrhythmias.

Drug Class: Antithyroid Medications Drug: Iodine-131 (131I) RADIOACTIVE ISOTOPE

Action: Selectively destroys hyperactive thyroid tissue Use: Treatment of hyperthyroidism for select individuals Common and serious adverse effects: Tenderness in the thyroid gland; hyperthyroidism; hypothyroidism Drug interaction: Lithium carbonate 3-6 months for full benefit Radioactive precautions Minimize exposure, Time, distance, shielding, double flush toilet, iron disposal unit If medication or excreta spills, follow agency policy and use containers for radioactive waste disposal Iodine added to water and swallowed

Drug Class: Class Ib Antidysrhythmic Agents Drug: IV lidocaine (Xylocaine), procainamide

Action: Shorten the duration of electrical stimulation Uses: Treats premature ventricular contractions, ventricular tachycardia, ventricular fibrillation Common adverse effects: Lightheadedness, muscle twitching, hallucinations, agitation, euphoria; respiratory depression Serious adverse effects: Dysrhythmias, neurotoxicity, seizures, confusion Lidocaine for dysrhythmia not for topical anesthetic

Drug Class: Central-Acting Alpha-2 Agonists

Action: Stimulate alpha-adrenergic receptors in the brainstem, reducing sympathetic outflow from CNS Uses: Considered adjunctive therapy; used only in combination with other antihypertensives Common adverse effects: Drowsiness, dizziness; dry mouth; altered urine color, altered test results Serious adverse effects: Depression; rash

Drug Class: Sulfonylurea Oral Hypoglycemic Agents -ride, -zide, glipizide/Glucotrol, glyburide

Action: Stimulate release of insulin from beta cells of pancreas Use: Effective in patients with type 2 diabetes mellitus Common adverse effects: Nausea, vomiting, anorexia, weight gain abdominal cramps

Drug Class: Meglitinide Oral Hypoglycemic Agents Drugs: Repaglinide (Prandin), nateglinide (Starlix)

Action: Stimulate the release of insulin from beta cells of the pancreas Use: Effective in patients with type 2 diabetes mellitus Common and serious adverse effect: Hypoglycemia

Drug Class: Uterine Stimulants

Action: Stimulate the uterus to induce labor Uses Induce or augment labor Control postpartum atony and hemorrhage Control postsurgical hemorrhage (as in cesarean birth) Induce therapeutic abortion See specific dosages and administration

Drug: Clomiphene Citrate (Clomid)

Action: Stimulates ovaries to release ova for potential fertilization Use: Induces ovulation in women with reduced estrogen levels Common adverse effects: Nausea, vomiting, diarrhea, constipation, hot flashes, abdominal cramps Serious adverse effects: Severe abdominal cramps, visual disturbances, dizziness Intercourse timing important to success Treatment raises the possibility of multiple fetuses.

Other Uterine Stimulants Drug: Oxytocin (Pitocin)

Action: Stimulates uterine smooth muscle, blood vessels, mammary glands Uses: Initiates active labor during third trimester; used postpartum to control uterine atony, hemorrhage Common adverse effects: Uterine contractions, nausea, vomiting Serious adverse effects: Fetal distress, hypotension, hypertension, water intoxication, dehydration, postpartum hemorrhage

Miscellaneous Urinary Agents Drug: Bethanechol chloride (Urecholine)

Action: Stimulation of the parasympathetic nerve that causes contraction in the bladder Use: Restores bladder tone and urination in nonobstructive urinary retention Other actions include stimulation of gastric motility, increased gastric tone, and restoration of peristalsis. Common adverse effects: Flushing of skin, headache S erious adverse effects: Nausea, vomiting, sweating, colicky pain, abdominal cramps, diarrhea, belching, involuntary defecation Atropine sulfate must be kept available to counteract serious adverse effects

Drug Class: Nonsteroidal Antiinflammatory Drugs (NSAIDs) Drugs: Diclofenac (Cataflam, Voltaren), etodolac, fenoprofen (Nalfon), flurbiprofen (Ansaid), ibuprofen (Motrin, Advil), others

Actions "Aspirin-like" but unrelated to salicylates Prostaglandin inhibitors Block cyclooxygenase (COX-1 and COX-2) Varying degrees of analgesic, antipyretic, and antiinflammatory activity Uses Relief of pain and inflammation from rheumatoid arthritis, osteoarthritis, ankylosing spondylitis, gout Dysmenorrhea, minor aches and pains Preferred options for patients who do not tolerate aspirin. Common adverse effects: Gastric irritation, constipation; dizziness, drowsiness Serious adverse effects: GI bleeding; hepatotoxicity; confusion; hives, pruritus, rash, facial swelling; nephrotoxicity; blood dyscrasias Drug interactions: Warfarin, phenytoin, valproic acid, lithium, aspirin, furosemide, etc.

Drug Therapy for Hypertension

Actions Alpha- and beta-adrenergic blocking agents Beta-adrenergic blocking agents Angiotensin-converting enzyme inhibitors Angiotensin II receptor blockers Renin inhibitors Aldosterone receptor antagonist Calcium channel (ion) blockers Alpha-1 adrenergic blocking agents Central-acting alpha-2 agonists Peripheral-acting adrenergic antagonists Direct vasodilators Diuretics Uses Key to long-term success with antihypertensive therapy is to individualize therapy for patient Adult patients with a 10-year cardiovascular risk of 10% or greater: Treatment should be initiated with one of the four classes of medications recommended Patients with high blood pressure and heart failure and/or chronic kidney disease should be treated with ACE inhibitors or ARBs

Anticonvulsants Drug: valproic acid (Depakene)

Actions Appears to support GABA activity as an inhibitory neurotransmitter Uses Control tonic-clonic seizures Only single-drug therapy to treat combination of generalized tonic-clonic, absence, or myoclonic seizures Treat acute mania of bipolar disorder Common adverse effects Nausea, vomiting, indigestion; sedation, drowsiness, dizziness; blurred vision Serious adverse effects Blood dyscrasias Birth defects: neural tube defects, craniofacial defects, cardiovascular malformation Hepatotoxicity Pancreatitis

Drug Class: Beta-Adrenergic Blocking Agents

Actions Block beta-adrenergic receptors in heart Reduce myocardial oxygen demand Reduce blood pressure Uses: Reduce the number of anginal attacks; reduce nitroglycerin use Patients with acute MI should receive beta-blocker Therapy should start at low doses and work upward for patient tolerance. Combination therapy with nitrates is more effective than using either drug alone.

Anticonvulsants Drug: pregabalin (Lyrica)

Actions Chemically related to gabapentin Does not appear to enhance GABA Uses In combination with other anticonvulsants to control partial seizures Treat pain from fibromyalgia, diabetic neuropathy, and postherpetic neuralgia Common adverse effects Sedation, drowsiness, dizziness; blurred vision Serious adverse effects Neurologic changes Excessive use or abuse Enhanced sedation with CNS depressants

Calcium Channel Blockers

Actions Inhibit flow of calcium ions across cell membrane Reduce peripheral vascular resistance Improve coronary blood flow Uses: Reduce the incidence of MI, secondary prevention for patients with known coronary artery disease Potent vasodilators; have an overall effect on myocardial activity. Should be used with caution in patients who may be developing heart failure.

Salicylates: Aspirin

Actions Inhibit prostaglandin synthesis Three pharmacologic effects: Analgesic, antipyretic, anti-inflammatory Aspirin has unique property of inhibiting platelet aggregation and clotting Uses Discomfort, pain, inflammation, or fever associated with bacterial and viral infections; drug of choice Headaches, muscle aches, rheumatoid arthritis Reduce risk of myocardial infarction, TIA, stroke Not recommended for children due to the risk of Reye's syndrome Common adverse effect: GI irritation Serious adverse effects: GI bleeding; salicylism (tinnitus, impaired hearing, dimming of vision, sweating, fever, lethargy, dizziness, mental confusion, nausea and vomiting) Increased risk of bleeding in older adults in the form of GI bleeding or a hemorrhagic stroke. No antidote exists for aspirin toxicity; discontinuing the drug is the only treatment and the condition is reversible.

Drug Class: Hydantoins

Actions Mechanism of action unknown Uses Anticonvulsants to control tonic-clonic seizures Example is phenytoin(Dilantin) the most commonly prescribed antiepileptic medication, it has a long history of safe use It is important to check serum therapeutic level, the normal level is 10-20 mcg/mL

Anticonvulsants Drug: topiramate (Topamax)

Actions Mechanism of action unknown; appears to prolong blockade of sodium channels, enhance the activity of GABA, antagonize certain receptors for the neurotransmitter Uses In combination with other anticonvulsants to control tonic-clonic seizures Prevention of migraine headaches Common adverse effects Sedation, drowsiness, dizziness Serious adverse effects Neurologic changes Cleft palate in newborns Decreased sweating and overheating, especially in children Enhanced sedation with CNS depressants

Miscellaneous Anticonvulsants Drug: gabapentin (Neurontin)

Actions Mechanism of action unknown; does not appear to enhance GABA Uses In combination with other anticonvulsants to control partial seizures, treat postherpetic neuralgia Common adverse effects Sedation, drowsiness, dizziness; blurred vision Serious adverse effects Neurologic changes

Drug Class: Benzodiazepines

Actions Thought to enhance inhibitory effects of GABA in postsynaptic clefts between nerve cells Uses Anticonvulsant Common adverse effects Sedation, drowsiness, dizziness, fatigue, lethargy; blurred vision Serious adverse effects Behavioral disturbances, blood dyscrasias, hepatotoxicity/ elevated liver enzymes

Drug: Erythromycin Ophthalmic Ointment (Ilotycin)

Actions and uses: Macrolide antibiotic used prophylactically to prevent ophthalmia neonatorum; effective against C. trachomatis Common adverse effect: Mild conjunctivitis Special administration technique A new tube of the medication should be started for each infant. DO NOT irrigate eyes after administration.

Drug Class: Opiate Agonists(Slide 1 of 2)

Actions: Act on same sites in the brain as morphine to stimulate analgesic effects; block the pain sensation Uses: Relieve acute or chronic moderate/severe pain; can be used preoperatively or to supplement anesthesia Prolonged use can produce drug tolerance or addiction (may develop after 3 to 6 weeks of use).

Drug Class: Estrogens Estradiol, conjugated estrogens

Actions: Affect release of gonadotropins that cause capillary dilation, fluid retention, protein metabolism, and inhibit ovulation and postpartum breast engorgement Uses: Relieve hot flash symptoms of menopause; contraception; hormone replacement therapy after oophorectomy; treat osteoporosis; treat severe acne: slow disease process in advanced prostatic cancer and breast cancer

Drug Class: Glucocorticoids -sone, -olone, prednisone, dexamethasone, triamcinolone

Actions: Antiinflammatory, antiallergenic, immunosuppression Uses: Certain cancers, organ transplantation, autoimmune diseases, allergies, shock Common and serious adverse effects: Electrolyte imbalance, fluid accumulation; susceptibility to infection; behavioral changes; hyperglycemia; peptic ulcer formation; delayed wound healing; visual disturbances; osteoporosis Pantoprazole given in concurrent when in acute setting and on IV tx. Always taper if long term use.

Drug Class: Class IV Antidysrhythmic Agents (Calcium Channel Blockers) Drugs: Verapamil (Calan, Isoptin), diltiazem (Cardizem)

Actions: Block calcium channels in SA and AV nodes; slow AV conduction, prolong refractoriness and decrease automaticity Use: Treat automatic and re-entrant tachycardias

Drug Class: Alpha-1 Adrenergic Blocking Agents

Actions: Block postsynaptic alpha-1 adrenergic receptors to produce vasodilation, decrease peripheral vascular resistance Uses: Alone or in combination with other antihypertensives to reduce blood pressure; reduce mild to moderate urinary obstruction Common adverse effects: Drowsiness, headache, weakness, lethargy; dizziness, tachycardia, fainting

Drug Class: Uterine Stimulants Drugs: Dinoprostone (Prostin E2, Prepidil, Cervidil)

Actions: Cause uterine and GI smooth muscle stimulation, start and continue cervical ripening at term Uses: Expel uterine contents after fetal death, benign hydatidiform mole, missed spontaneous miscarriage, second-trimester abortion Available as vaginal suppository or gel applied to the cervix. Common adverse effects: Nausea, vomiting, diarrhea, fever Antiemetics and antidiarrheals are ordered PRN. Serious adverse effects: Orthostatic hypotension Occasionally used in conjunction with oxytocin.

Drug Class: Biguanide Oral Antidiabetic Agent Drug: Metformin (Glucophage)

Actions: Decreases hepatic glucose production by inhibiting glycogenolysis and gluconeogenesis, reduces adsorption of glucose from intestine, increases insulin sensitivity Use: Treatment of type 2 diabetes mellitus Common adverse effects: Nausea, vomiting, anorexia, abdominal cramps, flatulence

Drug Class: Nitrates Nitroglycerin: Most common drug

Actions: Decreases oxygen demand on the heart; dilates arteries and veins; reduces blood volume; decreases preload on the heart Use: Drug of choice to treat angina pectoris Common adverse effects: Excessive hypotension, prolonged headache, tolerance (with longer-acting nitrates) Drug interaction: ED drugs [sildenafil (Viagra)] can potentially lower blood pressure and be fatal Nitrate-free periods are necessary. Administration forms Sublingual tablets: Dissolve rapidly, primarily for acute attacks Sustained-release capsules, tablets, ointment, transmucosal tablets, and transdermal patches: Used prophylactically to prevent anginal attacks Translingual spray: For acute attacks and prophylaxis Amyl nitrite for inhalation (glass vials) Intravenous form

Drug Class: Oral Contraceptives

Actions: Estrogens block the pituitary release of FSH; progestins inhibit pituitary release of LH Use: Induce contraception by inhibiting ovulation Common adverse effects: Nausea, weight gain, depression Serious adverse effects: Breakthrough bleeding, yeast infection, blurred vision, severe headaches, dizziness, leg pain, chest pain, shortness of breath, acute abdominal pain, blood clots, CV events Implementation: Pregnancy test before start Smoking increases risk for CV events in women over 35 (even greater with smoking history)

Drug Class: Thiazolidinedione Oral Hypoglycemic Agents -glitizone, pioglitazone/Actos

Actions: Increase sensitivity of muscle and fat tissue to insulin; inhibit hepatic gluconeogenesis, decrease hepatic glucose output Use: Effective in patients with type 2 DM Common adverse effects: Nausea, vomiting, anorexia, abdominal cramps Serious adverse effects: Hypoglycemia, hepatotoxicity, weight gain

Drug Class: Incretin-Mimetic Agents Drug: Exenatide (Byetta) -glutide, -natide

Actions: Increases serum insulin and reduces glucose concentrations, delays gastric emptying, reduces appetite Use: In combination with other hypoglycemic agents and metformin to reduce elevated fasting and postprandial hyperglycemia

Drug Class: Beta-Adrenergic Blocking Agents

Actions: Inhibit cardiac response to sympathetic nerve stimulation; inhibit renin release from kidneys Use: Initial therapy for stage 1 and 2 hypertension Common adverse effects: Bradycardia, peripheral vasoconstriction (purple, mottled skin); heart failure; bronchospasm, wheezing; masks hypoglycemia in diabetic patients Implications Hold medication if systolic BP is less than 100 mm Hg or if heart rate is less than 60 bpm; contact prescriber Sudden discontinuation of therapy has resulted in worsening angina, MI; medication should be gradually reduced over 1 to 2 weeks NSAIDs may inhibit effectiveness

Drug Class: HMG-CoA Reductase Inhibitors (Statins)

Actions: Inhibit enzyme responsible for converting HMG-CoA to mevalonate, ultimately reduce liver cholesterol Use: In conjunction with dietary therapy to reduce LDL and total cholesterol levels Common adverse effects: Headaches; nausea, abdominal bloating, gas Serious adverse effects: Liver dysfunction; myopathy, rhabdomyolysis; myoglobinuria Nursing considerations: Best administered at night because of peak cholesterol production at this time. Statins differ in potential drug interactions. Avoid Grapefruit juice: inhibits the metabolism of several statins

Drug Class: Prostaglandin Inhibitors Drug: Acetaminophen (Tylenol)

Actions: Inhibit prostaglandins; block generation of pain impulses in peripheral tissue Use: Discomfort associated with bacterial and viral infections, headache, and musculoskeletal pain Common adverse effect: Gastric irritation. Serious adverse effect: Hepatotoxicity (Max dose 4000 mg/day). Check Liver function tests Used with caution in liver failure Acetylcysteine is antidote

Drug Class: Progestins Progesterone, norethindrone

Actions: Inhibit secretion of pituitary gonadotropins, inhibit ovulation Uses: Treat secondary amenorrhea, breakthrough bleeding, endometriosis, contraception Common adverse effects: Weight gain, edema, tiredness, oily scalp, acne Serious adverse effects: Breakthrough bleeding, amenorrhea, cholestatic jaundice, headache, mental depression Contraindicated in pregnancy because of the possibility of birth defects.

Drug Class: Fosfomycin Antibiotics Drug: Fosfomycin (Monurol)

Actions: Inhibits bacterial cell wall synthesis, reduces bacteria's adherence to the urinary tract Use: Single-dose treatment for UTI Common adverse effects: Nausea, diarrhea, abdominal cramps, flatulence Serious adverse effects: Perineal burning, dysuria Implementation: Need to mix single-dose packet with 90-120 mL of water.

Drug Class: Antiandrogen Agents -steride Drug: Dutasteride (Avodart)

Actions: Inhibits enzyme 5-alpha reductase, reduce DHT levels Reduces hyperplastic cell growth Uses: Treatment of symptoms of BPH, reduces risks of urinary retention, minimizes need for surgery for BPH Common adverse effects: Impotence, decreased libido, decreased volume of ejaculate Monitor PSA level

Drug Class: Antiandrogen Agents Drug: Finasteride (Proscar)

Actions: Inhibits enzyme 5-alpha reductase, reduces DHT levels Uses: Treatment of symptoms of BPH, reduces risks of urinary retention, minimizes need for surgery for BPH, treatment of male pattern baldness Common adverse effects: Impotence, decreased libido, decreased volume of ejaculate Monitor PSA

Drug Class: Insulin Rapid-acting insulin Short-acting insulin Intermediate-acting insulin Long-acting insulin

Actions: Key regulator of metabolism, required for entry of glucose into skeletal muscle and fat, needed for protein and lipid metabolism Use: Control blood sugar in patients with diabetes mellitus Common and serious adverse effects: Hyperglycemia, hypoglycemia, allergic reactions, lipodystrophies (rotate injection sites).

Drug Class: Uterine Relaxants Tocolytic agents Drug: Magnesium sulfate

Actions: Produces anticonvulsant effects and smooth muscle relaxation, inhibits uterine muscle contractions Uses: Inhibits preterm labor, controls seizure activity associated with preeclampsia and eclampsia Serious adverse effects Absence of deep tendon reflexes, confusion, reduced urine output Calcium gluconate used as an antidote for magnesium toxicity Toxicity: Early signs of magnesium toxicity: Feeling hot all over, thirst, flushed skin, diaphoresis Next signs of magnesium toxicity: Hypotensive, depressed deep tendon reflexes Late signs of magnesium toxicity: CNS depression, anxiety, confusion, lethargy Very high: Cardiac depression, respiratory paralysis Use extreme caution with impaired renal function IM use painful, preferred via IV pump

ACE inhibitors

Actions: Promote vasodilation, minimize cellular aggregation, prevent thrombus formation Uses: Reduce the incidence of MI; secondary prevention for patients with known coronary artery disease (CAD) Also recommended for patients with acute MI or heart failure with left systolic dysfunction. Adverse effects such as dizziness, tachycardia, and fainting may occur within 3 hours after the first several doses.

Prokinetic Agents Drug: Metoclopramide (Reglan)

Actions: Reduces reflux, increases stomach contractions, relaxes pyloric valve, increases peristalsis Dopamine receptor blocker Uses: Treatment of gastric reflux esophagitis, diabetic gastroparesis; antiemetic Common adverse effects: Drowsiness, fatigue, lethargy, dizziness, nausea Serious adverse effects: Extrapyramidal symptoms (Restlessness, involuntary movements, facial grimacing, oculogyric crisis, torticollis, rhythmic tongue protrusion), risk of seizures

Drug: Rho(D) Immune Globulin Brand names: RhoGAM, HyperRHO, WinRho, Rhophylac, MICRhoGAM.

Actions: Suppresses stimulation of active immunity by Rh-positive foreign blood cells; prevents Rh hemolytic disease of newborns in subsequent pregnancies Use: Prevents Rh immunization of Rh-negative patient exposed to Rh-positive blood Common adverse effects: Localized tenderness, fever, arthralgias, generalized aches and pains Serious adverse effects: Urticaria, tachycardia, hypotension

Diseases associated with adrenal glands

Addison's disease, pheochromocytoma, and hyperpituitarism.

Nursing Implementations

Administer prescribed medications, monitor for adverse effects and for effectiveness Monitor lab studies, I&O, daily weights, pain Incontinence: Regular toileting schedule, bladder-training measures, easy access to toilet facilities, ensure safety and dignity

Warfarin

Adverse effects: Bleeding Skin, mucous membranes Internal bleeding Urine and stools Menstrual flow Surgical dressings and drains Contraindicated in pregnancy Antidote: Discontinue use, vitamin K Long half life Note numerous drug interactions

Common Stomach Disorders Peptic ulcer disease (PUD)

Aka acid indigestion •Several stomach disorders: Commonly gastric and duodenal ulcers •Symptoms: Burning, gnawing, aching •Goal of therapy: Relieve symptoms, Decrease frequency and duration of reflux, Heal tissue injury, Prevent recurrence, Lifestyle changes: no smoking, decrease ETOH and acidic foods

Nitrates Transdermal patch administration

Allows for control release of nitroglycerin Don gloves and apply disk to clean, dry, hairless intact skin. Don't shave hair or apply to scars, skinfolds, or wounds If disk dislodges, replace with new disk Sublingual nitroglycerin may be given for acute attack Remove for 8 to 12 hours to avoid tolerance Dispose of used patches out of the reach of children

Atherosclerotic Cardiovascular Disease

Almost one-third of the US population will die of a heart attack or stroke associated with atherosclerotic cardiovascular disease (ASCVD) Major treatable causes of ASCVD Cigarette smoking Sedentary lifestyle Poor eating habits leading to obesity Hypertension Type 2 diabetes mellitus Atherosclerosis

Rho(D) immune globulin (RhoGAM) is used to prevent a mother from producing antibodies against her fetus. Which situation calls for the administration of RhoGAM to the mother? A newborn baby is in the neonatal unit, born to an Rh-negative mother. An Rh-positive mother just delivered her child, who is Rh-negative. An Rh-negative mother is pregnant with her first child, who is Rh-positive. An Rh-negative mother is in labor with her second Rh-negative child.

An Rh-negative mother is pregnant with her first child, who is Rh-positive. Rationale: RhoGAM can be administered in a case where an Rh-negative woman is carrying an Rh-positive child. In this situation, there is a risk of fetal blood cells entering the maternal circulation, thus activating an antigen-antibody reaction and producing antibodies to the Rh-positive blood. The first child is born healthy, but a second child is at risk of hemolytic disease. RhoGAM can be administered prophylactically before birth to suppress the stimulation of active immunity by foreign red blood cells.

•A patient reports severe abdominal pain that occurs approximately 45 to 60 minutes after eating. The patient notes that eating dairy products or drinking milk alleviates the pain but eating Mexican food or drinking alcohol worsens the condition. The healthcare provider orders x-rays to be done in several days, but in the meantime, which type of drug will likely be recommended?

Antacid

Drug Therapy for Dysrhythmias

Antidysrhythmic agents classified according to effects on the heart's electrical conduction system. Class I: Myocardial depressant inhibits sodium ion movement Class Ia agents—Prolong duration of electrical stimulation Class Ib agents—Shorten the duration of electrical stimulation Class Ic agents—Potent myocardial depressants, slow conduction rate Class II: Beta-adrenergic blocking agents Class III: Slow rate of electrical conduction Class IV: Block calcium ion flow Miscellaneous

•A patient reports a harsh, nonproductive cough and muscle aches that have lasted for 5 days. There is no sore throat, temperature elevation, or swollen lymph nodes, but the patient is coughing so much that sleeping at night is difficult. Which type of medication will likely be prescribed for this patient?

Antitussive

Drug Class: Factor Xa Inhibitors

Apixaban, rivaroxaban, and edoxaban: Reduce risk of stroke and systemic embolism in patients with nonvalvular atrial fibrillation Common adverse effect is bleeding Do not need monitoring with PT/INR Prevention of DVT and PE and reduction of risk of thromboembolism in patients with atrial fibrillation. Does it have a reversal agent?

Nursing Implications for Osteoporosis

Assessment History of risk factors (smoking, dietary habits) Psychomotor functions Alcohol Dentition Pain Implementation and patient education Suggest patients stop smoking; provide educational materials Perform nursing assessments regularly Make referrals as needed Foster health maintenance

Drug Class: Alpha-1 Adrenergic Blocking Agents -osin Doxasosin/Cardura, tamsulosin/Flomax

BPH symptoms are similar to prostate cancer Action: Block alpha-1 receptors on the prostate gland, causing muscle relaxation, allowing greater urinary outflow do not reduce prostate size or inhibit testosterone synthesis Use: Reduce mild to moderate urinary obstruction in men with BPH Common adverse effects: Drowsiness, headache, dizziness, weakness, lethargy; tachycardia, fainting

Drug Therapy for Osteoporosis

Bisphosphonates and denosumab are appropriate as initial therapy Other treatments include abaloparatide, ibandronate, raloxifene, and teriparatide Dietary and supplemental calcium and vitamin D are also used for treatment.

Which adverse effect should a woman using the etonogestrel-ethinyl estradiol vaginal ring (NuvaRing) report to her healthcare provider? Nausea Weight gain Blurred vision Menstrual spotting

Blurred vision Rationale: Serious adverse effects of the vaginal ring are blurred vision, breakthrough bleeding, vaginal discharge, chest or leg pain, shortness of breath, or acute abdominal pain. The vaginal ring also has some common adverse effects like nausea, weight gain, spotting, change in menstrual flow, missed periods, depression, mood changes, chloasma, and headaches.

Complications Associated With Diabetes Mellitus

Cardiovascular disease Peripheral vascular disease Visual alterations Blindness Renal disease Infection Neuropathies Impotence Hypertension

Corticosteroid Therapy: Use With Caution

Carefully monitor patients with: Diabetes mellitus Heart failure Hypertension Peptic ulcer disease Mental disturbance Suspected infections

Hyperglycemia—High Blood Sugar

Caused by nonadherence, overeating, acute illness, or infection Symptoms: Headache, nausea and vomiting, abdominal pain, dizziness, rapid pulse, rapid shallow respirations, acetone odor to breath, may cause coma and death Treatment: Administration of IV fluids; insulin; monitoring blood glucose, ketones, and potassium

Hypoglycemia—Low Blood Sugar

Caused by too much insulin, insufficient food intake, vomiting and diarrhea, and excessive exercise Symptoms: Nervousness, tremors, headache, apprehension, sweating, cold and clammy skin, hunger; can lead to coma, death Treatments Administering food/liquids if able to swallow If unable to swallow, administer glucagon or IV fluids with 50% dextrose

Coumadin: Premedication Assessment

Check most recent PT/INR Assess for signs of bleeding Provide dietary education on foods high in vitamin K (green leafy vegetables) Note variety of dosages available 1, 2, 2½, 3, 4, 5, 6, 7½, 10 Stress need to comply with regimen and need for laboratory data

Laboratory Tests for Thromboembolic Diseases

Coagulation tests PT (prothrombin time): Monitors warfarin therapy aPTT (activated partial thromboplastin time): Monitors heparin therapy INR (international normalized ratio): Monitors warfarin therapy Platelet counts Diagnostic tests: PT, aPTT, hematocrit, platelet count, Doppler studies, exercise testing, serum triglycerides, arteriogram, cardiac enzyme studies

Oral Contraceptives

Combination pill: Taken for 21 days of the menstrual cycle; contains estrogen and progestin Subdivided into four classes: Monophasic, biphasic, triphasic, quadriphasic Minipill: Taken every day; contains only progestin Extended- and continuous-cycle contraceptives: 24- or 84-day cycles followed by a short placebo period Teach patient what to do if dose missed

Drug Class: Hydantoins

Common adverse effects 1--Folic acid deficiency folic acid is given to prevent anemia 2-- low platelet monitor for bleeding 3--leukopenia monitor infection/ CBC 4- rashes, stop the medication, notify the doctor, reassure the patient that the therapy will be resumed after the rash disappear

Drug Class: Opiate Agonists Drugs: Morphine and morphine-like derivatives; codeine, hydrocodone, oxycodone, meperidine-like derivatives; methadone-like derivatives; other opiate agonists

Common adverse effects: Lightheadedness, dizziness, sedation, sweating, confusion, disorientation (elderly); orthostatic hypotension, nausea, vomiting, constipation Serious adverse effects: Respiratory depression; urinary retention; excessive use or abuse, increased effect with CNS depressants Drug interactions: Tranquilizers, tricyclic antidepressants, antihistamines, alcohol. Observe for vital signs and mental status changes, especially respiratory rate. Hold medication if respirations are below 12/min for adult; consult with healthcare provider

Drug Class: Incretin-Mimetic Agents Two

Common adverse effects: Nausea, vomiting, diarrhea Severe adverse effects: Hypoglycemia, pancreatitis Associated with thyroid tumors in animals Administration: SC injection in thigh, abdomen, upper arm; don't give after meal; don't freeze, may be kept at room temperature for 30 days, then discard

Cardiac Medications

Common drug classes Beta blockers Ace inhibitors ARBs Calcium Channel Blocker (CCB) Diuretics Vasodilator Nitrates hydralzazine Statins

Overactive Bladder Syndrome

Common problem affecting many adults, especially those older than 65 Urgency, with or without urge incontinence, usually with frequency and nocturia Treatment goal: Reduce symptoms, decrease frequency by increasing volume voided, decrease urgency, and reduce incidents of urinary urge incontinence Patient education: Space liquids over day, avoid stimulants, bladder training, Kegel exercises, use absorbent undergarment products

Heparin Administration

Confirm calculation with another nurse Be certain dose strength is correct Therapeutic range: aPTT is 1.5 to 2.5 times control Subcutaneous injection into abdomen; don't massage site, alternate sites, use 90-degree angle, apply gentle pressure after Common adverse effect: Bleeding or hematoma at injection site Serious adverse effects: Bleeding Mucous membranes Skin Urine and stools Thrombocytopenia Internal bleeding

Which gonadal medication does the nurse expect to be prescribed for an older patient with prostate cancer? Conjugated estrogen (Premarin) Testosterone (Striant) Fluocinonide (Lidex) Fluoxymesterone (Androxy)

Conjugated estrogen (Premarin) Rationale: Premarin and other forms of estrogen may be used in the palliative treatment of prostate cancer. Male reproductive cancers are increased in the presence of testosterone, and the female hormone estrogen, taken in lower doses, can slow the progression of the disease.

Erectile Dysfunction

Consistent inability to achieve or maintain an erection sufficient for satisfactory sexual activity Diagnosis is based on a medical and sexual history, physical examination, and laboratory studies Risk factors include cigarette smoking, hyperlipidemia, hypertension, diabetes mellitus, coronary artery disease, and peripheral vascular disease

Glucocorticoids

Cortisone Hydrocortisone Prednisone

What is common adverse effect of glucocorticoids? Weight loss Hypoglycemia Appetite suppression Delayed wound healing

Delayed wound healing Rationale: Glucocorticoids produce many adverse effects, including delayed wound healing, hyperglycemia, weight gain, fluid retention, increased fat deposition, increased appetite, mood swings, and gastric ulcer formation.

Patient Education for Anticoagulation Therapy

Diet and nutrition Limit intake of leafy green vegetables (Vitamin K inhibits warfarin and is it's antidote) Drink six to eight 8-ounce glasses of fluid daily Exercise and activity after surgery to prevent venous stasis Do not flex knees or place pressure under knees; avoid being motionless Medication regimen Wear medical alert bracelet Dose and timing, common and serious adverse effects, drug interactions Report all signs of bleeding

Nutrition for DM

Diet used alone or with medications Exchange lists 15 carb counts a day 1 carb count = 15 g of carbohydrates Teach how to read a nutrition label Consistent carbs diabetes plan: 1500 to 2000 calories with 45% to 65% carbs, 10% to 35% proteins, 20% to 35% fats Weight loss recommended for high BMI Diet needs change with growing children, adolescents, pregnant/lactating women, older adults See sick day plan

Corticosteroid Therapy: Drug Interactions

Diuretics: Corticosteroids may enhance the loss of potassium Warfarin: Corticosteroids may enhance or decrease the anticoagulant effects of warfarin Oral hypoglycemic agents or insulin: Diabetics/prediabetic patients must be monitored for hyperglycemia

Drug Class: Central-Acting Alpha-2 Agonists

Do not abruptly discontinue clonidine; could cause a rebound effect with increased BP, nervousness, agitation, restlessness, etc. Withdrawal symptoms could appear within a few hours, become severe in 8 to 24 hours Use an adhesive overlay to keep the patch in place

Storage of Insulin

Don't freeze; store in refrigerator until opened Insulin loses potency at sustained higher than room temperature Insulin bottle or cartridges may be kept at room temperature until gone; discard after 30 days Do not shake insulin; can roll vial gently in palm of hand to warm and resuspend

Other Uterine Stimulants

Don't leave patient unattended, always use IV pump Monitor uterine contractions, fetal heart rate and rhythm, observe for fetal distress Overdose may cause hyperstimulation of the uterus, severe contractions, abruptio placentae, cervical lacerations, impaired uterine blood flow, uterine rupture, fetal trauma Fetal distress: Reduce oxytocin infusion, turn mother to left lateral, give O2, contact MD

Drug Class: Platelet Inhibitors

Drug: Aspirin, clopidogrel (Plavix), ticlopidine (Ticlid). Actions: NSAID, platelet aggregation inhibition Action: Inhibit platelet aggregation Uses: Primary prevention of MIs and stroke; prevent blood clots from forming Common adverse effects: Abdominal distress, hypotension Serious adverse effects Neutropenia, agranulocytosis, bleeding With clopidogrel: Thrombotic thrombocytopenic purpura (TTP)

Miscellaneous Antidysrhythmic Agents(Slide 3 of 3)

Drug: Digoxin (Lanoxin) Actions: Slows conduction through the AV node, reducing conduction velocity and automaticity; increases cardiac output Uses: Treats atrial fibrillation, atrial flutter, paroxysmal tachycardia

Drug Class: Bile Acid-Binding Resins

Drugs: Cholestyramine, colestipol, colesevelam Actions: Bind to bile acids, promote increased metabolism of cholesterol Use: In conjunction with dietary therapy to decrease elevated cholesterol Common adverse effects: Constipation, bloating, fullness, nausea, flatulence Serious adverse effect: Vitamin K deficiency (rare) See special mixing instructions: powder to mix with fluid Drug interactions: Digoxin, warfarin, thyroid hormones, thiazide diuretics, phenobarbital, NSAIDs, tetracycline, beta blockers, amiodarone, fat-soluble vitamins.

Drug Class: Class II Antidysrhythmic Agents (Beta Blockers)

Drugs: Esmolol (Brevibloc), metoprolol (Lopressor, Toprol) Action: Inhibit cardiac response to sympathetic nerve stimulation to reduce heart rate, systolic blood pressure, cardiac output Uses: Treat ventricular dysrhythmias, sinus tachycardia, paroxysmal supraventricular tachycardia, premature ventricular contractions, tachycardia-associated atrial fibrillation or flutter

Drug Class: Fibric Acids

Drugs: Gemfibrozil (Lopid), fenofibrate (Tricor) Action: Lower triglyceride levels; mechanism of action unknown Use: In conjunction with dietary therapy to treat hypertriglyceridemia Common adverse effects: Nausea, diarrhea, flatulence, bloating, abdominal distress Serious adverse effects: Fatigue, anorexia, nausea, malaise, jaundice Myopathy may occur if used in conjunction with statins. Serious adverse effects: Early symptoms of gallbladder disease and hepatotoxicity.

Drug Class: Fibrinolytic Agents

Drugs: Streptokinase, alteplase (Activase), reteplase (Retavase), tenecteplase (TNKase) Action: Stimulate the body's own clot-dissolving mechanism, converting plasminogen to plasmin, which digests fibrin Use: Dissolve fibrin clots secondary to coronary artery occlusion (MI), pulmonary emboli, cerebral emboli, deep venous thrombosis Serious adverse effects: Increased risk of bleeding, allergic reactions.

Which symptom is an adverse effect of anticholinergic agents used to treat overactive bladder syndrome (OAB)? Increased salivation Diarrhea Dry mouth Restlessness

Dry mouth Rationale: Anticholinergic agents used to treat OAB have many common adverse effects, such as dry mouth, blurred vision, constipation, confusion, and sedation.

The nurse instructs a patient taking fludrocortisone (Florinef) that she should notify the healthcare provider of the occurrence of which adverse effect? Fatigue Weight loss Edema of feet and ankles Nausea

Edema of feet and ankles Rationale: Edema of the feet and ankles can result from taking a prolonged dosage of fludrocortisone, and adverse effects associated with this medication must be reported. Fludrocortisone causes sodium and water retention and potassium excretion, which can then result in fluid leaking out of capillary beds and accumulating in feet and ankles. Weight will also increase due to fluid retention.

Benign Prostatic Hyperplasia

Enlarged prostate (prostatism) Common later in life Symptoms are highly variable and patient specific; get worse over time Obstructive and irritative

Thyroid Disorders Hyperthyroidism

Excess production of thyroid hormones Diseases causing overproduction: Graves' disease, nodular goiter, thyroiditis, thyroid carcinoma, tumors of the pituitary gland Overdose of thyroid hormones Thyrotoxicosis: Also known as hyperthyroidism Symptoms Nervous, agitated, tremors, diarrhea, increased appetite, weight loss, exophthalmos Increased temperature, pulse, BP

Mineralocorticoids

Fludrocortisone Aldosterone

Treatment of Thyroid Disease

Goal of therapy: Return to a normal thyroid state Two classes of drugs Thyroid replacement hormones (hypothyroid) Antithyroid agents (hyperthyroid) Hyperthyroidism: Three treatments used Subtotal thyroidectomy Radioactive iodine Antithyroid medications May take 1-3 weeks to see effects

Treatment of Diabetes Mellitus

Goals of treatment: (Prevent ketoacidosis, Minimize incidence and effects of hyperglycemia) Goals of dietary control: (Prevent excessive postprandial hyperglycemia) Prevent hypoglycemia Maintain normal weight Reduce elevated cholesterol and triglyceride levels Exercise and weight management

Nitrates Sublingual use for emergencies

Have patient sit or lie down Place nitroglycerin tablet under the tongue, allow dissolving without swallowing saliva immediately If chest pain not relieved within 5 minutes seek medical attention While waiting for emergency care, take 1 tablet 5 minutes later, if unrelieved in 5 minutes, take another tablet Discard medication after 6 months and obtain new bottle Store tablets in an original dark-colored glass container with a tight lid Carry nitroglycerin at all times, but NOT in pocket directly next to the body Determine if agency policy permits nitroglycerin at bedside. Nurse still responsible for determining effectiveness

Nursing Interventions for Hypothyroidism

History of prior treatment for thyroid disorders, cardiac disease, or adrenal insufficiency Request list of medications being taken Nutrition: Low-calorie, high-fiber diet, fluids Warm, quiet environment Lifelong thyroid replacement medications, need for periodic lab studies Patient may experience depression Focus on affected systems (not all may be present)

Nursing Assessment for Cardiac Medications

History of risk factors Hypertension Smoking Dietary habits Glucose intolerance Elevated serum lipid levels Obesity Psychomotor functions

Nursing Assessments for Urinary System Disease

History: Congenital disorders of urinary tract, STIs, recent delivery, catheterization or urologic procedure, prostate disease, neurologic bladder dysfunction, last BM, usual fluid intake and output Pattern of urination, pain Medication, including OTC and herbal Nutrition: Fasting, alcohol, dietary supplements, fluid intake, use of caffeine

Thyroid Functions

Hypothalamus secretes thyrotropin-releasing hormone (TRH) Anterior pituitary secretes thyroid-stimulating hormone (TSH) in response to TRH Thyroid gland secretes T3 and T4 in response to TSH Need iodine though food and water intake T3 and T4 regulate: General body metabolism Carbohydrate, protein, lipid metabolism Thermal regulation Cardiovascular function Growth and maturation Lactation and reproduction

Nausea and Vomiting

Implementation: Diet as prescribed, gradual progression of diet; usually stop solid foods, take oral rehydration solutions or clear liquids; NPO and/or NG tube if severe Infants: Milk products and solid foods discontinued, offer small volumes of liquids every 30 to 60 minutes Schedule antiemetic meds, rather than PRN

Thyroid Disorders Hypothyroidism

Inadequate thyroid hormones Myxedema: Occurs during adult life Cretinism: Born without a thyroid gland, or hypoactive one Symptoms Slowed motion, speech, mental process Lethargy, decreased appetite, weight gain Decreased temperature, pulse, BP Anemia and high cholesterol, constipation Increased susceptibility to narcotics, anesthesia

Thromboembolic Diseases

Include the process of forming a blood clot or thrombus Fragments of a thrombus can break off and circulate until trapped in a capillary, creating an embolus The clotting cascade is activated when a blood vessel is injured, or with increased viscosity Intrinsic clotting pathway: damage to the blood vessel Extrinsic clotting pathway: damage outside the blood vessel

Obstetric Complications

Infections Hyperemesis gravidarum Miscarriage, placental separation, abortion Preterm labor Premature rapture of membranes Gestational diabetes mellitus (GDM) Pregnancy-induced hypertension (PIH) Amniocentesis may determine fetal lung maturity and detect fetal disorders

Patient Education for DM

Intensive therapy: Comprehensive program of DM management Self-monitor blood glucose Medical nutrition therapy (MNT) Exercise Type 1: 3 or more insulin injections per day, or insulin pump Maintain blood pressure control Maintain normal blood lipids Maintain BMI <25 kg/m2 Recognize symptoms of hyperglycemia and hypoglycemia Constant education and re-education Smoking cessation highly recommended American Diabetics Association has great resources for HCP and patients

Patient Education for Corticosteroid Therapy

Know when to contact healthcare provider Perform appropriate skin care Cope with stress Avoid infections Ensure proper nutrition Ensure regular exercise Foster health maintenance Maintain a written record

A woman at 30 weeks' gestation is in active labor with still-intact membranes. Which medication does the nurse anticipate will be ordered in an attempt to slow her labor? Magnesium sulfate Oxytocin (Pitocin) Prolactin Ergonovine maleate (Ergotrate Maleate)

Magnesium sulfate Rationale: In this situation, magnesium sulfate depresses the central nervous system and blocks peripheral nerve transmission. This causes smooth uterine muscle relaxation, causing the drug to slow, then stop, labor. The patient must be monitored very closely during the drug's administration.

Activity and Exercise For DM

Maintain normal lifestyle, including exercise Gradually increase duration and frequency Patient should consult with prescriber before initiating exercise program Monitor glucose level before, during, and after exercise, drink sufficient fluids Exercise helps cells use glucose, lowers glucose level Stop exercising if feeling weak, dizzy, sick

Hyperlipidemia Abnormal elevation of cholesterol and triglycerides.

Major cause of atherosclerosis Atherosclerosis characterized by fatty deposits in artery walls Caused by genetic abnormalities and secondary factors such as lifestyle, drugs, or underlying diseases Low levels of HDL and high levels of LDL are risks for atherosclerosis and coronary heart disease

•A patient has a history of emphysema and has been coughing for a prolonged period after waking in the morning. The patient is having difficulty clearing the thickened mucus from the lungs. Which type of medication does the nurse anticipate will be ordered for this patient?

Mucolytic

Which category of drugs is contraindicated with the concurrent use of the phosphodiesterase inhibitor sildenafil (Viagra)? Beta-adrenergic blockers Alpha-adrenergic blockers Nitrates Anticholinergics

Nitrates Rationale: Patients receiving nitroglycerin or isosorbide should not take phosphodiesterase inhibitors due to a potentially fatal interaction. Sildenafil works by dilating blood vessels, which can cause a drop in blood pressure. Nitrates should not be taken with sildenafil, as a dangerously low blood pressure could result.

Drug Classes That Treat Angina

Nitrates* Beta-adrenergic blocking agents ACE inhibitors Calcium channel blockers Fatty oxidase enzyme inhibitors Statins Platelet-active agents

Drug Class: Biguanide Oral Antidiabetic Agent Drug: Metformin (Glucophage) Two

Note: Numerous drug/alcohol interactions Will not cause hypoglycemia, does not cause weight gain, affects triglycerides to a modest degree. Serious adverse effects Malaise, myalgias, respiratory distress, hypotension Lactic acidosis: Patients with reduced renal function, poor circulation, excessive alcohol intake are most susceptible IV radiopaque dyes can induce temporary renal insufficiency; metformin should be discontinued 24 to 48 hours before procedures and 2 to 3 days after procedure until normal renal function

Nursing Process for Anginal Therapy

Obtain a history of attacks: Precipitating factors Characterize attacks CNS involvement confusion, restlessness, or irritability, as well as syncope and anxiety. Cardiovascular signs palpitations, peripheral pulses, and vital signs Obtain medication history Prescription and nonprescription Effect of agents used on attacks Obtain nutritional history: History of high cholesterol

Variant angina

Occurs at rest, characteristic ECG changesProbable cause Probable ca use: Vasospasm of the coronary artery

Analgesics relieve pain; can be classified according to neurologic mechanisms

Opiate agonists: For severe acute pain Opiate partial agonists: For unrelieved or moderate acute pain Opiate antagonists: Reverse adverse effects of opiate agonists Salicylates: For mild acute pain Nonsteroidal antiinflammatory drugs (NSAIDs): For mild acute pain Miscellaneous

Osmotic Laxatives Polyethylene glycol (Colyte, Go-LYTELY, MiraLax), lactulose (Cephulac), glycerin

Osmotics: Draw water into the intestine from surrounding tissues •Use: Relieve acute constipation

A patient who is 41 weeks pregnant has been in labor for over 24 hours. The uterine contractions have slowed and are ineffective, and her cervix is nearly fully dilated. Which drug does the nurse anticipate will be ordered for this patient? Methylergonovine maleate (Methergine) Oxytocin (Pitocin) Ergonovine maleate (Ergotrate Maleate) Prolactin

Oxytocin (Pitocin) Rationale: Oxytocin, a hormone produced by the hypothalamus and stored in the pituitary gland, stimulates smooth muscle contraction of the uterus and is a common agent used to induce or augment labor. Ergonovine maleate produces intense uterine activity that is dangerous to the fetus and is therefore not used for the induction of labor.

Pain Three terms apply

Pain perception: Also called nociception Pain threshold: Where pain is first perceived Pain tolerance: Person's ability to endure pain

Nursing Implications For Diabetes 2

Physical assessment Hyperglycemic or hypoglycemic episodes Illness/stress Hyper and hypoglycemic episodes may occur Vascular changes Check vision regularly Neuropathy Foot care, wear shoes (no bare feet) check for breaks in skin/infection/wounds Weight Laboratory studies: Hemoglobin A1c Nutrition Psychosocial assessment Medications Activity and exercise

Which laboratory test result is the nurse especially aware of for a patient who is taking fludrocortisone (Florinef) for the treatment of Addison's disease? Potassium depletion Sodium loss Calcium loss Hydrogen increase

Potassium depletion Rationale: The nurse should be especially aware of decreased potassium levels, which can cause muscle weakness and increase the risk of cardiac rhythm abnormalities. Fludrocortisone's mineralocorticoid and glucocorticoid effects can disrupt fluid and electrolyte balance by acting on the distal renal tubules, causing sodium and water retention and potassium and hydrogen excretion.

Chronic stable angina

Precipitated by stress or exertion, short duration Relieved by rest or nitroglycerin Probable cause: Fixed atherosclerotic obstruction

Nursing Assessments in Obstetrics

Prenatal visit Nutritional history Elimination pattern Psychosocial cultural history Medication history, including prescription, OTC, herbal Street drugs and alcohol Physical examination Assessment during the first, second, and third trimesters

Nonpharmacologic Treatment of Thromboembolic Diseases

Prevention of conditions that cause clots to form Immobilization with venous stasis Surgery, trauma to lower limbs Heart failure, vasospasm Cancers of the lung, prostate, stomach, pancreas Pregnancy, oral contraceptives Ways to prevent stasis: Leg exercises, wearing stockings, leg elevation, sequential compression devices Revascularization treatments: Percutaneous coronary intervention, coronary artery bypass graft' Prevention best treatment: early mobilization and ambulation, turning schedule, Sequential Compression Devices, SCDs, (simulate walking by using air pressure to pump the veins circulation)

Drug Therapy for Diabetes Mellitus

Primary goal of treatment of type 1 and type 2 diabetes is normalization of blood glucose levels Patient should check blood glucose level before each meal and at bedtime ADA recommends patients with prediabetes be treated to prevent/delay onset of type 2 diabetes Patients should be encouraged to limit amount of time they spend being sedentary by breaking up extended amounts of time (>90 minutes) spent sitting

Drug Therapy Goals for Thromboembolic Diseases

Primary purpose is to prevent platelet aggregation or inhibit steps in the clotting cascade Four types of agents Platelet inhibitors: prevent platelet aggregation Anticoagulants: help keep clotting factors from activating Glycoprotein IIb/IIIa inhibitors Thrombolytics (only one that will dissolve clot) Anticoagulation therapy prevents new clot formation or extension of existing clots

Treatment of Hypertension

Primary purpose of controlling hypertension: Reduce frequency of cardiovascular disease Blood pressure must be reduced and maintained below 130/80 mm Hg in adults Adoption of DASH (Dietary Approaches to Stop Hypertension) diet Treatment schedules should interfere as little as possible with patient's lifestyle Lifestyle modification Weight reduction Adopt a healthy eating plan Dietary sodium reduction Physical activity Moderation in alcohol consumption

Hyperlipidemia Therapy

Primary treatment is therapeutic lifestyle changes (TLCs) Weight reduction Exercise 30 min/a day of moderate activity Diet low in cholesterol and fat When this fails, we go to medication therapy Bile acid-binding resins Niacin HMG-CoA reductase inhibitors-statins Fibric acids Omega-3 fatty acids Antilipemic agents used only if diet and exercise are unsuccessful Combining bile acid-binding resins with niacin or statin can lower LDL by 40% to 50% Before starting therapy, a lipid panel should be drawn and then repeated in 4 to 12 weeks after therapy is initiated. This is a fasting blood test

•What is the action of saline laxatives?

Promoting peristalsis by drawing water from blood plasma to increase the volume of the intestinal contents

Which action does the nurse take to provide improved care for a patient with hypothyroidism? Increases the calories in the patient's diet Reduces the temperature in the room Administers the patient's antithyroid medication on time Provides additional blankets

Provides additional blankets Rationale: The nurse can offer resources to warm the patient with hypothyroidism who is likely cold due to decreased metabolism.

Which adverse effect of the antithyroid agent propylthiouracil (PTU) is common and usually self-resolving? Bone marrow suppression Nephrotoxicity Purpuric rash Hepatotoxicity

Purpuric rash Rationale: The most common reaction (in 5% of all patients) to propylthiouracil is a purpuric, maculopapular skin eruption. It may occur during the first 2 weeks of therapy and usually resolves spontaneously without treatment. The other adverse effects are serious and should be reported to the healthcare provider.

Types of Insulin

Rapid-acting Onset: 10 minutes; peak: 1 to 3 hours; duration: 3 to 5 hours Short-acting Onset: 30 minutes; peak: 2.5 to 5 hours; duration: 5 to 10 hours Intermediate-acting Onset: 4 hours; peak: 4 to 12 hours; duration: 16 to 24 hours Long-acting Onset: 1 hour; no peak; duration: 24 hours When would you administer each type? Before meals, in the morning, at night? Based on the onset, peak, and duration of each type of insulin.

The Joint Commission current standards for pain management therapy

Relief of pain intensity and duration of pain Prevention of conversion of persistent pain to chronic pain Prevention of suffering and disability associated with pain Prevention of psychological and socioeconomic consequences associated with inadequate pain management Control of adverse effects associated with pain management Optimization of the ability to perform activities of daily living (ADLs)

Which protocol does a nurse enforce when caring for a patient receiving radioactive iodine? Not allowing visitors to enter the room Reporting any urine spills in the room to the supervisor Ensuring that there is no risk to the patient or nurse from the radioactive iodine Reporting any tenderness over the thyroid to the healthcare provider

Reporting any urine spills in the room to the supervisor Rationale: It is very important for the nurse to report any spills of urine, vomit, or stool to a supervisor and ensure that special procedures are followed to dispose of the material properly. Tenderness over the thyroid gland is a common adverse effect of radioactive iodine (radioactive thyroiditis), which usually occurs during the first few days or weeks after therapy and resolves on its own.

Nursing Interventions for Hyperthyroidism

Review history, request list of all medications Cool, quiet environment, may have anxiety High-calorie diet; avoid caffeine, laxatives, and other GI stimulants If surgery planned, order tracheostomy set at bedside; assess for bleeding, respiratory distress, hoarseness, tetany; have IV calcium available at bedside

Laboratory and Diagnostic Studies for Urinary System

Review urinalysis, renal function tests, voiding evaluator procedures, cystoscopy, complete blood count with differential, urine culture, and sensitivity results Urinalysis: Physical, chemical, and microscopic examination of the urine

Treatment of Angina Pectoris

Risk factors include diabetes mellitus, hypertension, and dyslipidemia. Goals: Prevent myocardial infarction and death; pain relief Alternatives to drug therapy: Coronary angioplasty; Coronary artery bypass graft surgery Patient education: Avoid precipitating factors, reduce risk factors, exercise

Drug Therapy for Diabetes Mellitus Biguanide: Metformin

Secretagogues (glyburide, glipizide, glimepiride) Thiazolidinediones (TZDs) Alpha-glucosidase inhibitors (acarbose; miglitol) Sodium-glucose cotransporter 2 (SGLT2) inhibitors Incretin-related therapy

Functions of Adrenal Glands

Secrete two types of corticosteroids (hormones) Mineralocorticoids Glucocorticoids

Drug: lamotrigine (Lamictal)

Serious adverse effects 10% of patients develop skin rash and urticaria, could become more serious Neurologic changes Aseptic meningitis (headache, fever, stiff neck, nausea, vomiting, rash, and sensitivity to light)

Drug Class: Sulfonylurea Two Oral Hypoglycemic Agents

Serious adverse effects: Hypoglycemia, hepatotoxicity, blood dyscrasias, dermatologic reactions Patients allergic to sulfonamides may be allergic to sulfonylureas\ Drug interactions: many and look at concurrent use with hypoglycemic agents

Causes (etiology)Associated with Hypertension

Sleep apnea Drug-induced or related causes Chronic kidney disease Primary aldosteronism Renovascular disease Chronic steroid therapy and Cushing's syndrome Pheochromocytoma Coarctation of the aorta Thyroid or parathyroid disease

What is a common use for the drug misoprostol (Cytotec)? Induce uterine contractions Stop premature labor Soften the cervix before inducing labor Reduced elevated blood pressure

Soften the cervix before inducing labor Rationale: Misoprostol is used to soften the cervix before inducing labor. Misoprostol is also used to empty the uterus of its contents when necessary.

Diarrhea Stimulant Stimulants: Bisacodyl (Correctol, Dulcolax, Modane), sennosides A&B (Ex-Lax), senna concentrate (X-Prep)

Stimulants: Cause irritation, promoting peristalsis and evacuation of the bowel

Nondrug Therapy for Seizures

Surgical intervention can treat refractory seizures. Lobectomy, implant vagus nerve stimulators is approved for children 12 years and older Ketogenic diet (restricts carbohydrates) fat as the primary fuel for the body; it has been shown to reduce refractory seizures in children who have not experienced effective control with drug therapy. Adverse effects include high lipid levels.

Constipation

Symptom-based disorder of unsatisfactory defecation characterized by infrequent stools, difficult stool passage, or both

What is the primary difference between a combination oral contraceptive and the minipill? The minipill contains only estrogen. The combination pill contains estrogen and progestin. The minipill has a decreased risk of tubal pregnancy. The combination pill is recommended for women with a history of migraine headaches.

The combination pill contains estrogen and progestin. Rationale: The combination pill contains both estrogen and progestin, whereas the minipill contains only progestin. The minipill is associated with a somewhat increased risk of tubal pregnancy, irregular periods, and spotting between periods.

Drug Class: Estrogens

Therapeutic outcomes: Contraception; hormonal balance; osteoporosis prevention; lessen severe acne in females Common adverse effects: Headache, migraine, insomnia, weight gain, edema, breast tenderness, nausea Serious adverse effects: Hypertension, thrombophlebitis, hyperglycemia, breakthrough bleeding Smoking increases risks Drug interactions: May diminish the anticoagulant effects of warfarin; may inhibit the metabolism of phenytoin resulting in phenytoin toxicity; increase in thyroid hormone dosage may be required if hypothyroidism results. May be ineffective with antibiotic use

Drug Therapy for Thyroid Disease Two general classes of drugs

Those used to replace thyroid hormones in patients whose thyroid glandular function is inadequate to meet metabolic requirements (hypothyroidism) Antithyroid agents used to suppress synthesis of thyroid hormones (hyperthyroidism)

What is the action of insulin? Enhancing the conversion of glycogen to glucose Promoting the conversion of protein to amino acid chains Releasing fatty acids from adipose tissue Transporting glucose through the cell membrane

Transporting glucose through the cell membrane Rationale: Insulin is necessary to transport glucose through the cell membrane. Cells require glucose for energy, and insulin is necessary in order to facilitate the inflow of glucose.

Diarrhea- Considered a symptom, not a disease

True

Nausea- Sensation of abdominal discomfort intermittently accompanied by a desire to vomit

True

DM Medications

Type 1: Insulin (pancreas cannot make insulin, so we have to provide it) Rapid, Short, Intermediate, Long term Type 2 (Decrease in beta cell activity, insulin deficiency, Insulin resistance, Increased liver production of glucose) PO medications primarily, Mainly effect liver, Increase Cell sensitivity Other specific types (Endocrinopathies, Drug- or chemical-induced infection, Genetic syndromes) Treated until resolved insulin or PO medications Gestational diabetes mellitus ([GDM] Abnormal glucose tolerance during pregnancy) Reclassified as Type 2 if not resolved 6 weeks after pregnancy PO Medications

Unstable angina

Unpredictable; changes in frequency, duration, onset Probable cause: Atherosclerosis and thrombus formation

The healthcare provider has ordered the use of an inhaler for an 8-year-old patient newly diagnosed with asthma. To use the inhaler correctly, what does the nurse instruct the patient to do?

Use a spacer between the inhaler and lips to control the medication.

Drug Class: Nitrates Intravenous nitroglycerin administration

Used in acute care areas, requires constant monitoring of vital signs Use infusion pump for accuracy, titrate Cannot be mixed with other medications Use special "Nitro" tubing to avoid plastic sets absorbing the medication

Drug Class: Urinary Antimicrobial Agents

Uses Based on identification of the pathogens by Gram staining or by urine culture in severe, recurrent, or chronic infections Fosfomycin and nitrofurantoin are used only for UTIs Fluid intake should be encouraged Duration of treatment depends on whether the infection is uncomplicated or complicated

Drug Class: Anticoagulants Low-molecular-weight heparin (LMWH), enoxaparin (Lovenox),

Uses: Prevent deep vein thrombosis after hip replacements or abdominal surgery; prevent MIs, combined with aspirin Common adverse effects: Hematoma formation, bleeding at injection site Serious adverse effects: Bleeding, thrombocytopenia Administered Subcutaneously in Abd Don't expel air bubble in the prefilled syringe prior to injection Inject entire needle into skinfold, inject slowly, leaving the needle in place for 10 seconds after injection Don't rub the injection site Alternate sites

Which assessment finding suggests that a patient may have hyperthyroidism? Weight loss despite increased appetite and food intake Decreased heart rate Decreased body temperature Eyes that appear sunken

Weight loss despite increased appetite and food intake Rationale: In a patient with hyperthyroidism, weight loss occurs despite greater food intake because the patient's metabolic rate is rapidly increased.

Common Stomach Disorders Gastroesophageal reflux disease (GERD)

• •Known as heartburn/sour stomach •Symptoms: Burning, bloating, belching, regurgitation •Reflux of gastric secretions such as pepsin and hydrochloric acid into the esophagus •

Mucolytic Agents Drug: Acetylcysteine (Mucomyst)

• •Smells like rotten eggs (sulfur) in liquid form •Action: Dissolves chemical bonds in mucus •Uses: Dissolves abnormally viscous mucus; treatment of chronic emphysema, emphysema with bronchitis, asthmatic bronchitis, pneumonia (treat Tylenol toxicity) •Therapeutic outcome: Improved airway flow. •Common adverse effects: Nausea and vomiting due to odor •Serious adverse effect: Bronchospasm (may use bronchodilator concurrently)

Opioid Antagonists Methylnaltrexone /Relistor injection

•Action: Bind to opioid receptors in the GI tract, inhibiting constipation •Used in the treatment of opioid-induced constipation

Histamine-2 Receptor Antagonists (idine) •famotidine/Pepcid, ranitidine/Zantac

•Action: Block H2 receptors resulting in decreased volume of acid secreted •Uses: Treat GERD, duodenal ulcers, stress ulcers •Common adverse effects: Dizziness, headache, somnolence, diarrhea, constipation Serious adverse effects: Confusion, disorientation, hallucinations, gynecomastia, hepatotoxicity

Serotonin Antagonists (setron) ondansetron/Zofran

•Action: Block the serotonin 5-HT3 receptors located in the chemoreceptor trigger zone of the medulla and in specialized cells of the GI tract •Uses: Treat nausea and vomiting associated with chemotherapy, radiation; PONV •Common adverse effects: Headache, diarrhea, constipation, sedation •Doesn't usually cause extrapyramidal effects

Antacids

•Action: Buffer hydrochloric acid to a lower concentration •Uses: Treat heartburn from excessive eating and drinking; acute ulcer treatment requires large volumes •Common adverse effect: Chalky taste •Serious adverse effects: Constipation (with calcium or aluminum), diarrhea (with magnesium) •Drug interactions: give after 2 hours of a H2 antagonist

Anticholinergic Agents (meclizine, scopolamine patch/Transderm-Scop, dimenhydrinate/Dramamine)

•Action: Counterbalance excessive amounts of acetylcholine thought to cause motion sickness •Uses: Treat motion sickness; nausea and vomiting associated with pregnancy •Meclizine commonly prescribed for vertigo •Common adverse effects: Anticholinergic effects, sedative effects •Scopolamine patch changed every 3 days behind the ear

Proton Pump Inhibitors •-prazole •Pantoprazole/Protonix, omeprazole/Prilosec, esomeprazole/Nexium

•Action: Inhibit gastric secretion by inhibiting gastric acid pump of the parietal cells •Uses: Treat severe esophagitis, GERD, gastric and duodenal ulcers •Common adverse effects: Diarrhea, headache, fatigue, muscle pain •Serious adverse effects: Rash, risk of fractures, hypomagnesemia •Drug interactions with warfarin, sucralfate, phenytoin, & diazepam

Respiratory Antiinflammatory Agents •Oral inhalant corticosteroids -sone: budesonide phosphate/Pulmicort, fluticasone proprionate/Flovent;

•Action: Inhibit inflammatory responses •Uses: For patients unresponsive to sympathomimetic agents or xanthine derivatives; prevent symptoms of asthma •Aerosols enhance the effects of beta-adrenergic bronchodilators and have a direct effect on smooth muscle relaxation. •Common adverse effects: Hoarseness, dry mouth •Serious adverse effect: Thrush •Oral hygiene following administration a must for prevention •May be in combination with bronchodilators (ex. Budesonide/formoterol, Symbicort, fluticasone/salmeterol, Advair)

Mouthwashes

•Action: Kill bacteria to reduce plaque formation and halitosis •Uses: Remove disagreeable tastes, reduce halitosis, reduce plaque buildup •Ingredients: Fluoride, Chlorhexidine: Antibacterial •Prevention of VAP (Ventilator associated Pneumonia), total care patients to prevent complications in acute setting •Zinc chloride: Decreases bleeding and irritation •Therapeutic outcomes: Temporary reduction in bleeding or irritation, relief of discomfort, refreshing taste, improvement of halitosis.

Lubricant Laxatives Mineral oil

•Action: Lubricate intestinal wall, allowing for smooth passage of fecal contents •Used as prophylactic for patients who should not strain during defecation

Anticholinergic Bronchodilating Agents (pium) Drugs: Ipratropium bromide (Atrovent), tiotropium (longer duration of action than ipratropium) bromide (Spiriva)

•Action: Produce bronchodilation •Use: Long-term treatment of reversible bronchospasm associated with COPD •Common adverse effects: Mouth dryness, throat irritation •Serious adverse effects: Tachycardia, urinary retention, exacerbation of symptoms

Antileukotriene Agents (lukast) Drugs: Montelukast (Singulair), Zafirlukast (Accolate)

•Action: Selective and competitive receptor antagonist of cysteinyl leukotriene receptor •Use: In combination with other drugs to treat asthma •Route: oral pill •Common adverse effects: Headache, nausea, dyspepsia

Cannabinoids Dronabinol (Marinol) Synthetic analog of THC

•Action: Several mechanisms inhibit pathways to the vomiting center •Uses: In patients refractory to other antiemetic regimens; only for patients receiving chemotherapy •Common adverse effect: Dysphoric effects, muddled thinking, drowsiness & dizziness •Schedule III controlled substance drug •Antihistamine increases effects

Beta-Adrenergic Bronchodilating Agents • terols

•Action: Stimulate beta receptors within smooth muscle of tracheobronchial tree •Uses: Reverse airway constriction; mainstay of all asthma therapy •Serious adverse effects: Tachycardia, palpitations, tremors, nervousness, anxiety, restlessness, headache, dizziness, nausea and vomiting

Antidiarrheal Agents Diphenoxylate with atropine/Lomotil, loperamide/Imodium A-D

•Actions •Locally acting agents: Absorb excess water to cause a formed stool and adsorb irritants or bacteria causing diarrhea •Systemic agents: Act through autonomic nervous system to reduce peristalsis and motility of the GI tract, allowing the mucosal lining to absorb nutrients, water, and electrolytes, leaving a formed stool •Uses: Treat sudden-onset diarrhea, inflammatory bowel disease, post-GI surgery •Therapeutic outcomes: Relief of incapacitation and discomfort of diarrhea •Common adverse effects: Abdominal distention, nausea, constipation •Serious adverse effects: Prolonged or worsened diarrhea •Don't use to treat diarrhea caused by toxic substances (C. Difficile); allows toxin to stay in GI tract

Expectorants Guaifenesin (Robitussin)

•Actions: Enhances output of respiratory tract fluid, decreases mucus viscosity (i.e. thins), promotes ciliary action •Uses: Relieve dry, nonproductive cough; treat symptoms of common cold, bronchitis, laryngitis, pharyngitis, sinusitis •Common adverse effects: GI upset, nausea, vomiting

Drug Therapy for Mucositis

•Basic oral hygiene is important •Purpose is to decrease complications associated with pain, microorganisms, and healing •Oral hygiene regimen should be started when chemotherapy or radiation therapy is initiated •Pain can be major complication •Topical applications of medications for pain must come into contact with tissue

•Nursing implementation Mucositis

•Cold sores •Canker sores •Mucositis •Plaque •Halitosis

•Chemotherapy-induced nausea and vomiting (CINV)

•Combination of drugs used because emesis likely produced by more than one mechanism •Ondansetron (Zofran), dolasetron (Anzemet), granisetron (Kytril) •High doses of metoclopramide (Reglan); dexamethasone (Decadron, Hexadrol); lorazepam (Ativan), diphenhydramine (Benadryl, Diphenhist) •haloperidol (Haldol) may be substituted for metoclopramide

Diarrhea

•Complications from severe or prolonged diarrhea •Dehydration, electrolyte depletion, exhaustion

Diarrhea

•Complications from severe or prolonged diarrhea •Dehydration, electrolyte depletion, exhaustion

Nursing Assessments Mucositis

•Drug history •Dental history •Oral cavity

Vomiting (emesis)

•Forceful expulsion of gastric contents up the esophagus and out of the mouth

Oral Candidiasis

•Fungal infection caused by Candida albicans •White curdlike appearance covering the oral mucosa •Commonly seen in infants, pregnant females, debilitated patients •Common with repeated antibiotic use and other medications. •Also seen in patients with diabetes mellitus, malnutrition, malignancies, and radiation therapy. •Local or systemic therapy with antifungal agents is effective treatment

Causes of Constipation

•Improper diet- too little fiber •Too little fluid intake- dehydration will harden stool •Lack of exercise/sedentary habits-slower motility •Failure to respond to normal defecation impulses •Muscular weakness of the colon •Diseases such as anemia and hypothyroidism •Frequent use of constipating medicines •Opioids & anticholinergic agents, iron supplement •Tumors of the bowel or pressure from tumors •Diseases of the rectum

Antitussive Agents •Benzonatate (Tessalon Perles), Codeine, Dextromethorphan (Robitussin, Delsym), Diphenhydramine (Diphen, Tusstat), Hydrocodone

•Indication: for nonproductive cough •Action: Suppress cough center in brain •Use: Suppress disruptive spasms Common adverse effects: Dry mouth, drowsiness, constipation

Antifungal: Nystatin

•Indication: thrush, oral candidiasis •Action: binds to fungal cell membrane. Allowing leakage of cellular contents •Side effects: N/V (generally well tolerated) •Implementation: swish and swallow oral suspension •Shake well •Paint the oral cavity for neonates, infant, and patients with no gag reflex (unable to swallow thin liquids due to aspiration risk) •Usually a 2 week therapy

Causes of Diarrhea

•Intestinal infections •Spicy or fatty foods •Enzyme deficiencies •Excessive use of laxatives •Drug therapy-antibiotics, magnesium antacids •Emotional stress •Hyperthyroidism •Inflammatory bowel disease-Chron's, ulcerative colitis, diverticulitis •Surgical bypass of the intestine

Retching

•Involuntary, labored, spasmodic contractions of the abdominal and respiratory muscles without the expulsion of gastric contents; also called dry heaves

Beta-Adrenergic Bronchodilating Agents

•Long-acting beta-2 agonists (LABAs) used to prevent acute deterioration •prophylaxis and maintenance • not for acute attacks. •Use LABAs for prevention, to decrease severity of attacks; once controlled, back off LABAs may make attacks that do occur more severe

Drug Therapy for Nausea and Vomiting

•Motion sickness •Most medications chemically related to antihistamines, probably because of anticholinergic properties •Psychogenic vomiting •Diagnosis made after all other causes eliminated •Metoclopramide or antianxiety drug may be prescribed with counseling

Drug Therapy for Postoperative Nausea and Vomiting

•Multimodal treatment approach •Hydration •Supplemental oxygen •Combination of antiemetics •Droperidol, dexamethasone, serotonin antagonists •Nonpharmacologic techniques prior to surgery •Acupuncture, acupressure, TENS units •NG tube to prevent abdominal distention

The cerebral cortex is the area of the brain that stimulates or suppresses vomiting.

•Nerves from pharynx, stomach, intestines, and other tissues connect to VC via vagus and splanchnic nerves •VC also responds to cerebral cortex, inner ear, and blood

Tiotropium Bromide (Spiriva) Capsule

•Not a rescue medicine with acute episodes •One capsule daily, administered with HandiHaler inhaler •Capsule placed in center chamber, press piercing button in and release •Close lips tightly around mouthpiece and inhale slowly and deeply to cause capsule vibration; inhale and hold breath as long as comfortable •Keep mouthpiece clean

Mucositis

•Painful inflammation of the mucous membranes of the mouth •Commonly associated with chemotherapy and radiation therapy •Erythematous ulcerations intermixed with white, patchy mucous membranes •Develops 5 to 7 days after chemotherapy or radiation treatment. •Candida infections are often present. •Can be severely debilitating.

Common Causes of Nausea and Vomiting

•Postoperative (PONV) from general anesthesia •Motion sickness •Pregnancy •Morning sickness •Hyperemesis gravidarum •Psychogenic •Self-induced or involuntary vomiting in response to threatening or distasteful situations •Chemotherapy (CINV) •Anticipatory nausea and vomiting •Acute CINV •Delayed emesis •Drug dependent severity •Radiation (RINV) Associated with high-energy radiation, external source or implanted

Regurgitation

•Rising of gastric or esophageal contents to the pharynx as a result of stomach pressure

Nursing Assessments Patient Education

•Teach patient proper cleansing techniques for oral hygiene consistent with conditions •Instruct patients who are to receive radiation or chemotherapy to start oral hygiene on scheduled regimen •Foster health maintenance