NurseReview.Org Pharmacology Bullet Review

Slide 1: Pharmacology Bullet Review Nursing Board Examination Review

Slide 2: Drug classification Pharmacodynamic s Nursing process Pharmacokinetics applied to pharmacology

Slide 4: Diuretics Comparison Diuretic class Major site of action Special Side effect (s) 1. Carbonic Proximal tubule Acidosis anhydrase inhibitor 2. Thiazide and Proximal tubule Hyperuricemia thiazide like Hypokalemia 3. Loop diuretics Loop of Henle Hypokalemia Ototoxicity 4. Potassium Distal tubule Hyperkalemia sparing 5. Osmotic Glomerulus Hypovolemia & diuretic hypotension

Slide 5: Diuretics Comparison Diuretic class Special Uses 1. Carbonic Mountain sickness anhydrase inhibitor Meniere’s disease Nephrolithiasis due to calcium stones 2. Thiazide and thiazide like Hypocalcemia Hypercalcemia 3. Loop diuretics 4. Potassium CHF taking digoxin sparing 5. Osmotic diuretic Increased ICP LITHIUM TOXICITY

Slide 6: Thiazides Prototype: Hydrochlorothiazide 1. Bendroflumethiazide  2. Benthiazide  3. Chlorothiazide (Diuril)  4. Hydroflumethiazide  5. Methylclothiazide  6. Trichlormethiazide 

Slide 7: Thiazide-like 1. Indapamide  2. Quinethazone  3. Metolazone  4. Chlorthalidone 

Slide 8: Thiazides Pharmacodynamics  These drugs BLOCK the chloride pump  This will keep the Chloride and Sodium in the distal tubule to be excreted into the urine  Potassium is also flushed out!!

Slide 9: Thiazide Special Pharmacodynamics: Side effects  Hypokalemia   DECREASED calcium excretion hypercalcemia  DECREASED uric acid secretion hyperuricemia  Hyperglycemia

Slide 10: Loop Diuretics Prototype: Furosemide 1. Bumetanide  2. Ethacrynic acid  3. Torsemide 

Slide 11: Loop Diuretics Pharmacodynamics  High-ceiling diuretics  BLOCK the chloride pump in the ascending loop of Henle  SODIUM and CHLORIDE reabsorption is prevented  Potassium is also excreted together with Na and Cl

Slide 12: Loop Diuretics

Slide 13: Loop Diuretics Special Pharmacodynamics: side-effects  Hypokalemia   Bicarbonate is lost in the urine  INCREASED calcium excretion Hypocalcemia  Ototoxicity- due to the electrolyte imbalances

Slide 14: Potassium sparing diuretics Prototype: Spironolactone 1. Amiloride  2. Triamterene 

Slide 15: Potassium sparing diuretics Pharmacodynamics  Spironolactone is an ALDOSTERONE antagonist  Triamterene and Amiloride BLOCK the potassium secretion in the distal tubule  Diuretic effect is achieved by the sodium loss to offset potassium retention

Slide 16: Potassium sparing diuretics

Slide 17: Potassium sparing diuretics Pharmacokinetics: Side effects HYPERkalemia!  Avoid high potassium foods:  Bananas  Potatoes  Spinach  Broccoli  Nuts  Prunes  Tomatoes  Oranges  Peaches 

Slide 18: Osmotic Diuretics Prototype: Mannitol 1. Glycerin  2. Isosorbide  3. Urea 

Slide 19: Osmotic Diuretics Pharmacodynamics  Mannitol is a sugar not well absorbed in the nephron osmotic pull of water diuresis

Slide 20: Osmotic Diuretics Pharmacokinetics: side effects Sudden hypovolemia  Important for the nurse to warm the solution to allow the crystals to DISSOLVE in the bottle!

Slide 21: Carbonic Anhydrase Inhibitors Prototype: Acetazolamide 1. Methazolamide 

Slide 22: Carbonic Anhydrase Inhibitors Pharmacodynamics  Carbonic Anhydrase forms sodium bicarbonate  BLOCK of the enzyme results to slow movement of hydrogen and bicarbonate into the tubules  plus sodium is lost in the urine

Slide 23: Carbonic Anhydrase Inhibitors Pharmacokinetics: side effects Metabolic ACIDOSIS happens when  bicarbonate is lost  Hypokalemia

Slide 24: The Nursing Process and the diuretics ASSESSMENT  Assess the REASON why the drug is given: ______ ______ ______ ______

Slide 25: The Nursing Process and the diuretics ASSESSMENT  The nurse must elicit history of allergy to the drugs Allergy to sulfonamides may contraindicate the  use of thiazides Assess fluid and electrolyte balance  Assess other conditions like gout, diabetes,  pregnancy and lactation

Slide 26: The Nursing Process and the diuretics ASSESSMENT  Physical assessment Vital signs   Special electrolyte and laboratory examination Assess symptom of body weakness which may  indicate hypokalemia

Slide 27: The Nursing Process and the diuretics Nursing Diagnosis Fluid volume deficit related to diuretic effect   Alteration in urinary pattern  Potential for injury (ototoxocity, hypotension)  Knowledge deficit

Slide 28: The Nursing Process and the diuretics IMPLEMENTATION  Administer IV drug slowly  Safety precaution for dizziness/hypotension  Provide potassium RICH foods for most diuretics, with the exception of spironolactone  Provide skin care, oral care and urinary care

Slide 29: The Nursing Process and the diuretics IMPLEMENTATION  Monitor DAILY WEIGHT- to evaluate the effectiveness of the therapy  Monitor urine output, cardiac rhythm. Serum electrolytes  ADMINISTER in the MORNING!  Administer with FOOD!

Slide 30: The Nursing Process and the diuretics EVALUATION: for effectiveness of therapy Weight loss Increased urine output Resolution of edema Decreased congestion Normal BP

Slide 32: The ANXIOLYTICS AND HYPNOTICS These drugs are used to change the individual’s responses to the environment.

Slide 33: The ANXIOLYTICS AND HYPNOTICS The medications that can prevent the feelings of tension and fear are called ANXIOLYTICS. – Anti-anxiety drugs

Slide 34: The ANXIOLYTICS AND HYPNOTICS The drugs that can calm individuals making them unaware of the environment are called SEDATIVES.

Slide 35: The ANXIOLYTICS AND HYPNOTICS The drugs that can induce sleep are called HYPNOTICS.

Slide 36: The ANXIOLYTICS AND HYPNOTICS The drugs in this class are the – BENZODIAZEPINES – BARBITURATES

Slide 37: Use of The Drugs Clinical indications for the use of the anxiolytics, sedatives and hypnotics 1. Prevention of anxiety 2. Formation of sedative state 3. Induction of sleep

Slide 38: The BENZODIAZEPINES The benzodiazepines are the most frequently used anxiolytic drugs. These agents prevent anxiety states without causing much sedation, with less physical dependence than other agents.

Slide 39: The BENZODIAZEPINES The following are the benzodiazepines Alprazolam (Xanax) Chlordiazepoxide (Librium) clonazepam clorazepate Diazepam (Valium) estazolam flurazepam lorazepam midazolam oxazepam quazepam temazepam triazolam

Slide 40: The BENZODIAZEPINES Special uses Diazepam Status epilepticus (Valium) Chlordiazepoxide Alcohol (Librium) withdrawal Alprazolam Panic attack (Xanax)

Slide 41: The BENZODIAZEPINES The Mechanism of Action of the Benzodiazepines These agents act on the Limbic system and the RAS (reticular activating system) to make the GABA ( Gamma- aminobutyric acid) more effective causing interference with neuron firing.

Slide 42: The BENZODIAZEPINES The Mechanism of Action of the Benzodiazepines The GABA is an inhibitory neurotransmitter. This will result to an anxiolytic effect at lower doses than required for sedation/hypnosis.

Slide 43: The BENZODIAZEPINES These agents are indicated for the treatment of • anxiety disorders • alcohol withdrawal • hyperexcitability, and agitation • pre-operative relief of anxiety and tension and in induction of balanced anesthesia.

Slide 44: The BENZODIAZEPINES Pharmacodynamics: The adverse effects CNS effects= sedation, drowsiness, depression, lethargy, blurred vision GIT= dry mouth, constipation, nausea, vomiting CVS= Hypotension or hypertension, arrhythmias, palpitations, and respiratory difficulties. Hematologic= blood dyscrasias and anemia GU= urinary retention, hesitancy, loss of libido and sexual functions changes.

Slide 45: The BENZODIAZEPINES Nursing Considerations: Maintain patients on bed for at least 3 hours after drug administration. Instruct to avoid hazardous activities like driving and machine operation. Instruct to avoid consuming ALCOHOL while taking the drug.

Slide 46: The BENZODIAZEPINES Nursing Considerations: Provide comfort measures to help patients tolerate drug effects- – instruct to urinate before taking drug – give high fiber foods – use side-rails and assistance with ambulation. Have available FLUMAZENIL as an antidote for benzodiazepine overdose.

Slide 47: The BARBITURATES These are also anxiolytics and hypnotics with a greater likelihood of producing sedation, with increase risk of addiction and dependence.

Slide 48: The BARBITURATES The following are the barbiturates amobarbital aprobarbital butabarbital mephobarbital pentobarbital Phenobarbital secobarbital

Slide 49: The BARBITURATES The Mechanism of Action of the Barbiturates They depress the motor output from the brain. The results of their MOA are sedation, hypnosis and anesthesia, and if extreme, coma.

Slide 50: The BARBITURATES Clinical indications of the Barbiturates • Relief of anxiety manifestations • For sedation • For patients with insomnia • For pre-anesthesia • seizures/epilepsy • The rapid acting barbiturates are also used for the treatment of acute manic reactions and status epilepticus

Slide 51: The BARBITURATES Pharmacodynamics: The Adverse effects CNS= CNS depression, somnolence, vertigo, lethargy, ataxia, paradoxical excitement, anxiety and hallucinations. GIT= nausea, vomiting, constipation/diarrhea and epigastric pain CVS= bradycardia, Hypotension and syncope. Respi= serious hypoventilation, respiratory depression and laryngospasms Others= hypersensitivity and Stevens- Johnson syndrome.

Slide 52: The BARBITURATES Nursing Considerations Provide stand-by life support facilities in cases of severe respiratory depression or hypersensitivity reaction. Taper the drug gradually after long- term therapy to avoid withdrawal syndrome. Provide comfort measures including small frequent meals, access to bathroom facilities, high-fiber foods, environmental control, safety precaution and skin care.

Slide 53: The CNS stimulants These are drugs used to treat certain disorders • exogenous obesity • attention-deficit hyperactivity disorders (ADHD) • narcolepsy

Slide 54: The CNS stimulants What is unusual is the ability of the CNS stimulants to CALM hyperactive children, which allows them to focus on one activity for a longer period.

Slide 55: The CNS stimulants The following are the CNS stimulants: 1. Methylphenidate (Ritalin)= most commonly used for ADHD 2. Dextroamphetamine= a CNS stimulant that is used for short tem therapy for obesity. 3. Modafinil= used for narcolepsy 4. Pemoline= used for ADHD

Slide 56: The CNS stimulants The Mechanism of Action These agents act as to stimulate the cortical and reticular activating system (RAS) of the brain. This is by releasing neurotransmitters from the nerve cells leading to increased stimulation of the post-synaptic neurons.

Slide 57: The CNS stimulants The paradoxical effect of calming hyperexcitability through CNS stimulation seen in ADHD is believed to be related to the increased stimulation of an IMMATURE Reticular Activating System leading to the ability to be more selective in response to incoming stimuli.

Slide 58: The CNS stimulants Pharmacodynamics: Adverse effects of the CNS stimulants CNS= nervousness, insomnia, dizziness, headache, and blurred vision GIT= anorexia, nausea and weight loss CVS= hypertension, tachycardia arrhythmias, and angina Others= rashes, physical/psychological dependence.

Slide 59: The CNS stimulants Implementation The nurse must ensure that the drug is only given to the indicated conditions Administer the drug before 6 pm to reduce the effect of insomnia BEST given AFTER meals to prevent the effect of anorexia Consult with school personnel to monitor the patient under therapy Provide safety measures such as side-rails and assisted ambulation

Slide 60: The CNS stimulants Evaluation Evaluate the effectiveness of the drug: • Calming effect in the patient with ADHD • Alertness for patients with narcolepsy

Slide 61: The Anti-epileptics These agents, also called anticonvulsants, are used to treat epileptic conditions. Hydantoins, Barbiturates, benzodiazepines, Succinimides and many others are given to a specific type of seizure.

Slide 62: Anti-epileptics Agents for treating TONIC-CLONIC SEIZURES 1. Hydantoins – Phenytoin – Ethotoin – Fosphenytoin – Mephenytoin 2. Benzodiazepines – Diazepam – Clonazepam – Clorazepate 3. Barbiturates – Phenobarbital

Slide 63: Anti-epileptics Agents for treating ABSENCE SEIZURES 1. Succinimides a. Ethosuximide b. Methsuximide c. Phensuximide 2. Valproic Acid 3. Zosinamide

Slide 64: Anti-epileptics Agents for treating Partial FOCAL SEIZURES 1. Carbamazepine 2. Gabapentin 3.Lamotrigine 4. Tiagabine 5. Topiramate

Slide 65: The hydantoins These agents are utilized for general seizures because they can depress the central nervous system. They affect the entire brain and reduce the chance of sudden electrical outburst that causes seizures. These agents generally are less sedating than other anti-epileptics.

Slide 66: The hydantoins Mechanism of Action of the Hydantoins These agents STABILIZE the nerve cell membrane throughout the brain reducing and limiting the excitability and conduction through nerve pathways.

Slide 67: The hydantoins Clinical Indications of the hydantoins • Tonic-clonic seizures • Status epilepticus • For the prevention of seizures in neurosurgery • For muscle relaxation.

Slide 68: The hydantoins Contraindications and Precautions Hydantoins are NOT given to pregnant patient because it can cause fetal hydantoin syndrome.

Slide 69: The hydantoins Pharmacodynamics: Adverse effects of the Hydantoins CNS effects- depression, confusion, drowsiness, lethargy, fatigue GIT- GI upset, constipation, dry mouth, GINGIVAL HYPERPLASIA , severe liver toxicity which are all related to cellular toxicity. SKIN- hirsutism and coarsening of the facial skin Bone Marrow depression

Slide 70: The hydantoins Implementation Administer the drug with food to alleviate GI irritation Discontinue the drug at any sign of hypersensitivity reaction, severe liver dysfunction and severe skin rashes. Provide meticulous mouth oral care Rule out pregnancy and advise women to use contraceptive measures to prevent pregnancy.

Slide 72: Drugs affecting GI secretions There are five types of drugs that affect gastric acid secretions and are useful for the treatment of peptic ulcer. 2. Histamine (H2) receptor antagonist/blockers 3. Antacids 4. Proton pump inhibitors 5. Mucosal protectants 6. Prostaglandin analogs

Slide 73: Drugs affecting secretions: anti ulcer Anti-ulcer drugs Prototype Cimetidine Histamine (H2) receptor antagonist/blockers AlOH and MgOH Antacids Omeprazole Proton pump inhibitors Sucralfate Mucosal protectants Misoprostol Prostaglandin analog

Slide 74: General indication of the drugs affecting gastric acid secretion ► Peptic ulcer ► Gastritis ► Patient on NPO to prevent stress ulcer

Slide 75: General time of administration of the drugs affecting gastric acid secretion Anti-ulcer drugs Prototype Best time to give Histamine (H2) Cimetidine With FOOD or ONE receptor hour after ANTACID antagonist/blockers Antacids AlOH and MgOH Usually after meals Proton pump Omeprazole BEFORE MEALS inhibitors Mucosal Sucralfate BEFORE MEALS protectants Prostaglandin Misoprostol WITH MEALS analog

Slide 76: Pharmacology of Anti-ulcer drugs Drug Mechanism of Action Antacids- AlOH, MgOH Neutralize Gastric ACIDITY H2-Blockers- “tidine” Block Histamine receptor causing decreased secretion and Cimetidine, Ranitidine acidity Proton pump inhibitors- Inhibit Proton Pump in parietal “Prazoles” cell decreasing secretion and acidity Omeprazole, pantoprazole

Slide 77: Pharmacology of Anti-ulcer drugs Drug Mechanism of Action Anti-cholinergic- Prophanteline Blocks VAGUS nerve, decreases Bromide secretion Sucralfate (Carafate) Coats the mucosal lining Misoprostol (Cytotec) Prostaglandin Analogue, causes secretion of MUCUS

Slide 78: Pharmacodynamics Histamine (H2) receptor blockers ►These drugs BLOCK the release of hydrochloric acid in the stomach in response to gastrin

Slide 79: Drugs affecting GI secretions Antacids ►These drugs interact with the gastric acids at the chemical level to neutralize them

Slide 80: Drugs affecting GI secretions Proton pump inhibitors ►These drugs suppress the secretion of hydrochloric acid into the lumen of the stomach

Slide 81: Drugs affecting GI secretions Mucosal protectants ►These are agents that coat any injured area in the stomach to prevent further injury from acid

Slide 82: 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.

Slide 83: The H2 Blockers- “tidines” Prototype: Cimetidine ► 1. Ranitidine ► 2. Famotidine ► 3. Nizatidine

Slide 84: The H2 Blockers- “tidines” Pharmacodynamics: Drug Action ► The H2 blockers are antagonists at the receptors in the parietal cells of the stomach. ► The blockage results to inhibition of the hormone gastrin. ► There will be decreased production of gastric acid from the parietal cells. ► Also, the chief cells will secrete less pepsinogen.

Slide 85: The H2 Blockers- “tidines” Therapeutic use of the H2 blockers ► Short-term treatment of active duodenal ulcer or benign gastric ulcer ► Treatment of hypersecretory conditions like the Zollinger-Ellison syndrome ► Prevention of stress-induced ulcers and acute GI bleeding ► Treatment of erosive GERD (reflux disease) ► Relief of Symptoms of heart burn and acid indigestion

Slide 86: The H2 Blockers- “tidines” Precautions and Contraindications ► Any known allergy is a clear contraindication to the use of the agents. Conditions such as pregnancy, lactation, renal dysfunction and hepatic dysfunction should warrant cautious use. ► Nizatidine can be used in hepatic dysfunction.

Slide 87: The H2 Blockers- “tidines” Pharmocodynamics- Side effects and adverse effects ► GIT= diarrhea or constipation ► CNS= Dizziness, headache, drowsiness, confusion and hallucinations ► Cardio= arrhythmias, HYPOTENSION (related to H2 receptor blockage in the heart) ► Cimetidine= TREMORS, Gynecomastia and impotence in males

Slide 88: The H2 Blockers- “tidines” Drug-drug Interactions ► Cimetidine, Famotidine, Ranitidine are metabolized in the liver- they can cause slowing of excretion of other drugs leading to their increased concentration.

Slide 89: The H2 Blockers- “tidines” Drug-drug Interactions ► These drugs can interact with CIMETIDINE anticoagulants, phenytoin, alcohol, antidepressants.

Slide 90: The H2 Blockers- “tidines” Nursing considerations: ►Administer the drug WITH meals at BEDTIME to ensure therapeutic level ►One hour after Antacids ►Stress the importance of the continued use for the length of time prescribed

Slide 91: The H2 Blockers- “tidines” Nursing considerations: ►Monitor the cardiovascular status especially if the drugs are given IV ►Warn patient of the potential problems of increased drug concentration if the H2 blockers are used with other drugs or OTC drugs. Advise consultation first!

Slide 92: The H2 Blockers- “tidines” Nursing considerations: ► Provide comfort measures like analgesics for headache, assistance with ambulation and safety measures ► Warn the patients taking cimetidine that drowsiness may pose a hazard if driving or operating delicate machines.

Slide 93: The H2 Blockers- “tidines” Nursing considerations: ► Provide health teaching as to the dose, frequency, comfort measures to initiate when side-effects are intolerable Evaluate the effectiveness: ► Relief of symptoms of ulcer, heart burn and GERD

Slide 94: The Antacids ► These are drugs or inorganic chemicals that have been used for years to neutralize acid in the stomach. The following are the common antacids that can be bought OTC: ► Aluminum salts (hydroxide) ► Calcium salts (carbonate) ► Magnesium salts (milk of magnesia) ► Sodium bicarbonate ► Magaldrate (aluminum and magnesium combination)

Slide 95: The Antacids Pharmacodynamics: drug action ► These agents act to neutralize the acidic pH in the stomach. ► They do not affect the rate of gastric acid secretion.

Slide 96: The Antacids Pharmacodynamics: drug action ► The administration of antacid may cause an acid rebound. ► Neutralizing the stomach content to an alkaline level stimulates gastrin production to cause an increase in acid production and return the stomach to its normal acidic state.

Slide 97: The Antacids Therapeutic Indications ► Symptomatic relief of upset stomach associated with hyperacidity ► Hyperacidic conditions like peptic ulcer, gastritis, esophagitis and hiatal hernia ► Special use of AMPHOGEL (aluminum hydroxide): to BIND phosphate

Slide 98: The Antacids Precautions of Antacid Use ► Known allergy is a clear contraindication. Caution should be instituted if used in electrolyte imbalances, GI obstruction and renal dysfunction. ► Sodium bicarbonate is rarely used because of potential systemic absorption

Slide 99: The Antacids Pharmacokinetics ► These agents are taken orally and act locally in the stomach

Slide 100: The Antacids Pharmacodynamics: Effects of drugs 2. GIT= rebound acidity; alkalosis may occur. ► Calcium salts may lead to hypercalcemia ► Magnesium salts can cause DIARRHEA ► Aluminum salts may cause CONSTIPATION and hypophosphatemia by binding with phosphates in the GIT. 2. Fluid retention due to the high sodium content of the antacids.

Slide 101: 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

Slide 102: The Antacids Nursing Considerations: ► Provide comfort measures to alleviate constipation associated with aluminum and diarrhea associated with magnesium salts. ► Monitor for the side-effects, effectiveness of the comfort measures, patient’s response to the medication and the effectiveness of the health teachings

Slide 103: The Antacids Nursing Considerations: ► Evaluate for effectiveness: Decreased symptoms of ulcer and pyrosis Decreased Phosphate level (amphogel)

Slide 104: The PPI These are the newer agents for ulcer treatment ► The “prazoles” Prototype: Omeprazole ► Lanisoprazole ► Esomeprazole ► Pantoprazole

Slide 105: The PPI Pharmacodynamics: drug action ► They act at specific secretory surface receptors to prevent the final step of acid production and thus decrease the level of acid in the stomach. “pump” in the parietal cell is the H-K ► The ATPase enzyme system on the secretory surface of the gastric parietal cells

Slide 106: The PPI Clinical use of the PPIs ► Short-term treatment of active duodenal ulcers, GERD, erosive esophagitis and benign gastric ulcer. ► Long-term- maintenance therapy for healing of erosive disorders.

Slide 107: The PPI Clinical use of the PPIs. Precautions with the use of the PPIs ► Known allergy is a clear contraindication. Caution if patient is pregnant

Slide 108: The PPI Pharmacodynamics: Adverse effects ► CNS- dizziness, headache, asthenia (loss of strength), vertigo, insomnia, apathy ► GIT- diarrhea, abdominal pain, nausea, vomiting, dry mouth and tongue atrophy ► Respi- cough, stuffy nose, hoarseness and epistaxis.

Slide 109: The PPI Nursing considerations: ► Administer the drug BEFORE meals. Ensure that patient does not open, chew or crush the drug. ► Provide safety measures if CNS dysfunction happens. ► Arrange for a medical follow-up if symptoms are NOT resolved after 4-8 weeks of therapy.

Slide 110: The PPI Nursing considerations: ► Provide health teaching as to drug name, dosages and frequency, safety measures to handle common problems. ► Monitor patient response to the drug, the effectiveness of the teaching plan and the measures to employ

Slide 111: The PPI Nursing considerations: Evaluate for effectiveness of the drug ► Healing of peptic ulcer ► Decreased symptoms of ulcer

Slide 112: The Mucosal Protectant Sucralfate ► This is given to protect the eroded ulcer sites in the GIT from further damage by acid and digestive enzymes

Slide 113: Sucralfate Pharmacodynamics: Action of drug ► It forms an ulcer-adherent complex at duodenal ulcer sites, protecting the sites against acid, pepsin and bile. ► This action prevents further breakdown of proteins in the area and promotes healing.

Slide 114: Sucralfate Clinical use of sucralfate ► Short and long term management of duodenal ulcer. ► NSAIDs induced gastritis ► Prevention of stress ulcer ► Treatment of oral and esophageal ulcers due to radiation, chemotherapy or sclerotherapy.

Slide 115: Sucralfate Precautions on the use of Sucralfate ► This agent should NOT be given to any person with known allergy to the drug, and to those patients with renal failure/dialysis because of build-up of aluminum may occur if used with aluminum containing products.

Slide 116: The Mucosal Protectant Pharmacodynamics: Side-effects & adverse reactions ► Primarily GIT= CONSTIPATION, occasionally diarrhea, nausea, indigestion, gastric discomfort, and dry mouth may also occur ► CNS= dizziness, drowsiness, vertigo ► Others= rash and back pain

Slide 117: The Mucosal Protectant Drug-drug interactions ► If used with aluminum salts= high risk of accumulation of aluminum and toxicity. ► If used with phenytoin, fluoroquinolones and penicillamines- decreased levels of these drugs when taken with sucralfate

Slide 118: The Mucosal Protectant Nursing Considerations ► Administer drug ON AN EMPTY stomach, 1 hour before meals , or 2 hour after meals and at BEDTIME ► Monitor for side-effects like constipation and GI upset ► Encourage intake of high-fiber foods and increased fluid intake ► Administer antacids BETWEEN doses of sucralfate, NOT WITHIN 30 minutes of sucralfate dose

Slide 119: The Mucosal Protectant Nursing Considerations ► Provide comfort measures if CNS effects occur ► Provide health teaching as to drug name, dosages and frequency, safety measures to handle common problems. ► Monitor patient response to the drug, the effectiveness of the teaching plan and the measures employed

Slide 120: The Mucosal Protectant Nursing Considerations ► Evaluate effectiveness of therapy Healing of ulcer No formation of ulcer

Slide 121: Prostaglandin analogue Misoprostol ► This agent is a synthetic prostaglandin E1 analog that is employed to protect the lining of the mucosa of the stomach

Slide 122: Prostaglandin analogue Misoprostol: Pharmacodynamics ► Being a prostaglandin analog, it inhibits gastric acid secretion to some degree ► It INCREASES mucus production in the stomach lining.

Slide 123: Prostaglandin analogue Misoprostol: Clinical use ► NSAIDs-induced gastric ulcers ► Duodenal ulcers unresponsive to H2 antagonists.

Slide 124: Prostaglandin analogue Precautions of Misoprostol Use ► This drug is CONTRAINDICATED during pregnancy because it is an abortifacient. ► Women should be advised to have a negative pregnancy test within 2 weeks of beginning therapy and should begin the drug on the second or third day of the next menstrual cycle. ► They should be instructed in the use of contraceptives during therapy.

Slide 125: Prostaglandin analogue Pharmacodynamic effects: drug reactions ► GIT= Nausea, diarrhea, abdominal pain, flatulence, vomiting, dyspepsia ► GU effects= miscarriages, excessive uterine CRAMPING and bleeding, spotting, hypermenorrhea and menstrual disorders.

Slide 126: Prostaglandin analogue Nursing Considerations ► Administer to patients at risk for NSAIDs-induced ulcers during the full course of NSAIDs therapy ► Administer four times daily with meals and at bedtime ► Obtain pregnancy test within 2 weeks of beginning therapy. Begin the therapy on second or third day of menstrual period to ensure that the woman is not pregnant

Slide 127: Prostaglandin analogue Nursing Considerations ► Provide patient with both written and oral information regarding the associated risks of pregnancy ► Provide health teaching as to drug name, dosages and frequency, safety measures to handle common problems. ► Monitor patient response to the drug, the effectiveness of the teaching plan and the measures to employ

Slide 129: Laxatives Type Prototype Action Chemical Bisacodyl (Dulcolax) Direct stimulation of the stimulants GIT nerves Irritant laxatives Mechanical (bulk) Lactulose Increased fluid content of stimulants the fecal material causing stimulation of the local reflex Lubricants Docusate Lubricating the intestinal material to promote passage through the GIT

Slide 130: Laxatives ► Generally used to INCREASE the passage of the colonic contents ► The general classifications is as follows: 1. Chemical stimulants 2. Mechanical stimulants 3. Lubricants

Slide 131: Therapeutic Indications of the Laxatives term relief of Constipation ► SHORT ► 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

Slide 132: Contraindications in Laxative use ► ACUTE abdominal disorders Appendicitis  Diverticulitis  Ulcerative colitis 

Slide 133: Chemical Stimulant Cathartics Prototype: Bisacodyl Irritant laxatives: ► 1. Castor oil ► 2. Senna ► 3. Cascara ► 4. Phenolphthalein

Slide 134: Chemical Stimulant Cathartics Pharmacodynamics ► These agents DIRECTLY stimulate the nerve plexus in the intestinal wall ► The result is INCREASED movement or motility of the colon

Slide 135: Mechanical Stimulant Cathartics ► Prototype: LACTULOSE (Cephulac) Bulk-forming laxatives ► 1. Magnesium (citrate, hydroxide, sulfate) ► 2. Psyllium ► 3. Polycarbophil

Slide 136: Mechanical Stimulant Cathartics Pharmacodynamics ► These agents are rapid-acting laxatives that INCREASE the GI motility by Increasing the fluids in the colonic material  Stimulating the local stretch receptors  Activating local defection reflex 

Slide 137: Lubricants ► Prototype: Docusate ► 1. Glycerin ► 2. Mineral oil

Slide 138: Lubricants Pharmacodynamics ► Docusate increases the admixture of fat and water producing a softer stool ► Glycerin ► Mineral oil forms a slippery coat on the colonic contents

Slide 139: Pharmacokinetics: Common Side-effects of the Laxatives ► Diarrhea ► Abdominal cramping ► Nausea ► Fluid and electrolyte imbalance ► Sympathetic reactions- sweating, palpitations, flushing and fainting ► CATHARTIC dependence

Slide 140: 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

Slide 141: The Nursing Process and Laxative NURSING DIAGNOSIS ► Alteration in bowel pattern ► Alteration in comfort: pain ► Knowledge deficit

Slide 142: The Nursing Process and Laxative IMPLEMENTATION 2. Emphasize that it is use on a SHORT term basis 3. Provide comfort and safety measures like ready access to the bathroom, side-rails 4. Administer with a full glass of water

Slide 143: The Nursing Process and Laxative IMPLEMENTATION 4. Encourage fluid intake, high fiber diet and daily exercise 5. DO NOT administer if acute abdominal condition like appendicitis is present 6. Advise to change position slowly an avoid hazardous activities because of potential dizziness

Slide 144: The Nursing Process and Laxative EVALUATION of drug effectiveness 2. Evaluate relief of GI symptoms, absence of staining and increased evacuation of GI tract 3. For Lactulose: decreased ammonia

Slide 145: The Anti-diarrheals ► These are agents used to calm the irritation of the GIT for the symptomatic relief of diarrhea ► General Classifications 1. Local anti-motility 2. Local reflex inhibition 3. Central action on the CNS

Slide 146: The Anti-diarrheals Type Prototype Action Local reflex inhibitor Bismuth subsalicylate Locally coats the lining of the GIT to soothe irritation that may stimulate the reflex Local anti-motility Loperamide Directly inhibits the intestinal muscle activity to SLOW peristalsis Central acting agent Opium derivatives Stops GIT spasm by (paregoric) CNS action

Slide 147: 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

Slide 148: Contraindications of anti-diarrheal Use ► Poisoning ► Drug allergy ► GI obstruction ► Acute abdominal conditions

Slide 149: Pharmacokinetics: Side effects ► Constipation ► Nausea,vomiting ► Abdominal distention and discomfort ► TOXIC MEGACOLON

Slide 150: Nursing process and anti-diarrheals ASSESSMENT ► Nursing History – Elicit history of drug allergy, conditions like poisoning, GI obstruction and acute abdominal conditions ► Physical Examination- Abdominal examination ► Laboratory test- electrolyte levels

Slide 151: Nursing process and anti-diarrheals NURSING DIAGNOSIS ► Alteration in bowel pattern ► Alteration in comfort: pain

Slide 152: Nursing process and anti-diarrheals IMPLEMENTATION 2. Monitor patient response within 48 hours. Discontinue drug use if no effect 3. Provide comfort measures for pain 4. Provide teaching

Slide 153: Nursing process and anti-diarrheals EVALUATION 2. Monitor effectiveness of drug- RELIEF of diarrhea 3. Monitor adverse effects, effectiveness of pain measures and effectiveness of teaching plan

Slide 154: Emetics and Anti-emetics Emetic Agent ► Syrup of Ipecac Anti-emetics ► 1. Phenothiazines ► 2. Non-phenothiazines ► 3. Anticholinergics/Antihistamines ► 4. Serotonin receptor Blockers ► 5. Miscellaneous

Slide 155: EMETIC ► Prototype: Ipecac Syrup

Slide 156: EMETIC Pharmacodynamics ► Ipecac syrup irritates the GI mucosa locally, resulting to stimulation of the vomiting center ► It acts within 20 minutes

Slide 157: EMETIC Clinical Use of ipecac ► To induce vomiting as a treatment for drug overdose and certain poisonings

Slide 158: EMETIC Contraindications of Ipecac use ► Ingestion of CORROSIVE chemicals ► Ingestion of petroleum products ► Unconscious and convulsing patient

Slide 159: EMETIC Pharmacokinetics: side effects of Ipecac ► Nausea ► Diarrhea ► GI upset ► Mild CNS depression ► CARDIOTOXICITY if large amounts are absorbed in the