Pharmacology

transdermal medication administration (Page 86)

Transdermal medication is stored in a patch placed on the skin and is absorbed through the skin to produce a systemic effect. A patch may be left in place for as little as 12 hours or as long as 7 days depending on the drug. Transdermal drugs provide more consistent blood levels than oral and injectable forms, and they avoid GI absorption problems associated with oral products. To prevent skin breakdown, transdermal patches should be rotated to different sites and should not be reapplied over the exact same area every time. Additionally, the area should be thoroughly cleansed before administration of a new transdermal patch. 1.Perform hand hygiene and apply gloves when administering medicated patches to prevent transfer of medication; advise the patient to do the same for self-administration. Never cut the patch in half. 2.Advise patients to secure the patch with tape, being careful not to apply the tape too tightly, which could alter the drug delivery.

unit-dose system - how to use

•Another method of dispensing drugs is the unit dose method, in which drugs are individually wrapped and labeled for single-dose use for each patient. The unit dose method has reduced dosage errors because no calculations are required. Some facilities still use a multidose vial from the ADC. If this occurs, the nurse must complete a calculation to retrieve the correct amount ordered by the physician from the vial. If there is any medication left in the vial, it is disposed of according to the facility's policy for disposal of drugs. (PAGE 76)

broad spectrum antibiotics - how is this accomplished? (Page 603, 315)

•Broad-spectrum topical antiinfectives effective against many gram-positive and gram-negative organisms and fungi are applied to burn areas to prevent infection. Examples of these antiinfectives include mafenide acetate, silver sulfadiazine, and silver nitrate 0.5% solution. •adjunctive treatment for second- and third-degree burns, to prevent organism invasion of burned tissue areas, and to treat burn infections. Mechanism of Action: Bacteriostatic activity against many gram-negative and gram-positive bacteria, including Pseudomonas aeruginosa and other anaerobic strains. •Certain broad-spectrum antibiotics, such as tetracycline and third- and fifth-generation cephalosporins, can be effective against both gram-positive and gram-negative organisms. Because narrow-spectrum antibiotics are selective, they are more active against those single organisms than the broad-spectrum antibiotics. Broad-spectrum antibiotics are frequently used to treat infections when the offending microorganism has not been identified by the C&S test.

protein-bound drug - how does it work, what can happen if a person is taking two protein-bound drugs?

•Drugs that are more than 90% bound to protein are known as highly protein-bound drugs (e.g., warfarin, glyburide, sertraline, furosemide, and diazepam); drugs that are less than 10% bound to protein are weakly protein-bound drugs (e.g., gentamicin, metformin, metoprolol, and lisinopril). (PAGE 21) •When two highly protein-bound drugs are administered together, they compete for protein-binding sites, leading to an increase in free drug being released into the circulation. For example, if warfarin (99% protein bound) and furosemide (95% protein bound) were administered together, warfarin—the more highly bound drug—could displace furosemide from its binding site. In this situation, it is possible for drug accumulation to occur and for toxicity to result. Another factor that may alter protein binding is low plasma protein levels, which potentially decrease the number of available binding sites and can lead to an increase in the amount of free drug available, resulting in drug accumulation and toxicity. Patients with liver or kidney disease and those who are malnourished may have significantly lower serum albumin levels. Additionally, older adults are more likely to have hypoalbuminemia, particularly if they have multiple chronic illnesses. With these factors in mind, it is important for nurses to understand the concept of protein binding and check their patient's protein and albumin levels when administering drugs. (PAGE 21)

hepatic enzyme inducer (page 27,30)

•Drugs that promote induction of enzymes are called enzyme inducers. Some drugs—such as phenobarbital, carbamazepine, and rifampin—are enzyme inducers. Phenobarbital increases the metabolism of most antipsychotics and methylxanthine; phenobarbital, carbamazepine, and rifampin increase the metabolism of warfarin. •Chronic cigarette smoking leads to an increase in hepatic enzyme activity and can increase theophylline clearance. Asthmatics who smoke and take theophylline to manage their disease may require an increase in theophylline dosage. With chronic alcohol use, hepatic enzyme activities are increased; with acute alcohol use, metabolism is inhibited.

etanercept (Ebrel) - lab testing performed before and during therapy

•Etanercept was the first TNF blocker developed. It is administered subcutaneously, and the half-life ranges from 72 to 132 hours. •TB and hepatitis B virus (HBV) testing should be conducted on all patients before administering TNF inhibitors. •Obtain baseline laboratory values (complete blood count [CBC], lipid panel, renal function, and hepatic function).

MDI - how to evaluate teaching (PAGE 88)

•Explain the steps for administering the drug using a squeeze-and-breathe metered-dose inhaler (MDI), and demonstrate the steps when possible. Consult a pharmacist for details if necessary. •An MDI may be positioned in one of two ways: a. With the mouth closed around the MDI with the opening toward the back of the throat b. With the device positioned 1 to 2 inches from the mouth c. If a spacer is used, the patient closes the mouth around the mouthpiece of the spacer. Avoid covering the small exhalation slots with the lips.

tobramycin ointment (Nebcin) (page 583)

•For superficial external ocular infections. •May delay healing of corneal abrasion or lesions.

corticosteroids and spacer uasage (page 88)

•If a spacer is used, insert the MDI into the end of the spacer. Shake the inhaler vigorously five or six times before using. Remove the cap from the mouthpiece. Have the patient breathe out through the mouth and exhale. An MDI may be positioned in one of two ways: With the mouth closed around the MDI with the opening toward the back of the throat With the device positioned 1 to 2 inches from the mouth If a spacer is used, the patient closes the mouth around the mouthpiece of the spacer. Avoid covering the small exhalation slots with the lips. •When taking corticosteroids, potassium levels can be lowered.

Gregor Mendel (Page 33)

•In 1865 Gregor Mendel was the first to explain the difference between dominant and recessive genes in inheritance, using pea flowers as an example. •Established many of the rules of heredity, now referred to as the laws of mendelian inheritance.

medication side effects of drowsiness (Page 23, 26)

•In some instances, the side effects may be desirable (e.g., using diphenhydramine at bedtime, when its side effect of drowsiness is beneficial). •Pharmacodynamics: The primary effect of diphenhydramine is to treat the symptoms of allergy; the secondary effect is a central nervous system (CNS) depression that causes drowsiness. The secondary effect is undesirable when the patient drives a car, but at bedtime it could be desirable because it causes mild sedation. •Disulfiram: Inhibits aldehyde dehydrogenase, the enzyme involved in metabolizing alcohol. It is best used in people who are newly abstinent. Side effects: drowsiness, impotence, acne, and a metallic aftertaste.

injectable drugs - where is the fastest absorption

•Intravenous (IV)Action More rapid than IM or subcutaneous routes Sites -Accessible peripheral veins are preferred (e.g., cephalic or cubital vein of arm, dorsal vein of hand; Fig. 10.19). When possible, ask the patient about his or her preference, and avoid needless body restriction. In newborns, the veins of the feet, lower legs, and head may also be used after other sites have been exhausted. (PAGE 93) •Drugs given intramuscularly are absorbed faster in muscles that have increased blood flow (e.g., deltoid) than in those that do not (e.g., gluteus maximus). Subcutaneous tissue has decreased blood flow compared with muscle, so absorption is slower when drugs are given subcutaneously. However, drugs that are given subcutaneously have a more rapid and predictable rate of absorption than those given by mouth. Drugs given rectally are absorbed slower than drugs administered by the oral route. Absorption is slower because the surface area in the rectum is smaller than the stomach, and it has no villi. Additionally, the composition of the suppository base (e.g., fatty bases or water-soluble bases) affects drug absorption. (PAGE 20)

therapeutic effects (page 24)

•By giving a large initial dose, known as a loading dose, that is significantly higher than maintenance dosing, therapeutic effects can be obtained while a steady state is reached. It bears repeating that the loading dose is larger than the dose needed to maintain the drug at steady state; it would produce toxic side effects if given in repeated doses. After the loading dose, maintenance dosing is begun; this is the dose needed to maintain drug concentration at steady state when given repeatedly at a consistent dose and constant dosing interval. Duration of action is the length of time the drug exerts a therapeutic effect.Once steady state has been achieved, drug concentration can be determined by measuring peak and trough drug levels. Peak and trough levels are requested for drugs that have a narrow therapeutic index and are considered toxic. •Closely related to dose-response and efficacy is the therapeutic index (TI), which describes the relationship between the therapeutic dose of a drug (ED50) and the toxic dose of a drug (TD50). ED50 is the dose of a drug that produces a therapeutic response in 50% of the population; TD50 is the dose of a drug that produces a toxic response in 50% of the population. The therapeutic index is the difference between these two points (Fig. 3.7). If the ED50and TD50 are close, the drug is said to have a narrow therapeutic index. Drugs with a narrow therapeutic index—such as warfarin, digoxin, and phenytoin—require close monitoring to ensure patient safety. To be safe, plasma drug levels of drugs with a narrow therapeutic index must fall within the therapeutic range (also known as the therapeuticwindow). The therapeutic range is a range of doses that produce a therapeutic response without causing significant adverse effect in patients.

clinical drug trials

•Clinical experimentation in drug research and development encompasses four phases, each with its own objectives (see Fig. 2.1). A multidisciplinary team approach that includes nurses, physicians, pharmacologists, statisticians, and research associates is required to ensure safety and quality in all phases of clinical research. A brief description of each phase follows. Phase I: Researchers test a new drug or treatment in a small group of people for the first time to evaluate its safety, determine a safe dosage range, and identify side effects. Phase II: The drug or treatment is given to a larger group of people to see if it is effective and to further evaluate its safety. Phase III: The drug or treatment is given to large groups of people to confirm its effectiveness, monitor side effects, compare it with commonly used treatments, and collect information that will allow the drugor treatment to be used safely. Phase IV: Studies are done after the drug or treatment has been marketed to gather information on the drug's effects in various populations and to assess any side effects associated with long-term use. •An appropriate experimental design is important to answer questions about drug safety and efficacy. Studies are designed to determine the effect of the independent variable (treatment, such as with a drug) on the dependent variable (outcome, such as clinical effect). Intervening (extraneous) variables are factors that may interfere with study results, and these may include age, sex, weight, disease state, diet, and the subject's social environment. It is important to control for as many of the intervening variables as possible to increase study validity.The experimental group in drug trials is the group that receives the drug being tested. The control groupin drug trials may receive no drug; a different drug; a placebo (pharmacologically inert substance); or the same drug with a different dose, route, or frequency of administration.

drug incompatibility

•Drug incompatibility is a chemical or physical reaction that occurs among two or more drugs invitro. In other words, the reaction occurs between two or more drugs within a syringe, IV bag, or other artificial environment outside of the body. (PAGE 26)

isotretinoin (Amnesteem)

•Drugs for Acne Vulgaris and Psoriasis; For moderate to severe nodular acne unresponsive to conventional treatment, including antibiotics. Vitamin A derivative; reverses sebum production by reducing the size of sebaceous glands. Unlike vitamin A, isotretinoin does not accumulate in the liver. Adverse effects relate to toxicity to cardiovascular, endocrine, hematologic, GI, hepatic, musculoskeletal, respiratory, ocular, and otic systems. Interacts with tetracycline, vitamin A, methotrexate, contraceptives, and alcohol. Baseline hepatic function, lipid panel, and pregnancy tests must be obtained. Women of childbearing age must have a pregnancy test every 30 days.(PAGE 596) •Isotretinoin, a derivative of vitamin A taken orally, is used for treatment of severe cystic acne that is not responsive to conventional therapy. It decreases sebum formation and secretion and has antiinflammatory and antikeratinizing (keratolytic) effects, decreasing lesions and scars due to acne. Additional benefits of isotretinoin include a decrease in anxiety and depression. The typical patient takes this drug for 4 to 6 months. Adverse reactions may occur that are dose dependent; these include cheilitis, dizziness, cephalgia, conjunctivitis, skin irritation, pruritus, epistaxis, myalgia, arthralgia, temporary hair thinning, photosensitivity, depression, and suicidal thoughts. Usually, one course of treatment with isotretinoin controls severe acne. Because isotretinoin is a derivative of vitamin A, patients should not take vitamin A concomitantly. Using vitamin A or tetracycline with isotretinoinmay increase its adverse effects. Baseline blood tests—liver function tests (LFTs), serum lipid panel, and pregnancy tests among female patients of childbearing age—are required before initiating isotretinoin therapy and at intervals throughout therapy. Isotretinoin must not be used during pregnancy; it is a known teratogen. Additional cautions associated with isotretinoin are to not breastfeed or to give blood during or for 1 month after therapy; patients should not take other medications or herbal products without first consulting their health care provider, drive at night without knowing the effect of isotretinoin on night vision, or have cosmetic procedures to smooth skin. The patient should be instructed to avoid excessively vigorous activity and to contact the health care provider and stop taking isotretinoin if they experience muscle weakness, which may be an indication of serious muscle damage.(PAGE 599) •Because of isotretinoin's powerful teratogenicity, a risk-management system to prevent isotretinoin-related teratogenicity was implemented. iPLEDGE is the third risk-management program to prevent exposure to isotretinoin during pregnancy. Before starting isotretinoin therapy, both males and females must enroll in the iPLEDGE risk-management program and adhere to it. The program was created to ensure patients who receive isotretinoin use two forms of contraception, that no patient is pregnant when treatment is initiated, and that no patient becomes pregnant while taking the drug or for at least 1 month after completing a course of isotretinoin. (PAGE 599)

Drug Schedules (Schedule I)

-Some examples of drugs listed in Schedule I are heroin, lysergic acid diethylamide (LSD), Cannabis,peyote, methaqualone, and methylenedioxymethamphetamine (MDMA). -Substances in this schedulehave no currently accepted medical use in the United States, a lack of accepted safety for use under medical supervision, and a high potential for abuse.

Nurses should advise patients of the following when over-the-counter (OTC) drugs are considered:

1. Always read the instructions on the label. 2. Do not take OTC medicines in higher dosages or for a longer time than the label states. 3. If you do not get well, stop treating yourself and talk with a health care professional. 4. Side effects from OTCs are relatively uncommon, but it is your job to know what side effects might result from the medicines you are taking. 5. Because every person is different, your response to the medicine may be different than another person's response. 6. OTC medicines often interact with other medicines, and with food or alcohol, or they might have an effect on other health problems you may have. 7. If you do not understand the label, check with the pharmacist. 8. Do not take medicine if the package does not have a label on it. 9. Throw away medicines that have expired (are older than the date on the package). 10. Do not use medicine that belongs to a friend. 11. Buy products that treat only the symptoms you have. 12. If cost is an issue, generic OTC products may be cheaper than brand name items. 13. Avoid buying these products online, outside of well-known Internet insurance company sites, because many OTC preparations sold through the Internet are counterfeit products. These may not be what you ordered and may be dangerous.

Parents should know the following special information about using OTCs for children:

1. Parents should never guess about the amount of medicine to give a child. Half an adult dose may be too much or not enough to be effective. This is very true of medicines such as acetaminophen (Tylenol) or ibuprofen (Advil), in which repeated overdoses may lead to poisoning of the child, liver destruction, or coma. 2. If the label says to take 2 teaspoons and the dosing cup is marked with ounces only, get another measuring device. Don't try to guess about how much should be given. 3. Always follow the age limits listed. If the label says the product should not be given to a child younger than 2 years, do not give it. 4. Always use the child-resistant cap and relock the cap after use. 5. Throw away old, discolored, or expired medicine or medicine that has lost its label instructions. 6. Do not give medicine containing alcohol to children

All OTC drugs must have labels that provide the following information in this specific order

1. The product's active ingredients, including the amount in each dosage unit 2. The purpose of the product 3. The uses (indications) for the product 4. Specific warnings, including when the product should not be used under any circumstances, substances or activities to avoid, side effects that could occur, and when it is appropriate to consult with a doctor or pharmacist 5. Dosage instructions that include when, how, and how often to take the product 6. The product's inactive ingredients and important information to help consumers avoid ingredients that may cause an allergic reaction

Patient Teaching (Diet)

1.Advise the patient about foods to include in their diet and foods to avoid. Many foods interact with certain drugs. Depending on the nature of the interaction, certain foods have the ability to decrease drug absorption, increase the risk of drug toxicity, or create other problems that are important safety concerns. 2.Do not drink alcoholic beverages around the time you take your medications. Alcohol is absolutely contraindicated with certain medications, and it may alter the action and absorption of the med. 3.Smoking tobacco also can alter the absorption of some meds, (Theophylline-type drugs, antidepressants, pain meds).

A male patient is to begin therapy with isotretinoin and asks, "What do I have to remember to do while taking this medicine?" How would the nurse respond? (SATA) (PAGE 605)

1.Avoid Sunlight 2.Keep appointments for lab tests 3.Use two forms of contraceptives

Patient Teaching (Side Effects)

1.Give all information that can help minimize any side effects 2.Advise patients of any expected changes in the color of urine or stool, and counsel the patient who has dizziness caused by orthostatic hypotension to rise slowly from sitting to standing.

Patient Teaching(Important nursing considerations:)

1.Identify patients cultural need like cultural beliefs, practices, and values. 2.Space instruction over several sessions and be flexible in the timing of medication teaching as desired by the patient. 3.Allow time for patients to respond to questions. Ask open-ended questions, and have patients demonstrate their understanding of treatments rather than verbalizing them. 4.Review community resources related to the patient's plan of care including medications. 5.Collaborate with the patient and family and other health care staff and agencies to meet the patient's health care needs. 6.Identify patients at risk for noncompliance with their drug regimen. Alert the health care provider and pharmacist so they can develop a plan to minimize the number of drugs and the number of times drugs are administered. 7.Evaluate the patient's understanding of the medication regimen on a regular basis. 8.Empower the patient to take responsibility for his or her drug management.

Patient Teaching (Self Administration)

1.Instruct the patient according to the prescribed route: eye or nose instillation, subcutaneous injection, suppository, oral/mucosal (e.g., swish-and-swallow suspensions), and inhaled via a metered-dose inhaler with or without a spacer. Include a return demonstration in the instructions when appropriate. 2.The use of drug cards is a helpful teaching tool. Drug cards may include: the name of the drug; the reason for taking the drug; the drug dosage; times to take the drug; possible side effects; adverse effects; when to notify the care provider; and specific facts that should or should not be done when taking the medication (e.g., take with food, do not crush tablets).

Patient teaching (General):

1.Take drugs as prescribed, consistency in adhering to the prescribed drug regimen, provide simple written instructions with the doc and pharmacy names and numbers. 2.Notify health care provider if dose, frequency or time of drug is adjusted, female becomes pregnant, an OTC/Supplement is added. 3.If drugs are placed in a drug box, keep the original labeled containers. 4.All drugs out of reach from children 5.Bring all drugs when you visit the HCP

OTC medications (PAGE 15)

Although all drugs carry risk, over-the-counter (OTC) drugs have been found to be safe and appropriate for use without the direct supervision of a health care provider. They are available for purchase without a prescription in many retail locations. •Other OTC drugs (e.g., pseudoephedrine, emergency contraception) are available with some restrictions and must be kept behind the pharmacy counter; before dispensing, patient age and identify are verified, and education is provided. •Nurses must be aware of OTC drugs and the implications of their use. OTC drugs provide both advantages and potential serious complications for the consumer. The nurse needs to emphasize that many of these drugs are potent and can cause moderate to severe side effects, especially when taken with other drugs. Additionally, many OTC drugs contain the same active ingredients, potentially leading to overdose. Self-diagnosis and self-prescribing OTC drugs may mask the seriousness of clinical conditions. •Many individuals routinely reach for aspirin, acetaminophen, and ibuprofen to relieve discomfort or pain without being aware of potential drug interactions and/or side effects. For example, ibuprofen can increase fluid retention, which can worsen heart failure; use of ibuprofen on a daily basis may decrease the effectiveness of antihypertensive drugs. Ibuprofen has also been linked with cardiovascular events, such as myocardial infarction and stroke; this risk increases with long-term use. Acetaminophen has been associated with kidney disease, anemia and thrombocytopenia, myocardial infarction, stroke, and hypertension. Additionally, metabolism of the drug results in the development of toxic metabolites, which can cause liver damage. Patients may also develop allergic reactions (anaphylaxis) or potentially fatal skin reactions (Stevens-Johnson Syndrome [SJS] or toxic epidermal necrolysis [TEN]) when taking acetaminophen. Because of the potential for harm caused with high doses or long-term use, since 2011 the FDA has limited the dose of acetaminophen to 325 mg when packaged in combination with other drugs. •Some OTC drugs, such as cough medicine, are a combination product of two to four drugs. It is conceivable that there could be a drug-drug interaction with a cough medicine and one of the drugs prescribed by the patient's health care provider. Patients with asthma should be aware that aspirin can trigger an acute asthma episode. Patients may be allergic to aspirin, or aspirin may act as a deregulator of leukotrienes. Aspirin is also not recommended for children with influenza symptoms or chickenpox because it has been associated with Reye syndrome. Patients with kidney disease should avoid aspirin, acetaminophen, and ibuprofen because these can further decrease kidney function, especially with long-term use. Also, patients taking moderate to high doses of aspirin, ibuprofen, or naproxen concurrently with an oral anticoagulant may be at increased risk for bleeding. The previous examples are not all inclusive. Caution is advised before using any OTC preparation, including antacids, decongestants, and laxatives. Patients should check with their health care providers and read drug labels before taking OTC medications so they are aware of possible contraindications and adverse reactions. The acronym SAFER is a mnemonic for the instructions that the FDA recommends before taking any medicine: speak up, ask questions, find the facts, evaluate your choices, and read labels.

what are goals for patient teaching (PAGE 4)

Checklist for Health Teaching in Drug Therapy • Reinforce the importance of drug adherence. • Before giving the patient written material, ensure the patient can read. • Always complete a health history and physical assessment on the patient. • Assess all of the drugs on the patient's profile for possible drug interactions. • Explain the reason the patient is taking the drug, the time it should be administered, and whether it should be taken with or without food. • Review the side effects and adverse reactions, and make sure the patient has the doctor's telephone number and knows when to notify the health care provider or pharmacist. • Discern whether the patient needs baseline or monthly laboratory work to monitor drug levels. • Keep in mind that patient validation of learning may include a return demonstration of psychomotor skills (insulin administration). • Show the patient how to record drug administration on a sheet of paper by indicating day and time drug is taken. • Discuss the patient's financial resources and, if needed, consult a social worker for resources. • Discuss the patient's support system such as family or friends as caregivers. • Provide the patient with a list of community resources.

Drug Schedules (Schedules II)

Examples of Schedule II drugs include combination products with less than 15 milligrams of hydrocodone per dosage unit, cocaine, methamphetamine, methadone, hydromorphone, meperidine, oxycodone, fentanyl, dextroamphetamine, dextroamphetamine/amphetamine and methylphenidate. Substances in this schedulehave a high potential for abuse that may lead to severe psychological or physical dependence.

Drug Schedules (Schedule III)

Examples of Schedule III drugs include products containing less than 90 milligrams of codeine per dosage unit (acetaminophen with codeine), ketamine, anabolic steroids, and testosterone. Substances in this schedule have a potential for abuse less than substances in Schedules I or II, and abuse may lead to moderate or low physical dependence or high psychological dependence.

Drug Schedules (Schedule IV)

Examples of Schedule IV substances include alprazolam, carisoprodol, diazepam, lorazepam, zolpidem, and tramadol. Substances in this schedulehave a low potential for abuse relative to substances in Schedule III.

Drug Schedules (Schedule V)

Examples of Schedule V drugs include cough preparations containing not more than 200 mg of codeine or per 100 mL (codeine/guaifenesin), diphenoxylate/atropine, difenoxin/atropine, and pregabalin. Substances in this schedulehave a low potential for abuse relative to substances listed in Schedule IV and consist primarily of preparations containing limited quantities of certain narcotics.

The nurse recognizes that when a patient takes a hepatic enzyme inducer, the dose of warfarin is usually modified in which way

It is increased

A patient asks the nurse about drug interactions with over-the-counter preparations. What is the nurse's best response?

Read the labels carefully, and check with your health care provider.

correct dosing range (Page 26,51,52)

•It is important to know that the occurrence of side effects is one of the primary reasons patients stop taking their prescribed medications. An important role of the nurse includes teaching patients about a drug's side effects and encouraging them to report side effects. Many can be managed with dosage adjustments, changing to a different drug in the same class, or implementing other interventions. (PAGE 26) •Tolerance refers to a decreased responsiveness to a drug over the course of therapy; an individual with drug tolerance requires a higher dosage of drug to achieve the same therapeutic response. In contrast, tachyphylaxis refers to an acute, rapid decrease in response to a drug; it may occur after the first dose or after several doses. Tachyphylaxis has been demonstrated with drugs such as centrally acting analgesics, nitroglycerin, and ranitidine, to name a few. To provide safe and effective care, nurses must be aware of these potential reasons a patient may fail to respond therapeutically to drug administration. •It has been suggested that drugs for older adults should initially be prescribed at low dosages with a gradual increase in dosage based on therapeutic response; this practice is commonly stated as start low and go slow. This approach to drug prescribing reduces the chance of drug toxicity. •Changes in kidney function affect many drugs, leading to a prolonged half-life and elevated drug levels. Changes in kidney function require dosage adjustment, especially if the drug has a narrow therapeutic range.GFR can be calculated using the Cockcroft-Gault formula, which is the formula recommended by the US Food and Drug Administration (FDA) and therefore used by pharmaceutical manufacturers when determining dosage adjustments: Where: CCr (creatinine clearance) = mL/min, Age = years, Weight = kg, SCr (serum creatinine) = mg/dL

principle of justice (page 10, 36)

•Justice requires that the selection of research subjects be fair. Research must be conducted so that the distribution of benefits and burdens is equitable (i.e., research subjects reflect all social classes and racial and ethnic groups). •Justice 1.Equal and fair treatment of all. 2.However, not everyone has access to the same level of care, nor can everyone afford care.

pharmacogenetics - legal and ethical issues (PAGE 36)

•Legal ethical considerations encompass the principles of privacy, autonomy and justice. Privacy 1.Who has access to patient genetic information? 2.Who owns the genetic information? 3.Concerns about patient "labeling" based on genetic code. Autonomy 1.A patient may consent to or refuse genetic testing. 2.Patients may change their minds about obtaining genetic testing. Justice 1.Equal and fair treatment of all. 2. However, not everyone has access to the same level of care, nor can everyone afford care. •The health care community must not allow genetic profiling to occur. Within an ethnic group, not everyone shares the same genetic variations. Therefore, we must guard against denial of treatment based on race and ethnicity in the absence of available pharmacogenetic testing. It is vital to remember that medical conditions are not the result of genetics alone but the fusion of life choices and environment as well. People have voiced concerns regarding the use of genetic information. Many decline to have genetic testing performed due to fears their employers or insurance companies will unfairly use the results. In response to these concerns, in 2008 the Genetic Information Nondiscrimination Act (GINA) was enacted, which prohibits insurance companies from requiring genetic testing to obtain health insurance and from using genetic information to determine coverage and premiums. The protections provided by GINA allow people to have genetic tests as recommended by their providers without fear that the results will adversely affect insurance or employment decisions. However, these protections do not extend to life insurance, disability insurance, and long-term care insurance, nor do they apply to military members, Indian Health Services, the Veterans Health Administration, or the Federal Employees Health Benefits Program. Implementation of pharmacogenetics, in conjunction with other patient factors and clinical information, can improve patient safety, quality of care, morbidity, and mortality, and decrease cost. The hope for the future of pharmacogenetic is ensuring delivery of the right drug, at the right dose, to the right patient, via the right route, and administered at the right time.

acne vulgaris treatment (page 596-599)

•Nonpharmacologic measures should be tried before drug therapy is initiated. A prescribed or suggested cleansing agent, such as antibacterial soap, is necessary for all types of acne. The skin should be gently cleansed twice daily, but vigorous scrubbing should be avoided. Overscrubbing and overwashing can irritate the skin, worsening the acne and possibly causing an infection. The American Osteopathic College of Dermatology recommends not using abrasive cleaners. In addition to facial hygiene, shampooing hair to decrease the oiliness may help with acne. Keeping hair away from the face has also been shown to decrease acne. Cosmetics should be water based because oil-based products can increase the clogging of skin pores. A well-balanced diet low in fat and sugar is recommended, and excessive carbohydrates should be avoided. Decreasing emotional stress and increasing emotional support are also suggested. If drug therapy is necessary, nonpharmacologic measures should be maintained as well. •Acne is not curable, but it is manageable. Acnemedications may help decrease scar formation related to acne. The best course for patients with acne is to see a dermatologist who can prescribe treatment specific to the individual; therefore the course of therapy will vary according to the severity and extent of the acne. 1.Mild acne is generally treated with topical drugs that treat existing acne and prevent new eruptions. Commonly used topical therapies for mild acneinclude benzoyl peroxide (BP), retinoids, salicylic acid, antibiotics, or combinations of these in addition to gentle cleansing. 2.BP is an antibacterial medicine that kills P. acnes,the predominant organism in sebaceous follicles and comedones. BP releases free radical oxygen species that oxidize bacterial proteins. When included as an adjunct to an antibiotic regimen, control of acne is enhanced. Resolution of acne usually occurs within 4 to 6 weeks. BP is applied as a cream, lotion, or gel once or twice a day and can be left on or washed off. Washing BP off may be better tolerated in patients with sensitive skin. 3.Topical retinoids such as tretinoin, adapalene, and tazarotene are derivatives of vitamin A and are used for mild to moderate acne that alters keratinization. They are the mainstay of topical therapy because of their comedolytic activities, and they also have antiinflammatory properties. Retinoids alter the intracrine and paracrine mediators of cell differentiation and proliferation, apoptosis, and reproduction, thereby modifying gene expression, subsequent protein synthesis, and epithelial cell growth. Retinoids prevent horny cell cohesion, or keratolysis, and increase epithelial cell turnover. They do not affect microorganisms in acne and sebum production. Topical retinoids are appropriate for all types of acne when used in combination with other antiacne therapy. They also allow maintenance of acne clearance after discontinuing oral antibiotics. Of the retinoids, tazarotene is contraindicated with pregnancy. Retinoids should not be used before or after extended sun exposure or sunburn because they can increase the risk of sunburn and intensify existing sunburn. 4.Another antiacne topical drug, azelaic acid, has antibacterial, antiinflammatory, and mild comedolytic actions. Azelaic acid is as effective as BP and tretinoin combined. Salicylic acid is also a comedolytic treatment that is available over the counter (OTC) in various strengths. However, the efficacy of salicylic acid is still unknown. Topical treatments with retinoids, azelaic acid, and salicylic acid can cause burning, pruritus, and erythema after several applications; however, they are less common with azelaic acid. 5.Moderate to severe acne may require a stronger concentration of BP, and topical antibiotics, such as tetracycline, erythromycin, and clindamycin, may be added to the treatment regimen. Erythromycin and clindamycin are the recommended topical antibiotics for acne therapy; however, erythromycin has reduced efficacy compared with clindamycin. Topical antibiotics accumulate in the hair follicle and have both antiinflammatory and antibacterial effects. Topical antibiotics as monotherapy are notrecommended due to the development of antibiotic resistance. Severe, painful acne may be treated with steroid injection. •For severe acne, adjunctive treatment is usually warranted with oral antibiotics (e.g., doxycycline and minocycline [drugs of choice], tetracycline, amoxicillin) in addition to topical corticosteroids (Box 45.1). Tetracycline antibiotics, however, should not be used among the very young and among pregnant patients; drugs of the tetracycline class may cause dental discoloration to the developing teeth and have teratogenic effects on the fetus. Instead, amoxicillin or another nontetracycline drug may be given for severe acne. See Chapter 26for more information on antibacterials. •Isotretinoin, a derivative of vitamin A taken orally, is used for treatment of severe cystic acne that is not responsive to conventional therapy. It decreases sebum formation and secretion and has antiinflammatory and antikeratinizing (keratolytic) effects, decreasing lesions and scars due to acne. Additional benefits of isotretinoin include a decrease in anxiety and depression. The typical patient takes this drug for 4 to 6 months. Adverse reactions may occur that are dose dependent; these include cheilitis, dizziness, cephalgia, conjunctivitis, skin irritation, pruritus, epistaxis, myalgia, arthralgia, temporary hair thinning, photosensitivity, depression, and suicidal thoughts. Usually, one course of treatment with isotretinoin controls severe acne. Because isotretinoin is a derivative of vitamin A, patients should not take vitamin A concomitantly. Using vitamin A or tetracycline with isotretinoin may increase its adverse effects. Baseline blood tests—liver function tests (LFTs), serum lipid panel, and pregnancy tests among female patients of childbearing age—are required before initiating isotretinoin therapy and at intervals throughout therapy. Isotretinoin must not be used during pregnancy; it is a known teratogen. Additional cautions associated with isotretinoin are to not breastfeed or to give blood during or for 1 month after therapy; patients should not take other medications or herbal products without first consulting their health care provider, drive at night without knowing the effect of isotretinoin on night vision, or have cosmetic procedures to smooth skin. The patient should be instructed to avoid excessively vigorous activity and to contact the health care provider and stop taking isotretinoin if they experience muscle weakness, which may be an indication of serious muscle damage.

pilocarpine HCl (Isopto Carpine) (page 586)

•Ophthalmic cholinergic agents cause miosis, a constriction of the pupil and contraction of the ciliary muscle. These actions result in a widening of the trabecular meshwork to improve outflow of excess aqueous humor. Additionally, as the pupil constricts, it straightens the iris, thus opening or widening the drainage angle to relieve angle-closure glaucoma. The two types of cholinergics are cholinergic agonists and cholinesterase inhibitors. Although their outcomes are similar, cholinergic agonists and cholinesterase inhibitors differ in their mechanism of action. Cholinergic agonists are direct-acting cholinergics that directly stimulate cholinergic receptors. As a result, these drugs have the same action as the parasympathetic neurotransmitter acetylcholine. Pilocarpine is an example of a cholinergic agonist. •Cholinergic agonists and cholinesterase inhibitors are contraindicated for use in persons with closed-angle glaucoma. •Used to reduce pressure inside the eye and treat dry mouth.

Patient Teaching

•Patient teaching: 1.the patient's readiness to learn and investment in his or her learning. If the patient buys into wanting to practice good health principles, learning can be successful. The nurse and patient together must become fully engaged in the learning process. 2.Timing is another important factor. What is the best time for the patient to learn? Is the patient a morning or night person? People seem to learn best if the time between the learning and implementation is short. 3.The environment should be conducive to learning with a temperature that is comfortable and an environment that is quiet. 4.Pain is an obstacle, and the patient's teaching should be postponed until pain is relieved. 5.If the patient does not speak the same language as the nurse, an interpreter may be needed. Family members are not recommended as an effective interpreter because they may hinder communication. 6.The patient's age may be another important obstacle. If the patient is young, or perhaps elderly and forgetful, a family member or significant other will need to be present. 7.It is important that teachings are tailored to the patient's educational level and that the patient trusts the nurse for learning to begin. When possible, it is always important to include a family member or friend in the teaching to provide support to the patient with reminders and encouragement; they can also detect possible side effects that may occur in the patient.

patient problems related to antihypertensives and orthostatic hypotension (page 53)

•Pharmacodynamic responses to drugs are altered with aging as a result of changes in the number of receptor sites, which affects the affinity of certain drugs. These changes are seen most clearly in the cardiovascular system and central nervous system (CNS). Older adults experience a loss of sensitivity in adrenergic receptors, affecting both agonists and antagonists; this results in a reduced response to beta blockers and beta2 agonists. Older adults also experience a blunting in compensatory reflexes leading to orthostatic hypotension and falls. With age, there is a reduction in dopaminergic and cholinergic receptors, neurons, and available neural connections in the brain. There is reduced blood flow to the brain, and the blood-brain barrier also becomes more permeable. This puts the older adult at risk for CNS drug side effects, which include dizziness, seizures, confusion, sedation, and extrapyramidal effects.

hydrocodone (Lortab) (page 12, 64, 301)

•Schedule II drug when less than 15 milligram dosage unit. High potential for abuse that may lead to severe psychological or physical dependence. •Opioids (oxycodone, hydrocodone, morphine methadone, and fentanyl) are controlled substances legally prescribed to treat moderate to severe pain. These drugs interact with opioid receptors in the brain and nervous system to reduce pain. In addition to reducing pain, this receptor interaction floods the brain's reward system with dopamine, producing a sense of euphoria and tranquility. •Possible Side effects: headache, dyspepsia, nausea, vomiting, abdominal pain, constipation, arthralgia, dyspnea, dehydration, peripheral edema, flushing and infection. •Taper off upon discontinuation.

timolol - side effects and how to prevent

•Side Effects: Blurred vision, conjunctivitis, ocular irritation, weakness, dizziness, nausea, bradycardia, dyspnea, HF, pulmonary edema and dysrhythmias.

sulfadiazine (Silvadene)

•Silver sulfadiazine is a common anti-infective used to prevent and treat infections in second- and third-degree burns. It is applied at least twice daily, and it is not absorbed through intact skin. Silver sulfadiazine possesses activity against both gram-negative and gram-positive organisms and fungi. Unlike mafenide, it is not a carbonic anhydrase inhibitor. Sulfadiazine is metabolized by the liver and is excreted in the urine. It is contraindicated in near-term pregnancy and among neonates and infants younger than 2 months. Side effects and adverse reactions may include photosensitivity, skin discoloration, burning sensation, rashes, erythema multiforme, skin necrosis, and leukopenia. (PAGE 603) •Tx: Prevent and treat infection of second- and third-degree burns. Ten percent of drug is absorbed. Excessive use or extensive application area may cause sulfa crystals (crystalluria). (PAGE 604)

methoxsalen (Oxsoralen)

•Systemic antimetabolite for severe psoriasis not responsive to other therapy. Soft and hard gelatin capsules are noninterchangeable. Separate doses by at least 48 h. Administer with food or milk. Contraindicated in patients with history of or current invasive cutaneous carcinoma or melanoma. Avoid sunlight during drug therapy; sunlight could cause severe burning and blistering. (PAGE 596) •UVA may be used to suppress mitotic (cell division) activity. Photochemotherapy, a combination of UV radiation and the psoralen derivative methoxsalen (a photosensitive drug), is used to decrease proliferation of epidermal cells. This type of therapy is called psoralen and ultraviolet A (PUVA), which permits lower doses of methoxsalen and UVA to be given. Common side effects of PUVA include erythema, pruritus, xerosis, irregular pigmentation, and gastrointestinal (GI) symptoms such as nausea and vomiting. Other toxicities include blisters, melanonychia, hypertrichosis, and squamous cell carcinoma (SCC). PUVA is contraindicated in patients with known lupus erythematosus, xeroderma pigmentosum, and porphyria. A topical preparation of methoxsalen must be administered only by a trained clinician. (PAGE 600)

antibiotic treatment and oral contraceptives - what is needed if taking together (page 598/599)

•Tetracycline antibiotics, however, should not be used among the very young and among pregnant patients. •Drugs of this class can cause dental discolorations to the developing teeth and have teratogenic effects on the fetus. •Patient should have pregnancy test among female patients of childbearing age and required before treatment and throughout therapy. •Isotretinoin must not be used during pregnancy; it is a known teratogen. Additional cautions associated with isotretinoin are to not breastfeed or to give blood during or for 1 month after therapy; •Because of isotretinoin's powerful teratogenicity, a risk-management system to prevent isotretinoin-related teratogenicity was implemented. Males and Females must enroll in the iPledge risk management program and adhere to it. The program was created to ensure patients who receive isotretinoin use two forms of contraception, that no patient is pregnant when treatment is initiated, and that no patient becomes pregnant while taking or at least 1 month after completing course.

minimum effective concentration (MEC)

•The MEC is the minimum amount of drug required for drug effect. (PAGE 24) •Antibacterial drugs are used to achieve the minimum effective concentration (MEC) necessary to halt the growth of a microorganism. (PAGE 313)

Z track method - why used?

•The Z-track injection technique shown in Fig. 10.18 is recommended when administering IM injections to help minimize local skin irritation by sealing the medication in the muscle tissue. The ventrogluteal site is preferred. Using aseptic technique, draw up the medication. Replace the first needle with a second needle of appropriate gauge and length to ensure the needle will penetrate the muscle. Holding the skin taut, inject the needle deep into the muscle, and if there is no blood return on aspiration, slowly inject the medication. Allow the needle to remain inserted for 10 seconds for the medication to disperse evenly.•Z-Track Injection. (A) Use a deep muscle, such as in the ventrogluteal injection, and pull skin approximately 1 to 1½ inches laterally to one side, and hold it taut with the nondominant hand. (B) Inject the needle deep into the muscle, and if no blood returns on aspiration, slowly inject the medication. (C) Wait 10 seconds before withdrawing the needle and releasing the skin. This technique prevents medication entering subcutaneous tissue. (PAGE 93)

Disintegration

•The breakdown of an oral drug into smaller particles. The rate of dissolution is the time it takes the drug to disintegrate and dissolve to become available for the body to absorb it. Drugs in liquid form are more rapidly available for GI absorption than are solids. Generally, drugs are both disintegrated and absorbed faster in acidic fluids with a pH of 1 or 2 rather than in alkaline fluids (those with a pH greater than 7). •Enteric-coated (EC) drugs resist disintegration in the gastric acid of the stomach, so disintegration does not occur until the drug reaches the alkaline environment of the small intestine. EC tablets can remain in the stomach for a long time; therefore, their effect may be delayed in onset. EC tablets or capsules and sustained release (beaded) capsules should not be crushed because crushing alters the place and time of absorption of the drug. Food in the GI tract may interfere with the dissolution of certain drugs. Some drugs irritate the gastric mucosa, so fluids or food may be necessary to dilute the drug concentration and provide protection. (PAGE 20)

drug elimination and kidney function (PAGE 22, 23)

•The drug half-life (t½) is the time it takes for the amount of drug in the body to be reduced by half. The amount of drug administered, the amount of drug remaining in the body from previous doses, metabolism, and elimination affect the half-life of a drug. For example, with liver or kidney dysfunction, the half-life of the drug is prolonged, and less drug is metabolized and eliminated.A drug goes through several half-lives before complete elimination occurs, and drug half-life is used to determine dosing interval. •Prerenal, intrarenal, and postrenal conditions affect drug excretion. Prerenal conditions, such as dehydration or hemorrhage, reduce blood flow to the kidney and result in decreased glomerular filtration. Intrarenal conditions, such as glomerulonephritis and chronic kidney disease (CKD), affect glomerular filtration and tubular secretion and reabsorption. Postrenal conditions that obstruct urine flow—such as prostatic hypertrophy, stones, and neurogenic bladder—adversely affect glomerular filtration. With any of these situations, drug accumulation may occur, resulting in adverse drug reactions.Common tests used to determine renal function include creatinine and blood urea nitrogen (BUN). Creatinine is a metabolic by-product of muscle excreted by the kidneys; urea nitrogen is the metabolic breakdown product of protein metabolism. Based on National Kidney Foundation recommendations, the estimated glomerular filtration rate (eGFR) is now calculated as part of routine comprehensive metabolic panels (CMPs) and basic metabolic panels (BMPs). The eGFR is calculated using the person's creatinine level, age, body size, and gender. Decreased eGFR is expected in older adult and female patients because of their decreased muscle mass. It is important for nurses to know their patient's kidney function to ensure correct drug dosage. •Renal excretion is the predominant means of drug elimination. The glomerular filtration rate (GFR) in term neonates is roughly 30% that of adults. During infancy, the GFR rises, and by 12 months, it reaches adult levels. Nurses must carefully monitor renal function, urine flow, and drug effectiveness to evaluate the effect of drug administration on patient status.

generic drug

•The generic name is the official, nonproprietary name for the drug; this name is not owned by any drug company and is universally accepted. Nearly 80% of all prescription drugs in the United States are ordered by generic name. •Generic names are given in lower case letter (PAGE 14) •Must be approved by the FDA before they can be marketed. (PAGE 14) •If the generic drug is found to be bioequivalent to the brand-name drug, the generic drug is considered therapeutically equivalent and is given an "A" rating. If there is less than a 20% variance in drug absorption, distribution, metabolism, and excretion, a generic drug is considered equivalent to the brand-name drug (PAGE 14)

nursing process steps

•The nursing process is used by nurses for the appropriate delivery of patient care and drug administration. It describes the who, what, where, when, why, and how of nursing practice, including drug administration. By following the steps of the nursing process, the nurse is supported in prioritizing safe nursing care and medication administration. (PAGE 1) •The nursing process is a six-step decision-making approach that includes (1) Concept, (2) Assessment, (3) Patient Problem (replaces diagnosis), (4) Planning, (5) Implementation (nursing intervention), and (6) Evaluation. The purpose of the nursingprocess is to identify a patient's problem and provide care. The nursing process is an essential core of practice for nurses. It supports the nurse in prioritizing the safe, timely delivery of care, including drug administration. The nursing processis continuous and moves back and forth between the various steps. Careful attention to each phase of the process promotes the patient's success within the prescribed care including the medication regimen. These steps are discussed as each relates to health teaching and drug therapy. 1.During the assessment phase, the nurse gathers information from the patient about the patient's health and lifestyle. Assessment includes both subjective and objective data. The nurse should always perform a complete systemic assessment of the patient's body systems. 2.A patient problem is made based on analysis of the assessment data, and it determines the type of care the patient will receive. 3.During the planning phase, the nurse uses the data collected to set goals or expected outcomes and interventions that address the patient's problems.Goals are patient centered, describe a specific activity, and include a time frame for achievement and reevaluation. Planning includes the development of nursing interventions used to assist the patient in meeting medication goals. To develop patient-centered goals and outcomes, collaboration with the patient and/or family is necessary. 4.The implementation phase is the part of the nursingprocess in which the nurse provides education, drug administration, patient care, and other interventions necessary to assist the patient in accomplishing the established medication goals. In most practice settings, administration of drugs and assessment of the drug's effectiveness are important nursing responsibilities. 5.In the evaluation phase of the nursing process, the nurse determines whether the goals and teaching objectives have been met. The nurse continues to use ongoing assessment data to evaluate the successful attainment of the patient's objectives and goals. If the objectives and goals are not met, the nurse will revise the objectives, goals, and interventions to ensure success. If the objectives, goals, and interventions are met, the nurse will document the successful attainment in the nursing plan of care.

two forms of identification before giving medications

•The right patient determination is essential. TJC requires at least two forms of identification before drug administration. Ask the patient to state his or her full name and birth date, and compare these with the patient's identification (ID) band and the medication administration record (MAR). Many facilities have electronic health records (EHRs) that allow the nurse to directly scan the bar code from the patient's ID band. Once the band is scanned, the patient's medication record appears for the nurse to view (Fig. 9.1). Additional nursing implications include the following: Most hospitals have color-coded ID bands that include bands coded for allergy, do not resuscitate (DNR), fall risk, and restricted extremity. Always check facility policies for the use of color-coded bands and their meanings. Verify the patient's identification by using two methods of identificationeach time a medication is administered. If the patient is an adult with a cognitive disorder or a child, verify the patient's name with a family member. In the event a family member is unavailable and the patient is unable to self-identify, follow the facility's policy. Many facilities have policies that include a photo ID on the band with the patient's name and birth date affixed to the band.Distinguish between two patients with the same first or last name by placing "name-alert" stickers as warnings on the medical records.

Potentiation

•This effect results when one substance that does not normally have a toxic effect is added to another chemical, making the second chemical much more toxic. (GOOGLE) •When two or more drugs are given together, one drug can have a synergistic effect on another. In other words, the clinical effect of the two drugs given together is substantially greater than that of either drug alone. An example of this is the use of two cytotoxic drugs to reduce individual drug dosing, thereby decreasing side effects. An example of an undesirable effect occurs when alcohol and a sedative-hypnotic drug such as diazepam are combined. The resultant effect of this example is increased CNS depression. Some antibiotics have an enzyme inhibitor added to the drug to potentiate the therapeutic effect. Examples are ampicillin with sulbactam and amoxicillin with clavulanate, in which sulbactam and clavulanate potassium are bacterial enzyme inhibitors. Ampicillin and amoxicillin can be given without these inhibitors; however, the desired therapeutic effect may not occur because of the bacterial beta-lactamase, which inactivates the drugs and causes bacterial resistance. The combination of the antibiotic with either sulbactam or clavulanate inhibits bacterial enzyme activity and enhances the effect, or broadens the spectrum of activity, of the antibacterial agent. (PAGE 28)

Human subject research (Page 7, 10)

•Three core ethical principles are relevant to research involving human subjects: respect for persons (Treated as independent persons capable of making decisions in their own best interests.), beneficence (protect research subjects from harm), and justice (selection of research subject be fair. Distribution of benefits and burdens is equitable). •Historically, drug research was done only with Caucasian males, causing uncertainty as to the validity of research results for people of other ethnicities and for women and children. In 1993 Congress passed the National Institutes of Health (NIH) Revitalization Act, which helped establish guidelines to include women and minorities in clinical research.

rapid drug action

•Today an increasing number of drugs are administered by the IV route for direct absorption and fast action. Methods of IV administration include intermittent bolus (IV push [IVP]), usually with a syringe; intermittent infusions (IV piggyback [IVPB]); and continuous infusions. Drugs given IVP are usually small in volume and are administered over a few seconds to a few minutes. Drugs given IVP are usually small in volume and are administered over a few seconds to a few minutes. Medications administered by this route have a rapid onset of action, and calculation errors can have serious and even fatal consequences. (PAGE 116)

minoxidil (Rogaine)

•Tx: HTN and Alopecia •Side effects: headache, hypotension, tachycardia, angina, peripheral edema, erythema, pericardial effusion, and excess hair growth. (PAGE 520) •Minoxidil solution has been approved by the FDA for treating hair loss in men and women. A 5% solution is approved for men, 2% for women. The exact mechanism of action to stimulate hair growth is not known. Hair regrowth is usually seen after several months of using, but a few months after discontinuation, hair loss resumes. Minoxidil is available OTC in the form of a solution or foam. Systemic absorption of minoxidil is minimal, so adverse reactions seldom occur. Occasionally, headaches and a slight decrease in systolic blood pressure occur. (PAGE 603)

proparacaine - uses, side effects, how do you know if it is working?

•Use: Topical anesthetic used in selected aspects of a comprehensive eye examination and in a variety of ophthalmic procedures. Ophthalmic anesthetics act by locally blocking the pain signals at the eyes nerve endings. Administered by drops. Effects usually start occurring within 15 mins and the effects usually lasting 15 mins. •Side Effects: The blink reflex is temporarily lost; therefore, the corneal epithelium may become dry. Protecting the eye from irritating chemicals, foreign bodies, and corneal scratches are important. •How do you know if It is working? : Blink reflex is lost.