Drugs for Bacterial Infections

Appendix JCholinesterase Inhibitors* Neostigmine (Prostigmin)ACTION: Prevent the enzyme cholinesterase (CHE) from inactivating acetycholine (ACh), thereby increasing the amount of ACh available at receptor sites. Transmission of nerve impulses is increased at all sites responding to ACh as a transmitterTherapeutic Use (TU)increases muscle strength by increasing ACh effects at motor neurons in Myasthenia GravisCauses reversal of nondepolarizing neuromuscular blocking agents (tubocurarine) following surgerySide Effects/Adverse EffectsIncreased GI motility and secretion, bradycardia & urinary Urgency due to excessive muscarinic stimulation* 1) If effects become intolerable notify primary care provider, Side effects can be treated with ATROPINECholinergic Crisis- excessive muscarinic stimulation and respiratory depression from neuromuscular blockade* Treat with Muscarinic effects with ATROPINE* Provide resp. support through mechanical ventilationContraindications (CI) :In clients with obstruction of GI and GU systemPregnancy Risk Category CMed food/ InteractionAtropine : counteracts the effects of Neostigmine (Nursing interventions: ATROPINE is used to treat NEOSTIGMINE TOXICITY.if no recovery is noted apply mechanical ventilation until full muscle function is regained)Tubocurarine : Neostigmine reverses neuromuscular blockade after surgical procedures and overdoseSuccinylcholine (increase neuromuscular blockade) : Avoid concurrent useClient Education : Start at low dosages and titrate until desired muscle function is achieved, Encourage the client to keep track of self doasage administration, recognize signs of INADEQUATE DOSING, such as difficulty swallowing and signs of overmedication, such as urinary urgency, Advise the client to wear a medical alert braceletEffectiveness : Decreased fatigued, improved muscle strength as demonstrated by chewing, swallowing and performing hygiene Neuromuscular blocking agentDrug : Tubocuraine (non-depolarizing) & Succinycholine (Depolarizing)Action: Neuromuscular blocking agents block Ach at the neuromuscular junction resulting in muscle relaxation and hypotension. They d/n cross the blood-brain barrier so complete paralysis can be achieved w/o loss of consciousness or decreased pain sensationUSE:Used as adjuncts to general anesthesia to promote muscle relaxationUsed to control spontaneous respiratory movements in clients receiving mechanical ventilationThese Meds are used to diagnosis MYASTHENIA GRAVISSuccinycholine is preferred for : Seizure contol during electroconvulsive therapy, endotracheal tubation, endoscopyS/ERespiratory Arrest from paralyzed respiratory muscles (NI: monitor respirations and vitals continuously, equipment ready for resuscitation)Hypotension resulting from HISTAMINE RELEASE and GUANGLIONIC BLOCKADE, Bradycardia and dysrhythmiasS/E of SUCCINYLCHOLINE (ANECTINE)Malignant hyperthermia: 109.4 F (NI: Monitor vitals, stop med, ice or ice saline to cool the client, Administer Dantrolene: decreases metabolic activity of the skeletal muscle)Prolonged Apnea due to low Pseudocholinesterase (NI : Test clients blood and hold med if pseudo levels are low)HyperKalemiaMed/food IntGeneral anesthetics are often used concurrently in surgeryAminoglycosides, tetracyclines : increase effects of neuromuscular blockadeNeostigimine & Prostigmin) and other Cholinesterase inhibitors : decrease the effects of non-depolarizing neuromuscular blockers, such as Tubucurarine; increase the effects of depolarizing neuromuscular blockers, such as SuccinylcholineEducation: Continous Cardiac and respiratory monitoring (have life support equipment handy)Effectiveness: Muscle relaxation during surgery, absence of seizures in EC Therapy, Successful Endotracheal intubation, No spontaneous respiratory movementsClassification : Adrenergic AgonistDrug : Epinephrine (Adrenaline) other drugs Dopamine and DobutamineAction : Catecholamine adrenergic agonists c/n be taken by the oral route, d/n cross the blood brain barrier and the duration is shortReceptorsAlpha1 : Activation of receptors in arterioles of skin, viscera ad mucous membranes, and veins lead to vasoconstrictionBeta1 : Heart stimulation leads to increased HR. increased Myocardial contractility, increased rate of conduction through the AV node, Activation of receptors in the kidney lead to release of renninBeta2 : Activation of receptors in the arterioles of the heart, lungs, and skeletal muscles leading to vasodilation, Bronchial stimulation leads to bronchodilation, activation of receptors in the uterine smooth muscles causes relaxation, activation of receptors in the liver causes glycogenesis, activation of skeletal muscles leads to muscle contractionDopamine : activation of receptors in the kidney cause the renal blood vessels to dilateEstrogen acting on Alpha1VASOCONSTRICTIONTU: Increases B/P, decreases congestation of nasal mucosa, Manages superficial bleeding, slows absorption of local anestheticsEstrogen acting on Beta 1Increases HR, Myocardial contractility, rate of conduction through the AVTx: AV Block and Cardiac ArrestEstrogen acting on Beta2BronchodilationTx : AsthmaS/E : Hypertensive crisis : Due to Vasoconstriction of Alpha 1 receptors (NI: Continuous Cardiac monitor).Dysrhythmias : Do to activating Beta1 receptors which increases the workload of the heart and the oxygen demand of the heartContraindications- Pregnancy Risk C, In clients with Tachydysrhythmias and v.FibMed/Food Int- Avoid use of MAOIs in clients receiving Epinephrine.Tricylic Antidepressants increase the effects of epinephrine, may need to lower epinephrine dosage.General Anesthetics and epi can cause Dsyrhythmias so monitor ECG and notify primary care provider for signs of chest pain, increased HRPhentolamine Treats Epinephrine ToxicityPropranolol treats Chest Pain and dysrhythmiasEducation- Must be administered IV by continuous infusion, continuous ECG monitoringEffectiveness- urine output greater than 30ml/hr, improved mental status, systolic blood pressure maintained at greater than equal to 90mm hgClassification : Alpha Adrenergic Blockers (Sympatholytics)Drug : PRAZOSIN (MINIPRESS)Action: Venous and arterial dilation. Smooth muscle relaxation of the prostatic capsule and bladder neckTU: Tx: HTNDoxazosin mesylate (Cardura) may be used to decrease symptoms of benign prostatic hypertrophy (BPH) (e.g urgency, frequency, dysuria)S/EFirst-Dose Orthostatic Hypotension (NI: first dose may be given at night, monitor blood pressure for 2hr after the initiation of tx, instruct clients to avoid activity for the first 12-24hr, encourage pt. to change positions slowly)Contraindications (CI) : Pregnancy risk C. CI in clients with hypersensitivity to medicationMed/Food IntAnti-hypertensive MedicationsNSAIDs and Clonidine decrease Anit-HTN effectsEffectiviness*decrease in b/p, reduction in benign prostatic hypertrophy symptomsClassification : Centrally Acting Alpha2 AgonistsDrug : Clonidine (Catapres)Action :Act in the CNS to decrease sympathethic outflow. This results in a decrease of norepinephrine (NE) released from sympathetic nerves, thereby decreasing the amount of NE that is available to stimulate the adrenergic receptors (both alpha and beta receptors) of the heart and peripheral vascular systemdecreases sympathetic outflow to myocardium, results in bradycardia and decrease cardiac output (CO)decreases in synmpathetic outflow to peripheral vasculature results in, vasodilation, which leads to decrease blood pressureS/EDrowsiness and SedationDry Mouth (encourage the client to chew gum or hard candy, symptoms resolves in 2 to 4 weeks)Rebound HTN: Discontinue CLONIDINE gradually over the course of 2 to 4 daysMed & Food IntAntihypertensive Meds (may have hypotensive additive effects)Prazosin, MAOIs and Tricyclic Antidepressants (May counteract anti-hypertensive effects)Alcohol : CNS DepressantsEducation- Pregnancy must be ruled out before treatment is begunAdminister Twice a day in divided dosesTransdermal patches applied every seven daysEffectiveness- decreased blood pressure, absence of painClassification : Adrenergic Neuron-Blocking AgentsDrug: ReserpineAction- Depletion of NE from postganglionic symphathetic neurons which decreases the activation of alpha and beta adrenergic receptors..This slows HR and Reduces Cardiac OutputTU: Tx HTN and Can be, but is less commonly used to treat Psychotic StatesS/E-Severe Depression (NI: educate about signs of depression such as early morning insomnia, decreased appetite, change in moodCardiovascular Effects : Bradycardia, orthostatic hypotension, nasal congestion ((due to depletion of Noreepinephrine (NE))Bradycardia caused by decreased activation at the beta1 receptors, hypotension and nasal congestion caused by dec. activation at alpha receptorsGI Effects : Increase secretion of gastric acid causing Ulcer FormationCI: Patients who have a hx of DepressionClassification : Beta Adrenergic Blockers (Sympatholytics)Drugs : Propranolol and MetoprololAction : decrease HR, Myocardial contractility (inotropic), rate of conduction through the AV.Metoprolol blocks at Beta1 receptor, Propranolol (Inderal) blocks at Beta 2 receptorTU: Angina Pectoris, HTN, Cardiac Dysrhythmias, MI, Heart Failure,Other uses : hyperthyroidism, migraine headache, stage fright, glaucomaS/E of Metoprolol (lopressor): Bradycardia (Administer Atropine and Isoproterenol) Decrease In Cardiac output (Metoprolol may take like 1 to 3 months for effects to work) AV Block (D/n administer beta-blocker) Orthostatic hypotensive, rebound myocardium excitation (use of beta blockers shouldnt be abruptly stopped, discontinue over 1 to 2 weeks)S/E of Propranolol (Inderal) : Bronchoconstriction (Avoid in asthmatic clients), Glycogenolysis is inhibited (Contraindicated in Diabetic pt.s treat diabetic pt.s with Beta1 agent)ContraindicationsBeta adrenergic blockers are contraindicated in clients with AV block and Sinus BradyCardiaNon-Selective beta-adrenergic blockers are contraindicated in clients with asthma, bronchospasms and heart FailureUse cardioselective Beta-adrenergic blockers cautiously in clients with heart failure, asthma, bronchospasm, diabetes, hx of allergies and depressionMED and Food IntCCBs (Verapamil &Diltiazem (Cardizem) : intensifies the effects of beta-blockersmonitor closelyAntihypertensive Meds : Increases Hypotensive effectsmonitor b/pInsulin- prevents glycogenolysis: may need to adjust dosage of insulin when using Propranolol (Inderal)Education- Self monitor HR and B/p, D/N crush or chew extended release tablets, avoid sudden changes in positionEffectiveness- Absence of chest pain, cardiac dysrhythmias, normal b/p, control of signs of HFClassification : Muscarinic AgonistsDrug : Bethanechol (Urecholine)Action : Binds reversibly to muscarinic cholinergic receptors and causes activation, the principal structures affected by muscarinic activation are the heart, exocrine glands, smooth muscles, and eyeAt the heart : Causes BradycardiaAt Exocrine Glands : Causes increase sweat, salivation, bronchial secretions, and secretion of gastric acidIn the Smooth muscles of the lung and GI Tract : Promote contractionIn the bladder : contracts the detrusor muscle and relaxs the trigone and sphincter causeing BlADDER EMPTYINGTU : Tx for Urinary Retention in post opt and post pardum pt. NOT urinary retention caused by physiological obstruction..b/c it cam cause injury due to increased pressureS/E :Hypotension and bradycardia. Excessive salivation ,increased sec. of gastric acid, abdominal cramps and diarrheaCI : Patients with low blood pressure, gastric ulcers, intestinal obstruction (can rupture the bladder) patients with asthma (it causes bronchoconstriciton), hyperthyroid patients (Can cause dysrhythmias)Classification : Muscarinic Antagonists (Anticholinergic Drugs)Drug: AtropineAction : completely block the action of acetylcholine at muscarinic receptors. Exerts its influence primarily on the heart, exocrine glands, smooth muscles, and eye, just like the muscarinc agonistAt the heart : increase HRExocrine Glands : decrease secretion of salivation, bronchial glands, sweat glands and decreases gastric secretionsSmooth muscles: Atropine causes relaxation of the bronchi, decreased tone of the urinary bladder detrusor and decreased tone and motility of the GIEye : Dilates the pupil (mydriasis) focuses the lens for far vision (cycloplegia)CNS: can cause mild excitation at therapeutic doses, Toxic doses can causes delirium & hallucinationsTU:Helps during eye examinations for disorders of the eye. Tx Bradycardia. Tx : diverticulitis by decreasing tone and motility in the smooth muscles of the intestine. Used to Reverse Muscarinic Poisioning, Can treat Peptic Ulcers disease, Asthma (by bronchodilating)S/E : Xerostomia (Dry Mouth), Blurred Vision (paralyze ciliary muscle focus on far objects causes blurred vision) photophobia (paralysis of iris sphincter prevents constriction of the pupil) (NI: where glasses 4photophobia-when unable to adapt to bright light)Urinary Retention and Constipation (blockade of muscarinic receptors increase the pressure w/in bladder and increases the tone of the urinary sphincter and trigone)Anhidrosis (absence of sweat), Tachycardia, Asthma(cause thickening and drying of bronchial secretionsDrug Interactions : Anti-histamines, phenothiazines, antipsychotics, tricyclic antidepressantshave anticholinergic effects and can enhance the effects of AtropineNote : Anti-cholinergic means blockade at Muscarinic Receptors-not blockade at all cholinergic receptorsClassification : Ganglinic Blocking AgentsDrugs : MecamylamineAction : Blocks transmission through the ganglia of the ANS by completing with Ach for binding to nicotinic receptorsTU : Are used ONLY to decrease blood pressure, treats primary HTN in selected patients, only used when b/p c/n be reduced by all other medicationsS/E :Antimuscarinic effects (dry mouth, blurred vision, photophobia, urinary retention, constipation, tachycardia, anhidrosis)Orthostatic hypotension (by dilating veins causes pooling of blood decreasing blood return to the heart, reducing CO and subsequent fall in b/p)

CNS Effects ( tremor convulsions, and mental aberrationds)Central Nervous System Drugs

Drugs for Parkinsons diseaseDopaminergic Drugs:Anti-Parkinsons MedicationsDopaminergics: Levodopa (increases dopamine [DA] synthesis)

-levodopa plus carbidopa (Sinemet)

-Carbidopa (blocks levodopa destruction) Dopamine agonists: pramipexole (Mirapex)Centrally acting anticholinergics: Benztropine (Cogentin) Dopamine releaser (Antiviral): Amantadine (Symmetrel)Classification: Dopaminergics:Medications: Levodopa (Dopar, Larodopa), levodopa plus carbidopa (Sinemet)Actions:

-Levodopa crosses the blood brain barrier and is taken up by dopaminergic nerve terminals and converted to dopamine (DA). This newly synthesized DA is released into the synaptic space and causes stimulation of DA receptors

- Carbidopa does not possess any therapeutic effects, but is used to augment levodopa. Carbidopa inhibits conversion of levodopa to DA in the intestine and periphery, and thereby allows for increase amounts of levodopa to reach the CNSDopamine agonists:Medications: Pramipexole (Mirapex), Ropinirole (Requip), bromocrptine (Parlodel)Actions:

-Act directly on DA receptorsCentrally Acting Anticholinergics:Medications: Benztropine (Cogentin), Trihexyphenidyl (Artane)Actions: These medications block acetylcholine at muscarnic receptors, which assists in maintaining the balance between dopamine and acetylcholine in the brain. Dopamine releaser (Antiviral):Medications: Amantadine (Symmetrel)Actions: Antiviral stimulate DA release, prevent dopamine reuptake, and may block cholinergic and glutamate receptorsTherapeutic Uses: These medications do not halt the progression of Parkinsons disease (PD): however, they do offer symptomatic relief from dyskinesias (e.g., bradykinesis, resting tremors, and muscle rigidity). Levodopa may be used as a first-line medication for PD treatment Pramipexole (Mirapex) is used as monotherapy in early-stage PD, and used in conjunction with levodopa in late- stage PD. It is used often in younger clients who are more able to tolerate daytime drowsiness and postural hypotension Side/Adverse Effects: Nursing Interventions and Client EducationDopaminergics: levodopa- usually dose dependant N&V, drowsiness Administer in small doses at the start of treatment and with food Dyskinesias (e.g.), head bobbing, tics, grimacing, tremors) Decrease dosage of medication, but the decrease may result in resumption of PD symptoms Orthostatic hypotension Monitor the clients b/p Instruct the client about signs of postural hypotension Cardiovascular effects from beta1 stimulation (e.g., tachycardia, palpitations, irregular heartbeat) Monitor the clients vital signs Use cautiously in clients with cardiovascular disorders Monitor ECG Psychosis (e.g., visual hallucinations, nightmares) Administer antipsychotic medications such as clozapine (Clozaril) if symptoms occur. Discoloration of sweat and urine Advise the client that this is a harmless side effect Activation of malignant melanoma Avoid use of medication in clients with skin lesions that have not been diagnosedDopamine Agonists: Pramipexole (Mirapex) Sleep attacks Daytime sleepiness Advise the client to avoid the use of other CNS depressants such as alcohol Orthostatic hypotension Psychosis Dyskinesisas NauseaCentrally acting anticholinergics: benztropine (Cogentin) N&V Atropine-like effects (e.g., dry mouth, blurred vision, mydriasis, urinary retention, constipation) Advise the client to chew sugarless gum, eat foods high in fiber, and increase water intake to at least 8 to 10 glasses of water/day antihistamine effects (e.g. sedation, drowsiness) Antiviral: amatadine (Symmetrel) CNS effects (e.g., confusion, dizziness, restlessness) Atropine-like effects\ Discoloration of skin, also called livido, reticularis Advise the client that discoloration of the skin will subside when the medication is discontinuedLevodopa plus cardidopa (Sinemet)- Abnormal movements, psychiatric disordersContraindications/PrecautionsLevodopa Pregnancy Risk Category C Contraindicated in clients with malignant melanoma Do not use w/in 2 weeks of MAOI use Use cautiously in clients with heart disease and psychiatric disordersPramipexole (Mirapex) Pregnancy Risk Category C Use cautiously in clients with liver and kidney impairmentAnticholinergic agents Contraindicated in clients with narrow-angle glaucoma Use cautiously in older adults, the very young, clients with enlarged prostate glands, and a history of urinary retentionMedication/Food InteractionsDopaminergics: levodopa Proteins interfere with levodopa absorption and transport across the blood-brain barrier. High protein meal decrease therapeutic effects. Proteins trigger an off episode Advise the client to eat protein in several portions during the day Conventional-antipsychotic agents (e.g., chlorpromazine [Compazine], haloperidol [Haldol] decrease therapeutic effects. Avoid use with levodopa To treat levodopa-induced psychosis, use the atypical antipsychotic clozapine (Clozaril) Pyridoxine decrease therapeutic effects Advise client to avoid vitamin preparations that contain pyridoxine MAOIs cause hypertension Avoid concurrent use Carbidopa, dopamine agonists, anticholinergics, COMT inhibitors, and dopamine releasers increase therapeutic effects These medications can be used concurrently to increase the beneficial effects of levodopaDopamine agonists: pramipexole (Mirapex) Levodopa- concurrent use has beneficial and harmful interactions. Use with levodopa can decrease motor control fluctuations and allow for lower dosage of levodopa. Concurrent use can also increase the risk of orthostatic hypotension and dyskinesias Levodopa plus carbidopa (Sinemet) Beneficial interactions include allowing for lower dosage of levodopa, decrease cardiovascular responses to dopamine in the periphery, and decrease nausea.Cholinesterase InhibitorsPrototype Medication: Neostigime (Prostigmin)Action: Prevent the enzyme cholinesterase (ChE) from inactivating acetylcholine (Ach), thereby increasing the amount of Ach available at receptor sites. Transmission of nerve impulses is increased at all sites responding to Ach as a transmitter. Therapeutic Uses: Neostigmine (Prostigmin) increase muscle strength by increasing Ach effects at motor neurons in myasthenia gravis Neostigmine causes reversal of nondepolarizing neuromuscular blocking agents (tubocurarine) following surgerySide/Adverse Effects: Excessive muscarine stimulation as evidenced by increased GI motility, increased GI secretions, bradycardia, and urinary urgency Side effects may be treated with atropine Cholinergic crisis excessive muscarnic stimulation and respiratory depression from neuromuscular blockade Muscarinic effects can be treated with atropine Provide respiratory support through mechanical ventilation and oxygenContraindications/Precautions Pregnancy Risk Category C Contraindicated in clients with obstruction of GI and GU system Use cautiously in clients with seizure disorders, hyperthyroidism, peptic ulcer disease, asthma, bradycardia, and hypotension.Medication/Food InteractionsAtropine-counteracts the effects of neostigmine Used to treat neostigmine toxicity Monitor the client closely and provide mechanical ventilation until the client has regained full muscle functionTurocurarine: Neostigmine reverses neuromuscular blockade after surgical procedures and overdose. Monitor the client for return of respiratory function. Support respiratory function as necessary. If used to treat overdose, provide mechanical ventilation until the client has regained full muscle functionSuccinylcholine: increase blockade Avoid concurrent use Drugs for Epilepsy (Antiepileptics) AEDsSelect Prototype Medications:Barbiturates: Phenobarbital (Luminal)Hydantoins: phenytoin (Dilantin)Benzodiazepines: diazepam (Valium)Lorazepam (Ativan)Carbamazepine (Tegretol)Ethosuximide (Zarontin)Valproic acid (Depakote)Gabapentin (Neurontin)Action: AEDs control seizure disorders by various mechanism, which include Slowing the entrance of sodium and calcium back into the neuron and, thus extending the time it takes for the nerve to return to its active state Suppressing neuronal firing, which decreases seizure activity and prevents propagation of seizure activity into other areas of the brain Potentiating the inhibitory effects of gamma butyric acid (GABA) and thereby suppressing seizure activity.Therapeutic Uses Treatment of generalized seizures Tonic clonic ( Grand mal) Absence seizures (Petit mal) Atonic seizures Myoclonic seizures Status epilepticus Febrile seizures Treatment of partial seizures Simple partial Complex partial Complete eradication of seizure activityMedications/ Therapeutic UsesPhenobarbital (Luminal) Used for partial seizures and generalized tonic-clonic seizures Not effective against absence seizuresPhenytoin (Dilantin) Is effective against all major forms of epilepsy except absence seizures Use IV route for status epilepticus AntidysrhythmicCarbamazepine (Tegretol) Used for the treatment of partial (simple and complex) seizures, tonic-clonic seizures, bipolar disorder and trigeminal and glossopharyngeal neuralgiasEthosuximide (Zarontin) Only indicated for absence seizuresValproic acid (Depakote) Used for partial, generalized and absence seizures, bipolar disorder and migraine headaches.Gabapentin (Neurontin) Used a single agent for control of partial seizures. The medication is also used for neuropathic pain and the prevention of migraine headaches.Diazepam (Valium) Status epilepticusSide/Adverse Effects: Nursing Interventions and Client EducationBarbiturates: Phenobarbital (Luminal) CNS effects in adults manifest as drowsiness, sedation, confusion, and anxiety; in children, CNS effects manifest as irritability and hyperactivity Toxicity (e.g., nystagmus, ataxia, respiratory depression, coma, pinpoint pupils, hypotension, death) Stop medication. Administer oxygen and maintain respiratory function with ventilatory support Monitor clients vital signsHydantoins: phenytoin (Dilantin) CNS effects (e.g., nystagmus, sedation, ataxia, double vision) Gingival hyperplasia- softening and overgrowth of gum tissue resulting in tenderness and bleeding gums Advise the client to maintain good oral hygiene Skin rash Stop medication Teratogenic (e.g. cleft palate, heart defects) Avoid use in pregnancy Cardiovascular effects (e.g. dysrhythmias, hypotension) Administer at slow IV rate and in dilute solution to prevent adverse CV effects Endocrine and other effects (e.g., coarsening of facial features, hirsutism, and interference with vitamin D metabolism) Encourage the client to consume adequate amounts of calcium and vitamin DCarbamazepine (Tegretol) Cognitive function is minimally affected, but CNS effects can occur Administer in low doses initially and then gradually increase dose Administer dose at bedtime Blood dyscrasias (e.g., leucopenia, anemia, thrombocytopenia) Obtain the clients baseline CBC and platelets. Perform ongoing monitoring of CBC and platelets Observe the client for signs of bruising and bleeding gums Teratogenesis Hyo-osmolarity promotes secretion of ADH which inhibits water excretion by the kidneys, and places the client with heart failure at risk for fluid overload Monitor serum sodium periodically. Monitor the client for edema, decrease urine output and hypertension. Skin disorders (e.g., dermatitis, rash, Stevenson-Johnson syndrome Treat mild reactions with anti-inflammatory or antihistamine medications Medications should be discontinued if there is a severe reactionEthosuximide (Zarontin) Gastrointestinal effects N&V CNS effectsValproic acid (Depakote) Gastrointestinal effects Hepatoxicity (e.g., anorexia, abdominal pain, jaundice) Medication should be prescribed in lowest effective dose Pancreatits as evidenced by nausea, vomiting, and abdominal pain Monitor amylase level Medication should be discontinued if pancreatitis develops Thrombocytopenia Monitor platelet count Advise client to observe for signs of bruisingGabapentin (Neurotin) CNS effects Respiratory depression Monitor clients vital signs Have resuscitation equipment ready Administer oxygen\ Anterograde amnesia Monitor clients memory loss Teratogenic (e.g., cleft palate, heart defects)Contraindication/PrecautionsBarbiturates- contraindicated in clients with intermittent porphyriaPhenytoin contraindicated in clients with sinus bradycardia, sinoatrial blocks, second- and third degree AV block, or stokes-Adam syndromeCarbamazepine- contraindicated in clients with bone marrow suppression or with bleeding disordersValproic Acid- contraindicated in clients with liver disorders.Medication/Food interactionsPhenytoin (Dilantin) Oral contraceptives, warfarin (Coumadin), and glucocorticoids- phenytoin causes a decrease effects of these medications due to the stimulation of hepatic drug-metabolizing enzymes Advise the client to increase dose of oral contraceptives Alcohol, diazepam (valium), cimetidine (tagamet), and valproic acid increase phenytoin levels. Carbamazepine (Tegretol), Phenobarbital, and chronic alcohol use decrease phenytoin levels. CNS depressants (e.g., barbiturates, alcohol) Additive CNS depressant effects can occur with concurrent useCarbamazepine (Tergretol) Oral contraceptives and warfarin (Coumadin) carbamazepine causes decrease in the effects of these medications due to stimulation of hepatic drug-metabolizing enzymes Grapefruit juice inhibits metabolism, and thus increase carbamazepine levels Phenytoin and phenobarbital- decrease the effects of carbamazepineValproic acid (Depakote) Phenytoin and Phenobarbital concurrent use with valproic acid increase the levels of these medicationsDrugs for migraines:Nonsteroidal Anti-inflammatory drugsaspirin (Ecotrin):Action: Prevents platelets from clumping together by inhibiting enzymes and factors that normally lead to arterial clottingUses: Primary prevention of acute MI Prevention of reinfarction in clients following acute MI Prevention of strokeSide effects:GI effects such as bleeding, hemorrhagic stokeInteractions:Nsaids, heparin, warfarinLocal AnestheticsEster-type Local anesthetics: procaine (Novocain)Amide-type Local anesthetics: lidocaine (Xylocaine)Action:Decrease pain by blocking conduction of pain impulses in a circumscribed area. Loss of consciousness does not occurUse: Dental procedures Minor surgical procedures Labor and delivery Diagnostic proceduresSide effects:CNS excitation (seizures, followed by resp. depression, leading to unconsciousness), Hypotensiins, cardio suppression aeb bradycardia, heart block, and cardiac arrest, allergic rxns, spinal headache and urinary retentionGeneral AnestheticsInhalation Anesthetics: halothane (Fluothane)Action: Produces loss of consciousness, loss of all sensations, relaxation of muscles, and memory lossUses: Anesthesia for surgery Diagnostic procedures Cardiological procedures Relief of pain Muscle relaxationSide effects:Hypotension, respiratory and cardiac depression, malignant hyperthermia, hepatotoxicityInteractions: CNS depressants (barbiturates, benzodiazepines, alcohol), CNS stimulants (amphetamines, cocaine), Opioid analgesics (morphine), succinylcholineIntravenous Anesthetics: thiopental (Pentothal)Action:Produce loss of consciousness and elimination of response to painful stimuliUses: Adjunct to inhalation anesthetics Induction and maintenance of anesthesia AmnesiaSide effects:Respiratory and cardiovascular depression (hypotension)Interactions:CNS depressants (barbiturates, benzodiazepines, alcohol), CNS stimulants (amphetamines, cocaine), Opioid analgesics (morphine),Opioid (narcotic) Analgesics and Antagonists Pure Opioid Agonists: Morphine sulfateAction: Act on mu receptors and to lesser degree on kappa receptors. Activation of mu receptors produces analgesia, respiratory depression, euphoria, and sedation. Uses: Relief of moderate to sever pain Sedation Reduction of bowel motilitySide effects:Respiratory depression, constipation, orthostatic hypotension, urinary retention, coughs suppression, sedationInteractions:CNS depressants (barbiturates, benzodiazepines, Phenobarbital, alcohol), anticholinergic agents (antihistamines and tricyclic depressants, MAIOs, antihypertensiveAgonist-Antagonist Opioid: pentazocine (Talwin)Action: Compared to pure opioid agonists, these have a low potential for abuse causing little euphoria and less respiratory depressionUses: Relieve mild to moderate pain, not severe painSide effects:Abstinence syndrome (cramping, hypertension, vomiting)Pure Opiod Antagonists: naloxone (Narcan)Action:Interfere with the action of opioids by competing for opioid receptors. Opioid antagonists have no effect in the absence of opioids. Uses: Treatment of opioid overdose Reversal of effects of opioids, such as respiratory depression Reversal of respiratory depression in an infantSide effects:Tachycardia and tachypnea, abstinence syndrome (cramping, hypertension, vomiting)Antipsychotic drugsTraditional antipsychotic: chlorpromazine (Thorazine), haloperidol (Haldol)Actions:Dopamine, acetylcholine, histamines, and norepinephrine receptors in the brain and periphery are blocked. Uses: Schizophrenia Bipolar disorders Tourettes syndrome Delusional disorders Schizoaffective disorder Dementia and other organic mental syndromes Huntingtons chorea Side effects:Early extrapyramidal symptoms: acute dystonia (severe spasms of the tongue, neck, face, and back), parkinsonism tremors, akathisia (inability to stand still or sit). Late extrapyramidal symptoms: (tardive dyskinesia). Neuroleptic malignant syndrome ( sudden high grade fever, blood pressure fluctuations, dysrhythmias), anticholinergic effects.Interactions:Anticholinergic agents, CNS depressants (barbiturates, benzodiazepines, Phenobarbital, alcohol), LevodopaAtypical Antipsychotics: clozapine (Clozaril)Action: Block serotonin and dopamine receptorsUses: Severe schizophrenia Psychosis induced by levodopa therapySide effects:Agranulocytosis, seizures, new onset diabetes, weight gain, inflammation of the heart musclesInteractions:Immunosuppressive medications Antidepressants:Tyicyclic Antidepressants: imipramine (Tofranil)Action:Block reuptake of norepinephrine and serotonin Uses: Depression Bipolar disorders Side effects:Orthostatic hypotension, anticholinergic effects, cardiac toxicity, sedationInteractions:MAOIs, antihistamines, epinephrine, ephedrine, alcohol, benzodiazepines, opioidsSelective Serotonin Reuptake Inhibitors: fluoxetine (Prozac) Action:Block reuptake of serotoninUses: Major depression OCD Bulimia nervosa PMDD Panic disorders PTSDSide effects:Sexual dysfunction, weight gain, serotonin syndrome (mental confusion, agitation, anxiety), withdrawal syndrome, hyponatremia, rashInteractions:MAIOs, Coumadin, tricyclic antidepressnats and lithium, NSAIDs and anticoagulantsMonoamine Oxidase Inhibitors: phenelzine (Nardil)Action: Block MAO-A in the brain thereby increasing the amount of norepinephrine and serotonin available for transmission Uses: Atypical depression Bulimia nervosa OCDSide effects:CNS stimulation, orthostatic hypotension, hypertensive crisisInteractions:Ephedrine, amphetamine, tricylic antidepressants, SSRIs antihypertensices, Demerol, Tyramine rich foodsAtypical Antidepressants: bupropion HCL (Wellbutrin) Action:Inhibit dopamine uptakeUses: Treatment of depression Aid to quit smokingSide effects:Headache, dry mouth, constipation, increase heart rate, nausea, restlessness, weight loss, seizuresInteractions:MAOIs Drugs for Bipolar DisorderLithium carbonate, carbamazepine (Tegrertol), valproic acid (Depakote)Action: Produces neurochemical changes in the brain including serotonin receptor blockadeUses: Treatment of bipolar (they control episodes of acute mania, and help to prevent the return of mania or depression) Alcoholism Bulimia SchizophreniaSide effects:GI effects, tremors, polyuria, renal toxicity, goiter and hypothyroidism, teratogenesisInteractions: Diuretics, NSAIDs, anticholinergicsCLASS: Adrenergic AgonistsPRO: epinephrine and dopamine (catecholamine)ACTION: vasoconstriction (up BP), bronchodialation, increase heart rateSE: hypertensive crisis, dysrythmiasCONTRA: tachydysrhythmia and ventricular fibrillationIINTERACT: MAOIS and general anestheticsINTERVENTIONS: IV only and ECG monitoringCLASS: Alpha Adrenergic BlockersPRO: prazosin (minipress)ACTION: dilate arteries and veinsUSES: hypertensionSE: orthostatic hypertension (first dose at night, change position slow)INTERACT: antihypertensive meds (hypotension), NSAIDS counteract the effectsINTERVENTIONS: take with food and first dose at nightCLASS: centrally acting alpha2 agonistPRO: clonidine (catapres)ACTION: lower sympathetic outflow, lower nowepinephrine, lower BPUSE: hypertensionSE: drowsiness (will diminish), dry mouth (resolves in 2-4 wks)INTERACT: antihypertensive meds (hypotension), prazosin (counteract effects), alcoholINTERVENTIONS: take large dose at night to lower drowsiness, transdermal patches changed every 7dCLASS: beta adrenergic blockers (beta blockers)PRO: metoprolol (lopressor), propranolol (inderal)ACTION: lower HR, lower myocardial contractility, lower conduction through AV nodeUSE: angina pectoris, hypertension, dysrythmias, MI, heart failureSE: bradycardia, lower cardiac output (1-3 months for beneficial effects), bronchoconstriction (avoid

asthma pt)INTERACT: pt with AV block and sinus bradycardia, calcium channel blockers (intensifies), insulinINTERVENTIONS: avoid sudden position changesCLASS: ACE inhibitorsPRO: captopril, enalaprilACTION: block production of angiotensin II, vasodilation (arteries), excrete NA, retain KUSES: heart failure, hypertension, MISE: 1st dose orthostatic hypotension (stop med for 2-3 days if taking diuretic), cough, hyperkalemiaCONTRA: 2nd and 3rd trimester pregnancyINTERACT: diuretics (stop med for 2-3 d), K supplements, lithium (can up lithium levels), NSAIDS

(decrease andtihypertensive effect)INTERVENTIONS: captopril taken 1h before mealsCLASS: ARBs PRO: losartanACTION: blocks action of angiotensin II, vasodialation, excrete NA, retain KUSES: reduce hypertensionSE: angioedemaCONTRA: 2nd and 3rd trimester pregnancyINTERACT: antihypertensive med (additive effect)INTERVENTIONS: take with or w/o food*(ARBs not as effective as ACE inhibitors because they only block the action and not the production of angiotensin II)CLASS: Calcium Channel BlockersPRO: verapamil (affect heart and vessels)ACTION: blocks vasodilation in arteries, lower contraction force, lower HR, slower AV conductionUSES: angina pectoris, hypertension, cardiac dysrythmiasSE: Orthostatic hypertension, peripheral edema, constipationINTERVENTIONS: weigh daily, prescribe diuretic for edema, up fluid intake and fiber, IV admin over 2-3 minCONTRA: cautiously use digoxin, beta blockers, and grapefruit juicePRO: nifedipine (affect only vessels)ACTION: blocks vasodilation in arteriesUSES: angina pectoris, hypertension, cardiac dysrythmiasSE: reflex tachycardia, peripheral edemaINTERVENTIONS: administer beta blocker if tachy, prescribe diuretic for edema, IV admin over 2-3 minCONTRA: cautiously use digoxin, beta blockers, and grapefruit juiceCLASS: organic nitratesPRO: nitroglycerineACTION: lower cardiac O2 demand, dilating veins and decreasing preloadUSES: angina, periop (control BP or produce hypotension), heart failureSE: headache (take aspirin), toleranceCONTRA: traumatic head injury (increase intracranial pressure)INTERACT: alcohol, cautiously use with CCB, beta blockers, diuretics, Viagra (hypotension)INTERVENTIONS: angina attack 1) take rapid-acting 2) wait 5 min 3) can take 2 more doses at 5 min intervals if unrelievedCLASS: cardiac glycosidesPRO: digoxinACTION: increase force of contraction, decrease HRUSE: heart failure, dysrhythmias (A Fib)SE: dysrhythmias if toxicINTERACT: thiazide diuretics, ACE and ARB, dopamineINTERVENTIONS: take same time daily, avoid OTC drugs, do not take potassium-sparing diuretics, treat dysryhthmias with lidocaine, trear bradycardia with atropineCLASS: antidysrythmic medsPRO: Sodium Channel Blockers 1A (procainamide)ACTION: decrease electrical conduction, decrease rate of repolorizationUSE: Afib, AflutterSE: lupus, cardiotoxicityINTERACT: antichollinergicsPRO: Sodium Channel Blockers 1B (lidocaine)ACTION: decrease electrical conduction, increase rate of repolorizationUSE: short term dysrhythmiasSE: CNS effects, resp. arrestINTERACT: cimetidine, beta blockers phenytoinINTERVENTIONS: do not crushINTERVENTIONS: never administer with epinephrine, administrations is usually loading dose followed by maintenance dose of 1-4 mgCLASS: statinsPRO: Lipitor, lovastatinACTION: increase LDL receptors to remove greater amt of LDL, increase HDLUSES: hypercholesterolemiaSE: hepatotoxicity (up in serum tranaminase), myopathyCONTRA: pregnancyINTERACT: fibrates (up myopathy), grapefruit juiceINTERVENTION: lovastatin take with evening meal, increase med dose if taking erythromycinCLASS: bile-acid sequestrantsPRO: cholestyramine (questran)ACTION: increase LDL receptors to remove more LDLUSES: use adjunct with HMG CoA reductase inhibitors (atorvastatin)SE: so systemic effects, constipationINTERACT: digoxin, warfarin, thiazide (all interfere with absorption)INTERVENTION: take other med 1hr before or 4hr afterCLASS: loop diureticsPRO: furosemide (lasix)ACTION: block reabsorption of Na, Cl, and H2O in loop of henleUSE: pulmonary edema, conditions not responsive to other diuretics, renal impairmentSE: dehydration, hypotension, ototoxicity, hypokalemiaCONTRA: diabetes (cautious)INTERACT: digoxin, antihypertensives, lithium, NSAIDSINTERVENTION: weigh in morning, avoid administering late in dayCLASS: thiazide diureticsPRO: hydochlorothizaideACTION: block reabsorption of Na, Cl, and H2O in early distal convoluted tubuleUSE: essential hypertension, edema, liver and kidney diseaseSE: dehydration, hypokalemia, hyperglycemiaCONTRA: lower kidney functionINTERACT: digoxin, lithiumINTERVENTION: monitor K levels, eat foods high in KCLASS: potassium-sparing diureticsPRO: spironolactoneACTION: block aldosterone, potassium retension, Na and H20 secretionUSES: combined with other diuretics for K sparing effects, heart failureSE: hyperkalemiaINTERACT: ACE and K+ supplements (hyperkalemia)INTERVENTION: only given orally, avoid K+ salt substitutesGastrointestinal Drugs: Start on p. 891 in Lehne Drugs for Peptic Ulcer DiseaseAn example antibiotic regiment for H pylori would include:

Omeprazole + Amoxicillin + Clarithromycin for 10 days-remember that none is effective alone and a multi-drug regiment is to prevent development of resistance to H pylori. Other options listed in p. 894H2 Receptor Antagonists-Cimetidine [Tagamet], Ranitidine hydrochloride [Zantac]

Action: blocks receptor H2 receptor sites in PARIETAL cells lining the stomach

Therapeutic Use: GERDSides/Adverse Effects: Decreased libido and impotence (keep away from your partner)Contraindications/Precautions: Pregnancy Cat. B. Careful with older folks can cause antiadrenergic effects like impotence and CNS effects like confusion. Interactions: Increases the levels of Warfarin and Phenytoin (anticonvulsant).Interventions/Education: remember the drugs ending in tidine can be administed IV in acute situations. Also eat 6 small meals. Proton Pump Inhibitor Omeprazole [Prilosec]Action: reduce gastric acid secretion by irreversibly inhibiting the enzymes that produces gastric acid so it stays in the system for a few weeks. They also reduce basal and stimulated acid production. Therapeutic Use: Ulcers, GERD, and hypersecretory conditions like Zollinger-Ellison syndrome. Sides/Adverse Effects: Insignificant with short term use. Contraindications/Precautions: Preg C. Caution in children and women who are breastfeeding. Increase risk for pneumonia.Interactions: delayed absorption of ampicillin, digoxin, iron and ketocanazoleInterventions/Education: Do not crush, crew or break sustained-release capsules.Mucosal Protectants Sucralfate [Carafate]Action: uses acidic environment of stomach and duodenum into a viscous substance that adheres to an ulcer and protects from further injury.

Therapeutic Use: Acute duodenal ulcers and maintained therapy. Sides/Adverse Effects: increase dietary fiber to decrease constipation. Contraindications/Precautions: Preg B and contraindicated in those with hypersensitivityInteractions: May interfere with absorption of phenytoin, digoxin, warfarin and ciprofloxacin so spread out meds by 2h. Interventions/Education: empty stomach 1h before mealsAntacids Aluminum hydroxide gel [Amphojel]Action: neutralize gastric acid and inactivate pepsinmucosal protection may come into play by stimulating the production of prostaglandins. Therapeutic Use: PUD by promoting healing and relieving pain. Symptomatic relief for GERD. Sides/Adverse Effects: Can cause constipation. Can lead to hypophosphatemia.Contraindications/Precautions: Preg Cat. C. DO not administer to clients with perforation or obstruction Interactions: Al binds with warfarin and tetracycline which interferes with absorption Interventions/Education: Chew it up real good and drink 8oz of H20 or milk. Drugs for NSAID-- Induced Ulcers

MisoprostolAction: works on the GI tract to decrease acid secretion, increase the secretion of bicarbonate and protective mucous and promote vasodilatation to maintain submucosal blood flow.

Therapeutic Use: to prevent gastric ulcers in clients using NSAID long-termSides/Adverse Effects: Diarrhea and abdominal painnotify provider the dose may need to be reduced. Contraindications/Precautions: remember this drugs causes contractions of the uterus which could lead to spontaneous abortion. Interactions: NONE its a miracle!!!Interventions/Education: Besides ensuring contraception use teach client to take with meals and at bedtime. LAXATIVESSurfactants Docusate Sodium [Colace]Action: lower surface tension of the stool to allow penetration of H20Therapeutic Use: short term use r/t pregnancy or opoid use. To relieve painful elimination (hemorrhoids)., prevent straining, decrease risk of fetal impaction of immobile, promote peristalsis due to aging*other info belowStimulant Laxatives Bisacodyl [dulcolax]Action: stimulate intestinal peristalsis-act on the colon by reducing water and electrolyte absorption and increasing the secretion of water and ions into the intestine. Therapeutic Use: prior to surgery, short term treatment caused by high opoid use. Sides/Adverse Effects: discourage clients from using suppositories on a regular basis as it may cause burning and can lead to proctitis. *other belowOsmotic Laxatives-magnesium hydroxide [Milk of Mag]Action: Osmotic lax draw H2O into the mass of stool stretching musculature and stimulating peristalsisTherapeutic Use: used in clients to prevent painful elimination, prep for surgery of diagnostic test, evacuate bowel after ingestion of poison or antihelminthic to rid body of dead parasites. Sides/Adverse Effects: Can lead to accumulation of toxic level of Mg (avoid in folks with renal dysfunction). Osmotics can also cause dehydration.*General Information for this group: Sides/Adverse Effects: GI irritation-do not crush or chew enteric-coated tablets. Contraindications/Precautions: Contraindicated in clients with fecal impaction, bowel obstruction, and acute surgical abdomen to prevent perforation-also in clients with nausea, cramping and abdominal pain. Warn clients with heart disease to avoid laxatives that contain sodium. Interactions: Milk and antacids can destroy enteric coating of bisacodyl.Interventions/Education: Obtain a complete history of laxative use and provide teaching as appropriate. Teach client that chronic laxative use can lead to fluid and electrolyte imbalances. Promote fiber food so that normal bowel function may be resumed. AnitemeticsSerotonin Antagonists Ondansetron [Zofran]Action: blocks serotonin receptors in the chemoreceptor trigger zone (CTZ) and antagonizing the serotonin receptors on the afferent vagal neurons that travel from the upper GI tract to CTZTherapeutic Use: Sides/Adverse Effects: prevents emesis related to chemo, radiation therapy and postoperative recovery Sides/Adverse: Headache, diarrhea, dizziness*see belowDopamine Antagonists Prochlorperazine [Compazine]Action: Anitemetic effects result from blockade of dopamine receptors in the CTZ.Therapeutic Use: prevents emesis r/t chemo, opoid and postoperative recoverySides/Adverse Effects: EPS Extrapyramidal symptoms i.e. restlessness, anxiety, spasms of the neck and facetreat with an anticholinergic like benadryl *See belowCannabinoids; dronabinol [Marinol]Action: unknownTherapeutic Use: Control vomiting and nausea(CINV) in chemoSides/Adverse Effects: Potential for dissociation, dysphoriaContraindications/Precautions: avoid using in clients with mental health disorders* See Below*General information for this group: *General Contraindications/Precautions- Use cautiously with children and older adults due to EPS sides. Interactions: CNS depressants such as opoid medications can intensity CNS depression of antiemetics; antihypertensives concurrent use can intensify hypotensive effects of antiemetics; anticholinergics like antihistamines concurrent use can intensify anticholinergic effects of antiemetics. Nursing Interventions: Antiemetics prevent or treat nausea and vomiting from various causes match with cause. Using a combination allows for lower dosage and decrease the risk of side effects i.e. EPS system. Drugs for Adrenal insufficiency (Not in ATI-found in pharm)

Hydrocortisone (a glucocorticoid)

Prototype glucocorticoids

Key function replacement therapy used for acute adrenal insufficiency/nonendocrine applications used to treat a broad spectrum of nonendocrine disorders.Adverse Effects When taken in large doses to treat nonendocrine disorders, glucocorticoids are highly toxic. High dose therapy include adrenal suppression and productive cushing syndrome.Fludrocortisone (mineralocorticoid)

Prototype mineralocorticoidKey function treats addisons disease, primary hypoaldosteronism, and congenital adrenal hyperplasia. (In most cases used with glucocorticoid)Adverse Effects When dosage is too high, salt and water are retained in excess, while excessive amounts of potassium are lost. Expansion of blood volume, hypertension, edema, cardiac enlargement, hypokalemia.Intervention monitor weight gain, elevation of b/p, and hypokalemia.Womens HealthEstrogen (ATI pg 488-490)

Prototype Conjugated equine estrogens (Premarin)

Estradiol (Estrace)Action: estrogens are hormones needed for growth and maturation of the female reproductive tract and secondary sex characteristics. Estrogens block bone resorption and reduce low density lipoprotein levels. At high levels, estrogens suppress the release of follicle stimulating hormone needed for conception.Uses: contraception, relief of potmenopausal symptoms (hot flashes, mood changes), prevention of postmenopausal osteoporosis, treatment of dysfunctional uterine bleeding and endometriosis, treatment of prostate cancer.Side Effects: Endometrail and ovarian cancers occur when prolonged estrogen is the only potmenopausal therapy, potential risk for estrogen-dependent breast cancer, embolic events, impotence, and decrease libido in malesNursing interventions: Give the client progestins alson with estrogen, instruct the client to report persistent vaginal bleeding, encourage regular self-breast exams and mammograms, discourage smoking, monitor pain, swelling, warmth of legs for emboli (make sure pt takes the med at the same time each day)Interaction: estrogens can decrease the effectiveness of warfarin. (monitor INR) Use of phenytoin with estrogen can increase the risk of toxicity (monitor signs of toxicity)Contraceptive Agents (ATI pg 493-494)Combination Oral Contraceptives

Ethinyl Estradiol/norethindroneProgestin-Only Oral Contraceptives

NorethindroneLong-Acting Contraceptives

Subdermal progestin implant (Norplant)

Depot medroxyprogesterone acetateDrugs for Emergency Contraception

Leveonorgestrel alone

Ethinyl estradiol/levonorgestrel (the Yuzpe Regimen)PROTOTYPE: OVCON 35 (Necon 1/35, ortho-novum)

Action: Oral contraceptives decrease fertility by inhibiting ovulation, thickening cervical mucus, and making the lining of the endometrium less favorable for implantation.

Uses: Oral contraceptives are used to prevent pregnancy.

Side Effects: Thromboembolic events, hypertension, breakthrough or abnormal uterine bleeding, cervical cancer

Nursing Interventions: Discourage smoking, report warmth, edema, etc, may be emboli, monitor b/p, evaluate pt for possibility of pregnancy if two or more periods missed, routine pap smear.

Interactions: Carbamazephine, Phenobarbital, phenytoin, rifampin, tetracyclines, and ampicillin-oral contraceptive effectiveness decreases with concurrent use of these medications (Use additional contraceptive measures). Warfarin and oral hypoglycemics-oral contraceptives decrease the effects of these meds(check INR)Drugs for infertility(NOT FOUND IN ATI)Drugs for controlled ovarian stimulation

Clomiphene

Menotropins

Human chorionic gonadotropinDrugs for hyperporlactinemia

Cabergoline (dopamine agonist)Uterine Stimulatns and Relaxants

Uterine Stimulatns (Oxytocics) (ATI pg 481-483)

Prototype Oxytocin (Pitocin, Syntocinon)

Other med (Methylergonovine (Methergine)

Action: Uterine stimulants increases the strength, frequency, and length of uterine contractions.

Uses: Induction of labor, enhancement of labor, delivery of afterbirth, to control postpartum bleeding, fetal stress testing, intranasal promotion of milk let down.

Side Effects: Uterine rupture, hypertensive

Nursing intervention: Monitor the length, strength, and duration of contractions, have magnesium sulfate on standby to relax the myometrium, monitor the pt for symptoms of hypertension (headache, nausea, vomiting)

Interactions: vasopressors-can lead to hypertension (avoid use of oxytocin and vasopressors, monitor b/p)

Uterine Relaxants (Tocolytics)

Prototype terbutaline sulfate (brethine)Magnesium sulfateAction: Terbutaline selectively activates beta2 adrenergic receptors, resulting in uterine smooth muscle relaxation.Uses: IV or SC terbutaline can be used for up to 48 hr to delay preterm labor.Side Effects: tachycardia, palpitations, chest pain, tremors, anxiety, headache.Nursing Interventions: Monitor the pt for these beta1 side effects, intervene based on tolerance and physiological impact, monitor the pt for beta2 skeletal muscle stimulant side effects.CAUTION: Lactation enters breast milkInteractions: adrenergic agonists-concurrent use can cause additive effects, MAOIs-concurrent use can lead to hypertension, Beta blockers-concurrent use can blunt effect (monitor for tachycardia, tremors, b/p)***Terbutaline should be administered IV or SC due to high first pass effect with oral administration.

MENS HEALTH

Androgens

Prototype Testosterone enanthate (Delatestryl)Action: Androgens are a hormone needed for growth and maturation of male sex organs and secondary sex characteristics. This hormone promotes skeletal muscle growth in sexually mature males.Uses: Androgens are used for treatment of hypogonadism in androgen deficient men, treat delayed puberty, treat androgen-responsive breast cancer.Side Effects: Hepatotoxicity, Cardiovascular risk high LDL, lower HDL, edema, virilism effects, males- acne, facial hair, gynecomastia, impotence, priapism, females- deeper voice, unusual hair growth, clitoral enlargement, menstrual irreg, acne. HyercalcemiaNursing interventions: Liver function test, check cholesterol levels, edema, low sodium diet, hypercalcemiaInteractions: Warfarin, oral hypoglycemic, and glucocorticoids-androgen effects on metabolism can increase med levels of these meds. Heaptotoxic drugs can increase the risk of liver damage. (monitor INR, signs of bleeding, infection, liver function)***Instruct pt to report weight fain of more than 2 pounds in a week.Drugs for Erectile Dysfunction

Prototype sildenafil (Viagra)Action: augments the effects of nitric oxide released during sexual stimulation resulting in enhanced blood flow to corpus cavernosum and penile erection. Uses: treat erectile dysfunctionSide effects: MI, sudden death, priapismNursing Interventions: Monitor pt risk factors and history with regard to cardiovascular health, notify dr if erection lasts more than 4 hr.**Do not take with NitroglycerineInteraction: Organic nitrates (nitroglycerin)-can lead to fatal hypotension, Ketoconazole, erythromycin, grapefruit juice-inhibit metabolism of sildenafil thereby increases plasma level of med**Instruct pt to take 1 hr before sexual activity and limit use to once a dayDrugs for Benign Prostatic Hyperplasia (NOT IN ATI)Drugs for IBSAlosetron (Lotronex)Only approved for treating women with severe, diarrhea-predominant IBS that has lasted for 6 or more months. Causes selective blockade of type 3 serotonin receptors, which are found primarily on neurons that innervate the viscera. It decreases abdominal pain, increases colonic transit time, reduces intestinal secretions, and increases absorption of H2O and Na.Side EffectsMost common complication is constipation, which can be complicated by impaction, bowel obstruction, and perforation. Can also cause ischemic colitis (intestinal damage secondary to reduced blood flow).Drug InteractionsNo known adverse interactions with other drugs.Drugs for Bacterial InfectionsPenicillin G (Bicillin LA)Destroys bacteria by weakening the bacterial cell wall. Med of choice for gram-positive cocci, such as streptococcus pneumonia, meningitis.Side EffectsAllergies/anaphylaxis, renal impairment, hyperkalemia/dysrhythmias with high doses of penicillin G.Interventionsinterview client for prior allergy, observe client for 30 min following administration of parenteral penicillin. Monitor clients kidney function and I&O. Monitor clients cardiac status and electrolyte levels.Drug InteractionsAminoglycosidespenicillin inactivates aminoglcyosides when missed in the same IV solution. Oral contraceptivesApicillindecreases oral contraceptive efficacy.Cephalosporins (use cautiously in pts with renal impairment)CephalothinNot in ATI,Pharm,Mosbys drug book.Cephalosporins are similar to penicillins, they destroy the bacterial cell wall.Side Effectsallergic/hypersensitivity/anaphylaxis. Bleeding tendencies, Thrombophlebitis, Cross allergy to penicillin.InterventionsIf signs of allergy appear, stop immediately, observe for signs of bleeding, if bleeding administer parenteral vitamin K and stop cephalosporin, to avoid thrombophlebitis rotate injection sites and administer slowly over 3-5min. Also assess patient for allergy to penicillin.Drug InteractionsDisulfiram reaction (intolerance to alcohol) occurs with combined use of some cephalosporins with alcohol, but not cephalotin.Probenecid delays renal excretionOtherImipenem (Primaxin) (use cautiously in pts with renal impairment)Destroys bacterial cell walls causing destruction of micro-organisms.Primarily used with other antibiotics for broad spectrum with serious infections.Side EffectsAllergy/hypersensitivity, GI symptoms(nausea,vomiting,diarrhea), SuprainfectionInterventionsMonitor the patient for signs of allergic reactions. Observe client for any GI signs, notify primary caretaker, and watch I&O. For suprainfection, monitor patient for signs of colitis (e.g., diarrhea, oral thrush, vaginal yeast infection) and intervene accordingly.Drug InteractionsNone listed.Vancomycin (Vancocin) (use cautiously in pts with renal impairment)Destroys bacterial cell walls.Primarily used for serious infections caused by MRSA. Also used in antibiotic-associated pseudomembranous colitis.Side EffectsOtotoxicity, Infusion reaction (e.g., rashes, flushing, tachycardia, hypotension), and Thrombophlebitis.InterventionsAssess client for signs of hearing loss, obtain a baseline hearing test prior to administration, tell pt. to inform care provider if hearing loss occurs. To avoid infusion reactions, infuse vancomycin slowly over 60 min. To avoid thrombophlebitis, rotate injection sites and monitor infusion site for redness, swelling, and inflammation.Drug InteractionsNone listed.Bacteriostatic Inhibitors of Protein SynthesisTetracyclinesTetracycline Hydrochloride (Sumycin)Broad-spectrum antibiotics that inhibit micro-organism growth by preventing protein synthesis (bacteriostatic).Medication of choice topically and orally for acne vulgaris.Side EffectsGI discomfort (cramping, nausea, vomiting, diarrhea, esophageal ulceration), Yellow/brown tooth discoloration and/or hypoplasia of teeth enamel can occur, Hepatotoxicity, Photosensitivity, Suprainfection of the bowel. Should be avoided by pregnant women.InterventionsMonitor client for signs of GI upset. To avoid tooth discoloration and enamel problems, avoid giving to children under 8 years of age. To avoid hepatotoxicity, avoid giving high doses via IV. For photosensitivity, avoid long exposure to sun. For suprainfection, monitor GI system.Drug InteractionsMilk products, calcium supplements, iron supplements, magnesium-containing laxatives, and most antacids. Tetracyclines should be taken on an empty stomach with water. Give 1 hour before and 2 hours after meals and/or supplements containing calcium/magnesium.Oral contraceptives. Instruct the pt to report signs of reduced levels, such as breakthrough bleeding. Dose of oral contraceptive may need to be increased.MacrolidesErythromycin (E-Mycin)Slows the growth of micro-organisms by inhibiting protein synthesis.Used primarily to treat infections in patients with a penicillin allergy.Side EffectsGI discomfort (nausea, vomiting, epigastric pain), Thrombophlebitis.InterventionsTo avoid GI discomfort, administer with meals. To avoid thrombophlebitis, administer slowly and in a dilute solutionDrug InteractionsAntihistamines, theophylline (asthma med), carbamazepine (anticonvulsant), and warfarinconcurrent use with these meds could result in toxicity so avoid use of these with erythromycin.OxazolidinomesLinezolid (Zyvox)Works well against MRSA and vancomycin-resistant enterococci (VRE). Inhibits bacterial protein synthesisSide EffectsGenerally well tolerated. Most common side effects are diarrhea, nausea, and headache. Can cause myelosuppression, manifesting as anemia, leucopenia, thrombocytopenia, or pancytopenia.InterventionsMonitor for GI upset signs, and if pt. is receiving Linezolid for more than 2 weeks, CBC should be done weekly.Drug InteractionsLinezolid is a weak inhibitor of monoamine oxidase (MAO), and hence poses a risk for hypertensive crisis. Can also cause hypertensive crisis in conjunction with foods high in tyramine.GlycylcylinesTigecycline (Tygacil)A tetracycline derivative designed to overcome resistant bacteria. Active against a broad spectrum of bacteria, including many resistant strains.Side EffectsBecause it is a tetracycline derivative, side effects are very similar to those of tetracyclines. Most common side effects were nausea and vomiting. Should be avoided by pregnant women.Interventions-- Monitor client for signs of GI upset. To avoid tooth discoloration and enamel problems, avoid giving to children under 8 years of age. To avoid hepatotoxicity, avoid giving high doses via IV. For photosensitivity, avoid long exposure to sun. For suprainfection, monitor GI system.Drug InteractionsMinimal interactions, can delay the clearance of warfarin so coagulation should be monitored.OthersClyndamycin (Cleocin)Inhibits bacterial protein synthesis. Effective against most anaerobic bacteria and most gram-positive aerobes.Side EffectsAntibiotic-associated pseudomembranous colitis (AAPMC). This is the most severe toxicity. The cause is suprainfection of the bowel with C.difficile. AAPMC is characterized by profuse, watery diarrhea (10-20 stools /day), abdominal pain, fever, and leukocytosis. Stools often contain mucous or blood.InterventionsWatch for signs of AAPMC, or other GI problems. If AAPMC is present, vigorous replacement therapy with fluids and electrolytes is usually indicated. Drugs that decrease bowel motility should NOT be used because they may worsen the symptoms.Drug InteractionsThe site at which clyndamycin binds overlaps the binding sites for erythromycin and chloramphenicol. As a result, concurrent use of these with clyndamycin is not suggested.Drugs for Bacterial InfectionsClass: Aminoglycosides (Bactericidal Inhibitors of Protein Synthesis)Pro Drug- GentamicinUses: Medication of choice for aerobic gram negative bacilli ( escherichia coli, pneumoniae, etc)Side Effects: Ototoxicity (discontinue if this occurs), Nephrotoxicity (Monitor BUN, Creatinine and I&O.Do not mix Aminoglycosides with penicillins in the same IV solution. Class: FluoroquinolonesPro Drug- CiprofloxacinUses: A broad spectrum antimicrobial, can be used on gram positive or negative bacteria. Medication of choice for clients who have inhaled anthrax.Side Effects: GI discomfort, Achilles tendon rupture ( observe for swelling, redness or pain and to report to primary care provider and stop med).Do not give to children < 18, Warfarin levels can be increased with Ciprofloxacin, Do not use dairy products, antacids or salts until 1 hr before or 2 hrs after med is administeed.Class: Cyclic LipopeptidesPro Drug- DaptomycinUses: Can kill all gram positive bacterias. No need to monitor plasma level, Only side effect may be muscle injury due to IV. Does not have any significant interactions. Can be used for MRSAClass: Sulfonamides and TrimethoprimPro Drug- Trimethoprim/Sulfamethoxazole (Bactrim)Drug- SulfisoxazoleDrug- TrimethoprimUses: inhibit bacterial growth by preventing synthesis of folic acid, med of choice for UTIs.Side Effects: Do not administer to patients allergic to sulfa, thiazide diuretics, loop diuretics. Can cause crystalluria so increase fluid intake, photosensitivity, if sore throat or pallor notify provider.Drugs for TBPro Drug- Isoniazid (INH)Drug- RifampinDrug- PyrazinamideDrug- EthambutolUses: Inhibits growth of mycobacteria, indicated for latent TB. INH daily for 6 months.Side Effects: Peripheral neuropathy (give 50-200mg of vitamin B6 daily), HepatotoxcityInteracts with Phenytoin and levels may need to be adjusted, Avoid alcohol. Take on an empty stomach.Drugs for Funal InfectionsPro Drug- Polyene Macrolides (Amphotericin B)Drug- Azoles (Itraconazole)Drug- Echinocandins (Caspofungin)Uses: Used for systemic fungal infections, Azoles are used for superficial fungal infections.Side Effects: Infusion reactions (pretreat with diphenhydramine), Nephrotoxicty (monitor I&O, BUN), HypokalemiaGive 1 Liter of saline on day of amphotericin infusion. Contraindicated in renal failure patients. Avoid use with antimicrobials such as aminoglycosides.Viral InfectionsDrugs for Cytomegalovirus InfectionAction: prevents the reproduction of viral DNAUses:

- medication of choice for herpes simplex virus, varicella zoster virus, and

cytomegalovirus

- Ganciclovir is treatment choice for CMV retinitis in immunocompromised pts with

HIV, and transplant pts at risk for CMV infectionPro drug: acyclovir (Zovirax)

SE:

- phlebitis and inflammation at site of injection

- Nephrotoxicity

- mild discomfort

Contraindications:

- should be used cautiously in pts with renal impairment, dehydration, and pts taking

nephrotoxic meds

Interventions:

- administer slowly over 1 hr

- ensure adequate hydration during infusion and 2 hr after to minimize nephrotoxicityOther: Ganciclovir (Cytovene), ribavirin (Rebetol)

SE:

- granulocytopenia and thrombocytopenia

- reproductive toxicity

Contraindications:

- pregnancy

- pts with neutrophils count