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Nursing Pharmacology Prelim

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Information about Nursing Pharmacology Prelim

Published on February 8, 2008

Author: levouge777

Source: slideshare.net

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NURSING PHARMACOLOGY

I. Fundamentals of Pharmacology Pharmacology Study of the biological effects of chemicals. Drugs Chemicals that are introduced in the body to cause some sort of change. Pharmacokinetics Absorption, distribution, metabolism, and excretion of drug(s) in the body.

Pharmacology

Study of the biological effects of chemicals.

Drugs

Chemicals that are introduced in the body to cause some sort of change.

Pharmacokinetics

Absorption, distribution, metabolism, and

excretion of drug(s) in the body.

Pharmacotherapeutics The use of drugs to prevent or treat a disease. Pharmacodynamics The biochemical and physical effect of drug(s) and the mechanism of drug action.

Pharmacotherapeutics

The use of drugs to prevent or treat a disease.

Pharmacodynamics

The biochemical and physical effect of drug(s) and the mechanism of drug action.

pharmacokinetics pharmacotherapeutics pharmacodynamics pharmacology

Sources: Plants Earliest drug source (leaves, roots, bulbs, fruits, blossoms, extracts) Ex. Alkaloids – most active component in plants, reacts with acids to form a salt that easily dissolves in body fluids (caffeine, Nicotine, Atropine) Glycosides – naturally occurring plant active components that has both toxic and good effect (lanoxin, digoxin)

Plants

Earliest drug source (leaves, roots, bulbs, fruits, blossoms, extracts)

Ex. Alkaloids – most active component in plants, reacts with acids to form a salt that easily dissolves in body fluids (caffeine, Nicotine, Atropine)

Glycosides – naturally occurring plant active components that has both toxic and good effect (lanoxin, digoxin)



Resins – local irritants and caustic agents (laxatives) Oils – thick greasy liquids volatile:( peppermint, spearmint, juniper)/ fixed:( castor oil, olive oil) Animals Body fluids, glands of animals are also natural drug source Ex. Hormones – (insulin) Oils & Fats – (liver oils) Enzymes – catalyst produced by living cells (pepsin) Vaccines – suspension of killed, modified, or attenuated microorganism

Resins – local irritants and caustic agents (laxatives)

Oils – thick greasy liquids volatile:( peppermint, spearmint, juniper)/ fixed:( castor oil, olive oil)

Animals

Body fluids, glands of animals are also natural drug source

Ex. Hormones – (insulin)

Oils & Fats – (liver oils)

Enzymes – catalyst produced by living cells (pepsin)

Vaccines – suspension of killed, modified, or attenuated microorganism

Minerals Metallic and non metallic minerals that provides inorganic materials not available in plants or animals. Usually combined with other ingredients Ex. ( Fe S04, Mg SO4, ) Nursing Responsibilities Administer drug by using 10 R’s Assessing drug effects Intervening to make the drug treatment more tolerable Health teaching abt. The drug Monitoring overall px care plan to prevent medication error

Minerals

Metallic and non metallic minerals that provides inorganic materials not available in plants or animals.

Usually combined with other ingredients

Ex. ( Fe S04, Mg SO4, )

Nursing Responsibilities

Administer drug by using 10 R’s

Assessing drug effects

Intervening to make the drug treatment more tolerable

Health teaching abt. The drug

Monitoring overall px care plan to prevent medication error

Legal/Ethical Considerations Control of Drug Development, Evaluation {Pre clinical trials} {Phases of Drug studies I - IV} {Approval} {Continual Evaluation} Pregnancy Category {A – X} Production {Controlled Substance, Generic Drugs, Orphan Drugs,} Dispensing {OTC Drugs, Generic Drugs, DAW Drugs}

Control of Drug Development,

Evaluation {Pre clinical trials} {Phases of Drug studies I - IV} {Approval} {Continual Evaluation}

Pregnancy Category {A – X}

Production {Controlled Substance, Generic Drugs, Orphan Drugs,}

Dispensing {OTC Drugs, Generic Drugs, DAW Drugs}

R’s of Drug Administration Right drug and patient Right storage of drug Right route Right dosage Right preparation Right timing Right recording/ documentation Take complete px drug hx Know if px has any drug allergies Be aware of potential drug – drug or drug – food interactions Teach your px about the drug he is receiving

Right drug and patient

Right storage of drug

Right route

Right dosage

Right preparation

Right timing

Right recording/ documentation

Take complete px drug hx

Know if px has any drug allergies

Be aware of potential drug – drug or drug – food interactions

Teach your px about the drug he is receiving

Routes / Sites of Administration Enteral: Oral Solid Liquid Meds by NGT Enteral feedings Rectal Disposable Enemas

Enteral:

Oral

Solid

Liquid

Meds by NGT

Enteral feedings

Rectal

Disposable Enemas

Parenteral Intradermal Subcutaneous Intramuscular Intravenous Percutaneous Topical Creams, lotion, ointments Patch testing for allergies NTG (Transdermal) Medication to Mucus membranes Topical powder

Parenteral

Intradermal

Subcutaneous

Intramuscular

Intravenous

Percutaneous

Topical

Creams, lotion, ointments

Patch testing for allergies

NTG (Transdermal)

Medication to Mucus membranes

Topical powder

PHARMACODYNAMICS - how the drug affects the body DRUG ACTIONS: To replace or acts as a substitute for missing chemicals. Increase or stimulate certain cellular activities. To decrease or slow cellular activities. To interfere with the functioning of foreign cells such as invading microorganism or neoplasm

PHARMACODYNAMICS - how the drug affects the body

DRUG ACTIONS:

To replace or acts as a substitute for missing chemicals.

Increase or stimulate certain cellular activities.

To decrease or slow cellular activities.

To interfere with the functioning of foreign cells such as invading microorganism or neoplasm

Receptor Sites – specified areas in the cell that allows certain chemicals to cause an effect in the cell AGONIST – direct interaction of drug that causes same activity (Ex. Insulin-Insulin Receptor) ANTAGONIST – has an affinity for a receptor but displays no intrinsic activity Prevents a response from occurring

Receptor Sites – specified areas in the cell that allows certain chemicals to cause an effect in the cell

AGONIST – direct interaction of drug that causes same activity (Ex. Insulin-Insulin Receptor)

ANTAGONIST – has an affinity for a receptor but displays no intrinsic activity

Prevents a response from occurring

COMPETITIVE ANTAGONIST - competes c agonist for receptor sites Ex. (Curare vs. acethylcholine receptor sites) NON COMPETITIVE – binds to receptor sites & blocks the effect of the agonist (protects / prevent another antagonist from entering) DRUG ENZYME INTERACTIONS – drug effects by interfering c enzyme system that acts as a CATALYST for various chemical reactions blocks the cascade effect of enzyme SELECTIVE TOXICITY – choosy? Ex. (penicillin attacks enzyme system unique to bacterial cell death) NON SELECTIVE TOXICITY – not so choosy? Ex. (chemotherapeutic drugs destroying normal & neoplastic cells)

COMPETITIVE ANTAGONIST - competes c agonist for receptor sites Ex. (Curare vs. acethylcholine receptor sites)

NON COMPETITIVE – binds to receptor sites & blocks the effect of the agonist (protects / prevent another antagonist from entering)

DRUG ENZYME INTERACTIONS – drug effects by interfering c enzyme system that acts as a CATALYST for various chemical reactions

blocks the cascade effect of enzyme

SELECTIVE TOXICITY – choosy? Ex. (penicillin attacks enzyme system unique to bacterial cell death)

NON SELECTIVE TOXICITY – not so choosy? Ex. (chemotherapeutic drugs destroying normal & neoplastic cells)

PHARMACOKINETICS – how the body acts on the drug CRITICAL CONCENTRATION – sufficient / high concentration of the administered drug working at the (molecular level ) reactive tissues DOSAGE – based on the amount that must be given to eventually reach the critical concentration LOADING DOSE – usually drugs that are needed to take effect quickly Ex. (Aminophylline, Lanoxin) DYNAMIC EQUILIBRIUM – actual concentration that a drug reaches the body FACTORS: ABSORPTION FROM THE SITE OF ENTRY DISTRIBUTION ON THE ACTIVE SITE BIOTRANSFORMATION IN THE LIVER EXCRETION FROM THE BODY

PHARMACOKINETICS – how the body acts on the drug

CRITICAL CONCENTRATION – sufficient / high concentration of the administered drug working at the (molecular level ) reactive tissues

DOSAGE – based on the amount that must be given to eventually reach the critical concentration

LOADING DOSE – usually drugs that are needed to take effect quickly Ex. (Aminophylline, Lanoxin)

DYNAMIC EQUILIBRIUM – actual concentration that a drug reaches the body

FACTORS:

ABSORPTION FROM THE SITE OF ENTRY

DISTRIBUTION ON THE ACTIVE SITE

BIOTRANSFORMATION IN THE LIVER

EXCRETION FROM THE BODY

ABSORPTION- what happens to a drug from the time it is introduced to the body until it reaches the circulating fluids and tissues. Areas of Absorption: GI, Orally, Rectally, Skin, Mucus Membranes, Lungs, Muscles, Subcutaneous How Drugs are absorbed: ☺ Passive Diffusion- Major process of absorption - when there is ↑concentration in one side, drug molecules moves towards the area of ↓concentration

ABSORPTION- what happens to a drug from the time it is introduced to the body until it reaches the circulating fluids and tissues.

Areas of Absorption:

GI, Orally, Rectally, Skin, Mucus Membranes, Lungs, Muscles, Subcutaneous

How Drugs are absorbed:

☺ Passive Diffusion- Major process of absorption

- when there is ↑concentration in one side, drug molecules moves towards the area of ↓concentration

- movement towards the other side is faster if the molecules are smaller, soluble in water and lipid - no electrical charge that could repel it from the cell membrane Effortless process, passive process. Most common in oral form of medication. ☻ Active Transport – uses energy to actively move a molecule across a cell membrane - Molecule moves from an area of ↓ concentration to area of ↑concentration (usu. electrolytes)

- movement towards the other side is faster if the molecules are smaller, soluble in water and lipid

- no electrical charge that could repel it from the cell membrane

Effortless process, passive process.

Most common in oral form of medication.

☻ Active Transport – uses energy to actively move a molecule across a cell membrane

- Molecule moves from an area of ↓ concentration to area of ↑concentration (usu. electrolytes)

☻ ADMINISTRATION & ABSORPTION ☺ Ж ORAL – most common, non invasive, practical & viable easily broken down by the gastric juices affected by presence or absence of food in the stomach Ideal timing for administration ( ? ) Ψ INTRAVENOUS – drugs that cannot survive in enough quantity hen given orally - Reaches their full strength @ the time of injection More like ly to cause toxic effect (↑ margin for error ) Ω INTRAMUSCULAR – absorbed directly in the capillaries in the muscles & sent into circulation (1-5cc) (site of giving?) - Takes effect faster in men than in women ( Tº? )

☻ ADMINISTRATION & ABSORPTION ☺

Ж ORAL – most common, non invasive, practical & viable

easily broken down by the gastric juices

affected by presence or absence of food in the stomach

Ideal timing for administration ( ? )

Ψ INTRAVENOUS – drugs that cannot survive in enough quantity hen given orally

- Reaches their full strength @ the time of injection

More like ly to cause toxic effect (↑ margin for error )

Ω INTRAMUSCULAR – absorbed directly in the capillaries in the muscles & sent into circulation (1-5cc) (site of giving?)

- Takes effect faster in men than in women ( Tº? )

Ф SUBCUTANEOUS –small amt(0.5 – 1cc)usually in the upper arm, abdomen, thigh - drugs move rapidly in vessels than in oral ß RECTAL / VAGINAL – absorbed by the perfusion of local blood flow in the rectum/ vagina - treatment of local irritation or infection Ξ RESPIRATORY – available in all forms that targets the lungs - mostly in gas or inhalation form or mist - (ET route?) ₤ BUCCAL/SUB LINGUAL & TRANSLINGUAL – common route for certain cases of emergency - drugs prevent destruction/transformation in the GI

Ф SUBCUTANEOUS –small amt(0.5 – 1cc)usually in the upper arm, abdomen, thigh

- drugs move rapidly in vessels than in oral

ß RECTAL / VAGINAL – absorbed by the perfusion of local blood flow in the rectum/ vagina

- treatment of local irritation or infection

Ξ RESPIRATORY – available in all forms that targets the lungs

- mostly in gas or inhalation form or mist

- (ET route?)

₤ BUCCAL/SUB LINGUAL & TRANSLINGUAL – common route for certain cases of emergency

- drugs prevent destruction/transformation in the GI

 TOPICAL – superficial or external use only - used for dermatologic, ophthalmic, otic and nasal preparation ♣ SPECIAL AREAS / INFUSIONS – given to a specific area of the body Epidural – injected in epidural space Intrapleural – injected in the pleural cavity Intraperitoneal – injected in the peritoneal cavity Intraosseus – injected in the rich vascular bone network(long bone) Intra-articular – injected into a joint

 TOPICAL – superficial or external use only

- used for dermatologic, ophthalmic, otic and nasal preparation

♣ SPECIAL AREAS / INFUSIONS – given to a specific area of the body

Epidural – injected in epidural space

Intrapleural – injected in the pleural cavity

Intraperitoneal – injected in the peritoneal cavity

Intraosseus – injected in the rich vascular bone network(long bone)

Intra-articular – injected into a joint

FIRST PASS EFFECT – liver synthesizes and breakdown much of the component thereby needing a ↑ dose to have a desired effect - ◙ drug -> stomach -> small intestine -> portal venous system (liver)-> heart(® side) -> heart (left side)-> systemic circulation-> area (affected) in need of drug ☼ THINGS to consider in first pass effect Px diet / food preference Drug preparation / formulations Liver affectation

FIRST PASS EFFECT – liver synthesizes and breakdown much of the component thereby needing a ↑ dose to have a desired effect

- ◙ drug -> stomach -> small intestine -> portal venous system (liver)-> heart(® side) -> heart (left side)-> systemic circulation-> area (affected) in need of

drug ☼

THINGS to consider in first pass effect

Px diet / food preference

Drug preparation / formulations

Liver affectation

DISTRIBUTION – movement of the drugs that survived the first pass effect thru the body tissues FACTORS: BLOOD FLOW - ↑ blood flow ↑distribution & absorption SOLLUBILITY – fat soluble (easily crosses cell membrane, can cross BBB CNS) or H²O soluble BINDING – drugs bind c plasma protein (albumin) FREE / UNBOUNDED – exerts effectiveness, excreted quickly BOUNDED – slow release, long duration of action, hard to dispose

DISTRIBUTION – movement of the drugs that survived the first pass effect thru the body tissues

FACTORS:

BLOOD FLOW - ↑ blood flow ↑distribution & absorption

SOLLUBILITY – fat soluble (easily crosses cell membrane, can cross BBB CNS) or H²O soluble

BINDING – drugs bind c plasma protein (albumin)

FREE / UNBOUNDED – exerts effectiveness, excreted quickly

BOUNDED – slow release, long duration of action, hard to dispose

METABOLISM / BIOTRANSFORMATION – Conversion of drugs by the ◙ LIVER☼ thru the use of bodily system, enzymes Ability of the body to change a drug from its dosage form to a more water soluble form ► EXCRETION – Elimination of drugs from the body (kidneys, lungs, skin, salivary, mammary glands, GI tract) ♥ ½ LIFE♦ - The time it takes for the amt. of drug in the body to ↓ to ½ of the peak level it previously achieved - time it takes for ½ of the drug to be excreted by the body

METABOLISM / BIOTRANSFORMATION – Conversion of drugs by the ◙ LIVER☼ thru the use of bodily system, enzymes

Ability of the body to change a drug from its dosage form to a more water soluble form

► EXCRETION – Elimination of drugs from the body (kidneys, lungs, skin, salivary, mammary glands, GI tract)

♥ ½ LIFE♦ - The time it takes for the amt. of drug in the body to ↓ to ½ of the peak level it previously achieved

- time it takes for ½ of the drug to be excreted by the body

Factors: Rate of absorption Metabolism Appropriate dose Excretion Variables Influencing Drug Action Age Gender Weight Physiological Pathological CV Liver / Kidney dse. Genetic Psychological Environmental

Factors:

Rate of absorption

Metabolism

Appropriate dose

Excretion

Variables Influencing Drug Action

Age

Gender

Weight

Physiological

Pathological

CV

Liver / Kidney dse.

Genetic

Psychological

Environmental

TOLERANCE - ↑ Resistance to a drug effect 2° to ↑ biotransformation of drug components. DEPENDENCE – may come about if px manifest withdrawal S/Sx when drug is stopped. DRUG – DRUG INTERACTION SITUATIONS: At the site of absorption (tetracycline vs. Ca & Ca products*) During distribution (ASA* vs. methotrexate) During metabolism (coumadin* vs. anti tb) During excretion (Lanoxin vs. Quinidine*) At the site of action (Anti HPN vs. AH’s*)

TOLERANCE - ↑ Resistance to a drug effect 2° to ↑ biotransformation of drug components.

DEPENDENCE – may come about if px manifest withdrawal S/Sx when drug is stopped.

DRUG – DRUG INTERACTION

SITUATIONS:

At the site of absorption (tetracycline vs. Ca & Ca products*)

During distribution (ASA* vs. methotrexate)

During metabolism (coumadin* vs. anti tb)

During excretion (Lanoxin vs. Quinidine*)

At the site of action (Anti HPN vs. AH’s*)

DRUG TO FOOD INTERACTIONS : SOME FOODS AFFECTS DRUG FUNCTION AND EFFICIENCY TETRACYCLINES vs. Fe / Ca DRUG TO LAB TEST : GIVING DRUGS PRIOR TO A LAB TEST CAN ALTER THE RESULT ATB prior to sputum/ wound GS/ CS Anti DVT (Fragmin) alters (↑) liver fxn test exams

DRUG TO FOOD INTERACTIONS : SOME FOODS AFFECTS DRUG FUNCTION AND EFFICIENCY

TETRACYCLINES vs. Fe / Ca

DRUG TO LAB TEST : GIVING DRUGS PRIOR TO A LAB TEST CAN ALTER THE RESULT

ATB prior to sputum/ wound GS/ CS

Anti DVT (Fragmin) alters (↑) liver fxn test exams

PHARMACOTHERAPEUTICS – USE OF DRUG TO TREAT/ CURE A DISEASE ACUTE – CRITICALLY ILL Px THAT REQUIRES INTENSIVE THERAPY Ex.(Thrombolytics for AMI px) EMPERICAL – BASE ON PRACTICAL EXPERINCE RATHER THAN SCIENTIFIC DATA Ex.( EMPERIC ATB prior to GS / CS) SUPPLEMENTAL – REPLENISH / SUBSTITUTE FOR MISSING SUBSTANCE IN THE BODY Ex. (Ca for Osteoporotic px. Vit. B complex for DM px) SUPPORTIVE – DOES NOT TREAT THE CAUSE OF THE DISEASE BUT MAINTAINS OTHER BODY SYSTEMS INTEGRITY UNTIL Px CONDITION IMPROVES Ex. ( O² in a PTB px) PALLIATIVE – FOR END STAGE / TERMINAL Dse. PROMOTION OF COMFORT IS TOP PRIORITY Ex. (Bone CA px having continous M SO4 drip)

PHARMACOTHERAPEUTICS – USE OF DRUG TO TREAT/ CURE A DISEASE

ACUTE – CRITICALLY ILL Px THAT REQUIRES INTENSIVE THERAPY Ex.(Thrombolytics for AMI px)

EMPERICAL – BASE ON PRACTICAL EXPERINCE RATHER THAN SCIENTIFIC DATA Ex.( EMPERIC ATB prior to GS / CS)

SUPPLEMENTAL – REPLENISH / SUBSTITUTE FOR MISSING SUBSTANCE IN THE BODY Ex. (Ca for Osteoporotic px. Vit. B complex for DM px)

SUPPORTIVE – DOES NOT TREAT THE CAUSE OF THE DISEASE BUT MAINTAINS OTHER BODY SYSTEMS INTEGRITY UNTIL Px CONDITION IMPROVES Ex. ( O² in a PTB px)

PALLIATIVE – FOR END STAGE / TERMINAL Dse. PROMOTION OF COMFORT IS TOP PRIORITY Ex. (Bone CA px having continous M SO4 drip)

ADVERSE EFFECTS – HARMFUL / UNDESIRABLE EFFECTS THAN HAT HAS BEEN EXPECTED OF A DRUG KINDS: DOSE RELATED ? Px RELATED ? DRUG ACTIONS: Primary – can be caused by simple overdose Ex. (overdose of blood thinners can lead to profuse bleeding) Secondary – good or bad effect Ex. (AH’s can promote sleeping but what if the px will drive a vehicle) Hypersensitivity - ↑ response to 1° / 2° drug actions that can lead to a pathological condition

ADVERSE EFFECTS – HARMFUL / UNDESIRABLE EFFECTS THAN HAT HAS BEEN EXPECTED OF A DRUG

KINDS:

DOSE RELATED ?

Px RELATED ?

DRUG ACTIONS:

Primary – can be caused by simple overdose Ex. (overdose of blood thinners can lead to profuse bleeding)

Secondary – good or bad effect Ex. (AH’s can promote sleeping but what if the px will drive a vehicle)

Hypersensitivity - ↑ response to 1° / 2° drug actions that can lead to a pathological condition

DRUG ALLERGY – Occurs when the body forms an antibodies to a particular drug causing an immune response upon re- exposure TYPES ANAPHYLACTIC – CYTOTOXIC SERUM SICKNESS DELAYED RESPONSE IDIOSYNCRATIC EFFECT – Non pharma related but can be genetic in origin IATROGENIC EFFECT – Adverse drug reaction that tends to mimic a pathology Ex. (ASA cause GI irritation that mimics PUD)

DRUG ALLERGY – Occurs when the body forms an antibodies to a particular drug causing an immune response upon re- exposure

TYPES

ANAPHYLACTIC –

CYTOTOXIC

SERUM SICKNESS

DELAYED RESPONSE

IDIOSYNCRATIC EFFECT – Non pharma related but can be genetic in origin

IATROGENIC EFFECT – Adverse drug reaction that tends to mimic a pathology Ex. (ASA cause GI irritation that mimics PUD)

Nursing process Asssessment Nursing Dx Planning Intervention Evaluation

DERMATOLOGICAL RASH / HIVES - Assessment: color, turgor, pattern & other pertinent data Intervention: frequent skin care, avoid friction, rubbing, and tight clothing, hydration STOMATITIS – Assessment: observe for gingivitis, glositis, odinophagia, halitosis Intervention: frequent, proper oral care a non irritating solution, evaluate diet tolerance SUPER INFECTION – Assessment: S/Sx on infection(fever, diarrhea, itching, redness, pain, warmth, discharge Intervention: proper body hygiene (bathing, hand washing etc.,) DC causative meds. BLOOD DYSCRASIA – Assessment: fever, chills, ↓Hct /Hgb (Anemia), ↓Platelet count (thrombocytopenia), ↓ WBC (leukopenia), ↓CBC (pancytopenia) Intervention: supportive tx, prevent injury, monitor all lab exam / result

DERMATOLOGICAL

RASH / HIVES - Assessment: color, turgor, pattern & other pertinent data Intervention: frequent skin care, avoid friction, rubbing, and tight clothing, hydration

STOMATITIS – Assessment: observe for gingivitis, glositis, odinophagia, halitosis Intervention: frequent, proper oral care a non irritating solution, evaluate diet tolerance

SUPER INFECTION – Assessment: S/Sx on infection(fever, diarrhea, itching, redness, pain, warmth, discharge Intervention: proper body hygiene (bathing, hand washing etc.,) DC causative meds.

BLOOD DYSCRASIA – Assessment: fever, chills, ↓Hct /Hgb (Anemia), ↓Platelet count (thrombocytopenia), ↓ WBC (leukopenia), ↓CBC (pancytopenia) Intervention: supportive tx, prevent injury, monitor all lab exam / result

TOXICITY LIVER TOXICITY – Assessment: fever, malaise, N & V, jaundice, stool change, altered LOC, ↑ liver enzyme lab results Intervention: hygiene, frequent rest periods, DC causative drugs, monitor for bleeding and altered LOC. RENAL TOXICITY – Assessment: URINE (color, character, amount) monitor BUN, CREA level, edema Intervention: Strict / accurate I & O ( q 1 – q shift – q 24°), DC causative meds  (gentamycin, ampothericin B) POISONING – Occurs hen an overdose of drugs affects multiple body systems c possible or potential fatal reactions.

TOXICITY

LIVER TOXICITY – Assessment: fever, malaise, N & V, jaundice, stool change, altered LOC, ↑ liver enzyme lab results Intervention: hygiene, frequent rest periods, DC causative drugs, monitor for bleeding and altered LOC.

RENAL TOXICITY – Assessment: URINE (color, character, amount) monitor BUN, CREA level, edema Intervention: Strict / accurate I & O ( q 1 – q shift – q 24°), DC causative meds  (gentamycin, ampothericin B)

POISONING – Occurs hen an overdose of drugs affects multiple body systems c possible or potential fatal reactions.

ALTERATIONS IN GLUCOSE METABOLISM Hypoglycemia- OHA, Insulin Assessment: S/Sx: fatigue, drowsiness, hunger, , anxiety, headache, cold clammy skin, shaking and lack of coordination, ↑HR, ↑BP, numbness and tingling of mouth, tongue and lips, confusion, rapid shallow respiration, seizure and coma Interventions: Give hyperglycemic agents IV or Oral to prevent injury and falls

ALTERATIONS IN GLUCOSE METABOLISM

Hypoglycemia- OHA, Insulin

Assessment: S/Sx: fatigue, drowsiness, hunger, , anxiety, headache, cold clammy skin, shaking and lack of coordination, ↑HR, ↑BP, numbness and tingling of mouth, tongue and lips, confusion, rapid shallow respiration, seizure and coma

Interventions: Give hyperglycemic agents IV or Oral to prevent injury and falls

Hyperglycemia: Ex. (Ephedrine- bronchodilator/ Anti asthma that relieves nasal congestion causes ↑glucogenolysis Assessment: fatigue, polyuria, ↑thirst (polydipsia), deep respirations (kausmauls), restlessness, polyphagia, nausea, dry flushed skin, fruity odor breath Intervention: Insulin, OHA

Hyperglycemia: Ex. (Ephedrine- bronchodilator/ Anti asthma that relieves nasal congestion causes ↑glucogenolysis

Assessment: fatigue, polyuria, ↑thirst (polydipsia), deep respirations (kausmauls), restlessness, polyphagia, nausea, dry flushed skin, fruity odor breath

Intervention: Insulin, OHA

ELECTROLYTE IMBALANCE Hypokalemia- drug affects kidneys can cause ↓ K level in serum by altering renal exchange system (proximal tubules) Assessment: weakness, numbness, muscles cramps, nausea and vomiting, ↓bowel sounds, Hypokalemic paralysis Interventions: K rich diet (unless CIx, K supplements prevent injury or falls)

Hypokalemia- drug affects kidneys can cause ↓ K level in serum by altering renal exchange system (proximal tubules)

Assessment: weakness, numbness, muscles cramps, nausea and vomiting, ↓bowel sounds, Hypokalemic paralysis

Interventions: K rich diet (unless CIx, K supplements prevent injury or falls)

HYPERKALEMIA - ↑K supplements, ↑K sparing diuretics, ↑K rich diets in renal problems Assessment: weakness, DOB, bradycardia, Ms cramps, Numbness Intervention: Monitor px status (CV,LOC, Homeostasis) diet modification, K wasting drug regimens / protocols, monitor lab exams.

HYPERKALEMIA - ↑K supplements, ↑K sparing diuretics, ↑K rich diets in renal problems

Assessment: weakness, DOB, bradycardia, Ms cramps, Numbness

Intervention: Monitor px status (CV,LOC, Homeostasis) diet modification, K wasting drug regimens / protocols, monitor lab exams.

SENSORY EFFECTS OCCULAR TOXICITY – Tiny blood vessels in the retina “END ARTERIES” are affected, occluded by some drugs Ex. ( Chloroquine) Aralen causes inflamation, retinal damage, blindness ASSESSMENT: observe for visual acquity, color or vision changes, corneal, retinal affectation INTERVENTION: supportive tx, prevent injury, optic care – hygiene, proper drug administration

SENSORY EFFECTS

OCCULAR TOXICITY – Tiny blood vessels in the retina “END ARTERIES” are affected, occluded by some drugs Ex. ( Chloroquine) Aralen causes inflamation, retinal damage, blindness

ASSESSMENT: observe for visual acquity, color or vision changes, corneal, retinal affectation

INTERVENTION: supportive tx, prevent injury, optic care – hygiene, proper drug administration

AUDITORY TOXICITY : Tiny vessels & nerves can be affected by some drug hearing affectation / disturbance Ex. (ASA can cause tinnitus or aural fullness hen given in excessive doses) ASSESSMENT: hearing acquity, Rine’s test, Rombergs test, INTERVENTION: Prevent injury, monitor for perceptual losses, symptomatic drug treatment, (speak in medium tone firm voice)

AUDITORY TOXICITY : Tiny vessels & nerves can be affected by some drug hearing affectation / disturbance Ex. (ASA can cause tinnitus or aural fullness hen given in excessive doses)

ASSESSMENT: hearing acquity, Rine’s test, Rombergs test,

INTERVENTION: Prevent injury, monitor for perceptual losses, symptomatic drug treatment, (speak in medium tone firm voice)

Nursing process Eval Intervention/ Implementation Planning Nsg Dx Assessment

Common household measurements: 1quart= 4 cups 1pint = 2 cups 1cup= 8 ounces 1tbsp= 3tsp: 15 – 16 ml 1tsp = 60ugtts: 4-5ml Apothecary Measurements: 60minims = 1fluidram 8fluidram=1fl oz; 480minims 16 fl oz =1 pint 2pints=1quart 4quarts = 1gallon

Common household measurements:

1quart= 4 cups 1pint = 2 cups

1cup= 8 ounces 1tbsp= 3tsp: 15 – 16 ml

1tsp = 60ugtts: 4-5ml

Apothecary Measurements:

60minims = 1fluidram 8fluidram=1fl oz; 480minims 16 fl oz =1 pint 2pints=1quart

4quarts = 1gallon

Metric measurements: Units of length (meter) 1mm = .001m 1cm = .01m 1hectometer = 100 meters Units of volume (liter) 1ml = .001L 1decaliter = 10 Liters Units of wt (gram) 1ug/mcg = .00001gm 1mg = .001gm 1cg = .01gm 1dg = .1gm 1dg = .1gm 1kg = 1,000grams

Metric measurements:

Units of length (meter)

1mm = .001m 1cm = .01m

1hectometer = 100 meters

Units of volume (liter)

1ml = .001L 1decaliter = 10 Liters

Units of wt (gram)

1ug/mcg = .00001gm 1mg = .001gm

1cg = .01gm 1dg = .1gm

1dg = .1gm 1kg = 1,000grams

Other unit equivalents 1gm = 15 gr. 1gr. = 60mg 1mg = 1oooug 1ml =1cc;15gtts;60ugtts;1gram 1L = 1qt;1000ml 1gal = 4L; 4qt; 4000cc 1oz = 30gm;30cc 1kg = 2.2lbs 1lb = 16 oz

Other unit equivalents

1gm = 15 gr. 1gr. = 60mg

1mg = 1oooug

1ml =1cc;15gtts;60ugtts;1gram

1L = 1qt;1000ml

1gal = 4L; 4qt; 4000cc

1oz = 30gm;30cc

1kg = 2.2lbs

1lb = 16 oz

Drug computations Formulas: VOL. OF DRUG TO BE GIVEN: Q= Desired dose (mg) X vol of stock preparation(cc) Stock dose Ex: give 1000mg sulperazone iv q8 stock dose is 1500mg dillute it in 10cc Solution:1000mg/ 1.5mg x 10cc = 6.67cc iv q 8 Ex: dormicum 7.5 mg was ordered for a px having difficulty to sleep stock dose of dormicum is 15mg/tab. How many tablet will you give? What time will you give the drug? Ex: glucophage tab 750mg od was started for a diabetic px. Stock dose is 500mg /tab. Ho many will you give? Nursing considerations?

Drug computations

Formulas:

VOL. OF DRUG TO BE GIVEN:

Q= Desired dose (mg) X vol of stock preparation(cc)

Stock dose

Ex: give 1000mg sulperazone iv q8 stock dose is 1500mg dillute it in 10cc

Solution:1000mg/ 1.5mg x 10cc = 6.67cc iv q 8

Ex: dormicum 7.5 mg was ordered for a px having difficulty to sleep stock dose of dormicum is 15mg/tab. How many tablet will you give?

What time will you give the drug?

Ex: glucophage tab 750mg od was started for a diabetic px. Stock dose is 500mg /tab. Ho many will you give? Nursing considerations?

IV FLUID RATE: Macrodrops per minute(gtts/min) = total IVF vol(cc) x 15gtts/cc #hrs(infusion time) x 60min/hr Ex hook D5Lr 1L x 8 hrs, 16 hrs, 4 hrs. Solution: 1000cc x 15 gtts /cc 8 hrs x 60 min/ hr =15000 gtts / cc 480 min/hr =31.25cc/min

IV FLUID RATE:

Macrodrops per minute(gtts/min)

= total IVF vol(cc) x 15gtts/cc #hrs(infusion time) x 60min/hr

Ex hook D5Lr 1L x 8 hrs, 16 hrs, 4 hrs.

Solution: 1000cc x 15 gtts /cc

8 hrs x 60 min/ hr

=15000 gtts / cc

480 min/hr

=31.25cc/min

cc / hour Volume of iv fluid = cc/ hr # hours to be infuse Ex: start Pnss 1Liter x 8 hours for a DM patient 1000cc = 125cc/ hr 8 hour

cc / hour

Volume of iv fluid = cc/ hr

# hours to be infuse

Ex: start Pnss 1Liter x 8 hours for a DM patient

1000cc = 125cc/ hr

8 hour

Conversion (annex) Conversion of T° °C to ° F = (° C x 1.8) + 32 = °F °F to ° C = (°F - 32) (.55) =°C Ex. px has 39.5°c during admission.using the formula, convert it to °F (39.5C x 1.8) + 32 = 103.°F Ex.3y/o child has dengue,100.3 °F convert it to °C using the formula (100.3°F - 32) (.55) = 37.5°C

Conversion (annex)

Conversion of T°

°C to ° F = (° C x 1.8) + 32 = °F

°F to ° C = (°F - 32) (.55) =°C

Ex. px has 39.5°c during admission.using the formula, convert it to °F

(39.5C x 1.8) + 32 = 103.°F

Ex.3y/o child has dengue,100.3 °F convert it to °C using the formula

(100.3°F - 32) (.55) = 37.5°C

Computation (annex) pediatric doses Frieds’s rule: for a child less than 1y/old childs dose(age ≤1y/o)= infants age(in mos.) 150 mos. x ave. adult dose Young’s rule: children 1-12 y/o childs dose (age1-12 y/o) = childs age (in yrs.) child’s age (in yrs.) +12 x ave. adult dose Clark’s rule : wt. in lbs x usual adult dose = safe child’s dose 150 lbs

Computation (annex) pediatric doses

Frieds’s rule: for a child less than 1y/old

childs dose(age ≤1y/o)= infants age(in mos.)

150 mos.

x ave. adult dose

Young’s rule: children 1-12 y/o

childs dose (age1-12 y/o) = childs age (in yrs.)

child’s age (in yrs.) +12

x ave. adult dose

Clark’s rule :

wt. in lbs x usual adult dose = safe child’s dose

150 lbs

NERVOUS SYSTEM - operates through the use of electrical impulse and chemical messengers to transmit information throughout the body and to respond into internal & external stimuli. CENTRAL NERVOUS SYSTEM AUTONOMIC NERVOUS SYTEM PERIPHERAL NERVOUS SYSYTEM NEURONS – basic functional unit of the nervous system, about 14 billion are located in the brain the rest in the SC, PNS . PARTS: DENDRITE – Short, branchlike projections that conveys information from one neuron towards another neuron . CELL BODY ( SOMA ) – largest part of the neuron AXON - Elongated, carries information away from the neuron . EFFECTOR CELLS – Receives the signal sent by the axon(cells, muscles, glands, or another nerve) AFFERENT FIBERS - Nerve axons that run from PNS to CNS EFFERENT FIBERS - Nerve axons that carry impulse from the CNS to Periphery

NERVOUS SYSTEM - operates through the use of electrical impulse and chemical messengers to transmit information throughout the body and to respond into internal & external stimuli.

CENTRAL NERVOUS SYSTEM

AUTONOMIC NERVOUS SYTEM

PERIPHERAL NERVOUS SYSYTEM

NEURONS – basic functional unit of the nervous system, about 14 billion are located in the brain the rest in the SC, PNS .

PARTS:

DENDRITE – Short, branchlike projections that conveys information from one neuron towards another neuron .

CELL BODY ( SOMA ) – largest part of the neuron

AXON - Elongated, carries information away from the neuron .

EFFECTOR CELLS – Receives the signal sent by the axon(cells, muscles, glands, or another nerve)

AFFERENT FIBERS - Nerve axons that run from PNS to CNS

EFFERENT FIBERS - Nerve axons that carry impulse from the CNS to Periphery

Action potential – Electrical impulse sent by the nerves ☻ cell membranes & nerve membranes have pores or channels that controls the movement of a substance in & out of the cell ☻ some of these channels allows entry & exit of Na, K, Ca ☻ when cells are at rest, membranes are impermeable to Na but permeable to K Depolarization – Na channels open in response to the stimulus Na ions rush inside the cell (positive rush of Ion ) ☻a nerve cannot be stimulated again during depolarized stage☻ Repolarization - return of the cellular environment to the resting membrane potential ☻stage of responding / balance bet. Na & K occurs ☻ Resting membrane potential- negative environment inside the cell

Action potential – Electrical impulse sent by the nerves

☻ cell membranes & nerve membranes have pores or channels that controls the movement of a substance in & out of the cell

☻ some of these channels allows entry & exit of Na, K, Ca

☻ when cells are at rest, membranes are impermeable to Na but permeable to K

Depolarization – Na channels open in response to the stimulus Na ions rush inside the cell (positive rush of Ion ) ☻a nerve cannot be stimulated again during depolarized stage☻

Repolarization - return of the cellular environment to the resting membrane potential ☻stage of responding / balance bet. Na & K occurs ☻

Resting membrane potential- negative environment inside the cell

NERVE SYNAPSE – Where the communication bet.2 nerve occurs thru the release of a Neurotransmitter NEUROTRANSMITTER - chemical that stimulates the receptor sites by exciting or inhibiting them ☻ may either be reabsorbed (reuptake) or broken down by the enzymes in the area Ex. (MAO breaks down the neurotransmitter Epinephrine) (Acetylcholinesterase breaks don the neurotransmitter acethylcholine)☻ SELECTED NEUROTRANSMITTER Acetylcholine – communicates in the Ms & N, neurotransmitter in the ANS & Parasympathetic Norepi / Epi – classified as catecholamines eurotransmitter released by the sympathetic branch of the ANS, released as a hormone by the adrenal medulla Dopamine – found in ↑ amts. In the brain for coordination of impulse & responses both motor & intellectual. heart ?

NERVE SYNAPSE – Where the communication bet.2 nerve occurs thru the release of a Neurotransmitter

NEUROTRANSMITTER - chemical that stimulates the receptor sites by exciting or inhibiting them

☻ may either be reabsorbed (reuptake) or broken down by the enzymes in the area Ex. (MAO breaks down the neurotransmitter Epinephrine) (Acetylcholinesterase breaks don the neurotransmitter acethylcholine)☻

SELECTED NEUROTRANSMITTER

Acetylcholine – communicates in the Ms & N, neurotransmitter in the ANS & Parasympathetic

Norepi / Epi – classified as catecholamines eurotransmitter released by the sympathetic branch of the ANS, released as a hormone by the adrenal medulla

Dopamine – found in ↑ amts. In the brain for coordination of impulse & responses both motor & intellectual. heart ?

Gamma amino butyric acid (GABA) – found in the brain, inhibits or stimulation nerve activity & important in preventing overexcitability or stimulation such as seizure activity Serotonin – found in the limbic system, important for the in arousal and sleep, prevention of depression and motivation promotion Ω limbic system – area of the brain that contains ↑ amounts of neurotransmitters ( epi / norepi / serotonin) if responsible for the expressions of emotions ( anger, pleasure, motivation, how a person learns & react to stimuli) Ω

Gamma amino butyric acid (GABA) – found in the brain, inhibits or stimulation nerve activity & important in preventing overexcitability or stimulation such as seizure activity

Serotonin – found in the limbic system, important for the in arousal and sleep, prevention of depression and motivation promotion

Ω limbic system – area of the brain that contains ↑ amounts of neurotransmitters ( epi / norepi / serotonin) if responsible for the expressions of emotions ( anger, pleasure, motivation, how a person learns & react to stimuli) Ω

ANXIOLYTICS & HYPNOTIC AGENTS ANXIOLYTICS – D rugs that alter ‘s the individual’s response to the environment, prevents feelings of tension or fear ANXIETY - a feeling of tension, nervousness, apprehension, or fear that usually involves unpleasant reactions to stimulus HYPNOTICS – Drugs causes sleep or minor tranquilizers (provides hypnosis & sense of tranquility in anxious pxs) HYPNOSIS – Result of extreme sedation & CNS depression / sleep. SEDATIVES – Drugs that cause calmness, unaware of environment SEDATION - Loss of awareness and reaction to environmental stimulus. Desirable in (restless, nervous, irritable, or overreacting to a stimulus pxs)

ANXIOLYTICS & HYPNOTIC AGENTS

ANXIOLYTICS – D rugs that alter ‘s the individual’s response to the environment, prevents feelings of tension or fear

ANXIETY - a feeling of tension, nervousness, apprehension, or fear that usually involves unpleasant reactions to stimulus

HYPNOTICS – Drugs causes sleep or minor tranquilizers (provides hypnosis & sense of tranquility in anxious pxs)

HYPNOSIS – Result of extreme sedation & CNS depression / sleep.

SEDATIVES – Drugs that cause calmness, unaware of environment

SEDATION - Loss of awareness and reaction to environmental stimulus. Desirable in (restless, nervous, irritable, or overreacting to a stimulus pxs)

BENZODIAZEPINES: Most frequently used anxiolytics: prevents anxiety w/out causing much sedation ALPRAZOLAM / XANOR LORAZEPAM / ATIVAN DIAZEPAM / VALIUM Action: Acts in the limbic system & RAS to make GABA more effective causing interference in neuron firing. Indication : anxiety d/o, AWS, hyperexcitability,agitation. Pharmacokinetics: well absorbed in the GI,peaks30min- 2hrs, lipid soluble, crosses the placenta, enters breastmilk, CIx : +allergy, psychosis, shock, coma, narrow > glaucoma, acute alcohol intoxication, pregnancy, Cautions: elderly or debilitated px Adverse effects : Mild drowsiness, depression, lethargy,fatigue, restlessness, bradycardia, changes in libido, drug dependence. Antidote: Flumazenil / Romazicon :

BENZODIAZEPINES: Most frequently used anxiolytics: prevents anxiety w/out causing much sedation

ALPRAZOLAM / XANOR

LORAZEPAM / ATIVAN

DIAZEPAM / VALIUM

Action: Acts in the limbic system & RAS to make GABA more effective causing interference in neuron firing.

Indication : anxiety d/o, AWS, hyperexcitability,agitation.

Pharmacokinetics: well absorbed in the GI,peaks30min- 2hrs, lipid soluble, crosses the placenta, enters breastmilk,

CIx : +allergy, psychosis, shock, coma, narrow > glaucoma, acute alcohol intoxication, pregnancy,

Cautions: elderly or debilitated px

Adverse effects : Mild drowsiness, depression, lethargy,fatigue, restlessness, bradycardia, changes in libido, drug dependence.

Antidote: Flumazenil / Romazicon :

BARBITURATES: former drug of choice prior to benzodiazepines, risk of addiction , and dependence PHENOBARBITAL / LUMINAL BUTABARBITAL/ BUTISOL Action : CNS depressants ↓ neuronal impulse conduction in the RAS, ↓ cerebral cortex, alters cerebellar fxn, ↓motor output . Ix : Anxiety, sedation, insomnia, seizures, acute manic reactions. Pharmacokinetics: absorbed well, peaks20-60mins.,induces liver enzymes systems. lipid soluble, crosses placenta, enters breast milk CIx: +allergy, hepatic / kidney / respiratory d/o dse., pregnancy. Cautions : acute or paradoxical pain (masking?), lactating women Adverse effects : somnolence, agitation, confusion, hyperkinesia, ↓BP, syncope, apnea, Stevens- Johnsons

BARBITURATES: former drug of choice prior to benzodiazepines, risk of addiction , and dependence

PHENOBARBITAL / LUMINAL

BUTABARBITAL/ BUTISOL

Action : CNS depressants ↓ neuronal impulse conduction in the RAS, ↓ cerebral cortex, alters cerebellar fxn, ↓motor output .

Ix : Anxiety, sedation, insomnia, seizures, acute manic reactions.

Pharmacokinetics: absorbed well, peaks20-60mins.,induces liver enzymes systems. lipid soluble, crosses placenta, enters breast milk

CIx: +allergy, hepatic / kidney / respiratory d/o dse., pregnancy.

Cautions : acute or paradoxical pain (masking?), lactating women

Adverse effects : somnolence, agitation, confusion, hyperkinesia, ↓BP, syncope, apnea, Stevens- Johnsons

OTHER ANXIOLYTICS & HYPNOTICS : does not fall to benzodiazepines or barbiturates. AH’s: Benadryl / Dipenhydramine, Phenergan / Promethazine: can be sedating for some peoples, Tx for mild insomnia Paraldehyde / Paral : sedates px c delirium tremens or psych conditions characterized by extreme excitement. Excreted by the lungs and urine Buspirone / Buspar : anti anxiety agent, (-) sedative, anticonvulsant,Ms relaxant properties,

OTHER ANXIOLYTICS & HYPNOTICS : does not fall to benzodiazepines or barbiturates.

AH’s: Benadryl / Dipenhydramine, Phenergan / Promethazine: can be sedating for some peoples, Tx for mild insomnia

Paraldehyde / Paral : sedates px c delirium tremens or psych conditions characterized by extreme excitement. Excreted by the lungs and urine

Buspirone / Buspar : anti anxiety agent, (-) sedative, anticonvulsant,Ms relaxant properties,

AUTONOMIC NERVOUS SYSYTEM: involuntary, visceral nervous system (hypothalamus, medulla & SC) DIVISIONS: PARASYMPATHETIC / CRANIO SACRAL DIVISION SYMPATHETIC / THORACOLUMBAR DIVISION SYMPATETHIC - fight or flight ↑ CV fxn, BP, PR, RR, dilated pupils, bronchi’s dilate, ↑blood flow to the skeletal Ms., sweating↑, piloerection ,↑RAAS, GLYCOGENOLYSIS, ↓ Adrenergic Transmission: sympathetic nerves that synthesize,stores, release Norepinephrine RECEPTORS: ADRENERGIC : ALPHA ADRENERGIC : (ALPHA 1,) FOUND IN THE BLOOD VESSELS(VASOCONSTRICTORS), IRIS(DILATION), URINARY BLADDER(CONSTRICTION) ALPHA ADRENERGIC :(ALPHA 2) LOCATED IN THE NERVE MEMBRANES, MODULATORS FOR THE RELEASE OF NOR EPI BETA RECEPTORS : BETA 1: FOUND IN CARDIAC TISSUE HAVING (+) INOTROPIC, CHRONOTROPIC EFFECT,↑LIPOLYSIS BETA 2 : FOUND IN THE SMOOTH Ms.,PERIPHERY(↑Ms & LIVER GLYCOGEN BREAKDON) BLOOD VESSELS(VASODILATION), PERIPHERY, UTERINE Ms.(RELAXED UTERINE MS.

AUTONOMIC NERVOUS SYSYTEM: involuntary, visceral nervous system (hypothalamus, medulla & SC)

DIVISIONS:

PARASYMPATHETIC / CRANIO SACRAL DIVISION

SYMPATHETIC / THORACOLUMBAR DIVISION

SYMPATETHIC - fight or flight ↑ CV fxn, BP, PR, RR, dilated pupils, bronchi’s dilate, ↑blood flow to the skeletal Ms., sweating↑, piloerection ,↑RAAS, GLYCOGENOLYSIS, ↓

Adrenergic Transmission: sympathetic nerves that synthesize,stores, release Norepinephrine

RECEPTORS:

ADRENERGIC :

ALPHA ADRENERGIC : (ALPHA 1,) FOUND IN THE BLOOD VESSELS(VASOCONSTRICTORS), IRIS(DILATION), URINARY BLADDER(CONSTRICTION)

ALPHA ADRENERGIC :(ALPHA 2) LOCATED IN THE NERVE MEMBRANES, MODULATORS FOR THE RELEASE OF NOR EPI

BETA RECEPTORS :

BETA 1: FOUND IN CARDIAC TISSUE HAVING (+) INOTROPIC, CHRONOTROPIC EFFECT,↑LIPOLYSIS

BETA 2 : FOUND IN THE SMOOTH Ms.,PERIPHERY(↑Ms & LIVER GLYCOGEN BREAKDON) BLOOD VESSELS(VASODILATION), PERIPHERY, UTERINE Ms.(RELAXED UTERINE MS.

PARASYMPATHETIC - Rest & digest ↑GI motility & secretions, ↓HR, BP,RR, pupillary dilation Cholinergic Transmission:Neurons that uses ACh Cholinergic drugs: promotes the action of Acetylcholine Aka parasympathomimetic drug Major classes Cholinergic agonist – mimics the action of acetylcholine, stimulates cholinergic receptors Anticholinesterase – inhibits acetylcholinesterase, as a result, acetycholine is not broken down and begins to accumulate thus the effect of acetylcholine is prolonged

PARASYMPATHETIC - Rest & digest ↑GI motility & secretions, ↓HR, BP,RR, pupillary dilation

Cholinergic Transmission:Neurons that uses ACh

Cholinergic drugs: promotes the action of Acetylcholine

Aka parasympathomimetic drug

Major classes

Cholinergic agonist – mimics the action of acetylcholine, stimulates cholinergic receptors

Anticholinesterase – inhibits acetylcholinesterase, as a result, acetycholine is not broken down and begins to accumulate thus the effect of acetylcholine is prolonged

DIRECT CHOLINERGIC AGONIST: URECHOLINE PILOCARPINE Action: Parasympathetic action that ↓HR,(-)inotropic effect, vasodialtion, bronchoconstriction, ↑mucus, GI activity, bladder tone, relaxed GI, Bladder sphincters, pupil constriction(miosis). Indications: Acute post op, non obstructive urinary retention, bladder atony c retention Pharmacokinetics: short half life (1-6hrs), well absorbed CIx: (+) allergy,pregnant & lactating px’s, Bradycardia, Hypotension, CAD,asthma, Adverse effects: N & V, cramps, diarrhea,↑salivation, Bradycardia, heart block,hypotension, Cardiac arrest , Urinary urgency.

DIRECT CHOLINERGIC AGONIST:

URECHOLINE

PILOCARPINE

Action: Parasympathetic action that ↓HR,(-)inotropic effect, vasodialtion, bronchoconstriction, ↑mucus, GI activity, bladder tone, relaxed GI, Bladder sphincters, pupil constriction(miosis).

Indications: Acute post op, non obstructive urinary retention, bladder atony c retention

Pharmacokinetics: short half life (1-6hrs), well absorbed

CIx: (+) allergy,pregnant & lactating px’s, Bradycardia, Hypotension, CAD,asthma,

Adverse effects: N & V, cramps, diarrhea,↑salivation, Bradycardia, heart block,hypotension, Cardiac arrest , Urinary urgency.

INDIRECT CHOLINERGIC AGONIST: does not react c ACh receptor sites directly. reacts c Acetylcholinesterase(enzyme responsible for breakdown of Ach) NEOSTIGMINE PYRIDOSTIGMINE Action: cholinesterase inhibitor, ↑ ACh level faciltation of nerve transmission Indication: Myasthenia gravis , myasthenic crisis Pharmacokinetics: duration of 2-4 hrs,must be given every few hours (Pyridostigmine=3-6hrs), does not need to be taken frequently, Oral & Parenteral form, can be given in px that inhaled nerve gases CIx: cholinergic crisis (Endophonium iv=used to distinguish if the px is having w/c type of crisis is happening to the px.)

INDIRECT CHOLINERGIC AGONIST: does not react c ACh receptor sites directly. reacts c Acetylcholinesterase(enzyme responsible for breakdown of Ach)

NEOSTIGMINE

PYRIDOSTIGMINE

Action: cholinesterase inhibitor, ↑ ACh level faciltation of nerve transmission

Indication: Myasthenia gravis , myasthenic crisis

Pharmacokinetics: duration of 2-4 hrs,must be given every few hours

(Pyridostigmine=3-6hrs), does not need to be taken frequently, Oral & Parenteral form, can be given in px that inhaled nerve gases

CIx: cholinergic crisis

(Endophonium iv=used to distinguish if the px is having w/c type of crisis is happening to the px.)

Adverse effects:Bradycardia, Cardiac arrest, tearing,dysphagia, N & V, ↑bronchial secretions, incontinence, urinary frequency. Myasthenic Crisis – px condition improved p endophonium iv injection Cholinergic Crisis – px condition gets worst p giving endophonium iv injection Tensilon Test – Dx test for Myasthenia Gravis ☻ ALL MYASTHENIA GRAVIS DRUGS DOES NOT CROSS THE BLOOD BRAIN BARRIER☻

Adverse effects:Bradycardia, Cardiac arrest, tearing,dysphagia, N & V, ↑bronchial secretions, incontinence, urinary frequency.

Myasthenic Crisis – px condition improved p endophonium iv injection

Cholinergic Crisis – px condition gets worst p giving endophonium iv injection

Tensilon Test – Dx test for Myasthenia Gravis

☻ ALL MYASTHENIA GRAVIS DRUGS DOES NOT CROSS THE BLOOD BRAIN BARRIER☻

Alzheimer’s dse – progressive neural degeneration in the cortex leading to a marked memory loss & inability to do ADL’s.- ↑ loss of Ach producing hormones TACRINE (COGNEX)- mild – mod. dementia . GALANTAMINE (REMINYL)- mild – mod dementia RIVASTIGMINE (EXCELON)- liquid, capsule prep DONEZEPIL (ARICEPT)- o.d. dose only Action:indirect cholinergic blocks Ach’ase at the cells of the cortex & crosses the BBB Pharmacokinetics- metabolized by the liver, excreted by the kidney CIx Cautions:(+) allergy, Liver dse. Pregnant & lactating,bradycardic, intestinal & urinary obstruction Adverse effect:Insomnia, fatigue, rash,N&V,Ms cramps

Alzheimer’s dse – progressive neural degeneration in the cortex leading to a marked memory loss & inability to do ADL’s.- ↑ loss of Ach producing hormones

TACRINE (COGNEX)- mild – mod. dementia .

GALANTAMINE (REMINYL)- mild – mod dementia

RIVASTIGMINE (EXCELON)- liquid, capsule prep

DONEZEPIL (ARICEPT)- o.d. dose only

Action:indirect cholinergic blocks Ach’ase at the cells of the cortex & crosses the BBB

Pharmacokinetics- metabolized by the liver, excreted by the kidney

CIx Cautions:(+) allergy, Liver dse. Pregnant & lactating,bradycardic, intestinal & urinary obstruction

Adverse effect:Insomnia, fatigue, rash,N&V,Ms cramps

Anticholinergic Drugs- used to block the effects of Ach & the PNS (Parasympatholytic agents) BELLADONA: ATROPINE ( oral, parenteral, topical ) Action : blocks the effect of PNS there by promoting SNS effects(dilate pupils, ↑HR,RR,PR, ↓GI, URINARY, BLADDER FXN,salivation,bronchial secretions,) Ix: preop px, severe bradycardia,hyperactive bowel,pylorospasm Pharmacokinetics: well absorbed,cross the BBB,excreted in the urine CIx / Cautions: (+) allergy, glaucoma,GI obstruction,Prostate enlargement,bladder obstruction,tachycardia,myocardial ischemia,liver & kidney problem,breastfeeding & lactating px. Adverse effects: blurred vision, ↑IOP °, cyclopegia,Gi disturbance,dry mouth, insomnia,heartburn, constipation etc SCOPALAMINE, DICYCLOMINE,PROPANTHELINE

Anticholinergic Drugs- used to block the effects of Ach & the PNS (Parasympatholytic agents)

BELLADONA:

ATROPINE ( oral, parenteral, topical )

Action : blocks the effect of PNS there by promoting SNS effects(dilate pupils, ↑HR,RR,PR, ↓GI, URINARY, BLADDER FXN,salivation,bronchial secretions,)

Ix: preop px, severe bradycardia,hyperactive bowel,pylorospasm

Pharmacokinetics: well absorbed,cross the BBB,excreted in the urine

CIx / Cautions: (+) allergy, glaucoma,GI obstruction,Prostate enlargement,bladder obstruction,tachycardia,myocardial ischemia,liver & kidney problem,breastfeeding & lactating px.

Adverse effects: blurred vision, ↑IOP °, cyclopegia,Gi disturbance,dry mouth, insomnia,heartburn, constipation etc

SCOPALAMINE, DICYCLOMINE,PROPANTHELINE

PARKINSONS DSE - progressive neurologic d/o due to marked degeneration in the brain(basal ganglia & substantia nigra) thereby affecting Corpus striatum (helps maintain Ms tone not related to any movement) tremors leading to rigidity, weakness, bradykinesia, simian posture, difficulty in performing intentional movements, shuffling gait, slurred speech, mask face * corpus striatum is connected to substantia nigra by series of neuron that uses inhibitory GABA * substantia nigra sends back impulse to corpus striatum using the inhibitory neurotransmitter Dopamine

PARKINSONS DSE - progressive neurologic d/o due to marked degeneration in the brain(basal ganglia & substantia nigra) thereby affecting Corpus striatum (helps maintain Ms tone not related to any movement)

tremors leading to rigidity, weakness, bradykinesia, simian posture, difficulty in performing intentional movements, shuffling gait, slurred speech, mask face

* corpus striatum is connected to substantia nigra by series of neuron that uses inhibitory GABA

* substantia nigra sends back impulse to corpus striatum using the inhibitory neurotransmitter Dopamine

☻ higher neurons from the cerebral cortex secrete Ach in the corpus striatum as an excitatory neurotransmitter to coordinate intentional movements of the body=☻ ☻↓ dopamine in the area causes imbalance that allows the cholinergic / excitatory cells to dominate = ☻ ☻ affecting the fxn of basal ganglia & extrapyramidal motor system (provides coordination for unconscious Ms movements Ex. Position, posture, movement) ☻

☻ higher neurons from the cerebral cortex secrete Ach in the corpus striatum as an excitatory neurotransmitter to coordinate intentional movements of the body=☻

☻↓ dopamine in the area causes imbalance that allows the cholinergic / excitatory cells to dominate = ☻

☻ affecting the fxn of basal ganglia & extrapyramidal motor system (provides coordination for unconscious Ms movements Ex. Position, posture, movement) ☻

type 1(inhibition) antiparkinsonian drug: Dopaminergic : ↑ effects of dopa @ receptor sites,does not cross BBB proven to be much more effectve than Anticholinergics * effective only if there’s enough intact neuron in the substantia nigra (unextensive degeneration) Levodopa (Dopar): precursor of dopamine, crosses the BBB then converted to dopamine usually given c Carbidopa (Sinemet)= ↓ the effect of dopa decarboxylase enzyme in the GI tract & periphery leading to ↑ dopamine converted in the brain Amantadine(Symmetrel)- antiviral, ↑release of dopa Bromocryptine (Parlodel)- dopa agononist acting on dopa receptor directly-does not need further metabolism(more effective than dopar & Sinnemet

type 1(inhibition) antiparkinsonian drug:

Dopaminergic : ↑ effects of dopa @ receptor sites,does not cross BBB proven to be much more effectve than Anticholinergics

* effective only if there’s enough intact neuron in the substantia nigra (unextensive degeneration)

Levodopa (Dopar): precursor of dopamine, crosses the BBB then converted to dopamine usually given c

Carbidopa (Sinemet)= ↓ the effect of dopa decarboxylase enzyme in the GI tract & periphery leading to ↑ dopamine converted in the brain

Amantadine(Symmetrel)- antiviral, ↑release of dopa

Bromocryptine (Parlodel)- dopa agononist acting on dopa receptor directly-does not need further metabolism(more effective than dopar & Sinnemet

Pergolide (Permax )- adjunct to carbi-levodopa. Pramipexole (Mirapex)- effective if levodopa effect has decreased Ropinirole (Requip) – new drug. Used in early & late stage of PD when levodopa has lost its adequate effect. Apomorphine iv (Apokyn)- new drug.dopa agonist that manages hypomobility in PD.given SQ route Actions: ↑ level of dopa in the substantia nigra Pharmacokinetics: absorbed well in GI & body CIx/ ^Cautions : (+)allergy, closed angle glaucoma,^CVD, asthma,liver, renal dse. Adverse effects:anxiety,nervousness,arrythmias

Pergolide (Permax )- adjunct to carbi-levodopa.

Pramipexole (Mirapex)- effective if levodopa effect has decreased

Ropinirole (Requip) – new drug. Used in early & late stage of PD when levodopa has lost its adequate effect.

Apomorphine iv (Apokyn)- new drug.dopa agonist that manages hypomobility in PD.given SQ route

Actions: ↑ level of dopa in the substantia nigra

Pharmacokinetics: absorbed well in GI & body

CIx/ ^Cautions : (+)allergy, closed angle glaucoma,^CVD, asthma,liver, renal dse.

Adverse effects:anxiety,nervousness,arrythmias

type 2 (stimulation) antiparkinsonian drug: Anticholinergics: opposes the effects of Ach @ receptor sites in the Benztropine (Cogentin)- oral,im,iv for parkinsons due to phenothiazines Biperiden (Akineton)- oral, im, adjunctive tx for PD due to phenothiazines Dipenhydramine (Benadryl) used in px ho cannot tolerate more potent type of anti PD drugs(Old pxs) Procyclidine (Kemadrin)- oral,for any type of parkinsonism, controls excessive salivation due to use of neuroleptics Trihexyphenidyl ( Artane)- used c levodopa, used alone for control of drug induced Extrapyramidal d/o.

type 2 (stimulation) antiparkinsonian drug:

Anticholinergics: opposes the effects of Ach @ receptor sites in the

Benztropine (Cogentin)- oral,im,iv for parkinsons due to phenothiazines

Biperiden (Akineton)- oral, im, adjunctive tx for PD due to phenothiazines

Dipenhydramine (Benadryl) used in px ho cannot tolerate more potent type of anti PD drugs(Old pxs)

Procyclidine (Kemadrin)- oral,for any type of parkinsonism, controls excessive salivation due to use of neuroleptics

Trihexyphenidyl ( Artane)- used c levodopa, used alone for control of drug induced Extrapyramidal d/o.

Action: ↓ tremors & rigidity, drooling assoc. c PD Ix: Parkinsons dse., Parkinsonism(idiopathic, atherosclerotic,postencephalitic)releif of Extrapyramidal d/o due to phenothiazines Pharmacokinetics :variable absorption in GI, 1-4 hrs, metabolized in the liver CIx /^ Cautions: (+) allergy, closed angle glaucoma,GI, GU obstructions, prostate enlargement ^tachycardia, hypo/hypertension, pregnant & lactating px Adverse effects : disorientation,confusion, memory loss, agitation,delirium,weakness,dry mouth, N & V, ↓ GI, GU activity

Action: ↓ tremors & rigidity, drooling assoc. c PD

Ix: Parkinsons dse., Parkinsonism(idiopathic, atherosclerotic,postencephalitic)releif of Extrapyramidal d/o due to phenothiazines

Pharmacokinetics :variable absorption in GI, 1-4 hrs, metabolized in the liver

CIx /^ Cautions: (+) allergy, closed angle glaucoma,GI, GU obstructions, prostate enlargement ^tachycardia, hypo/hypertension, pregnant & lactating px

Adverse effects : disorientation,confusion, memory loss, agitation,delirium,weakness,dry mouth, N & V, ↓ GI, GU activity

Psychotherapeutic Agents: drugs aiding in the Tx Mx of mental d/o. Psychosis: perceptual & behavioral d/o Schizophrenia- most common type. (hallucinations, paranoia, delusion, speech abnormality, affective problems) strong genetic predisposition Mania- assoc. c bipolar illness (manic-depressive) periods of extreme depression followed by hyperactivity & excitement. Narcolepsy- char. by daytime sleepiness &sudden loss of wakefulness. Problem c RAS Attention-deficit d/o- inability to concentrate on an activity for longer than a few minutes & hyperkinesis

Psychotherapeutic Agents: drugs aiding in the Tx Mx of mental d/o.

Psychosis: perceptual & behavioral d/o

Schizophrenia- most common type. (hallucinations, paranoia, delusion, speech abnormality, affective problems) strong genetic predisposition

Mania- assoc. c bipolar illness (manic-depressive) periods of extreme depression followed by hyperactivity & excitement.

Narcolepsy- char. by daytime sleepiness &sudden loss of wakefulness. Problem c RAS

Attention-deficit d/o- inability to concentrate on an activity for longer than a few minutes & hyperkinesis

Antipsychotic /Neuroleptics, Major tranquilizers Antipsychotic - eliminate S/Sx of psychosis Neuroleptic- adverse neurobiologic effect causing abnormal body movements Major Tranquilizers- can calm agitated patient Major types: Typical & Atypical TYPICAL –dopamine receptor blocker{Phenothiazines} Ex: Chlorpromazine/Thorazine, Fluphenazine/Prolixin,Haldol/haloperidol Action: blocks dopa receptor,prevents stimulation of neuron by dopa,depress RAS

Antipsychotic /Neuroleptics, Major tranquilizers

Antipsychotic - eliminate S/Sx of psychosis

Neuroleptic- adverse neurobiologic effect causing abnormal body movements

Major Tranquilizers- can calm agitated patient

Major types: Typical & Atypical

TYPICAL –dopamine receptor blocker{Phenothiazines} Ex: Chlorpromazine/Thorazine, Fluphenazine/Prolixin,Haldol/haloperidol

Action: blocks dopa receptor,prevents stimulation of neuron by dopa,depress RAS

Ix : hallucination, schizophrenia, anxious/agitated px, dellusions, ADHD Pharmacokinetics: absorbed in GI, still present 6mos, p last dose, children metabolizes drugs faster than old px CIx/^ Cautions: (+) allergy, PD, CAD, blood dyscrasia, ^glaucoma, PUD, GI/Urinary obstruction Adverse Reaction: weakness, EPS (dystonia, akathisia, tardive dyskinesia), hypotension, urine color turns pink to reddish brown (minor harmless effect)

Ix : hallucination, schizophrenia, anxious/agitated px, dellusions, ADHD

Pharmacokinetics: absorbed in GI, still present 6mos, p last dose, children metabolizes drugs faster than old px

CIx/^ Cautions: (+) allergy, PD, CAD, blood dyscrasia, ^glaucoma, PUD, GI/Urinary obstruction

Adverse Reaction: weakness, EPS (dystonia, akathisia, tardive dyskinesia), hypotension, urine color turns pink to reddish brown (minor harmless effect)

Atypical-

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