FUNDAMENTAL CONCEPTS OF PHARMACOLOGY

History, Definitions, Drug Information and Classifications

Pioneers of Medicine and Pharmacology:
 Hippocrates (450 B.C.)
 Francois Magendie (1783 - 1855)
 Claude Bernerd (1813 - 1878)
 Rudolf Buchheim (1820 to 1879)

1. What is Pharmacology?
 The study of drugs and origin
 From the Greek Pharmacon (drug), logos (a discourse or treatise)
 Broadly defined as how chemical agents affect living processes:
o Hormones
o Neurotransmitters
o Growth factors
o Drugs (pharmaceuticals)
o Toxic agents in the environment
 The medicinal/organic chemists may create the candidate compound (sometimes
referred to as a new chemical entity, NCE), it is the pharmacologist who is
responsible for testing it for pharmacological activity.
 Ultimately will lead to the discovery of novel drugs for therapeutic intervention
 Pharmacology is the unique combination of several Biomedical Sciences!
o Physiology o Biochemistry
o Chemistry o Medicine
o Pharmacology

2. What is a Drug?
 French: Drogue – a dry herb
 A single active chemical entity present in a medicine that is used for diagnosis,
prevention and treatment of diseases
 WHO – in 1966 – “ Drug is any substance or product which is used or intended to be
used to modify or explore physiological systems or pathological states for the
benefit of the recipient.”
 Therapeutic or diagnostic benefits
 Pharmacology studies the effects of drugs and how they exert their effects:
o Example: Paracetamol can reduce body temperature in case of fever by
inhibiting an enzyme known as cyclooxygenase in CNS, which is responsible for
the synthesis of a number of inflammatory mediators.
 Penicillin cures certain bacterial infections by disrupting the synthesis of
bacterial cell walls by inhibiting a key enzyme.

Drug - refers to the type of preparation in which the drug is supplied

- Preparation depends in the most suitable for its intended route of delivery and
means absorption
 Chemical name and code name
o Describe substances chemically
o For example - para - acet yl aminophen ol
 Non-proprietary Name – USAN, BAN, rINN, generic name.
 Proprietary Name (Brand Name) - Manufacturer
Example:
Chemical Name Non-proprietary Proprietary Name
N-acetyl-para-aminophenol (APAP) Paracetamol Crocin, Calpol and Decolgen,
acetaminophen (USAN US)
N-(4-Nitro-2-phenoxyphenyl) Nimesulide Nise, Nimulid
methanesulfonamide
Drug Nomenclature – New drug being developed
• Chemical Name or Code name – RO 15-17288
• Non-proprietary Name: Flumazenil
• (BAN, USAN and rINN) – approved name/official name
• Proprietary name: Anexate, Lanexat, Mazicon, Romazicon

3. Sources of Drugs
 Plant sources – Morphine, digoxin, quinine, atropine, reserpine, vinca alkaloids
and paclitaxel.
 Animal sources – Insulin, Thyroid extract, heparin, gonadotrophins and antitoxic
sera.
 Minerals – Liquid paraffin, magnesium sulfate, magnesium trisilicate, ferrous
sulfate and kaolin.
 Micro – organisms – Bacteria and fungi – Penicillin, Streptomycin
 Synthetic – Analgesics, hypnotics, anticancer drugs and antimicrobials
 Genetic Engineering – Human insulin, growth hormone genes
 Hybridoma technique – monoclonal antibodies origin

Plant Sources
 Alkaloids: Water soluble salts of water insoluble nitrogenous compounds
 Glycosides: Ether-like combination of sugar with other organic acids. Acid
hydrolysis separates sugar from non-sugar moiety
 Oils: Glycerides of oleic, palmitic or stearic acids
 Fixed oils: Peanut oil, coconut oil and castor oil
 Volatile oils: Peppermint oil, ginger, eucalyptus oil etc.
 Resins: Oxidized or polymerized volatile oils
 Oleoresins: Mixture of volatile oils and resins
 Gums: Secretory products of plants
 Opium Alkaloid Extraction

4. Drug Study
 Name (Generic and Brand Name) and classification
 Indications
 Preparation and Dosage
 Actions
 Side effects
 Contraindications
 Adverse reactions
 Cautions
 Interactions (to drug, food, sunlight)
6. Other Definition of Terms
 Pharmacoepidemiology: Study of effect of Drugs on populations
 Pharmacoeconomics: Study of cost effectiveness of drug treatment; the cost of
medications is of worldwide concern, particularly among certain groups such as
elderly and AIDS patients
 Chemotherapy: It is the branch of therapeutics which is concerned with the effects
of drugs upon microorganisms and parasites, living or multiplying in a living
organism. It also includes the drugs used in malignancy
 Pharmacognosy: is the science of identification of drugs
 Toxicology: is the science of poisons which includes detection and measurement of
poisons as well as treatment of poisoning. Poisons are the substances causing
harmful, dangerous or fatal symptoms in man and animals.
 National Formulary: It is the book published as product information on drugs
available to prescribers in respective countries
o Examples – National formulary – BNF by BMA and PSGB
 Essential Medicines
 WHO defines – “Essential Medicines are those that satisfy the priority
healthcare needs of the population. Essential medicines are intended to
be available within the context of functioning health systems at all
times and in adequate amounts, in appropriate dosage forms, with
assured quality and adequate information, and at a price the individual
and the community can afford.”
 Orphan Drugs
 These are the drugs or biological products for diagnosis, prevention
and treatment of a rare disease or a more common disease (endemic only
in poor countries) for which there is no reasonable expectation that
the cost of developing and marketing will be recovered from the sale of
these medicines.
 Examples: Rifabutin, Succimer, Fomepizole and liposomal
amphotericin B etc .
 Bioavailability - defined as both the relative amount of drug from an administered
dosage form which enters the systemic circulation and the rate at which the drug
appears in the blood stream.
 Blood flow rate - is the speed of blood perfusion in an organ, usually expressed in
ml/100 g organ weight/min. Blood flow rates, or immobilization, and exercise.
 Blood, Plasma or Serum Levels - demonstrate the concentration in blood, plasma or
serum upon administration of a dosage form by various routes of administration.
Blood, plasma, or serum level curves are plots of drug concentration versus time on
numeric or semi log graft paper. Blood plasma or serum levels are obtained from
blood samples by venipuncture by in certain time intervals after administration of
the drug product and chemical and microbiological analysis of the drug in the
biological fluid.
 Dosage Regimen or Dose Rate is the systematized dosage schedule for therapy, e.g.,
the proper dose sizes and the proper dosing intervals required to produces clinical
effectiveness or to maintain a therapeutic concentration in the body.
 Dose Dependency refers to a change of one or more of the pharmacokinetic processes
of absorption, distribution, metabolism and excretion with increasing dose size.
 Drug dependence is now referred to as substance use disorder. If an individual with
drug dependence stops taking that drug suddenly, that person will experience
predictable and measurable symptoms, known as a withdrawal syndrome.
 Dose Size is the amount of drug in gg(=mcg), mg, units or other dimensions to be
administered.
 Dosing Interval is the time period between administrations of maintenance doses.
 Drug Release or Liberation is the delivery of active ingredient from a dosage form
into solution. The Dissolution medium is either a biological fluid or an
artificial test fluid (in vitro). Drug release is characterized by the speed.
Liberation rate is constant and the amount of drug appearing in solution.
 Drug Tolerance is a person's diminished response to a drug, which occurs when the
drug is used repeatedly and the body adapts to the continued presence of the drug.
 Drug Resistance refers to the ability of microorganisms or cancer cells to
withstand the effects of a drug usually effective against them.
 A drug Product or Dosage Form is the gross pharmaceutical form containing the
active ingredient(s) (drug)s and vehicle substances necessary in formulating a
medicament of desired dosage, desired volume and desired application form, ready
for administration.
 Drug Receptor Interaction is the combining of drug molecule with the receptor for
which it has affinity, and the initiation of a pharmacologic response by its
intrinsic activity.
 Elimination Half-life of a drug is the time in hours necessary to deduce the drug
concentration in the blood, plasma or serum to self-half after equilibrium is
 reached. The elimination half-life may be influenced by: dose size, variation in
urinary excretion (pH), intersubject variation age, protein binding, other drugs
and diseases (especially renal and liver diseases). Loss of drug from the body, as
described by the elimination half-life, means the elimination of the administered
parent drug molecule (not its metabolites) by urinary excretion, metabolism or
other pathways of elimination (lung, skin, etc.)
 Excretion of drug is the final elimination from the body's systemic circulation via
kidney into urine, via bile and saliva into intestines and into feces, sweat, via
skin and via milk.
 Extravascular Administration refers to all routes of administration except those
where the drug is directly introduces into the blood stream. Extravascular routes
are IM, SC, PO, Oral, Rectal, IP, Topical, etc.
 Homeostasis is the maintenance of a steady state which characterizes the internal
environment of the healthy organism. An important function of homeostasis is the
regulation of the fluid medium and volume of the cell.
 Intravascular Administration refers to all routes of administration where the drug
is directly introduces into the blood stream i.e, IV, Intra-arterial and
intracardiac: bioavailability = 100 percent f= 1.
 I.V. Bolus is a physiologic nonsense and poor use (misuse) of language. A bolus
(greek bolos) is a bite, something solid which is swallowed and is then absorbed
from the intestines. The correct term would be I.V Push.
 Therapeutic range is the range of drug concentration in the blood, which gives the
desired effect without causing serious side effects or toxicity.

PRINCIPLES OF DRUG ACTIONS AND INTERACTIONS

Pharmacodynamics and Pharmacokinetics

LEARNING OBJECTIVES
1. Identify five basic principle of drug action
2. Explain potential problems associated with absorption of medications
3. Apply appropriate nursing concepts and actions holistically and comprehensively.
a. Discuss the pharmacodynamics of specific drugs.
b. Explain the pharmacokinetics of given drugs.
c. Analyze the factors affecting responses to drugs.
4. Identify the meaning and significance to the nurse of the half-life when used in
relation to drug therapy.
Therapeutic Methods
 Drug therapy – treatment with drugs
 Diet therapy – treatment by diet, such as a low-salt diet for CVD patients or
Kidney Failure
 Physiotherapy – treatment with natural physical forces such as water, light and
heat.
 Psychological therapy – identification of stressors and methods to reduce or
eliminate stress and/or the use of drugs.
Effects of Drug
a. Local or Systemic
b. Desired or Adverse
C. Indications and Side effects

Nontherapeutic Drug Actions/Effects

a. Side Effects
b. Adverse Reactions
c. Toxic Effects
a. Teratogenic
 b. Idiosyncrasy
c. Paradoxical/Paradoximal
d. Tolerance
e. Dependency
f. Hypersensitivity
d. Drug Allergy
e. Idiosyncratic Reaction
f. Drug Tolerance

Pharmacologic Process - important factors in determining the response of a drug at its

site of action

*Branches of Pharmacology
1. Pharmacokinetics: What Body does to Drugs?
 Study the FATE of drugs once ingested and the variability of drug response in
varying patient population
 The relationship between the dose of a drug and the drug’s concentration in
biological fluids
 Includes (LADME) liberation, absorption, distribution, metabolism, and excretion of
drugs
2. Pharmacodynamics: What Drugs do to the Body?
 Study the mechanisms by which Drugs act?
 The relationship between
o The concentration of drug at the site of action and
o The biochemical and
o Physiological effect
3. Pharmacotherapeutics: Use of drugs for prevention and cure of diseases
 Clinical management of diseases
*Pharmacodynamics
1. Therapeutic Index and Drug Safety
2. Graded Dose Response
3. Potency and Efficacy
4. Cellular Receptors and Drug Action
5. Types of Drug Receptor Interactions
*Pharmacokinetics (LADME)
1. Liberation
2. Absorption
3. Distribution
4. Metabolism (Biotransformation)
5. Excretion

Factors Influencing Responses to Drugs (Factors that may alter Drug actions)
1. Client Factors Influencing Drug Action
2. Client’s age, sex, weight and diet
3. Renal and liver function
4. Genetic factors
5. Amount of body fat
6. Psychological state

Drug Preparations and Administration

*Choices of Routes of Drugs

1. Drugs may be acidic, basic, or neutral and come in a variety of chemical forms such
as small organic molecules, large polymers such as proteins, carbohydrates and
other compounds with complex chemistries
 2. Physical and chemical properties of drug – solid/gas/liquid or solubility, pH etc.
3. Site of desired action – localized or generalized
4. Effect of digestive juices and first pass metabolism of drug
5. Accuracy of dosage required
6. Condition of the patient – unconscious, vomiting etc.

A. Local Routes
 Topical – External application of the drug to the surface for localized action,
e.g. lotion, ointment, cream, powder, paints, and spray etc.
 Deeper tissues – Certain deep areas can be approached by syringe and needle, e.g.
intra-articular, intra-medullary, intra-lesional injection, intrathecal and
infiltration
 Arterial supply – Closed intra-arterial injection, e.g. angiography and anticancer
drugs.
1. Enema
 Application of medicaments into rectum
 Two types:
o Evacuant enema: Mainly liquid form for local action e.g., soap water enema
 Quantity of fluid 600 ml
o Retention enema: Mainly solid form meant for systemic action e.g.,
prednisolone enema

B. Systemic Routes
a. Oral (enteral)
ADVANTAGES:
 Self-medication possible – no assistance required
 Vast area of absorption
 Simplicity of procedure – no extra cost
 Slow in action and hence safe with some risky drugs
 Both solid and liquid dosage forms can be given
DISADVANTAGES:
 Onset of action is tardy
 Irritant and unpalatable drugs cannot be administered
 Absorption is irregular with some drugs e.g. aminoglycosides
 May induce nausea and vomiting
 Not useful in presence of vomiting and diarrhea
 Can be destroyed by gastric juice – penicillin G, insulin
 Cannot be used in unconscious and uncooperative patient.
1. Enteric coated: with acetate-pthalate, glutean and anionic polymers of methacrylic
acid and its esters.
 To prevent gastric irritation and alteration of drug in stomach.
 To achieve desired concentration of drug in small intestine
 To retard the absorption of drug
2. Controlled release (CR): Timsules/Spansules
 To provide uniform medication for prolonged period
b. Sublingual
 Kept under the tongue or crushed and spread over the buccal mucosa
Advantages:
 rapid absorption – action in 1 minute
 liver is bypassed – directly in systemic circulation
 can spit out the drug
 Unconscious patients
Disadvantages:
 Only lipid soluble drugs
 Uncooperative patients
  Irritation of mucosa
 Drugs: GTN (Glyceryl trinitrate), Buprenorphine (Nifedipine)
c. Rectal
 Irritant and unpleasant drugs as suppositories or retention enema
 Can be used in presence of vomiting and unconsciousness
 Absorbed by external hemorrhoid veins – bypasses liver
 Drugs – Diazepam, Indomethacin and Aminophylline etc.
d. Inhalation
 Very rapid absorption due to vast surface area of lungs
 General anesthetics – gases and liquids
 Pressurized metered dose aerosols - MDI
 Dry powder inhalation - Rotahalers
e. Nasal
 Absorbed by mucous membrane of the nose
 Hepatic first pass metabolism and gastric juices are bypassed
 (GnRH agonists like Leuprolide, dDAVP and calcitonin)

C. Parenteral (Par – beyond, enteral – intestine)

Advantages:
 Unconscious and uncooperative patient
 In presence of vomiting and diarrhea
 Irritant drugs
 By pass alimentary juice and 1st pass metabolism
 Rapid action and accuracy of dose
Disadvantages:
 Costly and painful
 Self-medication is difficult
 Less safe and chance of infection
 Injury to nerves and arteries
 Risky
 Intradermal
 Subcutaneous
 Intramuscular
 Intravenous
 Intrathecal
 Intraperitoneal
a. Intradermal and Subcutaneous
 Intradermal: BCG and sensitivity Tests
 Subcutaneous: Non-irritant substances
 Small amount as less vascular
 Self-injection is possible
 Avoid in shock
 Repository depot preparations
 aqueous suspensions
 Best example – Insulin
 Hypodermoclysis
b. Intramuscular
 Soluble substances, mild irritants, suspensions and colloids
 Sites of Injection – buttock, deltoid muscle
 No IM injection to child before walking

D. Intravenous route
Advantages
 Quick action – ideal for emergency
 Desired concentration can be obtained
  No hepatic first pass metabolism
 Can be used in unconscious and uncooperative patients
Disadvantages
 Costly – special apparatus required
 Thrombophlebitis and local irritation
 Self-medication not possible
 Action cannot be halted
 Extravasation may cause severe irritation
 Aseptic and antiseptic measures to be maintained

E. Transcutaneous Routes
 Inunction: Nitroglycerin in angina pectoris
 Iontophoresis: Galvanic current is for penetration of drugs to deeper tissues –
anode and cathode iontophoresis e.g., salicylates
 Jet injection: Painless injection – high velocity jet produced through a microfine
orifice
 Transdermal therapeutic system (Novel drug delivery): Examples – GTN, Nicotine and
Estradiol
o Scopolamine patch
 Implants: Biodegradable and non-biodegradable. Example - Norplants

F. Transcutaneous images Transdermal Inunction Dermojet

Special Drug Delivery System
 Ocusert: Pilocarpine, progestasert
 Prodrug: Examples
o levodopa to dopamine
o Chloramphenicol palmitate
 Targeted delivery: Monoclonal antibodies
 Liposomes: daunorubicin, doxorubicin and amphotericin B etc.

SYNTHESIS
 Pharmacodynamics is the study of effect of a drug to an organism or the body,
whereas
 Pharmacokinetics is the study of how the organism affects the drug.
 Both together influence dosing, benefit, and adverse effects.
o what the DRUG does to the BODY (EFFECTS)
 Pharmacokinetics
o From-Loading dose –to- Volume of distribution (Initial) –to- Rate of infusion
-to- Onset of action –to-Biological half-life –to- Plasma protein binding –
to- Bioavailability
o what the BODY does to the DRUG (PROCESSES)
 Local action at the cellular or organ level; Systemic action, effecting changes
throughout the body
 Both local and systemic actions; Drug action is based on the half-life of a drug.

NURSING PROCESS and PHARMACOLOGY

LEARNING OBJECTIVES
1. Assess with the client one’s health status / competence in relation to drug
administration.
2. Formulate with the client reference to the prescribed medications a plan of care to
address the health needs / problems based on priorities.
3. Determine the specific nursing considerations / precautions in safe drug
administration
a. Interpret a medication order accurately.
b. Relate the rights in drug administration to patient safety.
 c. Practice correct decision-making skills in safe drug administration.
4. Provide appropriate health education related to drug therapy.
5. Evaluation compliance and response of client to the medication prescribed.
6. Use available clinical evidence that can ensure safe medication administration.
7. Document client’s condition / response / outcomes related to drug therapy.
8. Manage resources (human, physical, financial, time) efficiently and effectively in
safe drug administration.

A. ASSESSMENT
 Health History
 Medication History
 Allergies
 Prescription, Over-the-Counter Drugs
 Herbals and Alternative Therapies
 Biographical Data
 Pregnancy and Lactation Status
 Culture and Lifestyle
 Sensory and Cognitive Status
 Physical Examination
 Diagnostic and Laboratory Data
*Benefits
 Rapid Response
 Effective Absorption
 Accurate Titration
 Less Discomfort
*Risks
 Solution and drug incompatibilities.
 Poor vascular access in some clients.
 Immediate adverse reactions.
*Incompatibility
Drug + Diluent = must be compatible
 The more complex the solution, the greater the risk of incompatibility
 Incompatibility may result in the loss of therapeutic effects and may occur when:
- Several drugs are added to large volume of fluid to produce an admixture.
- Drugs in separate solutions are administered concurrently or in close
succession via the same IV line
- A single drug is reconstituted or diluted with the wrong solution
- One drug reacts with another drug’s preservative
Factors that influence the unique safety needs of an individual
1.Age 5. Individual Drug History
2.Body Size 6. Disease Condition
3.Sex 7. Psychological Factor
4.Body Organs System

Hazards of intravenous medications

 Mixing of two incompatible drugs in a solution can cause an adverse interaction
Poor Vascular Access
 Clients who require frequent or prolonged I.V. therapy may developed small,
scarred,
 inaccessible veins from repeated venipunctures or infusion of irritating drugs.
 If peripheral venous access isn’t possible, the doctor may use a central vein,
commonly by the subclavian route.
Adverse Drug Reaction
  A response to a drug that is noxious and unintended and occurs at doses normally
used in man for the prophylaxis, diagnosis or therapy of disease, or for
modification of physiological function (WHO).
 The following are some adverse drug reactions that you might notice:
o Skin rash
o Easy bruising
o Bleeding
o Severe nausea and vomiting 5. Diarrhea
o Constipation
o Confusion
o Breathing difficulties
B. NURSING DIAGNOSES
 Deficient Knowledge
 Ineffective Therapeutic Regimen Management
 Ineffective Health Maintenance
 Impaired Physical Mobility
 Disturbed Sensory Perception
 Impaired Swallowing
 Impaired Memory
 Noncompliance
C. PLANNING
 Ensures that clients receive medications at the appropriate time.
 Ensures that medications that should not be given are withheld until their
administration can be clarified with the health care practitioner.
 Adequate planning provides for questions and discussion by the client and
demonstration of skills learned.
I.V. Medication may be given by:
1. Drug injection
2. Intermittent infusion
3. Continuous infusion
Avoiding Errors
 Avoid use of periods
 Must be written and signed by provider
 Telephone orders differ by state
 Question any incomplete orders
 Question orders as necessary to ensure accuracy
 Intervention
Knowledge of the Drug
1. Drug Name
2. Route of Administration and Frequency
3. Usual Dose
4. Mode of Action
5. Side Effects
6. Contraindications
7. Nursing Responsibilities (Before, During, After the administration of drugs)
D. IMPLEMENTATION
 Interpretation of Doctor’s Order for Drugs)
An I.V. Medications may be ordered when:
 rapid therapeutic effect.
 can’t be absorbed by the GI tract.
 the client may receive nothing by mouth.
 controlled administration rate
Component/Parts of Medication Orders
 Parts of a Medication Order
 Name of the client
  Date and time when the order is written
 Name of the drug to be administered
 Dosage
 Route by which it is to be administered and special directives about its
administration
 Time of administration and frequency
 Signature of person writing the order
The nurse must understand the order perfectly before acting on it
 The Drug
 The Dose
 The Route
 The Frequency
o Note: If any of the above are unclear or open for interpretations, it is the
responsibility of the nurse to clarify the order with the physician
Types of Medication Orders
 Stat Orders
 Single-Dose Orders
 Standing Orders
 PRN Orders

TELEPHONE ORDERS - All telephone orders must be completely read back to the physician as
soon as they are recorded on the medical record and BEFORE they are executed. The order
read-back includes the patient's name, date, time of the order, the name of the med, the
dose, the route, the frequency of administration, any parameters or criteria for
administration.
VERBAL ORDERS - Verbal orders can only be accepted in an emergency situation. For
accuracy, ALL verbal orders must be read back to the physician completely, as soon as
they are written in the medical record. An emergency situation is one in which the health
of the patient would be compromised if there were a delay in administering the
medication. The order read-back includes the patient's name, date, and time of the order,
the name of the med, the dose, the route, the frequency of administration, any parameters
or criteria for administration.

MEDICATION SAFETY
*Safe Drug Administration
 Do no harm
 One mistake can lead to catastrophe
 Be exact in prescribing medication
 Administration
 Appropriate dose for patient
*Pediatric Dosage
 Special considerations for children
 Age, weight, sex
 Metabolic, pathologic, or psychological
 Dosage is quantity per unit of body weight per unit of time
Geriatric Dosage
 Special considerations for older adults
 Reduced adult dosages
 Cumulative drug effects due to alterations in body function
 Carefully assess and monitor closely
*Avoiding Medical Errors
 Never leave a decimal point naked
 Never place a decimal point and zero after a whole number
 Avoid using decimals if possible
 Always question the order if you have difficulty interpreting it
  You are legally responsible to recognize inappropriate dosages
*Calculation Guidelines (Next topic)
 Calculations must always be 100% correct
 Check whether all measures are in the same system
 Write the problem in equation form
 Check accuracy of answer and have someone else verify it
 Basic calculation formula
 Cautions for basic calculation method
 Ratio and proportion method
 Cautions for ratio and proportion method

*Correct & complete written ANNOTATION FOR WRITTEN ORDERS

 Orders are required for each medication to be administered. If any part of the
order is missing, unclear, illegible, includes unacceptable abbreviations, or does
not conform to the patient's condition, the nurse must contact the physician to
correct the problem or clarify the order before administering the medication.

A. Use a leading zero in front of the decimal dose of the medication.

Correct: 0.35mg
Incorrect: .35mg
B. Do Not use a "trailing zero" after a whole number dose of a medication.
Correct: 4mg
Incorrect: 4.0mg
C. Never use a range of doses or times.
Correct: Percocet 1 tab. PO q4h
Incorrect: Percocet 1-2 tabs PO q3-4h

I. General Nursing Considerations

*Know each drug you administer.
1. Know how to calculate the amount of medicine by using the formulas in calculating
dosages.
2. Always use the 5 R’s in giving medicines with considerations on the other R’s.
3. Avoid distraction while preparing drugs.
4. Remove any outdated drugs.
5. If a patient questions a medicine, resolved the question before giving the drug.
6. Check for presence of allergies each time you prepare and give medicines.
7. Name the drug and state its intended purpose for the patient.
8. Document all medications as soon as possible after giving them.
9. Do not give any medication prepared by someone else.
10. The nurse who gave the medicine is responsible for their accuracy and outcome.
Standards of Care: The 10R’s
GOLDEN RULES ADDITIONAL INFORMATION
PAIN
 Patients must receive adequate pain control. Pain assessment, interventions, and
outcomes must be documented completely. If the medications ordered are not
controlling the patient's pain, a new order should be obtained from the physician.
Don't let the patient suffer!
 Documentation includes: Pain, assessment, treatment, comfort level achieved (the
pain goal for that patient), interventions when treatment is inadequate, and new
outcomes from those interventions.
DOUBLE IDENTIFICATION
 To identify each patient receiving medications, the nurse must use 2 forms of
identification Forms of identification include: Patient ID band (a must!); the MR
number, asking the patient his name, date of birth, phone #, photo license, etc.
MISSED MEDICATION DOSES
 Whenever a medication dose has been missed, the nurse should contact the physician
to clarify what is best for the patient. When a medication dose is missed eg. the
patient is off the unit, the nurse should not assume that the next dose is due. The
decision about the missed dose belongs to the physician.
DANGEROUS ABBREVIATIONS
 Certain previously acceptable abbreviation CAN NO LONGER BE USED in the medical
record. The JCAHO and the hospital policy now prohibit their use. If these
abbreviations appear in a medication order, the order must be clarified with the
physician and rewritten correctly.

Abbreviations Term to write out

U, u Units
IU International Units
Ug Micrograms, mcg
QD/OD Daily
QOD Every other day
D/c Discontinue or Discharge
Sc or sq Subcutaneously
HS, hs Bed time or half strength
MS/MSO4 Morphine sulfate (Morphine)
MgSO4 Magnesium sulfate
OS/OD/OU Left/Right/Both eyes
AS/AD/AU Left/Right//Both ears
Trailing xero (x.omg) Deleting the trailing zero
Lack of leading zero (.xmg) Insert a leading zero (0.xmg)
BT Bedtime

CLIENT EDUCATON
 Speak clearly
 Observe for comprehension
 Ask them to repeat the directions
 Written clearly
 Correct measuring devices

Patient / Family Teaching

 Inform the client about the medication you are about to administer.
 Reason why the medication is to be given.
 Adverse effect he may experience
o Pain
o Redness
o Swelling
  For safe self-administration in the community setting, educate client of the
following:
o Purpose of the medications
o Adherence to schedule
o Self-monitoring for side effects
o Potential for interactions from over-the-counter medications

E. EVALUATION
What should you do if you suspect an ADR?
 Stop the medication immediately.
 Report the incident to the physician.
 Monitor the client.
Common Medication Errors
 Wrong dose (overdose, underdose, missed dose)
 Wrong medication to wrong patient
 Wrong medication to right patient
 Wrong medication due to wrong dispensing
 Wrong interpretation of doctor’s prescriptions for drugs
 Wrong infusion rate (over infusion, under infusion, missed order)

F. RECORDING AND REPORTING

DOCUMENTATION
1. type and amount of drug given
2. date and time given
3. confirmation that the i.v. line was patent
4. patient’s response to the medication
5. condition of the insertion site
6. ongoing monitoring that you provided
Where to document
1. nurse’s progress notes
2. medication sheet
3. infusion sheet
4. vital signs monitoring sheet
5. input and output monitoring sheet
 Knowledge of abbreviations and symbols is essential
 Accurate interpretation of provider’s order
SYNTHESIS
 The nursing process and the holistic care needs of the patient.

MEDICATION FREQUENCY, MEASUREMENT AND COMPUTATION

Learning Outcomes
1. Interpret medication frequency and time correctly.
2. Compute accurately the drug dosage for a given medication orders.

RA 9173 – Philippine Nursing Law of 2002 have stated that parenteral injection is in the
scope of nursing practice.
Board of Nursing Resolution No.8 Sec.30 (c) Art.VII or administratively under Sec.21
Art.III – states that any registered nurse without training and who administers IV
injections to patients shall be held liable, either criminally whether causing or not an
injury or death to the patient.

A. MEDICATION FREQUENCY AND TIME

Abbreviation Meaning Abbreviation Meaning
ac Before Hs Hour of sleep
 pc After q Every
c With qh Every hour
s Without q2h Every 2 hours
prn As needed q4h Every 4 hours
stat Now q6h Every 6 hours
bid Twice a day q8h Every 8 hours
tid Three times a day q12h Every 12 hours
qid Four times a day m Minute
qod Every other day q hs Every hour of sleep
d/c Discontinue

B. UNIT MEASUREMENT
ABBREVIATIONS
gr.……………...grain C……………….Centigrade or Celsius
F…………….....Fahrenheit g., gm., G……...Gram
kg………………kilogram l…………….…..liter
lb…………….....pound m……………….minum
mcg………….....microgram mg…………......milligram
ml………………milliliter tbsp………….…tablespoon
oz……………….ounce tsp……………...teaspoon
U……………......Unit +……………….plus or and
<………………..greater than @........................at
>………………..less than

APPROXIMATE EQUIVALENTS, WEIGHTS AND VOLUMES

½ oz = 15 ml 1000 mcg. = 1 mg.
1 oz = 30ml 1000 mg. = 1 G
15 m = 1 ml (1 cc) 1gr. - 60mg. (0.06G)
1 tsp = 5ml 15gr. = 1 G
3 tsp = 1 tbsp = 15 ml 2.2lb. = 1000G (1 kg)
1 l – 1000 ml 1 inch = 2.54cm

C. DOSAGE CALCULATION
*Remember: Before doing the calculation, convert units of measurement to one system.
I. Basic Formula: Frequently used to calculate drug dosages.
D (Desired dose) = D (dose ordered or desired dose)
H (Dose on hand) = S (dose on container label or dose on hand)
V (Vehicle-tablet or liquid) = Q form and amount in which drug comes (tablet, capsule, liquid)
D__ x V = amount to give Or ___D__ x Q = amount to give
H S
Example 1: Order-Dilantin 50 mg p.o. TID
Drug available-Dilantin 125 mg/5ml
D=50 mg H=125 mg V=5 ml
50
125 x 5 = 250
125 = 2 ml
Desired X Quantity
Stock
Example 2: PenG Na 1,250,000“u” IV q 6h ANST
Supply: The vial labeled: add 9.5 to make
10ml=5,000,000“u”
D X Q = 1,250,000 “u” X 10ml
S 5,000,000 “u”
= 1 X 10ml
4
= 10
 4
= 2.5 ml

Example 3: Morphine Sulfate 15mg IV stat

Supply: Morphine Sulfate gr 1/4 per ml
Step 1: Convert to same size unit
gr 1 = 60mg therefore: = gr 1 X 60mg
4 gr 1
= 60mg_ = 15mg
4
Step 2: D X Q = 15mg X 1ml
S 15mg

= 1 ml
II. Ratio & Proportion: Oldest method used in calculating dosage.

Known unit of : Known = Desired unit of : Unknown

measurement equivalent measurement equivalent
Known = Desired

H : V :: D : X
Means
Extremes
Left side are known quantities
Right side is desired dose and amount to give
Multiply the means and the extremes
HX = DV
X = DV
H
Example 1: Order-Keflex 1 gm p.o. BID
Drug available-Keflex 250 mg per capsule

D = 1 gm (note: need to convert to milligrams)

1 gm = 1000 mg
H = 250 mg
V = 1 capsule
250 : 1 :: 1000 : X
250X = 1000
X = 1000
250
X = 4 capsules
Example 2: CMC 500mg q 6 h
H:V = D: X
(Known) = (Desired)
1000 mg : 1 g = 500 mg : X
1000 (X) = (1) 500
X = 500
1000
X = 0.5 g
Example 3: Demerol 60 mg IM on call
H:V = D: X
100 mg : 2 ml = 60 mg : X ml
100 (X) = (2) 60
X = 120
100
X = 1.2 ml
III. Flow Rates:
Macro = 15 gtts
Micro = 60 gtts

A. drops per minute = total volume (ml) X gtt. Factor

no. of hours 60
example: IVF D5LR 1L in 8hrs. using macroset

= 1000 ml X 15
8 60
= 1000ml X 1
8 4
= 1000 = 31 gtts/min
32

B. cc per hour = total volume in ml

no. of hour
example: Infuse 1L of D5W in 10 hours.
= 1000ml
10 hrs.
= 100 cc/hr

C. no. of hrs to infuse = total volume (ml) X gtt factor

no. of gtts/min 60
example: IVF of D5IMB 1/2L to run at 30 ugtts/min
using microset.
= 500 X 60
30 60
= 500
30
= 16.6 hrs;16 hrs and 36 minutes

IV. How to Calculate Continuous Infusions

A. mg/min (For example - Lidocaine, Pronestyl)
Solution cc x 60 min/hr x mg/min
Drug mg = cc/hr
Drug mg x cc/hr
Solution cc x 60 min/hr = mg/hr

B. mcg/min (For example - Nitroglycerin)

Solution cc x 60 min/hr x mcg/min
Drug mcg = cc/hr
Drug mcg x cc/hr
Solution cc x 60 min/hr = mcg/hr
C. mcg/kg/min (For example - Dopamine, Dobutamine, Nipride, etc.)

1. To calculate cc/hr (gtts/min)

Solution cc
Drug mcg x 60 min/hr x kg x mcg/kg/min = cc/hr
Example: Dopamine 400 mg/250 cc D5W to start at 5 mcg/kg/min.
Patient’s weight is 190 lbs.
250 cc
400,000 mcg x 60 min x 86.4 x 5 mcg/kg/min = 16.2 cc/hr
 2. To calculate mcg/kg/min
Drug mcg/ x cc/hr
Solution cc x 60 min/hr x kg = mcg/kg/min
Example: Nipride 100 mg/250 cc D5W was ordered to decrease your
patient’s blood pressure.
The patient’s weight is 143 lbs, and the IV pump is set at 25
cc/hr. How many mcg/kg/min of Nipride is the patient
receiving?
100,000 mcg x 25 cc/hr
250 cc x 60 min x 65 kg = 2,500,000
975,000 = 2.5 mcg/kg/min

V. How to calculate mcg/kg/min if you know the rate of the infusion

A. START…. Dosage (in mcg/cc/min) x rate on pump
Patient’s weight in kg = mcg/kg/min
For example:
400mg of Dopamine in 250 cc D5W = 1600 mcg/cc
60 min/hr
= 26.6 mcg/cc/min
26.6 is the dosage concentration for Dopamine in mcg/cc/min based on having 400 mg in 250 cc of IV fluid. You
need this to calculate this dosage concentration first for all drug calculations. Once you do this step, you can do
anything!
B. NOW DO THE REST!
If you have a 75 kg patient for example.........26.6 mcg/cc/min x 10 cc on pump
Patients’s weight in kg (75 kg) = 3.54 mcg/kg/min
= 3.5 mcg/kg/min (rounded down)
How to calculate drips in cc per hour when you know the mcg/kg/min that is ordered or desired
mcg/kg/min x patient’s weight in kg
dosage concentration in mcg/cc/min = rate on pump
For example:
400 mg Dopamine in 250 cc D5W = 26.6 mcg/cc/min
3.5 mcg/kg/min x 75 kg
26.6 mcg/cc/min = 9.86 cc
= 10 cc rounded up

ALWAYS WORK THE EQUATION BACKWARDS AGAIN TO DOUBLE CHECK YOUR MATH!
For example:
10 cc x 26.6 mcg/cc/min
75 Kg = 3.5 mcg/kg/min
Dosage (in mcg/cc/min) x rate on pump
Patient’s weight in kg = mcg/kg/min
For example:
400mg of Dopamine in 250 cc D5W = 1600 mcg/cc 60 min/hr = 26.6 mcg/cc/min
26.6 is the dosage concentration for Dopamine in mcg/cc/min based on having 400 mg in 250 cc of IV fluid. You
need this to calculate this dosage concentration first for all drug calculations. Once you do this step, you can do
anything!

SUMMARY
 Many nurses have difficulty with drug calculations. Mostly because they don’t enjoy
or understand math. Practicing drug calculations will help nurses develop stronger
and more confident math skills. Many drugs require some type of calculation prior
to administration. The drug calculations range in complexity from requiring a
simple conversion calculation to a more complex calculation for drugs administered
by mcg/kg/min. Regardless of the drug to be administered, careful and accurate
calculations are important to help prevent medication errors. Many nurses become
 overwhelmed when performing the drug calculations, when they require multiple steps
or involve life-threatening drugs. The main principle is to remain focused on what
you are doing and try to not let outside distractions cause you to make a error in
calculations. It is always a good idea to have another nurse double check your
calculations. Sometimes nurses have difficulty calculating dosages on drugs that
are potentially life threatening. This is often because they become focused on the
actual drug and the possible consequences of an error in calculation. The best way
to prevent this is to remember that the drug calculations are performed the same
way regardless of what the drug is. For example, whether the infusion is a big bag
of vitamins or a life threatening vasoactive cardiac drug, the calculation is done
exactly the same way.
 Many facilities use monitors to calculate the infusion rates, by plugging the
numbers in the computer or monitor with a keypad and getting the exact infusion
titration chart specifically for that patient. If you use this method for beginning
your infusions and titrating the infusion rates, be very careful that you have
entered the correct data to obtain the chart. Many errors take place because
erroneous data is first entered and not identified. The nurses then titrate the
drugs or administer the drugs based on an incorrect chart. A method to help prevent
errors with this type of system is to have another nurse double check the data and
the chart, or to do a hand calculation for comparison. It is suggested that the
nurse perform the hand calculations from time to time, to maintain her/his math
skills.

ANTI-INFECTIVES AGENTS
Antibiotics:
 Sulfonamides
 Penicillin
 Cephalosporins
 Tetracyclines
 Aminoglycosides
 Quinolones
 Macrolides
- Medications used to treat bacterial infections
- Ideally, before beginning antibiotic therapy, the suspected areas of infection
should be cultured to identify the causative organism and potential antibiotic
susceptibilities.
- Empiric therapy: treatment of an infection before specific culture information
has been reported or obtained.
- Prophylactic therapy: treatment with antibiotics to prevent an infection, as in
intra-abdominal surgery
Mechanism of Action
 Bactericidal: kill bacteria.
 Bacteriostatic: inhibit growth of susceptible bacteria, rather than killing them
immediately; will eventually lead to bacterial death.
Antibiotics: Sulfonamides
 One of the first groups of antibiotics: sulfadiazine, sulfamethizole,
sulfamethoxazole, sulfisoxazole.
Mechanism of Action
 Bacteriostatic action
- Prevent synthesis of folic acid required for synthesis of purines and nucleic
acid
- Does not affect human cells or certain bacteria—they can use preformed folic
acid
Sulfonamides:sulfamethoxazole
Therapeutic Uses
Azo-Gantanol
 Combined with phenazopyridine (an analgesic-anesthetic that affects the mucosa of
the urinary tract).
 Used to treat urinary tract infections (UTIs) and to reduce the pain associated
with UTIs.
Bactrim
 Combined with trimethoprim.
 Used to treat UTIs, Pneumocystis carinii pneumonia, ear infections, bronchitis,
gonorrhea, etc.
Azo-Gantrisin
 Combined with phenazopyridine
 Used for UTIs
Pediazole
 Combined with erythromycin
 Used to treat otitis media
Sulfonamides: Side Effects
Body System: Blood
Effect: Hemolytic and aplastic anemia, thrombocytopenia
Body System: Integumentary
Effect: Photosensitivity, exfoliative dermatitis, Stevens- Johnson syndrome, epidermal
necrolysis
Body System: GI
Effect: Nausea, vomiting, diarrhea, pancreatitis
Body System: Other
Effect: Convulsions, crystalluria, toxic nephrosis, headache, peripheral
neuritis, urticaria

Antibiotics: Penicillins
 Natural penicillins
 Penicillinase-resistant penicillins
 Aminopenicillins
 Extended-spectrum penicillins
Natural penicillins:
 penicillin G,
 penicillin V potassium
Penicillinase-resistant penicillins
 cloxacillin
 dicloxacillin
 methicillin
 nafcillin
 oxacillin
Aminopenicillins:
 amoxicillin
 ampicillin
 bacampicillin
Extended-spectrum penicillins:
 piperacillin
 ticarcillin
 carbenicillin
 mezlocillin
- First introduced in the 1940s
- Bactericidal: inhibit cell wall synthesis
- Kill a wide variety of bacteria
- Also called “beta-lactams”
- Bacteria produce enzymes capable of destroying penicillins.
 - These enzymes are known as beta-lactamases.
- As a result, the medication is not effective.
Chemicals have been developed to inhibit these enzymes:
 clavulanic acid
 tazobactam
 sulbactam
- These chemicals bind with beta-lactamase and prevent the enzyme from breaking down
the pecinillin
Penicillin-beta-lactamase inhibitor combination drugs:
 ampicillin + sulbactam = Unasyn
 amoxicillin + clavulanic acid = Augmentin
 ticarcillin + clavulanic acid = Timentin
 piperacillin + tazobactam = Zosyn

Penicillins: Mechanism of Action

 Penicillins enter the bacteria via the cell wall. Inside the cell, they bind to
penicillin- binding protein.
 Once bound, normal cell wall synthesis is disrupted.
 Result: bacteria cells die from cell lysis.
 Penicillins do not kill other cells in the body
Penicillins: Therapeutic Uses
 Prevention and treatment of infections caused by susceptible bacteria, such as:
gram-positive bacteria; Streptococcus, Enterococcus, Staphylococcus species
Penicillins: Adverse Effects
 Allergic reactions occur in 0.7% – 8% of treatments
 Urticaria, pruritus, angioedema
 10% of allergic reactions are life-threatening and
 10% of these are fatal
Penicillins: Common side effects:
 Nausea
 Vomiting
 Diarrhea
 Abdominal pain

Antibiotics: Cephalosporins
- Semisynthetic derivatives from a fungus
- Structurally and pharmacologically related to penicillins
- Bactericidal action: •Broad spectrum
- Divided into groups according to their antimicrobial activity
Cephalosporins: First Generation
 Cefadroxil
 Cephalexin
 Cephradine
 Cefazolin
 Cephalothin
 Cephapirin
- Good gram-positive coverage
- Poor gram-negative coverage
- cefazolin (Ancef and Kefzol) – IV and PO
- cephalexin (Keflex and Keftab) – PO
- used for surgical prophylaxis, URIs, otitis media
Cephalosporins: Second Generation
 Cefaclor
 Cefonicid
 Cefprozil
  Ceforanide
 Cefamandole
 Cefmetazole
 Cefoxitin
 Cefotetan
 Cefuroxime
- Good gram-positive coverage
- Better gram-negative coverage than first generation
- Cefoxitin (Mefoxin) and Cefuroxime (Kefurox and Ceftin) – IV and IM, PO
- Used prophylactically for Surgical prophylaxis: abdominal or colorectal surgeries
- Does not kill
Cephalosporins: Third Generation
 Cefixime
 Ceftizoxime
 Cefpodoxime proxetil
 Ceftriaxone
 Cefoperazone
 Ceftazidime
 Cefotaxime
 Moxalactam
- Most potent group against gram- negative
- Less active against gram-positive
- cefixime (Suprax) and ceftriaxone (Rocephin)
- Tablet and suspension
- Only oral third-generation agent
- Best of available oral cephalosporins against gram-negative
- IV and IM, long half-life, once-a-day dosing
- Easily passes meninges and diffused into CSF to treat CNS infections
ceftazidime (Ceptaz, Fortaz, Tazidime, Tazicef)
- IV and IM
- Excellent gram-negative coverage
- Used for difficult-to-treat organisms such as Pseudomonas.
- Eliminated renally instead of biliary route
- Excellent spectrum of coverage
Cephalosporins: Fourth Generation
Cefepime (Maxipime)
- Newest cephalosporin agents.
- Broader spectrum of antibacterial activity than third generation, especially
against gram-positive bacteria.
Cephalosporins: Side Effects: Similar to penicillins
Common side effects: nausea, vomiting, diarrhea, abdominal pain

Antibiotics: Tetracyclines
 Demeclocycline (Declomycin)
 Oxytetracycline
 Tetracycline
 Doxycycline (Doryx, Doxy-Caps, Vibramycin)
 Minocyclin
- Natural and semi-synthetic
- Obtained from cultures of Streptomyces
- Bacteriostatic—inhibit bacterial growth
- Inhibit protein synthesis
- Stop many essential functions of the bacteria
- Bind to Ca2+ and Mg2+ and Al3+ ions to form insoluble complexes
- Thus, dairy products, antacids, and iron salts reduce absorption of tetracyclines.
Tetracyclines: Therapeutic Uses
Wide spectrum:
 gram-negative, gram-positive, protozoa, Mycoplasma, Rickettsia, Chlamydia,
syphilis, Lyme disease
 Demeclocycline is also used to treat SIADH, and pleural and pericardial effusions
Tetracyclines: Side Effects
 Strong affinity for calcium
 Discoloration of permanent teeth and tooth enamel in fetuses and children
 May retard fetal skeletal development if taken during pregnancy
 Can cause photosensitivity (the patient becomes overly sensitive to light).
 Alteration in intestinal flora may result in:
o Superinfection (overgrowth of nonsusceptible organisms such as Candida)
o Diarrhea
o Pseudomembranous colitis
 May also cause:
o Vaginal moniliasis
o Gastric upset
o Enterocolitis
o Maculopapular rash

Antibiotics: Aminoglycosides
 gentamicin (Garamycin)
 kanamycin
 neomycin
 streptomycin
 tobramycin
 amikacin (Amikin)
 netilmicin
- Natural and semi-synthetic
- Produced from Streptomyces
- Poor oral absorption; no PO forms
- Very potent antibiotics with serious toxicities
- Bactericidal
- Kill mostly gram-negative; some gram-positive also
- Used to kill gram-negative bacteria such as Pseudomonas, E. coli, Proteus,
Klebsiella, Serratia.
- Often used in combination with other antibiotics for synergistic effect.
Three most common (systemic effect):
a. Gentamicin
b. Tobramycin
c. Amikacin
- Streptomycin is an aminoglycoside and damage on the 8th cranial nerve (ototoxicity)
is a common side effect of aminoglycosides.
- Cause serious toxicities:
o Nephrotoxicity (renal failure)
o Ototoxicity (auditory impairment and vestibular [eighth cranial nerve])
- Must monitor drug levels to prevent toxicities
Aminoglycosides: Side Effects
 Ototoxicity and nephrotoxicity are the most significant
 Headache
 Paresthesia
 Neuromuscular blockade
 Dizziness
 Vertigo
  Skin rash
 Fever

Antibiotics: Quinolones
 •ciprofloxacin (Cipro)
 enoxacin (Penetrex)
 lomefloxacin (Maxaquin)
 norfloxacin (Noroxin)
 ofloxacin (Floxin)
Quinolones: Mechanism of Action
 Bactericidal
 Effective against gram- negative organisms and some gram-positive organisms
 Alter DNA of bacteria, causing death
 Do not affect human DNA
 Excellent oral absorption
 Absorption reduced by antacids
 First oral antibiotics effective against gram-negative bacteria
Quinolones: Therapeutic Uses
 Lower respiratory tract infections
 Bone and joint infections
 Infectious diarrhea
 Urinary tract infections
 Skin infections
 Sexually transmitted diseases
Quinolones: Side Effects
Body System: CNS
Effect: headache, dizziness, fatigue, depression, restlessness
Body System:
Effect: nausea, vomiting, diarrhea, constipation, thrush, increased liver function
studies
Body System: Integumentary
Effect: rash, pruritus, urticaria, flushing, photosensitivity (with lomefloxacin)
Body System: Other
Effect: fever, chills, blurred vision, tinnitus

Antibiotics: Macrolides
 Erythromycin
 azithromycin (Zithromax)
 clarithromycin (Biaxin)
 dirithromycin
 troleandomycin
- bactericidal action
Macrolides: Therapeutic Uses
 Strep infections
 Streptococcus pyogenes (group A beta-hemolytic streptococci)
 Mild to moderate URI
 Haemophilus influenzae
 Spirochetal infections
 Syphilis and Lyme disease
Macrolides: Side Effects
 GI effects, primarily with erythromycin: nausea, vomiting, diarrhea,
hepatotoxicity, flatulence, jaundice, anorexia
 Newer agents, azithromycin and clarithromycin: fewer side effects, longer duration
of action, better efficacy, better tissue penetration
Antibiotics: Nursing Implications
 Before beginning therapy, assess drug allergies; hepatic, liver, and cardiac
function; and other lab studies.
 Be sure to obtain thorough patient health history, including immune status.
 Assess for conditions that may be contraindications to antibiotic use, or that may
indicate cautious use.
 Assess for potential drug interactions.
 It is ESSENTIAL to obtain cultures from appropriate sites BEFORE beginning
antibiotic therapy.
 Patients should be instructed to take antibiotics exactly as prescribed and for the
length of time prescribed; should not stop taking the medication early when they
feel better.
 Assess for signs and symptoms of superinfection: fever, perineal itching, cough,
lethargy, or any unusual discharge.
 For safety reasons, check the name of the medication carefully since there are many
agents that sound alike or have similar spellings.
 Each class of antibiotics has specific side effects and drug interactions that must
be carefully assessed and monitored.
 The most common side effects of antibiotics are nausea, vomiting, and diarrhea.
 All oral antibiotics are absorbed better if taken with at least 6 to 8 ounces of
water.
Antibiotics: Nursing Implications Sulfonamides
 Should be taken with at least 2400 mL of fluid per day, unless contraindicated.
 Due to photosensitivity, avoid sunlight and tanning beds.
 These agents reduce the effectiveness of oral contraceptives.
Antibiotics: Nursing Implications Penicillins
 Any patient taking a penicillin should be carefully monitored for an allergic
reaction for at least 30 minutes after its administration.
 The effectiveness of oral penicillins is decreased when taken with caffeine, citrus
fruit, cola beverages, fruit juices, or tomato juice.
Antibiotics: Nursing Implications Cephalosporins
 Orally administered forms should be given with food to decrease GI upset, even
though this will delay absorption.
 Some of these agents may cause an Antabuse-like reaction when taken with alcohol.
Antibiotics: Nursing Implications Tetracyclines
 Milk products, iron preparations, antacids, and other dairy products should be
avoided because of the chelation and drug-binding that occurs.
 All medications should be taken with 6 to 8 ounces of fluid, preferably water.
 Due to photosensitivity, avoid sunlight and tanning beds.
Antibiotics: Nursing Implications Aminoglycosides
 Monitor peak and trough blood levels of these agents to prevent nephrotoxicity and
ototoxicity.
 Symptoms of ototoxicity include dizziness, tinnitus, and hearing loss.
 Symptoms of nephrotoxicity include urinary casts, proteinuria, and increased BUN
and serum creatinine levels.
Antibiotics: Nursing Implications Quinolones
 Should be taken with at least 3 L of fluid per day, unless otherwise specified
Antibiotics: Nursing Implications Macrolides
 These agents are highly protein- bound and will cause severe interactions with
other protein-bound drugs.
 The absorption of oral erythromycin is enhanced when taken on an empty stomach, but
because of the high incidence of GI upset, many agents are taken after a meal or
snack.
Antibiotics: Nursing Implications
Monitor for therapeutic effects:
 Disappearance of fever, lethargy, drainage, and redness.

Cardiovascular System
Definition of Terms
 Inotropic drugs- increased myocardial contractility.
o e.g. dopamine
 Chronotropic drugs- influence the cardiac rate by increasing the impulse generated in the SA node.
o e.g. Epinephrine, ATSO4
 Dromotropic drugs- delayed the speed of conduction of nerve fibers.
o e.g. lidocaine, cordarone, verapamil
Common Drugs
1. Ace inhibitor
2. Beta Blockers
3. Calcium Channel Blockers
4. Diuretics
5. Nitrates
6. Antiplatelet/ anticoagulant/ fibronolytics/thrombolytics

Cardiovascular Drugs
Angiotensin
 Converting Enzyme (ACE) Inhibitors
 A vasodilator that interfere the production of angiotensin II. Reduce afterload & improve cardiac output
& renal blood flow

ACE Inhibitors
Examples Indications
 Enalapril -reduce mortality & improve
LV dysfunction in post MI
 Ramipril -delay progression of heart failure
 Captopril -decrease sudden death & recurrence of MI
 Lisinopril
Precautions/Contraindications
 C.I. in Pregnancy & Angioedema
 Hypersensitivity to Ace Inhibitors
 Reduce dose in renal failure
Nursing Responsibilities
 Avoid hypotension esp. following initial dose & in relative volume depletion
 Generally started w/in first 24 hours after fibrolytic therapy has been completed & BP has stabilized
 Monitor BP
 Instruct client to take at the same time every day to ensure a stable blood level.
 Avoid sudden change of position.
 Take captopril or moexipril 1 hour before meals.

BETA BLOCKERS
 Decrease myocardial O2 demand by decreasing HR, Bp, myocardial contractility & calcium output.
Examples Indication
 Metoprolol -MI & unstable angina in the absence of complications
 Atenolol -adjunctive agent w/ fibronolytic therapy
 Propanolol (Inderal) -convert to normal sinus rhythm or to slow ventricular response
 Esmolol (Brevibloc) (or both) in supraventricular tachyarrhythmias are 2nd line agent after
adenosine, diltiazem or digitalis derivative
 -reduce myocardial ischemia & damage in AMI pts. w/ elevated HR, BP or both
Precautions/Contraindications
 Concurrent IV administration w/ IV calcium channel blocking agents like verapamil or diltiazem can
cause severe hypotension
Nursing Responsibilities
 Assess PR before administration of the drug; w/hold if bradycardia is present
 Administer with food to prevent GI upset
 Do not administer propanolol to clients w/ asthma. It causes bronchoconstriction
 Do not administer propanolol to clients w/ DM. It causes hypoglycemia.
 Give w/ extreme caution in clients w/ heart failure
 Observe the side effect which are as follows: nausea, vomiting, mental depression, mild diarrhea,
fatigue & impotence.
 Check BP & HR (withhold if below 50BPM & normal limit)

CALCIUM CHANNEL BLOCKERS

 Inhibit calcium ion transportation into myocardial cells to depress inotropic with chronotropic activity,
decrease cardiac workload. Has vasodilatation effect & reduces coronary vasospasm.
Examples Indication
 Diltiazem -to control ventricular rate in atrial fibrillation & atrial flatter
 Verapamil -use after adenosine to treat
 Nifedipine refractory PSVT in pts. w/narrow QRS complex & adequate BP
 Calcibloc
Precautions/Contraindications
 Do not use for wide QRS tachycardia of uncertain origin or for poison/drug induced tachycardia
 Avoid pts. w/ WPW syndrome plus rapid atrial fibrillation or flutter, in pts. w/ SSS or AV block w/out a
pacemaker
 Expect BP drop resulting from peripheral vasodilatation (greater drop with verapamil than with
diltiazem)
 Avoid in pts. receiving oral B-blockers
 Concurrent IV administration w/ B-blockers can cause severe hypotension

DIURETICS
Examples Indication
 Furosemide -adjuvant therapy for pulmonary edema in pts.
 Diamox -with systolic BP >90 to 100mmHg (w/out symptoms of shock)
 Duiril -hypertensive emergencies
-increase ICP
Precautions/Contraindications
 Dehydration
 Hypovolemia
 Hypotension
 Hypokalemia or other electrolyte imbalances
Nursing Responsibilities
 Monitor BP, I&O, wt., edema, pulse. Furosemide can lead to profound water depletion
 Assess volume depletion; dizziness, hypotension, tachycardia, muscle cramping.
 Take with meals
 Avoid sudden change of position.
 Monitor serum electrolyte as baseline data.
 To prevent nocturia, give thru p.o. or I.M. preparation in the morning. Give 2nd dose in early afternoon
 Watch out for signs of hypokalemia such as muscle weakness & cramps.

NITRATES
Examples Indication
 Nitroglycerin -Initial antianginal for suspected ischemic pain
(nitrosts/Transderm patch/ -For initial 24 to 48 hours in pts.
nitro-ointment with AMI & CF, large anterior infarction,
  Isordil (Isosorbide Dinitrate) persistent or recurrent ischemia or hypertension
 Imdur (Isosorbide Mononitrate)
Precautions/Contraindications
 With evidence of AMI, limit SBP drop to 10% if pt. is normotensive, 30% drop if hypertensive & avoid
drop below 90mmHg
 Do not mix with other drug
 Pt. should sit or lie down when receiving the medication
 Hypotension
 Severe bradycardia or tachycardia
 RV infarction
 Viagra w/in 24 hours
Nursing Responsibilities
 Assume sitting or supine position when taking the drug to prevent orthostatic hypotension
 Take maximum of 3 doses at 5 mins. interval
 If taken sublingual, the medication causes burning or stinging sensation under the tongue
 Sublingual route produces onset of action w/in 1 to mins., duration of action is 30 mins.
 Offer sips of water before giving sublingual nitrates; dryness of mouth may inhibit absorption
 Administration of Intravenous Nitroglycerin infusion requires pump for accurate control of medication.
 Instruct pt. to always carry 3 tabs. in his pocket
 Store nitroglycerin in cool, dry place, use dark colored air tight container, maybe destroyed by heat,
light or moisture
 Change of stock of nitroglycerin every 6 mos.
 Observe the side effects: headache, flushed face, dizziness, faintness, tachycardia; these are common
during first few doses of the medication. Do not discontinue the drug
 Transderm patch is applied once a day, usually in the morning. Retention of the skin site is necessary,
usually the chest wall

Common Cardiovascular Drugs

 Antiplatelet
 Anticoagulant
 Fibrinolytic/Thrombolytic
Antiplatelet
 Aspirin
 Ticlopidine (Ticlid)
 Clopidogrel (Plavix)
 Dyperidamole (Persantin)
 Cilostazol (Pletaal)
IV Antiplatelet
 Glycoprotein IIb/IIIa Inhibitors
 Abciximab (Reopro)
 Tirofiban (Aggrastat)
Anticoagulant
 Unfractional or regular heparin
 Low molecular wt. (Fraxiparine)
 Warfarin (Coumadin)
Fibrinolytic/Thrombolytic
 Streptokinase
 Tissue Plasminogen Activators (TPA IV)
 Urokinase

Antiplatelet: Aspirin
 Blocks formation of thromboxane A2, w/c causes platelets to aggregate, arteries to constrict. This
reduces overall AMI mortality, reinfarction, nonfatal stroke. Administer to any person with symptoms:
pressure, heavy weight, squeezing, particularly reperfusion candidates unless hypersensitive to aspirin.
Precautions/Contraindications
 Contraindicated in pts. with active ulcer or asthma and with known hypersensitivity to aspirin
IV Antiplatelet: Glycoprotein IIb/IIIa Inhibitors
 These drugs inhibit the integrin glycoprotein IIb/IIIa receptor in the membrane of platelets, inhibiting
platelet aggregation.
Precautions/Contraindications
 Active internal bleeding or bleeding disorder in past 30 days
 History of intracranial hemorrhage or other bleeding
 Surgical procedure or trauma w/in 1 mo.
 Platelet count <150,000/mm3
 Hypersensitivity & concomitant of another GP IIb/IIIa inhibitor.
Nursing Responsibilities: Platelet Aggregation Inhibitor
 Assess for signs & symptoms of bleeding
 Avoid straining at stool
 Do not give ASA w/ Coumadin
 ASA should be given food
 Observe for toxicity (tinnitus)
Nursing Responsibilities: Heparin Sodium
 Assess for signs & symptoms of bleeding
 Keep Protamine sulfate available. It is the antidote of heparin Na
 If administered SQ, do not aspirate, do not massage to prevent hematoma formation
 Use of maximum of 2 wks.
Nursing Responsibilities: Coumadin
 Assess for signs & symptoms of bleeding
 Keep vit. K readily available
 Monitor prothrombine time
 Minimize green leafy vegetables in the diet. These contain vit. K

Agent Used in Full Cardiac Arrest

OXYGEN
Mechanism of Action
 Elevate arterial O2
Indication
 Chest pain due to cardiac ischemia
 Hypoxemia
 Cardiac arrest

EPINEPHRINE
Mechanism of Action
 Increase HR & myocardial O2 requirements
 Increases automaticity
 Improves coronary & cerebral perfusion pressure due to its peripheral vasoconstriction effects
Indication
 Pulse less V-tach -cardiac arrest
 Asystole -bronchospasm hypersensitivity
 V-fib -severe hypotension
Dosage
 Bolus: 1 mg q 3-5 mins.
 Drip: 30 mg in 250cc D5W
Nursing Responsibilities
 Take BP, HR
 Assess signs of shock
 Teach pt. to take pulse
 Difficulty in voiding in male pts.
 Don’t mix w/ bicarbonate

ATROPINE SULFATE
Mechanism of Action
 Parasympatholytic drug
 Enhances both sinus node automaticity & atrioventricular conduction via its direct vagolytic action
Indication
 Severe sinus bradycardia
 AV blocks (1st degree AV block or mobitz type)
Dosage:
 0.5 - 1 mg. Maximum of 2 – 3 mg
Nursing Responsibilities
 Assess if pt. has glaucoma, BPH
 Severe mouth dryness
Side Effects
 dry mouth
 respiratory depression
 dilatation of pupil

ANTI-ARRHYTHMIC AGENTS (LIDOCAINE)

Mechanism of Action
 Local anesthetic
 Suppresses ventricular arrhythmias by decreasing automaticity
Indication
 V-tach
 Cardiac arrest
 V-fib
Dosage
 Bolus: 0.5 – 3 mg/kg.
 Drip: 2 – 4 mg/min
Nursing Responsibilities
 Watch out for signs of lidocaine induced neurological toxicity
 Correct K level first to reach its maximum effect
 Record weight

SODIUM BICARBONATE
Mechanism of Action
 Clinically widely used buffer agent
 Dissociates to Na and HCO3 ions
 the presence of hydrogen ions, these are converted to carbonic acid & hence to CO2 which is
transported to & excreted by the lungs
Indication
 Metabolic acidosis
 Prolonged cardiac arrest
 Hyperkalemia
Nursing Responsibilities
 Determine ABG esp pH & CO2 content
 Ensure IV line is patent, extravasations of tissue may cause slouching or necrosis
 Not to be mix w/ Dopamine

MORPHINE SULFATE
Mechanism of Action
 Increases venous capacitance & reduces systemic vascular resistance, relieving pulmonary congestion
 Reduces intramyocardial wall tension which decreases myocardial O2 requirements
Indication
 AMI
 Acute cardiogenic pulmonary edema
Dosage
 Bolus: 1 - 3 mg IVP 1-5 mins.
Inotropic Agents
 Norepinephrine
 Dopamine
 Dobutamine
 Lanoxin
NOREPINEPHRINE
Mechanism of Action
 Naturally occurring catecholamine
 Potent peripheral vasoconstrictor (alpha receptor stimulating agent) resulting to increase in BP
 Increases myocardial contractility (beta receptor stimulating agent)
Indication
 Hypotension
 Cardiogenic shock
Nursing Responsibilities
 Monitor BP closely
 Titrate gradually to avoid abrupt & severe hypotension
 Infuse through a central line to prevent extravasations & necrosis

DOPAMINE
Mechanism of Action
 Chemical precursor of norepinephrine that stimulates dopaminergic, beta & alpha adrenergic
 Low dose (1-5) renal vasodilation. Causes renal, mesenteric & cerebrovascular dilation. Tends to
produce an increase in renal output.
 Moderate dose (5-10) cardiac dose. Enhances myocardial contractility, increased cardiac output & rise
in BP
 High dose (10-20) vasopressor dose Produces peripheral arterial & venous vasoconstriction
Indication
 Hypovolemia
 Septic shock
 Hypotension w/ symptomatic bradycardia
Nursing Responsibilities
 Monitor HR, BP
 Taper gradually to avoid acute hypotension
 Watch out nausea & vomiting
 Do not mix w/ NaHCO3

DOBUTAMINE
Mechanism of Action
 Improves myocardial contractility, increases CO, decreases ventricular filling pressure, decreases total
systemic & pulmonary vascular resistance
 Increases renal blood flow due to increased CO
Indication
 tx of CHF
 AMI
 Cardiogenic & septic chock
Nursing Responsibilities
 Monitor for tachycardia & presence of arrhythmia
 Monitor BP

LANOXIN
Mechanism of Action
 Increases myocardial contractility
 Controls ventricular response to atrial flutter and fibrillation
Indication
 CHF, chronic
  SVT, A-fib, A flutter
Nursing Responsibilities
 Monitor severe bradycardia
 Watch out rhythm & EKG changes, ventricular disrrhythmias & AV blocks
 Monitor for renal dysfunction & electrolytes imbalances.
 Seeing yellow spots and colored vision are common symptoms of digitalis toxicity
Signs of digitalis toxicity
 Visual disturbances such as seeing yellow spots
o Seeing yellow spots and colored vision are common symptoms of digitalis toxicity

Respiratory System
Key Terms
 Ventilation
 Perfusion
 Diffusion
 Pulmonary Circulation
 Surfactant
 pneumocytes
Drugs for Asthma and Other Bronchoconstrictive Disorders
 Asthma—inflammation, hyperreactivity, and bronchoconstriction
 GERD may cause microaspiration/resultant nighttime cough
 Antiasthma medications can also exacerbate GERD
Asthma
 May be triggered by viruses
 Irritants
 Allergens
 Can develop at any age
 Seen more often in children who are exposed to airway irritants during infancy
Asthma
 Bronchoconstriction
 Inflammation
 Mucosal edema
 Excessive mucous
Pathophysiology of Asthma
 Mast cells
 Chemical mediators such as histamine, prostaglandins, acetylcholine, cGMP, interleukins, leukotrienes
are released when triggered. Mobilization of eosinophils. All cause movement of fluid and proteins into
tissues.
 Bronchoconstrictive substances antagonized by cAMP
Chronic Obstructive Pulmonary Disease
 Combination of chronic bronchitis and emphysema
 Bronchoconstriction and inflammation are more constant, less reversibility
 Anatomic and physiologic changes occur over years
 Leads to increasing dyspnea and activity intolerance
Drug Therapy
 Bronchodilators and anti-inflammatories
Categories of Asthma
 Step 1-Mild Intermittent—symptoms 2 days/week or less or 2 nights/month or less. No daily medication
needed; treat with inhaled beta2 agonist
 Step 2-Mild persistent—symptoms >2/week but <1x/day or >2 nights/month. In those >5 years old, use
inhaled corticosteroid, leukotriene modifier, Intal (cromolyn), or sustained release theophylline
o Children 5 years and younger—inhaled corticosteroid by nebulizer of MDI with a holding
chamber. Can also use leukotriene modifier or Intal by nebulizer
 Step 3—Moderate persistent. Symptoms daily and > one night per week.
o Older than 5yo—low to med. Dose corticosteroid and long acting beta 2 agonist. Alternatives p.
714
 o Children < 5 yo: low dose inhaled corticosteroid and a long acting beta 2 agonist or medium
dose inhaled corticosteroid
 Step 4—Severe persistent—symptoms continual during daytime and frequently at night.
o >5yo—high dose inhaled corticosteroid, long acting beta 2 agonist; intermittent admin. of oral
corticosteroids
o Children less than 5 yo—same as for adults and older children
Bronchodilators
 Adrenergics—stimulate beta 2 receptors in smooth muscle of bronchi and bronchioles
 Receptors stimulate cAMP =bronchodilation
 Cardiac stimulation is an adverse effect of these medications
Bronchodilators--adrenergics
 Cautious use in hypertension and cardiac disease
 Selective beta 2 agonists by inhalation are drugs of choice
 Epinephrine sc in acute bronchoconstriction
Short acting bronchodilators
 Proventil (albuterol)
 Xopenex (levalbuterol)
 Treatment of first choice to relieve acute asthma
 Aerosol or nebulization
 Overuse will diminish their bronchodilating effects>>>>tolerance
Other bronchodilators
 Foradil (formoterol) and Serevent (salmeterol) are long acting beta 2 adrenergic agonists used only for
prophylaxis. Black box warning on Serevent—use in deteriorating asthma can be life-threatening
 Alupent (metaproterenol)—intermediate acting. Useful in exercise induced asthma, tx acute
bronchospasm.
 Brethine (terbutaline)—selective beta 2 adrenergic agonist that is a long-acting bronchodilator
 When given subq, loses selectivity
 Also used to decrease premature uterine contractions during pregnancy
Anticholinergics
 Block the action of acetylcholine in bronchial smooth muscle when given by inhalation
 Action reduces intracellular guanosine monophosphate (GMP) which is a bronchoconstrictive
substance
 Atrovent (ipratropium)—caution in BPH, narrow-angle glaucoma
 Spiriva (tiotropium)
Xanthines
 Theophylline
 Mechanism of action unclear
 Bronchodilate, inhibit pulmonary edema, increase action of cilia, strengthen diaphragmatic contractions,
over-all anti-inflammatory action
 Increases CO, causes peripheral vasodilation, mild diuresis, stimulates CNS
 Contraindicated in acute gastritis and PUD
 Second line
 Narrow therapeutic window—therapeutic range is 5-15 mcg/mLh
 Multiple drug interactions
Anti-Inflammatory Agents
 Suppress inflammation by inhibiting movement of fluid and protein into tissues; migration and function
of neutrophils and eosinophils, synthesis of histamine in mast cells, and production of proinflammatory
substances
 Benefits: decreased mucous secretion, decreased edema and reduced reactivity
Corticosteroids
 Second action is to increase the number and sensitivity of beta 2 adrenergic receptors
 Can be given PO or IV
 Pulmonary function usually improves within 6-8 hours
 Continue drugs for 7-10 days
Steroids
 Fewer long term side effects if inhaled
  End-stage COPD may become steroid dependent
 In asthma, systemic steroids generally are used only temporarily
 Taper high dose oral steroids to avoid hypothalamic-pituitary axis suppression
 For inhalation:
o Beclovent—beclomethasone
o Pulmicor—budesonide
o Aerobid—flunisolide
o Flovent—fluticasone
o Azmacort—triamcinolone
o Most inhaled steroids are being reformulated with HFA
 Systemic use: prednisone, methylprednisolone, and hydrocortisone
 In acute, severe asthma—a systemic corticosteroid may be indicated when inhaled beta 2 agonists are
ineffective
Leukotriene Modifiers
 Leukotrienes are strong chemical mediators of bronchoconstriction and inflammation
 Increase mucous secretion and mucosal edema
 Formed by the lipoxygenase pathway of arachidonic acid metabolism in response to cellular injury
 Are release more slowly than histamine
Leukotriene Modifier Drugs
 Developed to counteract the effects of leukotrienes
 Indicated for long term treatment of asthma in adults and children
 Prevent attacks induced by some allergens, exercise, cold air, hyperventilation, irritants and
ASA/NSAIDs
 Not useful in acute attacks
Leukotriene Modifiers
 Injured cell
 Arachidonic acid
XXXX
 Lipooxygenase
 Leukotrienes
XXXX
 Bronchi, WBCs
 Bronchoconstriction
Leukotriene Modifier Drugs
 Singulair (montelukast) and Accolate (zafirlukast) are leukotriene receptor antagonists
 Can be used in combination with bronchodilators and corticosteroids
 Less effective than low doses of inhaled steroids
 Should not be used during lactation
 Can cause HA, nausea, diarrhea, other
Mast Cell Stabilizers
 Intal (cromolyn)
 Tilade (nedocromil)
 Prevent release of bronchoconstrictive and inflammatory substances when mast cells are confronted
with allergens and other stimuli
 Prophylaxis only
 Inhalation, nebulizer or MDI, nasal spray as well
Immunosuppressant Monoclonal Antibody
 Xolair (omalizumab) works by binding to IgE, blocking receptors on surfaces of mast cells and
basophils
 Prevents release of chemical mediators of allergic reactions
 Adjunctive therapy
 Can cause life-threatening anaphylaxis

Antihistamines and Allergic Disorders

 Histamine is the first chemical mediator released in immune and inflammatory responses
 Concentrated in skin, mucosal surfaces of eyes, nose, lungs, CNS and GI tract
  Located in mast cells and basophils
 Interacts with histamine receptors on target organs called H1 and H2
Antihistamines
 H1 receptors are located mainly on smooth muscle cells in blood vessels and the respiratory and GI
tracts
 H1 binding causes: pruritus, flushing, increased mucous production, increased permeability of veins—
edema, contraction of smooth muscle in bronchi>>bronchoconstriction and cough
 With H2 receptor stimulation, main effects are increased secretion of gastric acid and pepsin,
decreased immunologic and proinflammatory reactions, increased rate and force of myocardial
contraction
Allergic Reactions
 Are exaggerated responses by the immune system that produce tissue injury and possible serious
disease
 Allergic reactions may result from specific antibodies, sensitized T lymphocytes, or both, formed durng
exposure to an antigen.
Types of Responses to Cell-Mediated Invasion
 Type I—immediate hypersensitivity, IgE induced response triggered by the interaction of antigen with
antigen-specific IgE bound on mast cells
 Anaphylaxis is an example
 Does not occur on first exposure to an antigen
 Can develop profound vasodilation resulting in hypotension, laryngeal edema, bronchoconstriction
Allergic Reactions
 Type II—IgG or IgM mediated which generate direct damage to cell surfaces. Examples include: blood
transfusion reactions, hemolytic disease of newborns, hypersensitivity reactions to drugs such as
heparin or penicillin
 Type III is an IgG or IgM mediated reaction characterized by formation of antigen-antibody complexes
that induce inflammatory reaction in tissues. Prototype is Serum Sickness. Immune response can occur
following antitoxin administration, pcn or sulfa drugs
 Type IV Hypersensitivity
o Delayed hypersensitivity
o Cell mediated response where sensitized T lymphocytes react with an antigen to cause
inflammation, release of lymphokines , direct cytotoxicity or both
o Classic examples are tuberculin test, contact dermatitis and some graft rejections
Allergic Rhinitis
 IgE mediated
 Inflammation of nasal mucosa caused by a hypersensitivity reaction to inhaled allergens
 Presents with itching of throat, eyes and ears
 Seasonal and perennial
 Can lead to chronic fatigue, difficulty sleeping, sinus infections, postnasal drip, cough and headache
Intranasal Drugs for Allergic Rhinitis
 Atrovent nasal spray
 Beconase (beclomethasone)
 Rhinocort (budesonide)
 Flonase (fluticasone)
 Nasonex (mometasone)
 Nasalcrom (a mast cell stabilizer)
Allergic Contact Dermatitis
 Type IV hypersensitivity reaction
 Poison ivy an example
 Usually occurs >24h after re-exposure
Other reactions
 Allergic food reactions—result from ingestion of a protein
o Most common food allergy is shellfish, others include milk, eggs, peanuts
 Allergic drug reactions—unpredictable, may occur 7-10 days after initial exposure
 Pseudoallergic drug reactions—resemble immune responses but do not produce antibodies, i.e.
anaphylactoid
Antihistamines
 Inhibit smooth muscle constriction in blood vessels and the respiratory and GI tracts
 Decrease capillary permeability
 Decrease salivation and tear formation
 Act by binding with the histamine receptor
Indications for Use
 Allergic rhinitis
 Anaphylaxis
 Allergic conjunctivitis
 Drug allergies
 Transfusions of blood products
 Dermatologic conditions
 Nonallergic such as motion sickness, nausea and vomiting, sleep
Precautions
 Caution in pregnancy
 BPH
 Bladder neck obstruction
 Narrow angle glaucoma
First Generation H1 Receptor Antagonists
 Bind to central and peripheral receptors
 Can cause CNS depression or stimulation
 Have substantial anticholinergic effects
 Examples:
o Chlor-Trimeton (chlorpheniramine)
o Benadryl (diphenhydramine)
o Vistaril (hydroxyzine)
o Phenergan (promethazine)
Second Generation H1 Receptor Antagonists
 Selective or nonsedating
 Do not cross blood brain barrier
 Examples:
o Astelin (azelastine)
o Allegra (fexofenadine)
o Claritin (loratadine)
o Clarinex (desloratadine)
o Zyrtec
o Xyzal
Nasal Decongestants
 Relieve nasal obstruction and discharge
 Adrenergic
 Rebound nasal swelling called “rhinitis medicamentosa”
 Afrin
 Sudafed (pseudoephedrine)
 Contraindicated in severe hypertension, CAD, narrow angle glaucoma, TCAs or MAOIs
Antitussives
 Suppress cough by depressing cough center in medulla or by increasing flow of saliva
 For dry, hacking, non-productive cough
 Not recommended in children and adolescents
 Codeine, hydrocodone dextromethorphan
Expectorants
 Liquefy respiratory secretions
 Guiafenesin
Mucolytics
 By inhalation to liquefy mucous
 Mucomyst (acetylcysteine)
 May be used in treating acetaminophen overdose
Cold Remedies
 Contain antihistamine, decongestant and an analgesic
 Chlorpheniramine, pseudoephedrine, acetaminophen, dextromethorphan and guiafenesin
 Decongestants can cause stasis of secretions
 PM contains antihistamine
 Tamiflu can be used to limit spread of virus in respiratory tract

Gastro Intestinal Tract

There are five types of drugs that affect gastric acid secretions and are useful for the treatment of
peptic ulcer.
1. Histamine (H2) receptor antagonist/blockers
2. Antacids
3. Proton pump inhibitors
4. Mucosal protectants
5. Prostaglandin analogs
Drugs affecting secretions:
Anti-ulcer drugs
Prototype
• Histamine (H2) receptor: Cimetidine antagonist/blockers
• Antacids: AlOH and MgOH
• Proton pump inhibitors: Omeprazole
• Mucosal protectants: Sucralfate
• Prostaglandin analog: Misoprostol
General indication of the drugs affecting gastric acid secretion
• Peptic ulcer
• Gastritis
• Patient on NPO to prevent stress ulcer

General time of administration of the drugs affecting gastric acid secretion

o Histamine (H2) Cimetidine with FOOD or ONE receptor hour after
o ANTACID antagonist/blockers Antacids AlOH and MgOH Usually after meals
o Proton pump inhibitors Omeprazole BEFORE MEALS
o Mucosal protectants Sucralfate BEFORE MEALS
o Prostaglandin analogs Misoprostol WITH MEALS

Pharmacodynamics Histamine (H2) receptor blockers

 These drugs BLOCK the release of hydrochloric acid in the stomach in response to gastrin
Drugs affecting GI secretions Antacids
 These drugs interact with the gastric acids at the chemical level to neutralize them
Drugs affecting GI secretions Proton pump inhibitors
 These drugs suppress the secretion of hydrochloric acid into the lumen of the stomach
Drugs affecting GI secretions Mucosal protectants
 These are agents that coat any injured area in the stomach to prevent further injury from acid
Drugs affecting GI secretions Prostaglandin analogs
 These are agents that inhibit the secretion of gastrin and • increase the secretion of mucus lining of the
stomach, providing a buffer.

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

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

PPI
The newer agents for ulcer treatment
The “prazoles”
Prototype: Omeprazole
o Lanisoprazole
o Esomeprazole
o Pantoprazole
Pharmacodynamics: drug action
 They act at specific secretory surface receptors to prevent the final step of acid production and thus
decrease the level of acid in the stomach.
 The “pump” in the parietal cell is the H- K ATPase enzyme system on the secretory surface of the
gastric parietal cells.
Clinical use of the PPIs
 Short-term treatment of active duodenal ulcers, GERD, erosive esophagitis and benign gastric ulcer
 Long-term- maintenance therapy for healing of erosive disorders.
Precautions
 Known allergy is a clear contraindication
 Caution if patient is pregnant
Pharmacodynamics: Adverse effects
 CNS - dizziness, headache, asthenia (loss of strength), vertigo, insomnia, apathy
 GIT- diarrhea, abdominal pain, nausea, vomiting, dry mouth and tongue atrophy
  Respi- cough, stuffy nose, hoarseness and epistaxis.
Nursing considerations:
 Administer the drug BEFORE meals. Ensure that patient does not open, chew or crush the drug.
 Provide safety measures if CNS dysfunction happens.
 Arrange for a medical follow-up if symptoms are NOT resolved after 4-8 weeks of therapy.
 Provide health teaching as to drug name, dosages and frequency, safety measures to handle common
problems.
 Monitor patient response to the drug, the effectiveness of the teaching plan and the measures to
employ
 Evaluate for effectiveness of the drug
o Healing of peptic ulcer
o Decreased symptoms of ulcer

The Mucosal Protectant Sucralfate (Caralfate/ Iselpin)

 This is given to protect the eroded ulcer sites in the GIT from further damage by acid and digestive
enzymes
Pharmacodynamics: Action of drug
 It forms an ulcer-adherent complex at duodenal ulcer sites, protecting the sites against acid, pepsin and
bile.
 This action prevents further breakdown of proteins in the area and promotes healing.
Clinical use of sucralfate
 Short- and long-term management of duodenal ulcer.
 NSAIDs induced gastritis
 Prevention of stress ulcer
 Treatment of oral and esophageal ulcers due to radiation, chemotherapy or sclerotherapy.
Precautions on the use of Sucralfate
 This agent should NOT be given to any person with known allergy to the drug, and to those patients
with renal failure/dialysis because of build-up of aluminum may occur if used with aluminum containing
products.
Pharmacodynamics: Side-effects & adverse reactions
 Primarily GIT= CONSTIPATION, occasionally diarrhea, nausea, indigestion, gastric discomfort, and dry
mouth may also occur.
 CNS= dizziness, drowsiness, vertigo.
 Others= rash and back pain.
Drug-drug interactions
 If used with aluminum salts = high risk of accumulation of aluminum and toxicity.
 If used with phenytoin, fluoroquinolones and penicillamines = decreased levels of these drugs when
taken with sucralfate.
Nursing Considerations
 Administer drug ON AN EMPTY stomach, 1 hour before meals, or 2 hours after meals and at BEDTIME
 Monitor for side-effects like constipation and GI upset
 Encourage intake of high-fiber foods and increased fluid intake
 Administer antacids BETWEEN doses of sucralfate, NOT WITHIN 30 minutes of sucralfate dose
 Provide comfort measures if CNS effects occur
 Provide health teaching as to drug name, dosages and frequency, safety measures to handle common
problems.
 Monitor patient response to the drug, the effectiveness of the teaching plan and the measures
employed
 Evaluate effectiveness of therapy
o Healing of ulcer
o No formation of ulcer

Prostaglandin analogue Misoprostol

  This agent is a synthetic prostaglandin E1 analog that is employed to protect the lining of the mucosa of
the stomach.
Pharmacodynamics
 Being a prostaglandin analog, it inhibits gastric acid secretion to some degree.
 It INCREASES mucus production in the stomach lining.
Clinical use
 NSAIDs-induced gastric ulcers
 Duodenal ulcers unresponsive to H2 antagonists
 This drug is CONTRAINDICATED during pregnancy because it is an abortifacient.
 Women should be advised to have a negative pregnancy test within 2 weeks of beginning therapy and
should begin the drug on the second or third day of the next menstrual cycle.
 They should be instructed in the use of contraceptives during therapy.
Effects: drug reactions
 GIT = Nausea, diarrhea, abdominal pain, flatulence, vomiting, dyspepsia
 GU effects = miscarriages, excessive uterine CRAMPING and bleeding, spotting, hyper-menorrhea and
menstrual disorders.
Nursing Considerations
 Administer to patients at risk for NSAIDs- induced ulcers during the full course of NSAIDs therapy
 Administer four times daily with meals and at bedtime
 Obtain pregnancy test within 2 weeks of beginning therapy.
 Begin the therapy on second or third day of menstrual period to ensure that the woman is not pregnant
 Provide patient with both written and oral information regarding the associated risks of pregnancy
 Provide health teaching as to drug name, dosages and frequency, safety measures to handle common
problems.
 Monitor patient response to the drug, the effectiveness of the teaching plan and the measures to
employ

Laxatives
 Generally used to INCREASE the passage of the colonic contents.
 The general classifications is as follows:
o Chemical stimulants – irritants
o Mechanical stimulants- hyperosmotic agents and saline cathartics
o Lubricants and stool softeners.
 They promote bowel evacuation for various purposes.
 They are classified into their mode of action.
Action:
 Direct stimulation of the Chemical Bisacodyl
 GIT nerves stimulants (Dulcolax)
 Irritant laxatives
 Increased fluid content
 Mechanical Lactulose of the fecal material (bulk) causing stimulation of stimulants the local reflex
 Lubricating the Lubricants Docusate intestinal material to Mineral oil promote passage through the GIT
Therapeutic Indications of the Laxatives
 SHORT term relief of Constipation
 Prevention of straining in conditions like CHF, post-MI, post partum, post-op
 Preparation for diagnostic examination
 Removal of poison or toxins
 Adjunct in anti-helminthic therapy
 To remove AMMONIA by use of lactulose
Contraindications in Laxative use
 ACUTE abdominal disorders
o Appendicitis
o Diverticulitis
o Ulcerative colitis
Chemical Stimulant Cathartics
 Prototype: Bisacodyl Irritant laxatives:
o Castor oil – most commonly used in hospitals
o Senna
o Cascara
o Phenolphthalein
 These agents DIRECTLY stimulate the nerve plexus in the intestinal wall
 The result is INCREASED movement or motility of the colon
LACTULOSE (Cephulac) Bulk-forming laxatives
o Magnesium (citrate, hydroxide, sulfate)- saline cathartic
o Psyllium
o Polycarbophil
Pharmacodynamics
 These agents are rapid-acting laxatives that INCREASE the GI motility by:
o Increasing the fluids in the colonic material
o Stimulating the local stretch receptors
o Activating local defection reflex

Lubricants-Stool softener
Prototype: Docusate
 Glycerin
 Mineral oil
Pharmacodynamics
 Docusate increases the admixture of fat and water producing a softer stool
 Glycerin and Mineral oil form a slippery coat on the colonic contents
Pharmacokinetics: Common Side-effects of the Laxatives
 Diarrhea
 Abdominal cramping
 Nausea
 Fluid and electrolyte imbalance
 Sympathetic reactions – sweating, palpitations, flushing and fainting
 CATHARTIC dependence

The Nursing Process and Laxative

ASSESSMENT
 Nursing History - elicit allergy to any laxatives, elicit history of conditions like diverticulitis and ulcerative
colitis
 Physical Examination- abdominal assessment
 Laboratory Test: fecalysis, electrolyte levels
NURSING DIAGNOSIS
 Alteration in bowel pattern
 Alteration in comfort: pain
 Knowledge deficit
IMPLEMENTATION
 Emphasize that it is use on a SHORT term basis
 Provide comfort and safety measures like ready access to the bathroom, side-rails
 Administer with a full glass of water
 Encourage fluid intake, high fiber diet and daily exercise
 DO NOT administer if acute abdominal condition like appendicitis is present
 Advise to change position slowly and avoid hazardous activities because of potential dizziness
 Record intake and output to assess fluid alteration
 If possible, observe the character of stools
 Caution the patient that chronic use may promote dependence and use during pregnancy may cause
uterine cramping and Vitamin deficiency
EVALUATION of drug effectiveness
 Evaluate relief of GI symptoms, absence of staining and increased evacuation of GI tract
 For Lactulose: decreased ammonia
 Normal bowel function is restored

The Anti-diarrheals
 These are agents used to calm the irritation of the GIT for the symptomatic relief of diarrhea
General Classifications
 Local anti-motility
 Local reflex inhibition
 Central action on the CNS
Action:
 Action Locally coats the lining
 Local reflex Bismuth of the GIT to soothe inhibitor subsalicylate irritation
 Directly inhibits the Local anti- Loperamide intestinal muscle motility activity to SLOW peristalsis
 Stops GIT spasm by Central acting Opium CNS action agent derivatives (paregoric)
Clinical Indications of drug use
 Relief of symptoms of acute and chronic diarrhea
 Reduction of fecal volume discharges from ileostomies
 Prevention and treatment of traveler's diarrhea
Contraindications of anti-diarrheal Use
 Poisoning
 Drug allergy
 GI obstruction
 Acute abdominal conditions
Pharmacokinetics: Side effects
 Constipation
 Nausea, vomiting
 Abdominal distention and discomfort
 TOXIC MEGACOLON
Nursing process and anti-diarrheals
ASSESSMENT
 Nursing History
o Elicit history of drug allergy, conditions like poisoning, GI obstruction and acute abdominal
conditions
 Physical Examination
o Abdominal examination
 Laboratory test
o Electrolyte levels
NURSING DIAGNOSIS
 Alteration in bowel pattern
 Alteration in comfort: pain
IMPLEMENTATION
 Monitor patient response within 48 hours. Discontinue drug use if no effect
 Provide comfort measures for pain
 Provide teaching regarding its short term use only
EVALUATION
 Monitor effectiveness of drug- RELIEF of diarrhea
 Monitor adverse effects, effectiveness of pain measures and effectiveness of teaching plan

Emetics and Anti-emetics

Emetic Agent
 Syrup of Ipecac
Anti-emetics
  Phenothiazines
 Non-phenothiazines
 Anticholinergics/Antihistamines
 Serotonin receptor Blockers
 Miscellaneous
EMETIC • Prototype: Ipecac Syrup
Pharmacodynamics
 Ipecac syrup irritates the GI mucosa locally, resulting to stimulation of the vomiting center
 It acts within 20 minutes
Clinical Use
 To induce vomiting as a treatment for drug overdose and certain poisonings
Contraindications
 Ingestion of CORROSIVE chemicals
 Ingestion of petroleum products
 Unconscious and convulsing patient
Pharmacokinetics: side effects of Ipecac
 Nausea
 Diarrhea
 GI upset
 Mild CNS depression
 CARDIOTOXICITY if large amounts are absorbed in the body
Nursing process and the EMETIC
ASSESSMENT
 Nursing History - elicit the exact nature of poisoning
 Physical Examination- CNS status and abdominal exam
IMPLEMENTATION
 Administer to conscious patient only
 Administer ipecac as soon as possible
 Administer with a large amount of water
 Vomiting should occur within 20 minutes of the first dose. Repeat the dose and expect vomiting to
occur with
 20 minutes
5. Provide comfort measures like ready access to bathroom, assistance with ambulation
 Offer support
EVALUATION
 Evaluate patient response within 20 minutes of drug ingestion
 Monitor for adverse effects
 Evaluate effectiveness of comfort measures and teaching plan
ANTI-EMETICS
 These are agents used to manage nausea and vomiting.
 They act either locally or centrally.
 In general, they may inhibit the chemoreceptor trigger zone in the medulla by blocking DOPAMINE
receptor.
 Others act by decreasing the sensitivity of the vestibular apparatus.
Anti-emetic types
Common examples
 Phenothiazines Prochlorperazine, Promethazine Non-phenothiazines Metoclopramide Anticholinergics
and Meclizine, buclizine Antihistaminics Serotonin Receptor “setron”- dolasetron blockers
Miscellaneous Dronabinol, hydroxyzine
Pharmacodynamics
 Centrally block the vomiting center in Phenothiazines the medulla Non-phenothiazine
 Reduces the responsiveness of the nerve cell in the medulla; also blocks the dopamine receptors
 Block the transmission of the impulses Anticholinergics to the medulla Serotonin receptor
 Centrally and locally inhibits the serotonin receptors blockers
  Act in the CNS, either in the medulla or Miscellaneous in the cortex
Clinical Use
 N/V associated with Phenothiazines anesthesia
 Intractable hiccups
 N/V associated with chemical Non-phenothiazine stimulation
 N/V associated with motion
 Anticholinergics sickness Serotonin-receptor
 N/V associated with Blockers chemotherapy Miscellaneous
 N/V associated with chemotherapy
Indications
 Prevention and treatment of vomiting
 Motion sickness
Contraindications
 Severe CNS depression
 Severe liver dysfunction
Pharmacokinetics:
 Oral absorption is good if vomiting is not present
 IV drugs can be given if vomiting is active
 Most drugs are metabolized in the liver excreted in the kidneys
Pharmacokinetics: Side-effects
 PHOTHOSENSITIVITY
 Drowsiness, dizziness, weakness and tremors and DEHYDRATON
 Phenothiazines= autonomic anti- cholinergic effects like dry mouth, nasal congestion and urinary
retention
 Metoclopramide= EPS due to dopamine receptor blockage
Nursing Process and the ANTIEMETICS
ASSESSMENT
 Nursing History - elicit allergy, impaired hepatic function and CNS depression
 Physical Examination - CNS status and abdominal examination
 Laboratory test- Liver function studies
NURSING DIAGNOSIS
 Alteration in comfort: pain
 High risk for injury
 Knowledge deficit
IMPLEMENTATION
 Assess patient’s intake of other drugs that may cause dangerous drug interaction
 Emphasize that this is given on a short-term basis
 Provide comfort and safety measures
o Advise to change position slowly
o Avoid hazardous activities
o Provide mouth care and ice chips
o Monitor for dehydration and offer fluids if it occurs
 Protect from sun exposure
o Sunscreens
o Protective covering
 Provide health teaching
EVALUATION
 Monitor for the drug effectiveness
o Relief of nausea and vomiting
 Monitor for adverse effects
 Evaluate effectiveness of comfort measures and teaching plan

Drugs Affecting the Endocrine System

 Posterior Pituitary Hormones
  Animal posterior pituitary hormone extract
 Example : Pitressin (vasopressin) IM, SC
DDAVP (desmopressin) synthetic. IV, SC, intranasal
 MOA: Natural antidiuretics. Produces concentrated urine by increasing tubular reabsorption of water.
 Uses: Diabetes insipidus, SIADH caused by trauma, surgery, etc. Bedwetting (DDAVP) Monitor BP,
I&O, weight, and urine specific gravity.
 Anterior Pituitary Hormone
 Genotropin (somatropin)
 MOA: Promotes growth in children whose growth has been impaired by a deficiency of growth
hormone.
 Uses: Children with deficiency of growth hormone, adults with deficiency of growth hormone from
disease, surgery or radiation of pituitary.
 Thyroid Hormones
 Examples: Synthroid, Levothroid (levothyroxine) synthetic thyroxine (T4)
 MOA: Increase metabolic activity of body
 Uses: Drug of choice for long-term hypothyroidism, simple goiter.
 Adverse Effects: S/S of hyperthyroidism –tachycardia, sweating, intolerance to heat, diarrhea,
abdominal cramping, weight loss, decreased bone density in the hip & spine.
 Antithyroid Drugs
 Examples: PTU (propylthiouracil) prototype, Tapazole (methimazole), Lugol’s solution (strong iodine
solution).
 MOA: PTU and Tapazole interfere with synthesis of thyroid hormone and inhibits conversion of T4 to
the more active T3.
 Lugol’s Inhibits the release of thyroid hormone, causing them to accumulate in the thyroid gland.
 Uses: Short-term treatment of hyperthyroid to bring patient to euthyroid pre-op, decrease the size and
vascularity of thyroid pre-op.
 Adverse Effects: Hypothyroidism, hair loss, allergic reaction.
 Corticosteroids / Mineralocorticoids
 Example: Florinef (fludrocortisone)
 MOA: Promote Na and water retention. Help maintain fluid and electrolyte balance. Aldosterone is the
main mineralocorticoid.
 Uses: Chronic adrenocortical insufficiency.
 Adverse Effects: Hypokalemia, fluid retention, hypertension, HA
 Glucocorticoids
 Examples: Decadron (dexamethasone), Solu-Medrol (methylpredinisolone), Prednisone, Celestone
(betamethasone), Aristocort (triancinolone), Nasonex, Azmacort
 MOA: Affect CHO, protein and lipid metabolism by: Increasing the catabolism of protein in bone, skin
and connective tissue. Increasing output of glucose by the liver and decreasing cellular use of glucose.
Mobilizing amino acids to increase energy in times of stress. Anti-inflammatory response protects cells
from damage related to immune response.
 Uses: Replacement therapy in deficiency states. Antiinflammatory for hpersensitivity and inflammatory
diseases like arthritis, lupus, psoriasis. Bronchospasm and edema related to emphysema, asthma and
other respiratory diseases or injuries. Mature lungs in preterm fetus prior to delivery.
 Adverse Effects: Edema, hyperglycemia, hypokalemia, muscle wasting, peptic ulcer, hypertension,
immunosuppression, increased WBC, masks signs of infection, thin skin.
 Nursing Measures:
o Give PO with food. Give at 9am to mimic normal corticosteroid levels and minimize adrenal
suppression. Weigh daily. Monitor BP, blood sugars, and electrolytes. Monitor for s/s of adverse
effects.
o Teach to moderate salt intake, eat K rich foods, diet high in protein. Avoid licorice (may intensify
hypokalemia), alcohol and caffeine.
o Medic Alert. Tapering drugs.
 Adrenal Sex Hormones
 Androgens – male hormones secreted by the adrenal cortex in both sexes and are responsible for the
physiological effects exerted by adrenal sex hormones.
  They increase protein synthesis (anabolism), which increases muscle and bone mass and strength,
effect development of male secondary sex characteristics.
 They increase hair growth and libido in women.
 Excessive secretion: masculine effects in women.
 Female sex hormones exert few effects. Excessive secretion: feminine characteristics in men.
 Oxytoxics
 Examples: Pitocin (oxytocin)
 MOA: Enhances contractile activity of the uterine smooth muscle.
 Uses: Induce or stimulate labor, control post partum hemorrhage.
 Adverse Effects: Uterine rupture, fetal hypoxia or trauma.
 Nursing Measures:
o Accurate dose, Close monitoring of contractions and FHT in labor.
o Careful administration and monitoring. Pitocin (oxytocin)
 Methergine (methylergonovine)
 MOA: Direct spasmogenic action on uterine muscle.
 Uses: Post-partum hemorrhage only.
 Adverse Effects: Hypertension, CVA
 Premature Labor Inhibitors
 Examples: Yutopar (ritodrine)
 MOA: Selective beta 2 receptor agonist that activates the beta 2 receptors of the uterine smooth
muscle inhibiting contractions.
 Uses: Preterm labor if gestation is > 20 weeks.
 Adverse Effects: N,V, HA, palpitations, tachycardia, hypotension. Intermediate Acting Insulin
 Isophane insulin suspension
 NPH, NPH Iletin II, Humulin N, Novolin N.
 Modified by adding protamine and zinc.
 Insulin zinc suspension
 Lente, Ilentin II, Lente L, Humulin L, Novolin L.
 Modified by adding zinc. May be used interchangeably with NPH insulin.
 Onset 1-11/2 hr, peak 8-12 hr, duration 18-24 hr.
 Long Acting Insulin
 Extended Insulin zinc suspension: Humulin U, Ultralente
 Modified by adding zinc. Large crystals that are absorbed slowly.
 Route – SC
 Onset 4-8 hr, peak 10-30 hr, duration > 36 hr.
 Rarely used.
 Mixed Insulin
 NPH 70%, Regular 30% - Humulin 70/30, Novolin 70/30.
 NPH 50%, Regular 50% - Humulin 50/50
 Stable mixtures with onset, peak and duration of action the same as the N and R components.
 Route – SC
 Frequently used when patients have trouble mixing N and R insulin accurately themselves.
 Insulin Lispro – Humalog
 A synthetic insulin made using recombinant DNA techniques. Two amino acids are reversed to make it
have a faster peak and shorter duration of action than regular insulin.
 It is intended for use with an intermediate acting insulin.
 Route – SC
 Onset 15 min, peak ½-11/2 hr, duration 6-8
 More effective than R at decreasing postparandial glucose and decreasing incidence of hypoglycemia
before next meal.
 Insulin aspart – Novalog
 Similar to Humalog
 Has even more rapid onset and shorter duration than Humalog.
 Route – SC
 Onset 15 min, peak 1-3 hr, duration 3-5 hr.
 Insulin gargline – Lantus
 MOA: Long acting provides action similar to endogenous insulin secretion. Recombinant DNA
technique alters amino acid structure.
 No addition of zinc or protamine.
 Route – SC once daily, usually at bedtime.
 Onset 1 hr, peak NONE, duration 24 hr.
 Clear solution, must not be diluted or mixed with any other insulin or solution.
 Nursing Measures
o Careful administration of correct dose.
o Close observation for hypoglycemia (before lunch for R and before dinner for N.
o Monitor blood glucose.
o Ensure compliance with diet.
o When giving IV use glass bottles because insulin adheres to plastic bags and tubing (up to 30%
of dose).
o Observe circulation – foot care.
 Patient Education : Instruct patient and a family member:
o Type of insulin, differences in types.
o Dosage and how to draw up and administer SC in abdomen rotating sites.
o S/S of hypoglycemia (HA, hunger, nervousness, weakness, tachycardia, blurred vision,
disorientation, sweating, unconsciousness, seizures).
o Teach how to check blood glucose.
o Teach how to treat hypoglycemia: Take 4 oz of OJ for < 70 and recheck glucose in 15 min., if <
70 repeat the OJ. If longer than 30 min. to next meal, eat a snack.
o Be sure they understand diabetic diet, sick day diet and the importance of compliance.
o Be sure they understand the importance of regular exercise, foot care, and need for regular
check-ups and eye exams.
o Instruct family how to manage unconscious patient and how to use Glucagon.
 Oral Hypoglycemic Agents
 Sulfonylureas – the oldest and largest group or oral agents. Second generation agents are safer and
more potent than first generation agents such as Diabinese.
 Examples: Amaryl (glimepiride), Glucotrol (glipizide), DiaBeta, Micronase (glyburide).
 MOA: Stimulate the production of insulin in patients who still some ability to produce insulin. Increase
the number of insulin receptors on the cells and may influence activity within the cells after glucose is
inside.
 Hypoglycemic Agents
 Uses: Type 2 Diabetes
 Adverse Effects: Hypoglycemia, N,D, rash.
 Contraindications: Sulfa allergy, pregnancy and lactation, severe liver or renal disease.
 May be used alone or in combination with other oral agents or with insulin.
 Alpha Glucosidase Inhibitors
 Examples: Precose (acarbose), Glyset (migitol).
 MOA: Block alpha-glucosidase in the small intestines to reduce CHO absorption. This helps prevent
postparandial hyperglycemia.
 Uses: Type 2 Diabetes
 Adverse Effects: Hypoglycemia, flatulence, abdominal pain.
 Take with first bite of meal. Use glucose tablets or gel for hypoglycemia because it can inhibit the
breakdown of sucrose to glucose.
 Biguanides
 Example: Glucophage (metformin)
 MOA: NO stimulation of insulin release. Potentiates insulin suppression of gluconeogenesis. Enhances
glucose utilization by muscles by recruitment of glucose transporters. Increases intestinal utilization of
glucose and reduces intestinal absorption of glucose.
 Uses: Type 2 Diabetes
 Adverse Effects: Rare lactic acidosis (use of alcohol or steroids increase risk), bloating.
 Contraindications: Renal impairment.
 Glitazones/TZDs/Insulin Sensitizers
 Examples: Actos (pioglitazone), Avandia (rosiglitazone)
 MOA: Decrease insulin resistance. Stimulate muscle, fat, and liver cell receptors to increase or restore
the effectiveness of circulating insulin. This leads to increased uptake of glucose by the tissues and
suppresses production of glucose by the liver.
 Uses: Type 2 Diabetes
 Adverse Effects: Liver toxicity – must check labs.
 There is an increased response in females and in obese clients.
 Meglitinides
 Examples: Prandin (repaglinide), Starlix (natelinide)
 MOA: Nonsulfonylureas that stimulate secretion of insulin.
 Uses: Monotherapy or with metformin.
 Onset 20 min., peak 1 hr, duration 3-4 hr.
 Take with or 30 min. before meals. If a meal is skipped the dose should be skipped. If meal is added,
add a dose.
 Glucagon
 MOA: Appears to increase synthesis of phosporylase activity which increases hepatic
gluconeogenesis.
 Uses: Emergency treatment of severe hypoglycemia reactions when patient is unconscious or unable
to swallow.
 Types of Insulin
 Onset → when insulin begins to work
 Peak → when insulin is working hardest
 Duration → how long insulin works
 Species of Insulin
 Beef Insulin → from pancreas of cattle
 Pork Insulin → from pancreas of pigs
 Beef – Pork Mixture → combination of beef and pork insulin
 Human Insulin
o Bio – synthetic → bacteria are genetically altered
o Semi – synthetic → pork insulin is chemically altered
 Storing Insulin
 Vials not in use
o → Keep in refrigerator
o → Avoid extremes of temperature (freezing or exposure to direct sunlight)
 Vials in use → Keep at room temperature (up to 1 month)
 Spare vials → Keep in refrigerator
 To mix cloudy insulin
o → Invert vial
o → Roll vial between hands
o → Do not shake vial
 Inspect for flocculation (frosted, whitish coating inside vial)
 Selecting Syringes
 Types of U – 100 Insulin Syringes
 Standard 100 – Unit Dual Scale → Even – and Odd – Numbered Scales
o → Size: 1 ml
o → Marked in 2 – unit increments
50 – U Lo – Dose 30 – U Lo – Dose
→ Size: 0.5 ml → Size: 0.3 ml
→ Marked in 1 – unit increments → Marked in 1 – unit increments

 Insulin Syringes
Normal/Obese Clients Thin Clients/Children
→ 27 – to 29 – gauge → 29 – to 30 – gauge
→ 0.5 inch long → 8 mm long
 Key Points
 Always measure insulin in insulin syringe
 Equivalents of insulin units to milliliters:
o 100 U of U – 100 insulin = 1 ml
 Use smallest capacity insulin syringe possible to most accurately measure insulin dosages
 Key Points
 Lo – Dose U – 100 insulin syringes are still intended for measurement of U – 100 insulin although they
only measure maximum of 30 or 50 units
 Two nurses should double – check insulin dosage
 Administer all forms of insulin subcutaneously
 Use of alcohol to cleanse skin is not recommended
 Do not aspirate
 Do not massage
 Use only regular insulin for IV administration
 Mixing Insulins
 Inject air first into cloudy insulin vial
 Draw up insulin first from clear insulin vial
 Selecting and Rotating Site
4 Main Areas for Injection
 Abdomen → where speed of absorption is greatest
 Arms (posterior surface)
 Thighs (anterior surface)
 Hips
 Approaches to Rotation
 Rotate sites within same anatomic area → use all available injection sites within one area → administer
each injection 0.5 to 1 inch away from previous injection
 Use same area at same time of day
 Principles to Rotation
 Do not use same site more than once in 2 to 3 weeks
 Do not inject insulin into limb that will be exercised

ANTINEOPLASTIC AGENTS
 One branch of chemotherapy involves drugs developed to act on and kill or alter human cells, designed
to fight neoplasms, or drugs inhibit and combat the development of cancers.
 It also alter human cells in a variety of ways, and they are intended to have a greater impact on the
abnormal cells that make up the neoplasm or cancer than on normal cells.
 Most commonly, chemotherapy acts by killing cells that divide rapidly, one of the main properties of
most cancer cells. This means that it also harms cells that divide rapidly under normal circumstances:
o cells in the bone marrow
o digestive tract
o hair follicles
The most common side effects of chemotherapy:
1. Myelosuppression (decreased production of blood cells, hence also immunosuppression)
2. Mucositis (inflammation of the lining of the digestive tract)
3. Alopecia (hair loss).

CYTOPROTECTANT AGENTS
 The cytoprotectant agents are a small group of drugs that assist in lessening the harsh & sometimes
life-threatening adverse effects of the anti-neoplastic agents.

Focus of Anti-Neoplastic Treatment

Depending on the:
a. Type
b. Size
c. Location of cancer, as well as your overall health
Chemotherapy may focus to achieve any of the following goals:
 Curative: Curative chemotherapy is intended to kill all the cancer cells in the body, curing the patient of
cancer.
 Palliative: This approach involves prolonging the patient's life by controlling cancer growth, spread,
and invasion into other tissues. Palliative treatments are also used to help relieve cancer-related
symptoms, improving the patient’s quality of life.
 Adjuvant: This treatment strategy involves using chemotherapy alongside other cancer treatment
options. Adjuvant chemotherapy is usually administered after surgery or radiotherapy to kill any
remaining cancer cells in the body.
 Neoadjuvant Chemotherapy: The focus of neoadjuvant chemotherapy is to reduce the size of a tumor
preceding surgery or other treatment options.

DRUG CLASSIFICATIONS/CATEGORIES:
 Alkylating agents
 Antimetabolites
 Antibiotics
 Plant alkaloids
 Hormones &hormone modulators
 Miscellaneous agents
 Cytoprotectant agents

ALKYLATING DRUGS
 These chemical agents utilize the cellular property of electronegativity to add alkyl groups to cells.
Electronegativity is a cell’s ability to attract electrons. When a cell inadvertently attracts alkyl groups,
the alkyl alters the cell’s DNA, resulting in cell death or impaired mitosis.
Indications :
 Palliative treatment of chronic lymphocytic leukemia; malignant lymphomas, including lymphosarcoma,
giant follicular lymphoma; brain tumors; Hodgkin·s lymphoma; multiple myelomas; testicular cancers;
pancreatic cancer; ovarian & breast cancers.
 Used as part of multiple-drug regimens.
The following chemotherapeutic drugs are alkylating agents:
 Cisplatin
 Carboplatin
 Oxaloplatin
 Mechlorethamine
 Cyclophosphamide
 Chlorambucil

ANTI-METABOLITES
 These chemical agents mask themselves as purine (one of the building blocks of DNA). When a cell
accepts the masked anti-metabolites, it becomes unable to incorporate genuine purine into its DNA.
This results in cellular DNA damage. Anti-metabolites are among the most widely used
chemotherapeutic drugs.
Indication:
 Trophoblastic Tumors (choriocarcinoma, H-mole), Acute lymphoblastic and lymphatic leukemia,
meningeal leukemia, Burkitts lymphoma (stage I or II), Lymphosarcoma (stage III), Osteaocarcinom
Classification
 Folic Acid Analogues (Methotrexate) acute lymphoblastic leukemia, lymphocytic leukemia, CNS
diseases, choriocarcinoma, osteogenic carcinoma (bone cancer), malignant lymphomas, carcinomas of
the head, neck, bladder, testis, and breast.
 Pyramidine analogues (capecitabine, cytarabine, floxuridine, fluorouracil, gemcitabine) Acute
leukemias, GIT adenocarcinomas, carcinomas of the breast and ovaries and malignant lymphomas
 Purine Analogues (cladribine, fludarabine phosphate, mercaptopurine, pemtostatin, thioguanine.) acute
and chronic luekemias and maybe useful in the treatment of lymphomas

ANTI-TUMOR ANTIBIOTICS
  These are antimicrobial products that produce tumoricidal effects by binding with DNA chemical agents
involve the patient’s own immune system in the inhibition of mitosis. These drug inhibit cellular process
of normal and malignant cells.
Indication:
 Hodgkins disease and malignant lymphomas, testicular carcinoma,squamous cell carcinoma of the
head, neck, and cervix, Wilms tumor (a malignant neoplasm of the kidney, occurring in young children)
Osteogenic sarcoma and rhabdomyosarcoma (malignant neoplasm composed of striated muscle cells),
Ewings sarcoma (a malignant tumor that originates in the bone marrow, typically in long bones or the
pelvis) and other soft-tissue sarcomas, breast, ovarian, bladder, and lung
cancer, melanoma, carcinomas of GIT, choriocarcinoma and acute leukemia.
Examples of these chemotherapeutic drugs include:
 Trastuzumab (Herceptin)
 Cetuximab
 Rituximab
 Anthracyclines
 Bleomycin
 Dactinomycin
 Mitomycin
 Mitoxantrone.
PLANT ALKALOIDS
 These chemical agents are derived from plant cells. They inhibit microtubule function in a cell.
Microtubules are the structural components of a cell that are responsible for mitosis, among other
cellular functions.

HORMONES & HORMONE MODULATORS

 Prescribed to alter the growth of malignant neoplasms or to manage and treat their physiologic effects.
Indication
 Proved effective against hormone-dependent tumors, such as cancers of the prostate and
endometrium.
Classification:
 Aromatase inhibitors
 Antiestrogens
o Ex: Tamoxifen Citrate and Toremifene citrate(NON STEROIDAL ESTROGEN), and fulvestrant.
(PURE ESTROGEN ANTAGONIST)
 Androgens
o Ex: Fluoxymesterone, testolactone, testosterone enanthate, testosterone propionate
 Antiandrogens
o Oral androgens (Fluoxymesterone, testolactone) are absorbed well.
o The parenteral ones (testosterone enanthate, testosterone propionate) are designed for slow
absorption after IM injection.
 Progestins
 Gonadotropin-releasing hormone analouges
o Goserilin Acetate
o Lueprolide Acetate
o Triptorelin Pamoate

Side Effects of Anti-Neoplastic Agents

 Although side effect management has come along way in recent years, chemotherapy drugs still affect
healthy cells. Sometimes the effects of cell damage are temporary, but sometimes they are long-term or
even permanent.
 The onset of these symptoms may also be the result of cellular damage elsewhere in the body.
 Most of these side effects will diminish or disappear completely after you stop your chemo treatments.
There are medications available to accompany your chemo treatments that may help reduce the
negative effects of chemotherapy.
Short-Term Side Effects
  Hair Loss, Bleeding, Fatigue, Infertility, Cognitive Impairment, Lung Damage, Nervous Tissue Damage,
Liver Damage, Sensory Abnormalities: Food tastes different, odors are perceived differently, etc.,
Gastrointestinal Damage: Damage to the fast-dividing cells of your gastrointestinal tract (stomach,
intestines, esophagus, and other digestive components) may result in a myriad of side effects, such as:
 Temporary effects may include:
Nausea Vomiting
Diarrhea Dry Mouth
Constipation Mouth Sores
Difficulty Swallowing Loss of Appetite
Long-Term Side Effects
 Rare. As cancer patients live longer and longer lives, doctors are uncovering side effects that don't
show until many years after treatment ends. Discuss the possibility off long-term effects with your
doctor before beginning any treatment.
 Long-term effects may include:
o Nervous Tissue Damage: This may result in sensory abnormalities and impaired cognitive
function. This is rare.
o Hematuria: Blood in the urine.
o Organ Damage: This typically involves heart, lung, or kidney impairment.

NURSING INTERVENTION: ALKYLATING DRUGS

 Arrange for blood tests to evaluate hematopoietic function prior to & weekly during therapy; severe
bone marrow suppression is possible.
 Restrict dosage within 4 weeks after a full course of radiation therapy or chemotherapy because of risk
of severe bone marrow depression.
 Ensure that patient is well hydrated before treatment.
 Arrange for frequent small meals & dietary consultation to maintain nutrition if
 GI upset occurs.
 Suggest use of contraception; serious fetal abnormalities or death is possible.

NURSING RESPONSIBILITIES: TEACHING POINTS FOR ALKYLATING AGENTS

Side effects:
 n/v, loss of appetite (dividing dose may help; frequent small meals may help; maintain fluid intake &
nutrition; drink at least 10-12 glasses of fluid each day);
 infertility (potentially irreversible & irregular menses to amenorrhea & aspermia; these drugs can cause
severe birth defects; use birth control methods while on these drugs).
 Report any unusual bleeding or bruising; fever; chills; sore throat; cough; shortness of breath; yellowing
of the skin & eyes; flank or stomach pain
Nursing Responsibilities: Antibiotic: ANTINEOPLASTIC DRUGS
 Try to ease anxiety in the patient and his family before treatment.
 Keep epinephrine, corticosteroids, and antihistamines available during therapy. Anaphylactoid
reacttions may occur
Nursing Responsibilities: Hormonal and hormone modulators: AROMATASE INHIBITORS
 Don’t give the drug with estrogen-containing drugs because doing so could interfere with the drugs
intended action.
 Administer the drug after meals.
Nursing Responsibilities: Hormonal and hormone modulators: ANTIESTROGENS
 Don’t give the drug with estrogen-containing drugs because doing so could interfere with the drugs
intended action.
 Administer the drug after meals.
Nursing Responsibilities: hormonal and hormone modulators: ANDROGENS
 Encourage to drink fluids to aid calcium excretion
 Encourage to exercise to prevent hypercalcemia.
 Inform patient that therapeutic response may not be immediate, it may take up to 3 months for the
benefit to be noted.
Nursing Responsibilities: Hormonal and hormone modulators: ANTIANDROGENS
 Drug may be given without regard to meals.
 Monitor the patient for adverse effects and DI.
Nursing Responsibilities: Hormonal and hormone modulators: PROGESTINES
 Rotate injection sites to prevent muscle atrophy.
 Warn patient that IM injection maybe painful.
 Instruct the patient to avoid caffeine and smoking during drug therapy.
 Teach a female patient how to perform routine monthly breast self- examinations
Nursing Responsibilties in Administering Anti-neoplastic Agents
 Standardize Medication Orders. Standards should be established for the content of an acceptable
medication order, requirements for patient-specific measurements, and data that must be included on
medication-order
 The following standards are recommended:
1. All orders for patient care services should be clearly dated;
2. When ordering antineoplastic medications, the generic drug name should be used. Brand
names are not acceptable unless they aid in identifying combination drug products or a
particular drug formulation (e.g., to distinguish betweenliposomal and nonliposomal product
formulations);
3. The dosage form;
4. Orders for medications should include the patientspecific data from which drug doses are
calculated (height, weight, BSA, laboratory test results). When drug dosages and schedules are
modified for current or anticipated pathologies, treatment plans and medication orders should
explicitly identify the factors on which treatment modifications are based;
5. Drug dosages and calculated doses should be expressed in metric notation whenever possible.
The word units should never be abbreviated in medication orders where drug dosages and
administration rates are expressed in biological activity units (e.g., aldesleukin, asparaginase,
bleomycin);
6. Medication orders should specify the drug dosage, calculated dose, and append the total cycle
or course dosage;
7. Administration vehicle solutions and volumes should be specified, unless standard solutions and
volumes have been established;
8. The administration route;
9. The administration rate;
10. The administration schedule and the duration of treatment. Treatment plans and medication
orders should specify the interval between repeated doses, the days on which each dose is to
be given within a treatment cycle or course, and the total length of a treatment cycle or course;
11. Direction indicating event in the adminstration of drug should be clear:
a. The dates and times when drug administration is to commence, when 1200 is written as
12 a.m. or 12 p.m., it may be incorrectly interpreted. Directions indicating events for
1200 should be written as 12:00 noon, or 12:00 midnight, or expressed in the 24-hour
system.
b. Identify the temporal sequence in which each medication is to be administered. A
medication order that complies with these recommendations would appear as follows for
a patient: Azorhubarb injection 100 mg/m2/dose = 200 mg in 100 mL 5% dextrose
injection/dose, administer by continuous intravenous infusion over 24 hours, every 48
hours for three doses days 1, 3, and 5. Start at 8:00 a.m. on April 1,2001 (total
dose/cycle = 600 mg).

Checking Orders for Administering Antineoplastic Medications.

 Medication orders for antineoplastics are commonly checked by two nurses working independently.
Double checks by two licensed health care providers help to ensure that medications are prescribed
and administered appropriately.
 Evaluate and confirm the functional integrity of vascular access devices (and devices for other
administration routes), medication pumps, and other devices that control medication delivery.
Recording and Tracking Antineoplastic Use.
  After medications have been administered, it is a nurse’s responsibility to record the activity. The
documentation should include the:
o patient’s name
o the names of all medications administered
o dosages
o administration routes
o rates of administration
o the date and time administration began
o the duration of administration or time that treatment was completed
o whether adverse effects were observed or reported by the patient during or after administration.
 Nurses and other personnel should immediately report to medically responsible personnel and their
supervisors any instance in which medications were used incorrectly and the events attributable to the
error.
 In response to discovering a medication-use error, a provider’s primary responsibility is to ensure the
patient’s safety.
 Subsequently, the error and related circumstances should be recorded as is indicated by specific
policies and procedures.
 Medication-use error reports (also called occurrence or incident reports) should be written in an
objective,chronological, narrative style without editorial remarks and speculative comments.
 Reevaluate practice standards in order to assess how well a medication-use system functions, make
appropriate changes, and, ultimately, improve patient safety and the quality of care.
 Health care providers administering antineoplastic medications should not deviate from previously
stated guidelines for ordering, preparing, and administering antineoplastic agents. Examples of
inappropriate practice include borrowing medications from a patient’s drug supply to give to another
patient and preparing agents without the proper facilities or staff
 To prevent medication errors, nurses and other personnel who administer anti-neoplastic medications
must comply with policies and procedures that define standards of practice.
 To prevent the inadvertent duplication of treatment, it is recommended that one individual assumes the
primary responsibility for each patient during a work period (shift or tour of duty).
Cautions and Responsibilities
 Soft foods and cool liquids
 Accurate I&O
 Report symptoms and side effects
 Aseptic technique
 Assessment of vital signs
 Cautions and Responsibilities
 Administer as prescribed
 Carefully check IV sites
 Don’t let medications contact skin or eyes
 Use of antiemetics
 Thorough oral hygiene
 Cautions and Responsibilities
 Verbal and nonverbal communications
 Careful attention to detail
 Reassurance by support personnel
Patient Education
 Expected side effects
 Comfort measures
 Appropriate diet
 Aseptic technique
 Oral hygiene
 Observe for bleeding
 Patient Education
 Reporting of side effects
 Available community resources
 Obtaining information
  Right of patient to terminate therapy
 Cytotoxic Drug Dangers
Safe Handling Methods
 Protect and secure packages
 Inform and educate personnel
 Prevent leakage of drugs from containers
 Avoid inadvertent ingestion, inhalation, and skin/eye contact
Specific Recommendations
 Wear personal protective equipment
 Precautions when administering drug
 Disposal of supplies
 Protection when handing excreta
 Don’t treat patient if pregnant, breast-feeding, or trying to conceive