Pharmacology Kechn Notes 2 1
Pharmacology Kechn Notes 2 1
Pharmacology Kechn Notes 2 1
Kimosop
PHARMACOLOGY:
- It is a Latin word meaning drug knowledge.
- Pharmacou = drug, Ology = science or knowledge.
Sources of drugs:
Drugs and biologic products are derived from 4 main sources:
1. Plants: examples of which are digitalis.
2. Animals and human: from which drugs such as insulin, epinephrine
3. Minerals or mineral products: examples such as iodine and iron.
4. Chemicals; sodium bicarbonate , sulfonomides and adrenocorticosteroids.
Common Drug Preparations:
1. Solutions and Suspensions:
Aqueous Solutions: have one or more substance dissolved in water e.g. Epinephrine
nasal sol.
Aqueous suspensions: are preparations of finely divided drugs either intended for
suspension or already in suspension in some suitable liquid vehicle.
Sterile suspensions are intended for intramuscular or subcutaneous injections but they
can’t be given intravenously or intrathecally into spinal fluid.
Oral suspensions are NOT sterile and must NOT be injected.
N.B.: - Suspensions tend to settle slowly and should be CHAKED WELL before use to
provide uniform distribution of the drug.
Syrup: medication dissolved in a concentrated sugar solution.
2. DOSAGE FORMS:-
- Capsules
- controlled- release or sustained- release capsules
-tablets,
- pills and
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- troches are used to provide a drug or mixture of drugs into definite doses and avoid the
inconvenience of preparing the dose from dry powder.
-Capsules and coated tablets are a convenient way of giving drugs that have unpleasant
taste.
Capsules:- are solid dosage form for oral use medication in a powder, liquid or oil form
are incased in gelatin shell, capsule colored to avoid mistakes in product identification.
Tablet:- Powdered dosage form compressed into hard disks or cylinders. In addition to
primary drug, they contain binders (adhesive to allow powder to stick together) and
disintegrates (to promote tablet dissolution).
NOTES
1-Some gelatin capsules and tablets may be coated with substances that resist the action
of gastric juice so that will not disintegrate until they reach the alkaline secretions of the
intestine.
2-Sustained- release dosage forms, contain small particles of the drug coated with
materials that require a varying amount of time to dissolve. This provides for a long
continuous period of absorption and effect.
Pill:- Solid dosage form containing one or more drug. Recently, they were replaced by
tablets.
Ampoules and vials:- Ampoules and vials contain powder or liquid drug usually
intended for injection.
Disposable Syringes:- Disposable syringes containing single dose of drug preparations
are widely used.
Large volume intravenous Solutions:- In glass, flexible plastic or semi-rigid plastic
usually of 250, 500, 100 ml e.g. 0.9% sodium chloride.
Intermittent IV. Solution:- These solutions are similar to the I.V. solutions except they
come in smaller volumes.
3-Additional Formulations:-
Drops:- are aqueous solutions that anesthetize, soothe or medicate eyes, ears, or nose.
Instillations:- are aqueous solution instilled into the body cavities or wound and allowed
to dwell there in contact with tissue.
Foams and aerosols:- are powders or solutions for spraying skin as topical anesthesia to
soothe or protect or inhalation for bronchodilation.
4- Others:-
Lotions:- Liquid suspensions or dispersions used for external applications e.g. calamine
lotion.
Creams:- aqueous and oily emulsions to soothe skin.
Ointments:- semisolid preparations of medical substances in some type of base such as
petrolatum lanolin used for their soothing or bacteriostatic effect.
Ophthalmic ointment: Are sterile (e.g. Synthomycin) ophthalmic ointment.
Pastes:- Ointment- like preparations suited for only external application. e.g. Zinc oxide
paste.
Suppositories:- are mixtures of drugs with a firm base that can be molded in shapes
suitable for insertion manually or with an applicator into body cavity or orifice e.g.
Aminophylline , anusol suppositories.
N.B. :- they should be kept cool.
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- Children and elderly persons are highly responsive to drug.
Infants often has immature hepatic and renal systems and therefore incomplete metabolic
& excretory mechanisms.
N.B. :- Aged individuals may demonstrate different responses to drug therapy because of
deterioration of hepatic and renal function which is often accompanied by concurrent
disease process such as C.V.D. (cardiovascular disease).
2- Weight :-
The greater the weight, the greater must be the dose.
However, body weight due to fat or edema fluid should not be taken into consideration.
For very lean and very obese individuals, drug dosage is frequently determined on the
basis of drug/kg of body weight or body surface area.
3- Sex :-
Females don’t always respond to the action of drug in the same manner as do men.
Women are usually smaller than men, which lead to high drug concentration if dosage is
prescribed indifferently.
Female’s body is composed of higher % of adipose tissue than males, absorption rate of
drug are slower in fatty tissue than in skeletal muscle, so the effect of drug will be more
pronounced and prolonged.
N.B. :- During pregnancy, lactation, and menstruation many drugs are stopped:-
One) Aspirin: not used during menstruation as it increase blood fluidity.
Two) Those excreted in milk don’t given during lactation as penicillins.
Three) Uterine stimulant should be avoided during pregnancy as they may produce
abortion such as prostaglandin.
Four) Drugs that might affect fetus and placenta.
4- Time of administration:-
Drug is more rapidly absorbed when the GIT is free of food, while irritating drugs are
more readily tolerated if there is food in stomach.
Body resistant to drug is generally greater in the early morning when the body is at its
lowest point of physiologic functioning and conversely, the body is more sensitive to
drugs effect during time of maximal activity.
5- Pathologic state :-
Diseases alter the functional activity and accordingly its response to drug. e.g. sever pain
tends to increase patient’s requirement to opiates.
The presence of circulatory, hepatic and/ or renal dysfunction will interfere with the
physiologic process of drug action.
6- Environmental Milieu :-
Drugs affecting mood & behavior are particularly susceptible to the influence of the
patient’s environment.
With such drugs one has to consider effects in light of
4 FACTORS:-
1. The drug itself.
2. The personality of the user.
3. The environment of the user.
4. The interaction of these 3 components.
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Heat relaxes peripheral blood vessels while cold has the opposite effect.
7- Genetic factors:
Channels of Administration
1- The ORAL Route:- (p.o.)
The first and most convenient mean is the oral route i.e. the patient usually swallows the
drug, which then enters the gastrointestinal tract and absorbed from that area.
Advantages:-
This route accounts for 80% of all medications administered to patients.
Doctors usually decide the amount and frequency and the patient administer the drug to
himself.
The cost of medication and therapy is low.
Oral administration is painless and there is no necessity to practice sterile technique .
Disadvantages:-
Inconsistent absorption from the gastrointestinal tract.
Blood level may vary among different patients because of different GI characteristics e.g.
acidity, gastric motility & intestinal mucosa.
Drug irritation that causes nausea & vomiting.
Unconscious patient & vomiting patients can’t be given the drug by this route.
2- Parenteral Route :-
The next most popular route of drug administration.
The word parenteral indicates that the drug is administered by a route other than enteral
route (GI), common agreement has come to indicate the injectable route.
Advantages :-
Drugs that cannot be given through GIT.
Eliminate the unpredictability of absorption from GIT i.e. the amount of drug will be
delivered to the patient from injection site.
Medication can be given to an unconscious patient.
Disadvantages :-
Need sterile technique.
More expensive than oral preparations.
Patient usually not able to medicate himself especially when medication needs to be
injected deep into a muscle.
Accidental penetration of blood vessel, especially if medication is not suitable for I.V.
administration (complication).
There are a number of techniques for administering drugs by injection, these are related to
the target area of the injection: -
Subcutaneous Injection:-
SC injection is administration of a drug into the subcutaneous tissues.
slow drug absorption (advantage)
Disadvantages:-
1-The most painful route.
1- Not effective in emergency (poor blood supply).
N.B. :- Drug absorption from SC injection can be reduced by:-
Addition of vasoconstrictor e.g. epinephrine.
Application of cold packs (also vasoconstriction).
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Heat causes vasodilation which result in increased blood supply to the area and thus
quicker drug absorption.
This manipulation may be used to reduce the severity of toxicity from a SC injection.
Intramuscular Route:- IM
Is the second most widely used route for injectable drugs.
Suitable for administration of both solutions and suspensions.
Drugs that are very water insoluble can be given IM in an oil base. (Remain for an
extended period of time).
Has greater vascular network than SC, so drug absorption is more quickly than SC route.
Less painful (less nerve supply).
Intravenous Injection :- I V
Administering a quantity of medication through a needle into the circulation.
2 methods of intravenous injection are used :-
One) Administering the drug as a bolus.
Two) Continuous infusion of a drug, which is called IV drip.
Advantages:-
1) To achieve highly, accurate and quick blood level.
2) A channel to administer drugs that irritate another sites e.g. chemotherapy.
3) Less painful during drug administration.
Disadvantages:-
1) Accidental overdose, and there is no way to withdraw the drug from
circulation once it is injected.
2) Infiltrating the area around the vein i.e. needle slip out of the vein.
3) Thrombophlebitis from repeated injections. To minimize this phenomena (but
doesn’t exclude it), drug should be given I.V. drip.
4) Inadvertent intra-arterial injection instead of a vein.
N.B. :-
IV solutions must be completely homogenous. No solution containing particulate matter,
regardless of how fine the particles should ever be injected IV because of the danger of
creating EMBLOI .
Intradermal (ID) and Intrathecal administration:-
ID is a route of administration in which the drug is injected just below the epidermis.
- Injection is usually used for allergy test.
Used for TB tests and for penicillin sensitivity test.
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The physician desires not to use the injectable route or .
When self-medication other than PO is desired, the rectal route of administration is used.
N.B. :- Systemic effects can be realized by application of drugs to this area, as well as
local effect.
Disadvantages:-
- Erratic absorption from the rectal area result in an inaccurate predicted blood
level of drug so the dosage must be adjusted.
- Rectal route is ineffective when the patient suffers from diarrhea.
Examples:-
Rectal supp. ___ used to treat hemorrhoids.
Vaginal supp.____ used to treat vaginitis.
Urethral supp.___ used to treat bladder conditions.
Topical route:-
- Are intended for use at the site of administration (there are exceptions e.g. Nitroglycerin
ointment that is rubbed into the skin and systemic effect is achieved. – Two topical
preparations are frequently confused with each other ( ointment and creams).
1- Ointments:-
Are usually made up of a petrolatum type of base.
They are quite greasy, as they intended for prolonged contact with the skin.
They don’t disappear or penetrate the skin, but remain on the surface.
2- Creams:-
Made of viscous water-soluble chemicals, which usually disappear after being placed to
the skin.
Patient prefers cream to ointment, as creams don’t discolor clothing.
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1. Immediate reaction
Due to antigen and antibody reaction resulting in histamine release.
In mild cases the reaction is limited to urticaria (wheals and itching of the skin).
In severe cases (anaphylactic reaction) characterized by circulatory collapse or asphyxia
due to swelling of the larynx & occlusion of the air way passages.
Example penicillin allergy.
2. Delayed reaction :-
Occurs several days or even weeks after the drug has been administered.
It is Characterized by; fever (drug fever), swelling of the joints, reaction may involves
blood-forming organs and kidneys.
Treatment of anaphylactic reaction may include administration of :
1) Epinephrine
2) Oxygen
3) Antihistamines
4) Corticosteroids
DRUG IDIOSYNCRASIES:-
Def:- Reactions that occur in patients with a genetically determined abnormal response
to a drug.
Reaction may be excessive and unusual.
Example:- Succinylcholine,(muscle relaxant) usually broken down rapidly by enzymes
in plasma and liver so that the effects of the drug last only for a few minutes.
In few patients, a normal dose of this drug produces profound muscle relaxation and
suppression of respiration, lasting up to several hours. These patients have a genetic
defect that produces unusual enzymes & succinylcholine is not broken down.
Drug Hypersensitivity:-
It occurs when the patient shows extreme sensitivity to an effect of the drug.
The response is to the usual pharmacological drug dosage.
A simple decrease in the dose may be sufficient to eliminate this type of reactions.
GENERAL SIDE EFFECTS:-
Def:- Refers to unpleasant or unwanted reaction to a drug upon administration of
the normal dose.
General side effects include:-
1.Dermatologic reactions:-pruritus, urticaria, alopecia, granulumas, rashes ,
photosensitivity ETC
2.Blood dyscrasias: In some patients, bone marrow is sensitive to certain drugs, this may
result to insufficient production of platelets, RBCs, WBCs.
N.B. :- Patients who receive a drug that may cause bone-marrow depression are monitored
closely by frequent blood counts & for early signs & symptoms of infection.
Some forms of blood dyscrasias:-
Agranulocytosis.
Aplastic anemia (Pancytopnea -reduction of all formed elements of blood).
Hemolytic anemia.
Thrombocytopinea. ( platelets deficiency= hemorrhage).
3. Hepatotoxicity. (Liver damage) =Abdominal pain & jaundice.
4. Nephrotoxicity. (Kidney damage) = hematuria, anuria, proteinuria, edema & uremia.
5.Ototoxicity (ear damage)- damage of vestibular or/and auditory portion of the
8th cranial nerve.
6. CNS toxicity- loss of judgement, loss of movement & coordination loss of
consciousness, Convulsions, tardive dyskinesia (reduce knee-jerk reflex) ETC.
7.GI disturbance ;- nausea, vomiting, abdominal pain, diarrhea ETC.
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8.Drug dependence- characterized by the appearance of physical symptoms
when the administration of drug is discontinued.
9.Sexual dysfunction- change in libido.
Drugs orders and prescriptions
Prescription :-
Medicating a patient begin when the medication is suggested and authorized by a legal
prescriber, usually a licensed physician, dentist or veterinarian.
On the other hand the prescriber’s order has several elements that should be
presented and identified:-
1- Patient’s name and other identifying data.
2- Date that the order was written.
3- Medication name.
4- Dosage to be administered each time.
5- Route of administration.
6- Frequency of administration and special instructions.
7- Prescriber’s signature.
* Types of orders *
It is probably obvious, that outpatients are free to medicate themselves with any
accessible medication.
Once an individual is admitted to a clinical institution, usually neither the patient nor the
nurse may legally administer any medication without a written order.
Use of variant or non-standard abbreviations should be avoided because of the danger of
misinterpretation.
1. ROUTINE Order :-
The most common type. It means that the drug as ordered to be regularly administered
until a formal discontinuation order is written, or until a specified termination date is
reached.
Automatic termination or stop may be explicit in agency policy.
e.g. Antibiotics 5 days, steroids 7 days ……… .
The policies act as stimulus to the prescriber to evaluate continued need for these drugs
that require especially close attention.
2. SINGLE Order :-
Drug is to be administered once at the time indicated.
e.g. a preoperative medication (Atropine) 0.1 mg IM on call to OR.
3. STAT Order :-
This is a single order that drug is to be administered immediately. Stat orders are written
often for emergency when the client’s condition change suddenly.
Example:- Give Aprisoline 10 mg IM stat.
4. PRN Orders :-
These drugs to be administered by the nurse as necessary within the order criteria
specified by the doctor order, the decision of when to medicate is left to the nurse
judgment.
Medications to reduce the perception of pain make up the bulk of Prn orders.
Keep nursing assessment of the pain is required to carry out these Prn orders
appropriately.
5. Telephone order and verbal order:-
Usually given in emergency and should be written in the patient’s chart and signed
by the nurse who receive the order and to be signed by doctor as soon as possible.
Disadvantages :-
1) Forgotten if not written at that time.
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2) It is illegal until the order is signed for by the prescriber.
3) Can easily be miscommunicated, misinterpreted or not clearly heard.
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1 drop = 1 minim
1 ml = 15 minims
1 pound (lb.) = 454 gram
1 kg = 2.2 Libra (lb.)
1 gm = 15 grains
ANTI-INFECTIVE
Introduction:-
The beginning of modem medicine is generally related to 2 events:-
1- The proof by Pasteur that many diseases are caused by microorganisms.
2- The discovery of effective anti-microbial drugs.
- sulfonamides ( 1938).
- Penicillin ( 1940) .
ANTI-INFECTIVE DRUGS CAN BE DIVIDED INTO:-
1. Bacteriostatic:
arrest the multiplication and further development of the infectious agent.
2. Bactericidal:
They eradicate all living microorganisms.
-Some anti-infectives halt the growth or eradicate many different microorganism
and are termed as broad-spectrum antibiotics.
-Others affect only certain specific organisms and are termed narrow- spectrum
antibiotics.
ANTIBIOTICS
Def :- Are drugs produced by microorganisms or other live organisms to kill other
microorganisms , it could be produced synthetically.
Because of differences in susceptibility of infectious agent to anti-infectives, the
sensitivity of the microorganism to the drug ordered should be determined before
treatment is initiated.
Several sensitivity tests are commonly used for this purpose. e.g (Culture and
sensitivity).
USES OF ANT-INFECTIVES
A: Prophylactic
1- To protect persons exposed to a known specific organism.
2- To prevent secondary bacterial infections in acutely ill clients suffering from
infections unresponsive to antibiotics.
3- To reduce risk of infection in clients suffering from chronic illness.
4- To inhibit spread of infection from a clearly defined focus as after surgery or
accidents.
5- To sterilize the bowel or other areas of the body in preparation for extensive
surgery.
B. Acute Infections:
-Antibiotics are used to treat acute infections such as tonsillitis and acute upper respiratory
tract infections ETC.
ANTI-BACTERIALS
1. PENICILLINS
class: Antibiotic
Action: Inhibit bacterial cell wall synthesis.
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-It is bactericidal & bacteriostatic “ according to concentration of drug and microorganism”.
It is most effective against young, rapidly dividing organisms, therefore, they are not used for
bacteria in resting phase.
They diffuse well into body tissues and fluids
They are excreted in the urine in the therapeutic concentration.
They do not kill bacteria in the resting phase.
INDICATION:
1- Gram +ve cocci “streptococci, meningococci, pneumococci ETC.
2- Sub-acute bacterial endocarditis caused by group A streptococci.
3- Gonorrhea due to gonococci,syphilis
4- Diphtheria, tetanus, anthrax, gas gangrene.
5- Prophylaxis for rheumatic fever.
Note: Not all penicillins are used for the above diseases.
Specific uses are indicated for each of the individually listed drugs.
Contraindications:
Hypersensitivity to penicillins & cephalosporins.
Side effects:
Allergic - skin rashes, pruritis,
wheezing
fever.
G.I.T Distubances-Diarrhea , abdominal cramps \pain , nausea, vomiting.
Psendomembranous colitis
thrombocytopinea
leukopenea
Thrombophlebitis + Electrolytes imbalance following I.V. use.
Hepatotoxicity.
I.M. injection may cause pain at the injection site.
N.B. :- Emergency treatment of allergy includes:
1- epinephrine
2- corticosteroids
3- oxygen
4- antihistamines
Dosage: Individualized.
General Nursing considerations for penicillins:
1- These antibiotics should be injected slowly to minimize local irritation.
2- I.M. injections are made deeply into the gluteal muscle.
3- Assess regularly for allergic reactions. If reaction occurs the drug must be
discontinued immediately, Epinephrine ‘O2’ antihistamines + corticosteroids must be
immediately available.
4- Detain client in an ambulatory care site for at least 20 min after administering
Penicillin .
5- Don’t administer long-acting types I.V. , they are only for I.M. use & don’t massage
after injection because rate of absorption should not be increased.
6- Take oral penicillin 1 hr before or 2-3 hr after meals.
7- Complete entire prescribed course of therapy.
“
1) AMPICILLIN:
Trade name: Penbritin .
Class: Antibiotic, penicillin.
-Broad – spectrum antibiotic.
Uses: Is particularly recommended in respiratory, urinary & GI tract infections & other
infection due to ampicillin sensitive organisms.
Dosage forms:
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Capsules 250 mg, suspension 125 mg\5ml, vials 250, 500, 1000 mg.
Ampecilin forte capsules 500 mg, ampicillin forte suspension 250 mg\ 5ml.
Dosage:
- P.O.\I.V. or I.M. 250 mg – 500 mg q 6 hr ( adult)
- Children 50 mg\kg /1 day in 4 divided doses.
- N.B. For bacterial meningitis
- Adults: 12g is given in divided doses q 6 hr.
- Children: up to 400 mg\kg daily in divided doses q 4 hr.
Side effects-Refer penicillin
Specific nursing considerations:
After reconstitution for I.M., I.V. administration, the solution must be used within the
hour.
I.V. administration, should be given slowly within 3-5 minutes or by infusion.
2) AMOXYCILLIN :
Trade name: moxypen.
Class: Antibiotic, penicillin.
Is a broad spectrum antibiotic.
Absorbed well from the GIT.
Indication:
UTI, Respiratory infections, gonorrhea ,skin infections .
Dosage Forms :
Caps. – 250 mg, suspension 125 mg \5 ml
Amoxycillin forte caps. 500 mg , forte suspension. 250 mg\5ml
Dosage: 250-500 mg q 8 hr.
Specific nursing consideration:
Reconstituted suspension is stable for 1 week at room temp. & for 2 weeks at 2- 8
Centigrade degrees.
Side effects- Refer penicillin
3) AMOXYCILLIN & POTASSIUM CLAVULANATE:-
Trade name: Augmentin.
Class: Antibiotic, penicillin .
Note: Potassium clavulanate inactivates beta-lactamase enzymes which are responsible for
resistance to penicillins.
25-50mg/kg/bwt
Side effects/contraindications- see penicillin
4) CLOXACILLIN:
Trade name: Orbenin
Class. : Antibiotic, penicillin.
N.B. More resistant to penicillinase than is penicilin G.
Uses: Infections caused by penicillinase- producing staphylococci, streptococci,
pneumococci.
Osteomylitis,
pneumonia
infected wounds & burns
impetigo
Septic arthritis.
Dosage forms: vials containing 250 mg, 1g .
Capsules 250 mg - 500 mg.
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Syrup 125 mg\ 5 ml, 250 mg\5ml.
Dose:
- Adult: 500 mg q 6 hr.
- Children: 50 mg\kg per day in 4 divided doses.
Nursing considerations:
Administer on an empty stomach.
Refrigerate reconstituted solution & discard remaining amount after 14 days.
N.B. : To prepare oral suspension, add amount of water stated on label and shake well.
shake the bottle well before each use.
BENZANTHINE G PENICILLIN.
Trade name : Penadur, L-A ( long acting penicillin) .
Class. : Antibiotic, penicillin.
N.B. The parenteral product is long – acting form of penicillin in an aqueous vehicle.
It is administered as a sterile suspension.
Uses: Most gram +ve (streptococci , staphylococci, pneumococci) & some gram -ve (gonococci)
organisms .
Syphillis
Prophylaxis of glomerulonephritis & rheumatic fever.
Surgical infections.
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Secondary infections following tooth extraction + tonsillectomy.
Contraindications: Hypersensitivity to penicillin.
Dosage form: vial containing;0.6,1.2 & 2.4 mu.
Dosage:
Parenteral suspension:
-Adults2,400,000 units as single dose
-Pediatric 300,000 – 900,000 units as a single dose.
Early syphilis: 2,400,000 units once a wk for 3-4 weeks.
Prophylaxis of Rheumatic fever: 2,400,000 units as a single dose every 4 weeks.
Children 6-12 yrs: half the adult dose.
Side effects + Nursing considerations:
See the previous drug.
Nursing considerations:
I.M. is preferred, minimize discomfort by using solution of up to 100,000 units \ml.
Monitor intake & output .
Solution may be stored at room temp. for 24 hr or in refrigerator for 1 week.
Use 1% - 2% lidocaine as a diluent for I.M. use to decrease pain at injection site.
Note the penicillin G should not be mixed during I.V. administration with the following drugs:
aminophylline, gentamycin, heparin, vancomycin & sodium bicarbonate.
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-Chemically, it is closely related to penicillin and ampicillin.
-Addition of clavulanic acid to amoxicillin in Augmentin enhances the effectiveness of this
antibiotic against many other bacteria that are ordinarily resistant to amoxicillin.
INDICATIONS
-It is effective against different bacteria such as H. influenzae, N. gonorrhea, E. coli,
Pneumococci, Streptococci, and certain strains of Staphylococci.
tonsillitis
pneumonia
ear infections
bronchitis
urinary tract infections
gonorrhea
infections of the skin.
Side effects and contraindications- refer penicillin
Others-
- Ampiclox
-Flucloxacillin
Indications- same as cloxacillin
NB/ Probenecid (usual dose of 500mg four times daily) blocks renal tubular transport of penicillin
resulting in a 2-fold increase in penicillin blood levels.
AMINOGLYCOSIDES
Are broad- spectrum antibiotics primarilly used for the treatment of serious gram
negative infection caused by Pseudomonas , E.coli, proteus and klebsiella.
It is distributed in extracellular fluids, cross the placenta barriers but not the BBB.
N.B. :- Penetration of the C.S.F. is increased when the meninges are inflamed.
Are excreted largely in the urine, so it is suitable for urinary tract infections.
Are powerful antibiotics that can induce serious side effects.
MODE OF ACTION
They inhibit bacterial protein synthesis. ( by binding irreversibly to ribosome which leads to
production of nonfunctional protein.)
-Are Bactericidal.
N.B./- They are poorly absorbed from the GI tract, therefore are usually administered parenterally.
COMMON PROPERTIES OF AMINOGLYCOSIDES
1.All are given by injection if systemic effect is required.
2.All are excreted by the kidney and accumulation occurs in renal failure.
3.All are ototoxic( impaire hearing and balance) and nephrotoxic(kidney damage)
4. ALL are broad spectrum antibiotics
USES
Gram negative bacteria causing :-
Bone and joint infections.
Respiratory tract infections.
Septicemia (including neonatal sepsis).
Urinary tract infection (U.I,T)- due to E. coli
Post operative infections.
Intra –abdominal infections (as peritonitis) .
Skin infections (including burns) .
Brucella abortus
septicaemia/ Abscesses- S. aureus
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N.B. :- It should be used for gram +ve bacteria only when other less toxic drugs either
ineffective or contraindicated.
Contraindications:-
Hypersensitivity to aminoglycosides.
Long –term therapy “except streptomycin for tuberculosis”.
Patients with impaired renal function
Patients with pre-existing hearing impairment.
Side effects
Ototoxicity: tinnitis , hearing impairment, ataxia & dizziness.
Renal impairment (Nephrotoxicity) hematuria, proteinuria……. .
Neurotoxicity: headache, tremor, lethargy, numbness, burning of face.
nausea, vomiting
skin rash
superinfection.
DRUG CONSIDERATIONS :-
IM administered deep into muscle to minimize pain.
Admin. for only 7-10 days.
Assess history of hypersensitivity.
Obtain lab. studies for renal function.
Continue to monitor for ototoxicity.
Discuss with the client / family the importance of taking medications at the
appropriate prescribed time intervals.
Examples : -
1) AMIKACIN SULFATE :-
Trade name :- Amikin.
Classification :- Antibiotic, aminoglycoside .
Dosage :- IM (preferred) I.V. adults, children 15 mg/ kg / day in 2-3 equally divided doses
q 8-12 hr for 7-10 days.
Newborns loading dose, 10 mg/ kg followed by 7.5 mg\ kg q 12 hr.
2) Gentamycin Sulfate :-
Trade name :- Garamycin.
Class :- antibiotic, aminoglycosides.
Dose: Children:2- 3 mg/kg/day divided into once a day IV or IM.
Adults;- 5mg/kg/bwt once IV or IM
NB/ May be given OD, as single dose
N.B. It is the drug of choice for hospital- acquired gram negative sepsis
including neonatal sepsis.
Serious staphylococcal infections.
Side effects :-
alopecia
CNS: ototoxicity, dizziness,( ringing in the ears), vertigo.
GI: nausea, vomiting, anorexia, abdominal cramps, weight loss, increased salivation.
C.V.S : palpitation, hypotensioin.
Hematologic: Decrease number of blood cells.
URINARY SYSTEM: nephrotoxicity
Local: Pain and irritation at IM injection site.
Skin rashes
Formulation:-
Vial 2 ml containing 20 mg.
Ampoule 2 ml containing 80 mg.
Dosage:- IM (usual) . I.V. adults 3 mg\kg q 8 hr up to 5 mg\kg daily.
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Children 2-2.5 mg\kg q 8 hr.
Newborns 2.5 mg\ kg q 12 hr.
Ophthalmic solution 0.3% , 1-2 drops q 15-30 minutes.
Topical ointment 0.1% , 1-5 times daily to the affected area.
N.B. :- should not be mixed with other drugs for parenteral use.
Drug Consideration:
When given IM, give it slowly and deep in the muscle.
Dilute dose when given IV.
Monitor for kidney function tests, complete blood count when used for more than 7 days. Consult
with Dr. accordingly.
3) NEOMYCIN SULFATE :-
Class.:- antibiotic, aminoglycocide.
Action :- Neomycin is an aminoglycosides antibiotic which is poorly absorbed from the GI tract,
following oral administration, the growth of most intestinal bacteria is rapidly suppressed .
Indications ( uses) :-
A.) P.O
1- Diarrhea due to enteropathogenic E.coli.
2-Suppression of intestinal bacteria for short-term therapy prior to intestinal surgery.
3-Suppression of the intestinal flora for long-term therapy in hepatic coma.
4- Used in opthalmological conditions
B.) Topical :- inflamed skin conditions, burns .
Add. Contraindication :- intestinal obstruction., pregnancy .
Add. Side effects :- steatorrhea & electrolytes imbalance (mal-absorption).
Formulation:- Tablets 500 mg.
Oral for hepatic coma: 4-12 g/d in divided doses for 5-6 days.
NB/-Neomycin is effective against many Gram +VE/-VE & T.B bacteria, however, due to its
toxicity is NOT given by injection
4) STREPTOMYCIN SULFATE :-
Class: antibiotic, aminoglycosides
Additional uses :- Tuberculosis (T.B.) , plague, cholera, bacterial endocarditis caused by
hemophillus influenza, brucellosis abortus .
Add. Contraindications :- contact dermatitis , myasthenia gravis.
Dosage :- for T.B. initially 1 g daily with other anti-tuberculosis drugs.
Route-I.M
CEPHALOSPORINS
Are semi-synthetic antibiotics that resemble the penicillins both chemically and
pharmacologically.
Are absorbed rapidly from the GI tract and quickly reach effective concentrations in the urinary,
GI and respiratory tracts except in patients with pernicious anemia or obstructive jaundice &
eliminated rapidly in patients with normal renal function.
They are broad- spectrum antibiotics that have been classified as first, second and third
generation drugs. The difference among generations is based on antibacterial spectra.
Third generation cephalosporins have more activity against gram negative organisms and
resistant organisms & less activity against gram positive organisms than first generation drugs.
They are also stable against beta-lactamases enzymes.
The cost increases from 1st to 3rd generation cephalosporins.
Mode of Action
-They interfere with the final step in bacterial cell wall synthesis.(by binding to enzymes
called penicillin binding proteins(PBP)
-Are Bacteriocidal
- N.B. :- 1st & 2nd generation drugs don’t enter the CSF well, but 3rd generation drugs enter
inflamed meninges readily.
P a g e | 18
- Cephabsporins are excreted rapidly by the kidneys.
USES:
- They are effective against infections of :-
1.Biliary tract
2.GI tract
3.GU tract
4.Bones & joints
5.Upper & lower respiratory tract
6.Skin
7.Meningitis
8..Osteomyelitis
9.Peritonitis
10-Otitis media
11-Gonorrhea
12-Prophylaxis prior to surgery.
CONTRAINDICATIONS :
- Hypersensitivity to cephalosporins or Penicillin,
- renal failure,
- Pregnancy &, Lactation.
SIDE EFFECTS :-
G.I disturbances; Nausea , vomiting, diarrhea, anorexia, abdominal pain,
flatulence heartburn.
Skin rashes
Super-infection
Sore mouth
Bone marrow depression: (Decrease WBC, decreased platelets, decreased
Hct)
Nephrotoxicity
Pain, abscess at injection site, phlebitis and inflammation at IV site
DRUG CONSIDERATIONS:-
Infuse over 30 minutes unless otherwise indicated.
Therapy should be continued for at least 2-3 days after symptoms of infection have
disappeared.
Assess client with a history of hypersensitivity reaction. “for peniaillin or
cephalosporins.”
Assess client financial status.( drugs expensive).
If GI upset occurs administer. drugs with meals. “should be administered on empty
stomach”.
Obtain liver & renal studies.
Examples :-
1) CEFACLOR :-
Trade name:- ceclor
Classification :- antibiotic, cephalosporin “ second generation”
Uses: otitis media, infections of upper & lower respiratory tract. UTI & skin infections.
Dosage:- Capsules, oral suspension. 250 mg q 8 hr & may be doubled in case of severe
infection. (for adults). Children 20 mg /kg/day in 3 divided doses.
P a g e | 19
2.CEFOTAXIME SODIUM:-
Trade name :- claforan.
Class. :- Antibiotic, cephalosporin (third generation).
N.B.:- Treatment should be continued for a minimum of 10 days for group A beta-hemolytic
streptococcal infections to minimize the risk of glomarulonephritis or rheumatic fever.
The I.V. route is preferable for patients with severe or life – threatening infections.
Uses:- Pneumonia – GU tract infections - meningitis, Peritonitis, septicemia, pelvic cellulitis –
endometritis .
N.B. used with aminoglycosides when causative agent has not been identified.
Dosage:- I.V. , I.M. 1 gm q 12 hr (adult).
Moderate to severe inf. 1-2 g q 6-8 hr.
Pre-op. Prophylaxis , 1 g 30-90 min prior to surgery .
Drug considerations:-
- Should not be mixed with aminoglycosides. ( each should be given separately)
- For I.V. use, should be mixed with 10 ml sterile water & administer over 3-5 minutes.
2) CEFTRIAXONE SODUIM:-
Trade name :- Rocephin.
Class:- Cephalosporin (third generation) , antibiotic .
Uses:- pneumonia, UTI , infections of skin , bone & abdomen. Meningitis, bacterial
septicemia, pre-op. prophylaxis.
Dosage :- I.V. , I.M. adult 1-2g daily in single or divided doses q 12 hr.
- Pediatric: 50-75 mg\kg \day (other than meningitis) meningitis 100 mg\kg 1 day.
Drug considerations:-
I.M. injection should be deep into the body of large muscle.
I.V. injection should be diluted.
For stability of solution the package insert should be checked carefully.
Dosage should be maintained for at least 2 days after symptoms of infection have
disappeared (usual course is 4-14 days).
3) CEFUROXIME SODIUM:-
Trade names :- Zinacef , Zinnat.
Class:- Antibiotic, cephalosporin (second generation).
Uses:- P.O. ( pharyngitis, tonsillitis, UTI , bronchitis), I.M. or I.V. (pneumonia,
UTI , osteomyelitis, meningitis, septicemia, pre-op. Prophylaxis).
Add. Side effects :- in Hb & HCT ( hematocrit).
Dosage:- tablets 250-500 mg q 12 hr . (adult)
125 mg bid (children).
I.M. –I.V. 750 mg q 8 hr
Severe infection 1.5 g q 6-8 hr.
4.CEPHALEXIN MONOHYDRATE:-
Trade names :- Keflex , Jeflex.
Class.:- antibiotic – cephalosporin (first generation).
Uses:- infections of respiratory tract, skin, bones &GU.
Add. Side-effects:- Nepbrotoxicity . cholestatic jaundice.
Dosage :- caps. , suspension, tab. 250-500 mg q 6 hr.
5.CEPHALOTHIN SODIUM:-
Trade name :- Keflin.
Class: Antibiotic, cephalosporin (first generation).
N.B.:- poorly absorbed from GI tract & must be given parenterally.
P a g e | 20
Dosage:- Deep I.M. or I.V. 500-1000 mg a 4-6 hr.
Uses:- see Keflex.
Chloramphenicol:
Trade names:- chloromycetin , synthomycetin, synthomycin
Was originally isolated from streptomyces venezuelle & now is produced synthetically.
N.B./ It can be extremely toxic due to protein synthesis inhibition in rapidly proliferating cells as
bone marrow and should not be used for trivial infections.
Available for hospital use only.
Mode of Action
-It inhibits protein synthesis in bacteria by binding to ribosomes.
-The drug is mostly bacteriostatic “ bactericidal in high doses”,
-well absorbed from the GI tract and distributed to all parts of the body including C.S.F. .
INDICATIONS
NB/ Not to be used for trivial infections such as, prophylaxis of infection
cold , throat infections or flu, the benefits should be greater than the risks of its toxicity.
Treatment of choice for typhoid fever (not for carrier state).
Meningitis due to hemophilus influenza, pneumococci or meningococci.
Skin infections (topically).
Brain abscesses.
Eye and ear bacterial infections.
CONTRAINDICATIMS:
Hypersensitivity to chloramphenicol.
Pregnancy
Nursing mothers.
Renal and hepatic failure.
SIDE EFFECTS:-
Bone depression resulting to:-
-A plastic anemia, pancytopenia, WBC & platelets depression
nausea,
vomiting
abdominal distention ,
“progressive pallid cyanoses,
ashen gray color,
tachypnea ,
vasomotor collapse &
death”,
Gray syndrome in infants,
super infections
Formulation:- tablets 250 mg , vial 1g.
Dosage:- 50 mg\kg daily in 4 divided doses q 6hr .
DRUG CONSIDERATIONS:-
- Administer I.V. as 10% solution over at least 1 min.
Note any history of hypersensitivity & other contraindications, & if
client takes antidiabetic or other medications that cause bone marrow
depression.
Neonates should be observed closely ( greater hazards of toxicity) .
- Arrange for further hematologic studies to be conducted every 2 days to detect early signs of
bone marrow depression.
- The drug should be taken at regular intervals to be most effective .
- The drug should be taken 1 hr before or 2 hr after meals ( if GI upset occurs it can taken with
food).
MACROLIDES
P a g e | 21
Are a group of closely related cpds characterized by a macrocyclic lactone ring (containing
14 or 16 atoms) to which deoxy sugars are attached.
Erythromycin, was obtained in 1952 from Streptomyces erythreus.
Clarithromycin and azithromycin are semisynthetic derivatives of erythromycin.
1.ERYTHROMYCIN :-
Mode Of Action
Inhibits Bacterial protein synthesis by binding to ribosome.
It is effective only against rapidly multiplying organisms.
Absorbed readily from the upper GIT (small intestine ) .
Used as alternative in penicillin allergic patients
It is bacteriostatic antibiotic
USES:-
1- The drug of choice to treat respiratory tract infections.
2- Intestinal amoebiasis.
3- An alternate drug to treat the following conditions in patients who are allergic to penicillin.
Infections due to group A- beta hemolytic streptococci.
To prevent bacterial endocarditis prior to dental procedures.
S.T.I :-gonorrhea or syphilis or chlamydia.
4- Conjunctivitis of the newborn.
5- Long term prophylaxes in rheumatic fever.
CONTRAINDICATION:-
Hypersensitivity.
Formulation:-
Tablets 250 mg , suspension: 125 mg, 200 mg , 400mg.
Dosage:-
- The usual adult dose is 250 mg q 6 hr (can be doubled in sever infections).
- Children , 30-50 mg\kg in divided doses .
Drug Consideration:
1. Should be taken on an empty stomach.
2. In the treatment of sterptococcal infections, should be administered for at least 10 days.
3. Don’t administer with fruit juice or other acidic drinks because it may decrease the activity of
the drug.
TETRACYCLINES
MODE OF ACTION
The tetracyclines inhibit Bacterial protein synthesis by binding to its ribosomes, thereby
interfering with protein synthesis.
-Bacteriostatic and are effective only against multiplying bacteria.
-Well absorbed from the stomach & upper GIT.
- And can pass through the placental barrier.
N.B. : They are deposited in the fetal skeleton and calcifying teeth.
USES:
N.B. : Due to development of resistance , they are usually not used for infections by common gram
+ve & gram –ve organisms , however, are active against many gram-positive and gram-negative
bacteria, including anaerobes, rickettsiae, chlamydiae, mycoplasmas, and against some protozoa,
eg, amebas..
They are the drugs of choice for rickettsial infections such as:
1.Rocky mountain spotted fever .
2.Endemic typhus.
Others:
UTI Eg: Urethritis due to mycoplasma.
Prophylaxis of plague after exposure.
P a g e | 22
Adjunct treatment of trachoma, & acute intestinal amoebiasis.
Bacterial Gastroenteritis (GE)
They are the drug of choice for gram –ve bacteria causing:
1.Cholera
2.Brucellosis.
Alternative treatment to penicillin for uncomplicated gonorrhea.
Vaginitis,
severe acne.
Topical uses include skin granuloma.
Neonatal bacterial conjuctivitis Rx & prophylaxis
CONTRAINDICATIONS:
- Hypersensitivity.
During tooth development stage:
1- pregnancy-esp. last trimester.
2- Neonatal period.
3- During breast feeding.
4- During childhood up to 12 years- Because they interfere with enamel formation and dental
pigmentation.
SIDE EFFECTS:
P a g e | 23
SIDE EFFECTS
Hypersensitivity reactions (drug fever, skin rashes) to tetracyclines are uncommon.
Most adverse effects are due to direct toxicity of the drug or to alteration of
microbial flora.
A. GASTROINTESTINAL ADVERSE EFFECTS
Nausea, vomiting, and diarrhea are the most common reasons for discontinuing
tetracycline medication. These effects are attributable to direct local irritation of the
intestinal tract. Nausea, anorexia, and diarrhea can usually be controlled by
administering the drug with food or carboxymethylcellulose, reducing drug dosage,
or discontinuing the drug.
Tetracyclines modify the normal flora, with suppression of susceptible coliform
organisms and overgrowth of pseudomonas, proteus, staphylococci, resistant
coliforms, clostridia, and candida. This can result in intestinal functional
disturbances, anal pruritus, vaginal or oral candidiasis, or enterocolitis with shock
and death.
most common:-
Nausea, vomiting, thirst, diarrhea flatulence, sore throat & anorexia.
Black hairy tongue
esophageal ulcer .
Skin rashes.
photosensitivity.
Discoloration of nails & infants & children’s teeth.
P a g e | 24
Delayed bone growth.
I.V. use may cause thrombophlebitis.
Dosage : Individualized.
NURSING CONSIDERATIONS:
Don’t use outdated or deteriorated drugs. , Discard unused medications.
Adm. I.M. deeply in large muscle mass.
Adm. on an empty stomach (1hr before or 2 hr after meals).
If the client is female & pregnant, determine what trimester she is in.
Report side effects to physician.
Avoid direct sunlight, which can cause a severe sunburn-like reaction.
Examples:
1- TETRACYCLINE HCL
For candidal infections./ophthalmic/acne/brochitis
2- Chlortetracycline Hcl (ophthalmic & topical 3% on affected area 1-5 times daily).
3- DOXYCYCLINE :
Trade names: Doxylin , Doxypal , Doxypharm, vibramycin, doxacylin.
Class: Antibiotic, tetracycline.
Dosage form: Caps., film-coated tab. 100 mg
Dose: The usual dose for adults.
First-day 100mg q 12hr(Bd) followed by 1 tab. a day.
In severe cases: 2 tablets daily in divided doses.
SIDE EFFECTS: nausea, vomiting, diarrhea, headache, hypertension, colitis,
hemolytic anemia.
NURSING CONSIDERATION:
do not give with antacid, milk, or any product that contains Calcium, zinc, aluminum,
magnisium, and ferrus salts, because these products decrease the absorption of the drug.
4- OXYTETRACYCLINE:
Trade name: Terramycin
Class: antibiotic , tetracycline.
Dose: tab., see the previous drug.
I.M. 250 mg once daily.
OTHERS:
Minocycline
Tigecycline
Demeclocycline
note/
SULFONAMIDES
Bacteria needs para-aminobenzoic acid (dihydrofolic acid) to multiply.
They are absorbed from the stomach and small intestine and distributed widely to
tissues and body fluids (including CNS and CSF), placenta, and fetus.
MODE OF ACTION
- sulfonamides affect Bacteria by interfering with the use of para-aminobenzoic
acid (PABA) a precursor of folic acid used by bacteria for cell division.
Bacteriostatic .
Relatively inexpensive drugs.
Excreted mainly via kidneys.
Active to most gram negative/positive bacteria
USES:
Less useful because of bacterial resistance & development of other antibiotics.
Many strains of formerly susceptible species, including meningococci, pneumococci,
streptococci, staphylococci, and gonococci, are now resistant.
P a g e | 25
The fixed-drug combination of trimethoprim-sulfamethoxazole is the drug of choice for
infections such as Pneumocystis jiroveci (formerly P carinii) pneumonia, toxoplasmosis,
nocardiosis, and occasionally other bacterial infections.
UTI e.g. E. coli, proteus & staph. Aureus. “ cephalosporines are given now”.
To eliminate meningococci from nasopharynx ( carriers).
As alternative to penicillin for prophylaxis in rheumatic fever.
As alternative to tetracycline in treatment of chlamydia, trachoma & conjunctivitis.
In combination with penicillin to treat otitis media.
CONTRAINDICATIONS:
Pregnancy except for treatment of toxoplasmosis.
Used with caution in patients with impaired liver & kidney function & blood disorders.
History of sulfur hypersensitivity
SIDE EFFECTS
GI disturbances ;Nausea, vomiting, stomatitis, abdominal pain
CNS; headache, dizziness, ataxia,
photosenitivity
Skin rashes.
Steven –Johnson syndrome (rhinitis, conjunctivitis, fever, stomatitis, & rash).
Renal damage- crystaluria, hematuria, proteinuria.
Hemolytic anemia, aplastic anemia. , Jaundice.
Superinfection.
Note
Vitamin K should be administered to patient taking long-term sulfonamide because of blood
dyscrasias.
NURSING CONSIDERATION:
Obtain a thorough nursing and drug history.
If the client is pregnant, the physician should be informed so that, another type of medication not
harmful to a developing fetus may be used.
Take with plenty of water to avoid crystal formation in urine.
During drug therapy, assess client for any of the following: reactions that may require
withdrawal of the drugs:
Skin rashes
Abdominal pain & anorexia.
Jaundice (hepatic involvement).
Renal colic, oliguria, anuria, proteinuria (renal involvement).
Jaundice, pallor, weakness (blood dyscrasias).
Rhinitis, stomatitis, fever, headache, conjunctivitis (Steven Johnson syndrome) .
Hemorrhage, due to vitamin K deficiency.
Monitor intake and output.
SILVER SULFADIAZINE CREAM.
USES /INDICATIONS: -
Topically for prevention and treatment of sepsis in second and third degree burns.
Minor bacterial skin infections and dermal ulcers.
- Dosage: Once or twice daily topically by sterile gloves over a clean or debried burn.
Contraindications:
Pregnancy, lactation, infant below 2 months.
P a g e | 26
Dosage : As silver sulfadiazine.
Add. Contraindications:
- Megaloblastic anemia due to folate deficiency.
- Infants less than one month of age.
Dosage: one or 2 tablets q 12 hours/adults, or 4 teaspoonful 12 hrs for 10-14 days.
4- Sulfasalazine: Salazopyrin
Uses: ulcerative colitis
GLYCOPEPTIDE
1. VANCOMYCIN HYDROCHLORIDE:-
Trade name: vancocin.
Class : Antibiotic, miscellaneous .
-It is derived from streptomyces orientalis
MODE OF ACTION
Inhibit bacterial cell wall synthesis.
- lysing the cytoplasmic membrane by a mechanism that is different from that of penicillin.
-It is bacteicidal for most organisms and bactereostatic for enterococci.
N.B. : It is poorly absorbed from GIT so it should be administered parenterally only for life
threatening infections.
USES:
drug should be reserved for treatment of life threatening infections when other treatment have
been ineffective .
1 Patients with severe staphylococcal infections resistant or allergic to penicillins or
cephalosporins such as:
Endocarditis
Osteomylitis
Pneumonia
Septicemia
2 Oral administration is useful in treatment of:
enterocolitis
pseudomembranous colitis
CONTRAINDICATIONs :
* Hypersensitivity
* Minor infectious.
SIDE EFFECTS:
- Ototoxicity deafness
- Nephrotoxicity uremia
P a g e | 27
Red-Neck syndrome: “chills, erythema of neck and back fever”.
Skin rashes, Drug fever
Hypotension (due to rapid administration) .
Thrombophlegitis at site of injection.
Dosage: Caps., syrup, or I.V. 0.5 g q 6hr or 1g q 12 hr.
DRUG CONSIDERATIONS:
Intermittent infusion is the preferred route.
Avoid rapid I.V. administration - nausea & hypotension.
Avoid extravastion during injections .
Monitor vital signs, intake of output.
Lincosamides Antibiotics
QUINOLONES
1.CIPROFLOXACIN HYDROCHLORIDE:
Trade name: cipro ( ciproxin)
Class. Antibacterial , quinolone derivative .
MODE OF ACTION
-Iinhibits the synthesis of bacterial DNA by inhibiting the enzyme DNA gyrase.
-Is a synthetic quinolone with broad- spectrum bactericidal activity
USES:
UTI,
infectious diarrhea
Infection of lower respiratory tract,
bone, joints & skin infections.
Typhoid fever
CONTRAINDICATIONS:
Hypersensitivity
children- cause joint pain
lactation .
SIDE- EFFECTS:
-Nausea vomiting . dysphagia, crystalluria, hematuria.
Rashes, bad taste , GI bleeding , Headache , insomnia .
Dosage: 250-500 mg q 12hr for 7-14 days.
DRUG CONSIDERATIONS:
Give medication 2 hr after meals.
P a g e | 28
Stress importance of drinking increased amounts of fluids to keep urine acidic & to minimize the
risk of crystalluria.
NALIDIXIC ACID: NEGRAM, UROGRAM ( QUINOLONE)
Class: Quinolone
ACTION:
- Inhibit bacterial DNA synthesis.
-Partially metabolized in the liver & rapidly execrated in urine.
USES:
Acute and chronic UTI.
.
Side effect: Nausea, vomiting, diarrhea, seizure, headache dizziness, leukopenea,
thrombocytopnea, hemolytic anemia due to G-6-PD deficiency.
Contraindications
To be administered with caution in patients with :
- liver disease. -Impaired kidney function - Epilepsy
- Pregnancy - Lactation - children - cerebral arteriosclesois
Dose: 1g q.i.d. for 1-2 weeks.
NITROFURANTOIN: FURADANTIN
Class.: urinary germicide
ACTION:
-Interfere with bacterial CHO metabolism and bacterial cell wall synthesis.
-Bacteriostatic at low concentration, bactericidal at high concentration.
USES:
severe UTI (pyelonephritis, cystitis) .
CONTRAINDICATIONS:
anuria ,
ologuria,
impaired renal function.
Pregnancy,
lactation,
infant less than 1 month of age.
P a g e | 29
SIDE EFFECT: Nausea , vomiting, pancreatitis, abdominal pain, leukopnea, megaloblastic
anemia, headache , vertigo, hemolytic anemia in patients with G-6-PD deficiency.
Nsg considerations: As those for all anti-infectives.
ANTIFUNGAL AGENTS
Several types of fungi or yeasts are pathogenic for humans.
Fungal infections may be systemic, limited to skin, hair or nails or infect
moist mucous membranes including the GI tract and vagina.
Candida organisms belong to this group.
Drug therapy depends both on the infectious agent & on the type of infection .
An accurate diagnosis of the infection before therapy is most important for the choice of
the therapeutic agents.
It is important that drug therapy be continued until the infectious agent has been
completely eradicated to avoid the emergence of resistant strains.
1- AMPHOTERICIN B:
Trade name: Fungizone.
Class: Antibiotic, antifungal.
ACTION: It is produced by streptomyeces nodosum & the drug of choice for deep infections. It
binds to specific chemical structures “sterols” of the fungal cellular membrane, increasing
cellular permeability and promoting loss of potassium and other substances.
Fungistatic or fungicidal “ depending on the dose”.
Is poorly absorbed from the GIT , It can be adm. I.V. , intrathecally or topically.
Uses :
N.B. : The drug is toxic and should be used only for patients under close medical supervision
with a relatively certain diagnosis of deep mycotic infections.
I.V. adm. usually reserved for life threatening diseases because it is toxic.
Systemic fungal infections. e.g. histoplasmosis, disseminated candidiasis & monilial over growth
resulting from oral antibiotic therapy.
Topical coetaneous & mucocutaneous infections of candida “monilia” infections .
Contraindications: Hypersensitivity.
SIDE EFFECTS:
Topical use: pruritis, dry skin, and irritation.
IV use: nausea , vomiting , diarrhea, melena, abd. cramps.
Fever, headache, thrombophlebitis, bone marrow depression, pancytopnea. anaphylaxis.
2- NYSTATIN:
Trade name: mycostatin.
Class: antibiotic , antifungal.
Action: It is natural antifungal antibiotic is derived from streptomyces noursei & both fungistatic
& fungicidal against all species of candida, It binds to fungal cell membranes “ sterols” ,
resulting in altered cellular membrane permeability & leakage of potassium & other essential
components & excreted in feces.
USES:
candida infections of the skin, mucous membranes, GI tract, vagina & mouth (thrush) .
N.B. : The drug is too toxic for systemic infections , although it can be given
P.O. for intestinal moniliasis infections as it is not absorbed from the
GI tract.
SIDE EFFECTS:
Has few toxic effects - nausea , vomiting , diarrhea.
Dosage forms:
Suspension: contains 100,000 units\ ml “12 ml bottle with dropper”.
Ointment: contains 100,000 units\g “15 g tube”.
P a g e | 30
Vaginal tab.: Contains 100,000 units.
DOSAGE:
Suspension:-
- For adult: 2 ml, 4 times daily.
-Pediatric: 1 m. 4 times daily.
Vaginal cream or tablet:-
- 1 tab. inserted into vagina once or twice each day for 2 weeks.
NURSING CONSIDERATIONS:
Don’t miss oral suspension in foods since the mediation will be inactivated.
Apply cream/ointment with a swab.
Instruct client to keep medication in mouth as possible before swallowing.
Insert vaginal tab. high in vagina with an applicator.
Treatment should be continued for at least 48 hr after clinical cure has been achieved to prevent
relapse.
3.NATAMYCIN:
Trade name: Natacyn.
Class: antifungal (ophthalmic).
Action: see Nystatin.
Uses: for ophthalmic use only. e.g. fungal blepharitis & conjunctivitis.
Contraindications: Hypersensitivity.
Side effects: eye irritation.
Dosage: 1 g tt of 5% susp. q 1-2 hr, reduced after 3-4 days to 1 gtt q 6-8 hr.
4.MICONAZOLE:
Trade name: Daktarin.
Class: antifungal agent.
Actions: as Nystatin. It also inhibits biosynthesis of triglycerides &
phospholipids & also inhibits oxidative enzyme activity.
USES:
Systemic fungal infection e.g.
mucocutaneous candiasis.
Skin , nail & hair infections.
tinea pedis ( athlete’s foot) , tinea corpuris.
Oral thrush (oral gel) .
Against some gram +ve bacteria.
CONTRAINDICATION: Hypersensitivity.
SIDE EFFECTS:
Topical:- skin rashes, headache, burning , irritation.
Systemic :- nausea, vomiting, diarrhea, anorexia fever
thrombocytopnea.
Dosage forms: -
-Cream, tubes of 15g or 30g.
-Lotion - bottles of 20 ml.
-Oral gel- tubes of 40 g.
Dosage: I.V. 300 – 3600 mg / day in divided doses .
Topical apply to cover affected areas in morning & evening.
Vaginal cream\supp. One supp. Daily at bedtime for 7 days.
2. KETOCONAZOLE:
Trade name: Nizoral.
Class.: Broad- spectrum antifungal .
Action: see miconazole.
USES:
candidiasis, oral thrush.
P a g e | 31
CONTRAINDICATIONS:
Hypersensitivity.
Lactation.
Ophthalmic use.
SIDE EFFECTS:
-G.I.T nausea, vomiting, diarrhea,-
fever,
headache,
photophobia,
hepatotoxicity.
Gynecomastia,
impotence,
thrombocytopnea.
Dosage: tab. \oral susp. 200 – 400 mg. As asingle dose\day.
OTHERS:
GRISEOFULVIN
Drug of choice for tenia infection
Dosage
Tabs griseofulvin 500mg/ 250mg /125mg
Adults 500mg q 24hrs for 3-4 wks
Children 10mg in divided doses (bd/ tid)
ANTHELMINTICS
Helminths (worms) may infest the intestinal mucosa or lumen and can migrate to a particular
tissue.
Treatment of worms infection is complicated since a worm may have one or more morphological
stages.
All family members should be examined since infestations are transmitted by sharing bathrooms
(hygiene is very important).
- Worms divided into 3 groups:
1- CESTODES:
Tape worm e.g. taenia saginata ( beef), taenia solium (pork).
2- NEMATODES:
1. Filaria: filariasis
2. Hook worm: ancylostoma.
3. Pinworm: oxyuriasis ( common in school age).
4. Round worm: ascaris ( can cause GI & respiratory obstruction).
5. Threadworm: strongoloid.
6. Whipworm.
3- TREMATODES: Bilharziasis
NURSING CONSIDERATIONS:
Instruct responsible family member how to prevent infestation with pinworm by :
Washing hands after toiling + before meals .
Keep nails short.
Applying antipruritic ointment to/and area to reduce scratching which transfers pin worms.
Alert all family members to be examined for pinworms.
Emphasize the need for follow-up examinations to check the results of treatment.
1- MEBENDAZOLE: VERMOX
Class: anthelmintic.
ACTION: Blocks the glucose uptake of the organism causing it die..
USES:
P a g e | 32
whipworm, pinworm, roundworm infestation.
Contraindications: Hypersensitivity.
Special concerns: Pregnancy, children less than 2 years.
Side effects: Transient abdominal pain, diarrhea.
Dosage: for pinworm, 1 tablet one time.
Whipworm , roundworm, hookworm 1 tablet morning and evening on 3 consecutive days.
Note: All treatments can be repeated after 2-3 weeks.
2- NICLOSAMIDE: YOMESAN
Class: anthelmintic.
Action: Inhibit oxidative phosphorylation in the mitochondria of the worm.
The drug is not absorbed from GIT and execrated in feces.
Uses : For tape worn only( ie T.saginata, T.solium, Diphyllobothrium latum, Hymenolepsis nana.
Special concerns: pregnancy, lactation , children under 2 years.
Side effects: nausea, vomiting, anorexia, bad month odor, shin rash, alopecia, dizziness , fever,
sweating.
Dose: 2g as a single dose ( 4 tabs X 0.5 g) .
- For hymenolepsis nana: 2g as a single dose daily for 7 days.
3- PIPERAZINE: VERMIZINE
Class: anthelmintic
Action: Paralyze the muscle of the parasite dislodge & excretion .
- Absorbed via GIT , metabolize in liver & execreted in urine.
Uses: Pinworm (oxyuriasis) , round worm (ascariasis) .
- Note: Recommended for pediatric use.
Contraindications: lmpaired liver & kidney function, seizures, and hypersensitivity.
Side effects: nausea, vomiting, diarrhea, tremors, ataxia, blurring of vision, cataract,
bronchospasm , rash .
ANTI-MYCOBACTERIAL AGENTS.
The main mycobacterial infections in human are tuberculosis and leprosy, are chronic
infections caused by mycobacterium tuberculosis and mycobacterium leprae,
respectively.
ANTI-TUBERCULAR AGENTS(ANTI-TB/KOCKS)
More than one drug is used.
TB usually chronic because of the slow growth of mycobacterium.
The long duration of drug therapy increases the risk for complications.
Drugs of T.B. are categorized as 1st line and 2nd line depending on their efficacy, activity &
incidence of side effects.
* 1st line drugs: Ethambutol, Isoniazide, Rifampin, pyrazinamide, Streptomycin.
* 2nd line drugs: Capreomycin, Kanamycin,
1- ETHAMBUTOL HCL
Effective only against mycobacteria.
Class: 1st line antitubercular agent.
Action: Arrest multiplication of rapidly dividing tubercle bacilli probably by interfering with
RNA synthesis.
Absorbed from GIT & widely spread in body tissues except CSF.
65% of metabolized & unchanged drug execrated in urine & accumulate in patients with renal
insufficiency.
USES:
Pulmonary T.B. in combination therapy.
CONTRAINDICATIONS:
Hypersensitivity,
less than 13 years of age
P a g e | 33
preexisting optic neuritis.
Special concerns: pregnancy, impaired renal function, gout.
SIDE EFFECTS:
optic neuritis
loss of color discrimination.(begin as red-green color blindness)
Loss of vision (temporary) .
Peripheral neuritis (tingling).
Hyperuricemia.
Note: side effects appear in early months, then disappear & color vision should be monitored
during prolonged treatment.
2- ISONIAZIDE: INH
“ Is the most effective tuberculostatic agent”
Class: 1st line antilubercular agent.
Action: interfere with lipid & nucleic acid metabolism of growing bacteria hence alteration of
bacterial wall.
Absorbed after oral or IM administration & is widely spread in body tissues.
Uses:
T.B. due to human, bovine & BCG.
Prophylaxis of T.B.
Contraindications: Hypersensitivity.
SIDE EFFECTS:
peripheral neuritis,
ataxia,
jaundice
optic neuritis
thrombocytopnea.
Note: B-complex or pyridoxine 10-15mg \day may be given to relieve CNS side effects.
Liver function & ophthalmic test are recommended periodically.
3- STREPTOMYCIN SULFATE:
Class: 1st line antilubercular agent , aminoglycoside .
Dose : 1g once a day for 1 month , then 1g 2-3 times/week for a minimum of 1 year.
SIDE EFFECTS:
ototoxicity
nephrotowicity
neurotocixity.
P a g e | 34
LEPROSTATICS
LEPROSY:
Causative agent: Mycobacterium Leprae
Incurable chronic infection of the skin, mucus membrane and nerves.
Transmitted by direct contact.
Incubation period (1-3 years).
Lead to paralysis , disfigurement & deformity.
1- CLOFAZIMINE
Class. : Leprostatic
Action: Has a bactericidal effect on the mycobacterium, inhibit the growth of mycobacterium by
binding to its DNA
-It is concentrated in fatty tissues & RES, excreted in feces via bile as well as in sputum, sweat &
sebum.
Special concerns: pregnancy, lactation, children, abdominal pain & diarrhea.
Side effects:
Nausea , vomiting, abdominal pain ,diarrhea.
Dry skin, brownish to black discoloration of the skin, rash, jaundice, lymphadenopathy
hypokalemia.
USES:
Dapsone resistant Leprosy.
Dose: 100 mg daily in combination therapy for 3 years.
2- DAPSONE
Class: leprostatic(anti-leprosy)
Action: unknown, synthetic agent has bactericidal & bacteriostatic activity. Act similarly to
sulfonamides.
USES:
Leprosy
prophylaxis of malaria.
Contraindications: Advanced amyloidosis of the kidneys, lactation
special concerns: pregnancy .
Side effects: hemolytic anemia, methemoglobinemia nausea, vomiting, vertigo, and
photosensitivity.
Dose: 50-100 mg \day without interruption for 3 years.
ANTIMALARIALS
P a g e | 35
ARTEMETHER/ LUMEFANTRINE(AL)
TYPE: Artemesinin Combination Therapy (ACT), Blood Schizonticide
-It is the first line treatment in Kenya except during first trimester of pregnancy(unless quinine
not available)
MODE OF ACTION
Rapidly destroys asexual blood forms of the malarial parasites(gametocidal) ie interferes with the
P. falciparum metabolism and synthesis.
INDICATIONS
First line treatment of acute uncomplicated malaria( due to P. falciparum)
Supplimentary treatment of severe malaria after parenteral Quinine /or artesunate
CONTRAINDICATIONS
Severe or complicated malaria(eg celebral malaria)
First trimester of pregnancy
Breastfeeding- stop during bf, and for 1 wk after treatment
Patients with history of arrythmias
Patients with congenital prolongation of QT interval
DOSAGE
ADULTS:- start with 1 dose of 4 tablets, then take 5 more doses(of 4 tabs each) after 8hrs,
12hrs, 24hrs, 36hrs, and at 48hrs.(total= 24 tabs)
CHILDREN:-
< 3yrs (5-14kgs): 1 tab/ dose as above for a total of 6 doses( 6 tabs)
3-9 yrs (15-24 kgs): 2 tabs /dose as above (total=12 tabs)
25-34kgs: 3 tabs/dose as above(total=18 tabs)
SIDE EFFECTS
Headache
G.I.T Disturbances
Bradycardia
Palpitations
Elevated Liver Enzymes
ECG Abnormalities Eg Prolonged QT Interval
Tinnitus
Sleep Disorders
Dizziness
Athralgia/ Myalgia
Pruritus, Rash
Cough
Hypersensitivity
Neutropenia
NURSING CONSIDERATION
Administer the drug with food (preferably high fat) and plenty of fluid(preferably milk)
at the recommended interval
Repeat dose if patient vomits within 1 hr of taking
watch fo side effects eg sleepiness, dizzy etc
Instruct the patient to finish the dose even if he feels better
For missed dose take as soon as you remember. Take next dose on the scheduled time
(II) ARTESUNATE:- Artesun
-Given as an injection only
-Artemisinin derivative and it a potent and rapidly acting schizontocide against all causes of
malaria in man. It kills all young and mature stages of malarial parasites in RBCs
P a g e | 36
Mechanism of action:- It exert mode of action is not clear
INDICATION:- Treatment of severe malaria
DOSAGE:- 2.4MG/KG at 0, 12, 24 hours then daily until oral treatment can be substituted
ADMINISTRATION:- IV OR IM ,after dilution with 5% dextrose or 0.9 sodium chloride
(1) FOR IV :- Add approx. 5ml of 5% dextrose or 0.9 sodium chloride to create a solution
containing 10mg artesunate per ml(total volume 6ml) . Then withdraw the necessary amount and
inject slowly ie 3-4 ml/min
(2) FOR IM :- Add approx. 2ml of 5% dextrose or 0.9 sodium chloride to create a solution
containing 20mg artesunate per ml(total volume 3ml) . Then withdraw the necessary amount in
to a syringe and inject.
Description: white crystalline powder
(B) 4- AMINOQUINOLINES
Made up of 2 drugs: –
(i) chloroquine (aralen).
(ii)Hydroxychloroquine (plaquenil).
- Widely used for treatment of malaria.
-Synthetic agents resemble quinine .
- Also used as amoebicides .
Action: are believed to form a complex with DNA and preventing replication of the
organism. Rapidly absorbed from GIT and widely distributed to body tissues.
USES:
Treatment of malaria.
NOTE
Only effective on erythrocytic stage it will not prevent infection.
Extraintestinal amebiasis caused by entamoeba histolytica.(hepatic abscess)
Untoward reaction: chloroquine: exacerbate psoriasis, eye toxicity
Retinopathy -blindness.
Others- Amodiaquine it resembles chloroquine
(C)8- AMINOQUINOLINE
PRIMAQUINE PHOSPHATE.
Class: antimalarial .
Action: Bind with and alter DNA and protein synthesis.
USES:
-Active against exoerythrocytic form of vivax and falciparum.
Administered with quinine and chloroquine.
Contraindications: Pregnancy, very active form of vivax and falciparum.
Side effects: Ocular neuritis , G-6-PD deficiency, arrhythmia, hypertension, abdominal cramp.
(D) QUINOLINES - METHANOLS
QUININE SULFATE
Class: antimalarial
It is a natural alkaloid derived from the bark of the cinchona
Presentation: Inj. 300mg/ml, 2ml ampoule (quinine dihydrochloride)
Tablets 300mg (quinine sulphate)
Action :
Has antimalarial , analgesic, antipyretic effects.
Relief muscle spasm.
Used increasingly, no resistance forms are found.
Its action not known, but thought to affect DNA replication.
USES:
Rx- resistant malaria.
Contraindication
tinnitus.
P a g e | 37
haemolysis/ haemoglobinuria
optic neuritis
DOSAGE
(A) IV QUININE INFUSION
ADULTS:
Loading dose: 20mg/kg (max. 1.2g) by slow iv infusion (over 4hr period) in 15ml/kg (max.
500ml) of isotonic solution (preferably 5% dextrose or 0.9 sodium chloride sol.)
Subsequent dose: 10mg/kg as above in 10ml/kg (max. 500ml ) isotonic solution. Dose is repeated
8hrly until patient improves and can take oral medication.
CHILDREN:
Loading dose: 15mg/kg by slow infusion (over 4hrs) in 15ml/kg of isotonic infusion
solution(preferably 5% dextrose or alternative 0.9 sodium chloride sol.)
(B) ORAL
ADULTS: 600mg 8hrly for 7 days
CHILDREN: 10mg/kg 8hrly for 7 days
(C) FOR IM INJECTION
In order to reduce pain & irritation , prepare a max. concentration of 50mg/ml by adding 5ml water
for injection to 1ml of 300mg/ml quinine injection (ie 300mg/6ml or 50mg/ml)
Side effects:
cinchonism (mild: tinnutus, headache, blurred vision, altered hearing, nausea. More
severe:- vomiting, diarrhoea, vertigo, confusion)
Hypersensitivity reactions eg angioedema, urticaria intense pruritus
Fever
skin rashes
hypoglycaemia
renal damage
blood dycrasias(disorders)eg thrombocytopenia intravascular coagulation)
cardiovascular effects
Others- mefloquin
SULFADOXINE/PYRIMETHAMINE(SP)
TRADE NAME:- FANSIDAR
Mode of action
Both drugs inhibit folate production and nucleic acid synthesis in sensitive microorganism
thus interfering with cell growth and division
INDICATION
Intermittent preventive treatment (IPT) of malaria during pregnancy
Dosage
Give 3 tabs in second and third trimester
give first dose between weeks 16-24
give second dose between weeks 28-36
In HIV +ve patient: give IPT on three occasion between weeks 16-36 with > 4 weeks between
doses
NOTE
1. supervise doses as directly observed therapy(DOT)
2. Record doses on the patient card and treatment register and summarize further on the
delivery book and monthly return
P a g e | 38
Contraindications
1. hypersensitivity to sulfonamides
2. severe renal impairment
3. severe hepatic impairment
4. long term prophylaxis(severe side effects)
Adverse effects
1. GIT Disturbance eg nausea ,vomiting ,stomatitis
2. Rashes ,pruritus
3. Slight hair loss
4. Steven johnson`s syndrome and toxic epidermal necrolysis
5. Hepatitis , leukopenia , thrombocytopenia, megaloblastic anaemia
6. Fatigue, fever, polyneuritis
7. Pulmonary infliltrates eg eosinophilic or allergic alveolitis
ANTI-AMOEBIC (AMEBICIDES AND TRICHOMONOCIDES)
1. METRONIDAZOLE: FLAGYL
Class: systemic trichomonocide, amebicide .
Action ; - effective against anaerobic bacteria & protozoa.
Inhibit growth of trichomona & amoeba by binding to DNA & inhibit nucleic acid
synthesis( leading to cell death) .
Well absorbed from GIT & widely distributed in tissues.
Eliminated in urine ( primarily) , 20% unchanged, hence red, brown discoloration in urine
following P.O. or I.V. use .
Uses:
A - SYSTEMIC:
amebiasis, trichomoniasis.
Amoebic dysentry
amebic liver abscess.
Septicaemia
Giardiasis
Endocarditis
to treat anaerobic infections of the abdomen following colorectal surgery, hysterectomy,
emergency appendectomy.
Contraindications:
Active organic disease of CNS.
Blood disorders
Lactation.
1st trimester of pregnancy.
Hypersensitivity.
Side effects: Dry mouth , metallic taste, diarrhea, dizziness abdominal discomfort, furry tongue,
ataxia, vertigo & leukopenea.
Dose: 500-750 mg , 3 times daily for 5-10 days.
Nursing considerations:
If used IV, drug should not be given by IV bolus.
If a primary IV fluid setup is used, discontinue the primary solution during infusion of
metronidazole.
Report any symptoms of CNS toxicity immediately e.g ataxia or tremor, which necessitate
withdrawal of drug.
The drug may turn urine brown.
Explain for the male partner , the necessity to have therapy.
OTHERS
TINIDAZOLE
P a g e | 39
ENTAMIZOLE
ANTIVIRAL DRUGS
- Viruses are obligate intracellular parasites; their replication depends primarily on synthetic
processes of the host cell.
-Therefore, to be effective, antiviral agents must either block viral entry into or exit from the cell
or be active inside the host cell.
-Most antibiotics are ineffective against viruses.
-Vaccines have been widely used to prevent certain viral infections e.g measles, small pox, polio
AGENTS TO TREAT HERPES SIMPLEX VIRUS (HSV) VARICELLA-ZOSTER
VIRUS (VZV) INFECTIONS
1) ACYCLOVIR : ZOVIRAX
Class. : Antiviral , anti-infective
ACTION
Drug is converted to acyclovir tri-phosphate which interfere with herpes simplex virus DNA
polymerase and therefore, inhibit DNA replication.
INDICATIONS
- P.O.: for initial + recurrent herpes infection in immunocompromised &
non-immunocompromised patients.
Parenteral: initial therapy of severe genital herpes, varicella zoster
infection in immunocompromised patients.
- Herpes simplex encephalitis.
- Given prophylactically to seropositive patients before bone marrow and after heart transplants to
protect such individuals during post-transplant immunosuppressive treatments.
- Topical- Limited for nonlife threatening herpes infection.
Contraindications: Hypersensitivity.
Side effects:
P.O - nausea, vomiting, anorexia, sore throat.
Parenteral - phlebitis, hypotension , skin rash.
Topical -Burning pain.
Dose:
Caps. & tabs Initial 200 mg /4 hrs for a total of 5 caps\day for 10 days.
Chronic 200 mg tid for up to 12 months.
IV infusion or ointment.
OTHERS
-VALACYCLOVIR
-FAMCICLOVIR
-PENCICLOVIR
2.ZIDOVUDINE : AZT, RETROVIR
Class: Antiviral
Uses: AIDS, Pneumocystis carinii pneumonia .
Contraindication: Allergy.
Side effect: Nausea, vomiting ,anemia, dizziness , headache malaise , diaphoresis.
ANTI-RETROVIRAL DRUGS
-Drugs used in HIV/ AIDS management
Four classes of antiretroviral agents are available:-
(1) NUCLEOSIDE NUCLEOTIDE REVERSE TRANSCRIPTASE INHIBITORS ( NRTI
Mode of action
The NRTIs act by competitive inhibition of HIV-1 reverse transcriptase and can also be
incorporated into the growing viral DNA chain to cause termination.
EXAMPLES:-
- LAMIVUDINE (3TC)
- STAVUDINE (D4T)
P a g e | 40
- ABACAVI
- DIDANOSINE (DDI)
- EMTRICITABINE
-ZALCITABINE (DDC)
-TENOFOVIR
-ZIDOVUDINE (AZT)
(2)NONNUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NNRTIs)
Mode of action
The NNRTIs bind directly to HIV-1 reverse transcriptase, resulting in blockade of RNA- and
DNA-dependent DNA polymerase
.EXAMPLES:
- NEVIRAPINE
- EFAVIRENZ
(3) PROTEASE INHIBITORS
EXAMPLES:
-AMPRENAVIR
- ATAZANAVIR
- FOSAMPRENAVIR
- INDINAVIR
(4) FUSION INHIBITORS
Mode of action
-It is a fusion inhibitor that blocks entry into the cell
EXAMPLE:
-ENFUVIRTIDE
CHEMOTHERAPY
ANTINEOPLASTIC OR CYTOTOXIC ( CELL POISONS) DRUGS
Toxic and interfere with the growth of normal as well as abnormal cells specially rapidly
growing cells e.g bone marrow, GI mucosal epithelium & hair follicles.
SIDE EFFECTS:
Bone marrow depression
leukopenia
thrombocytopenia
anemia.
alopecia.
G.I -nausea, vomiting, stomatitis.
GENERAL NURSING CONSIDERATIONS FOR ANTINEOPLASTIC AGENTS:
Administration:
Should be prepared by trained personnel.
Prepared away from cooling or heating vents & other people.
Use latex gloves to protect skin.
Wash hands before and after preparation.
Wear non-permeable surgical gown , close front , fit knit cuffs.
Use piggyback setup with electronic infusion pump.
Start infusion with solution not containing vesicant agent.
If possible, not use dorsum of the hand , wrist & cubital fossa, as a site of infusion & previously
used sites.
After starting unmedicated solution, check for blood return, pain, redness and edema.
Instruct client to report pain, redness, and edema during & after treatment.
Intake and output monitoring.
P a g e | 41
Report any extravasation to physician & follow policy to minimize effect.
Dose:
- P.O. 3-5 mg bid –tid.
- I.M. 2-5 mg q 4-8 hrs.
- In sever situations: I.V. 2-25 mg every 30 minutes.
SIDE EFFECTS:
Headache
tardive dyskinesia,
hypotension,
dry mouth
photosensitivity,
skin rashes,
G.I.T-Nausea, vomiting, and constipation.
CONTRAINDICATIONS:
Pregnancy
Lactation
Shock
Bone marrow depression
Hepatic & renal insufficiency.
NURSING CONSIDERATIONS:
Monitor vital signs before & during therapy.
Administer oral medication with food.
Administer IM deep into large muscle.
Don’t mix it with any other drugs.
If concentrated drug is spilled on skin, wash it immediately to prevent
dermatitis.
A) ALKYLATING AGENTS:
ACTION
Are highly reactive in that under physiologic conditions they donates an alkyl group to
biologically important molecules as DNA.
(i) CARBOPLATIN
Class: antineoplastic, alkylatig agent.
USES : ovarian cancer.
Add. Side effects: neurotoxicity, nephrotoxicity.
(ii) BUSULFAN
Class: antineoplastic, alkylating agent.
USES
leukemia.
(iii) CYCLOPHOSPHAMIDE
Class: antineoplastic, alkylating agent.
INDICATIONS
multiple myeloma
malignant lymphomas
Hodgkin’s disease.
Add. Side effects:
alopecia,
bone marrow depression,
hemolysis
cystitis
P a g e | 42
darkening of skin & fingernails.
(iv) IFOSFAMIDE
Class.: antineoplastic, alkylating agent.
INDICATIONS
acute leukemia,
testicular cancer,
malignant lymphomas.
Add. Side effects: hemorrhogic, cystitis.
(B). ANTI-METABOLITES
Action: Disrupt DNA replication by interfering with an essential step in its synthesis and
metabolism.
(i) CYTARBINE
Class: antineoplastic , antimetabolite.
INDICATIONS
acute myelocytic leukemia
Hodgkin’s lymphoma.
Add. Side effects: cytarbine syndrome occurs 6-12 hours following administration
manifested by myalgia, fever, and bone pain.
(ii) 5- FLUROURACIL
Class: antineoplastic, antimetabolite.
Uses:
systematic: for cancers of stomach , rectum, colon.
Topical: for mucosal leukoplakia. (Ointment).
(iii) METHOTREXATE
CLASS:- antimeabolite, folic acid analog.
Action: similar to sulfonamide .
Uses:
uterine choriocarcinoma
vesicular mole
leukemia.
In low doses for treatment of rheumatoid arthritis. Action not known .
Note : leucoverin is given as soon as possible to minimize side effects.
Side effects: severe bone marrow depression , hepatotoxicity, hemorrhagic entertis,
transient paresis or seizures.
Given intravenously and intrathecally.
C) ANTI-TUMOUR ANTIBIOTICS
All of the anticancer antibiotics now being used in clinical practice are products of various
strains of the soil microbe Streptomyces.
These include the anthracyclines, dactinomycin, bleomycin, and mitomycin
ACTION
Interfere with RNA, DNA cell replication.
o Bleomycin
o Dactinomycin eg actinomycin D .
o Adriamycin.
o anthracyclines eg doxorubicin
P a g e | 43
o Mitomycin eg mitomycin C
D) PLANTS ALKALOIDS
(I) CISPLATIN:
Class.: antineoplsstic, miscellaneous.
Side effect: Severe nausea and vomiting.
Note: Hydrate patient by I.V. fluids 8-12 hours before treatment.
Zoforan (antiemetic) is to be given to relief nausea and vomiting.
Iron Preparations:
A complex of iron and other substances are normally taken orally.
Sometimes administered parenterally when:-
(i) Some disorders limiting the amount of drug absorbed by GIT.
(ii) Patient is unable to tolerate oral iron.
Iron deficiency is common in infants (low iron in diet), during puberty in girls and
during pregnancy (increased requirements).
ACTION: Iron (diet or drug) absorbed from GIT and transported to bone marrow after
combining with protein transferrin, to incorporate with hemoglobin.
USES/INDICATIONS:- prophylaxis and treatment of iron deficiency anemia.
CONTRAINDICATIONS: Hemosiderosis , peptic ulcer , enteritis, ulcerative colitis and
liver cirrhosis.
DRUG INTERACTIONS:
- Antacids - decrease absorption of iron.
- Tetracycline -diminish affect of tetracycline absorption.
SIDE EFFECTS: constipation, gastric irritation, and abdominal cramps.
Toxic reaction: (parenteral) nausea, vomiting, peripheral vascular collapse. Occur
within 60 seconds of toxic dose. Symptoms may disappear then reappear after 6-24
hours.
NURSING CONSIDERATIONS:
Take a complete history, including use of antacids.
Ask about any evidence of GI bleeding.
Advise client to take iron with meals to reduce gastric irritation.
Take iron with citrus juices to enhance absorption.
Advise client not to take iron with milk or antacids.
Encourage client to eat a well balanced diet.
Keep drug out of reach of children (extremely toxic) .
When administering iron to child, dilute it with water or fruit juice & use a straw to
minimize teeth staining .
P a g e | 44
Discuss with client the possibility of indigestion, changes in stool color (black) and
constipation.
P a g e | 45
Initial dose of 10mg for 2 days
CONTRAINDICATIONS:
Hemorrhagic tendencies - Blood disorders.
Ulcerative lesion of GIT.
Impaired renal and hepatic function.
Severe hypertension.
Thrombocytopenia.
SIDE EFFECTS:- hemorrhagic accidents.
ANTIDOTE:- vitamin K .
NOTE: Because of its slow action warfarin is started 48hrs before discontinuation of
heparin
NURSING CONSIDERATIONS:
Daily monitoring of prothrombin time is recommended.
Instruct clients to take the drug before meal.
Remind clients to wear identification band that states that they are on anticoagulant
therapy.
Advise client to avoid activities that may cause injury.
Vitamin K should be available
Food rich in vitamin K should be avoided.
HEPARIN:
Class: anticoagulant
Naturally occurring substance isolated from porcine intestinal mucosa or bovine lung
tissue.
Must be given parentally.
Doesn’t interfere with wound healing.
ACTION: Potentiate (aid) the inhibitory action of antithrombin III on various coagulation
factors.
Inactivate thrombin and prevent the conversion of fibrinogen to fibrin.
USES:
To prevent extension of clots.
To prevent thrombi and emboli from recurring.
Prophylactic from thromboembolic diseases.
After some types of surgery ( cardiac & vascular) .
Prevent clotting during hemodialysis .
Treatment of DIC ( disseminated intravascular coagulation)
coronary occlusion after MI.
CONTRAINDICATIONS:
Blood disorders with bleeding tendencies ( hemophilia) .
Suspected intracranial hemorrhage.
Open wounds.
During surgery of the eyes, brain and spinal cord.
Menstruation.
Abortion.
SIDE EFFECTS: Hemorrhage.
OVERDOSE: nose bleeds , hematuria, petechiae , tarry stool.
ANTIDOTE: protamine sulfate.
Dose: IV or S.C measured in units according to bleeding & clotting time.
P a g e | 46
Between 5000iu - 10000iu
NURSING CONSIDERATIONS:
Should not be administered IM, administer by deep sc to minimize local irritation and to
prolong the action of drug.
Don’t massage before and after injection.
Change site of administration.
Instruct and stress the importance of reporting any signs of active bleeding.
Use electric razor for shaving, soft bristle tooth brush to decrease gum irritation.
Patient should be hospitalized for IV therapy.
Clotting time, PTT should be done before the start of therapy each dose of drug then
daily.
(B) HEMOSTATICS
SYSTEMIC AGENTS:
1.ANTI-HEMOPHILIC FACTOR A:( AHF FACTOR VIII.)
-A Deficiency of factor VIII is the cause of hemophilia A
-The dose of the factor is based on the degree of deficiency , patient`s weight and bleeding
severity.
Class: systemic haemostatic.
Uses: hemophilia A (deficiency of factor VIII)
CARDIAC DRUGS
GLYCOSIDES
Digoxins are plant alkaloids.
They increase myocardial contractions, which will increase blood supply to all organs
including the kidneys therefore causing diuresis, which will decrease the edema.
They are used to treat cardiac arrhythmia because they decrease heart rate.
Action:
They increase the force of myocardial contractions (positive inotropic).
It increase the contractility of the heart muscle by minimizing the movement of Na and K
ions and increasing the release of Ca ions in the myocardial cells.
It decreases the heart rate due to increase in parasympathetic nervous system and
decrease in the sympathetic tone.
They are primarily excreted through the kidneys.
The initial dose is the larger dose (the loading or digitalizing dose), the subsequent doses
are referred to as (Maintenance doses).
P a g e | 47
Results:
Decrease in venous pressure.
Coronary dilatation.
Reduce heart size.
Marked diuresis and decreasing edema.(because of increased blood flow through the
kidneys)
Indications:
1. Congestive heart failure (C.H.F).
2. Cardiac arrhythmia (atrial fibrillation, atrial flutter and sinus tachycardia.
Contraindication:
1. Hypersensitivity.
2. Angina pectoris in absence of CHF.
3. Given with caution for elderly and people who have kidney failure.
Side effects:
1. My cause cardiac arrhythmia such as bradycardia (below than 60 beat /minute),
ventricular fibrillation (which may lead to cardiac arrest and death), and Bigeminal
rhythm.
2. Nausea, vomiting, and diarrhea.
3. Headache, malaise and muscle weakness.
4. Skin rashes
5. blurring of vision, diplopia.(double vision)
6. drowsiness
7. Confusion
8. Hallucinations
Note They are extremely toxic and may cause death.
here is a narrow margin of safety between the therapeutic dose and the toxic dose.
Could cause overdose by cumulative effects of the drug so frequent assessment of the
serum level is essential.
NURSING CONSIDERATIONS:
Check doctor’s order, medication record and bottle label accurately.
Observe monitor for evidence of bradycardia or arrhythmia.- i.e pulse/E.C.G
Measure intake and output accurately.
Weigh the patient in daily basis.
Do not administer digoxin before confirming the pulse rate, and if less than 60 beats per
minute then do not give the drug.
Pulse should be checked by 2 nurses.
Provide the client with foods high in potassium as banana, orange.
Monitor serum digoxin level.
Elderly people should be assessed for early signs of toxicity.
Have digoxin antidote available (digoxin immune FAB).
CARDIAC DRUGS
DRUGS
P a g e | 48
1.DIGOXIN:crystodigin
-It is the oldest cardiac stimulant(Used first in 1785)
-Obtained from the leaf of foxglove
CLASS: cardiac glycoside
USES: drug of choice for maintenance in CHF
DOSE: digitalizing dose is 0.5 mg in 4-6 hours.
maintenance: 0.125 – 0.75 mg/day.
NB/- Individualized, paediatrics doses different
2. DIGOXIN IMMUNE FAB: (OVINE)
CLASS: digoxin antidote.
ACTION: antibodies bind to digoxin and excreted through the kidneys.
INDICATION -life threatening digitalis toxicity or overdose.
Note: cardiac arrest can be expected if an adult ingests 10 mg or if a child ingests 4 mg.
ANTI-HYPERTENSIVE
Hypertension: is a condition in which the mean arterial blood pressure is elevated.
Essential hypertension: could be mild, moderate, or sever and may lead to dangerous
changes in kidneys, eyes and blood vessels.
Secondary hypertension: a certain disease or condition leads to elevation of blood
pressure such as toxemia or pregnancy, acute kidney failure, etc.
Anti-hypertensive agents: are initiated when diastolic blood pressure is higher that
90mm/Hg.
Treatment of hypertension includes:
1. weight reduction.
2. Sodium restriction.
3. Alcohol restriction.
4. Stop smoking.
5. Exercise.
6. Behavior modification.
Single drug should be considered from the following classes:
1. Diuretics.
2. Beta-blocking agents.
3. Calcium channel blocking agents.
4. Angiotesin converting enzyme inhibitors.
Initial therapy is continued for one month. If there is no response, combination therapy is
needed.
NURSING CONSIDERATIONS:
Determine base line blood pressure before starting antihypertensive treatment.
Evaluate the extent of the client’s understanding of the disease and the therapy.
Ascertain lifestyle changes.
Determine client’s ability to take his BP measurement.
Record significant changes in BP readings.
Advise client to adhere to low sodium diet.
Explain the importance of adhering to treatments plan.
Teach the patient/family how to measure intake and output
P a g e | 49
(i) NIFEDIPINE:( ADALAT)
CLASS: calcium channel blocking agent (anti-angina, antihypertensive).
INDICATIONS:
1. Angina Pectoris,
2. Hypertension
CONTRAINDICATIONS: hypersensitivity, lactation.
SIDE EFFECTS: pulmonary and peripheral edema, MI, hypotension, headache, muscle
cramps.
Dosage: 10- 30 mg tid.
In hypertensive emergencies: 10-20 mg given orally or sublingually by puncturing the
capsule and squeezing contents under the tongue.
CAPTOPRIL:
Trade name: Capotin..
Calss: antihypertensive, inhibitor of angiotensin synthesis.
Action:
- captopril is a highly specific competitive inhibitor of angiotensin I
converting enzyme.(The enzyme is responsible for the conversion of
angiotensin I to angiotensin II which increcrease BP)
Indications:
1. Hypertension.
2. In combination with diuretics and digitalis in the treatment of CHF.
Contraindication:
1. Hypersensitivity
2. renal-vascular disease
3. pregnancy.
P a g e | 50
Side effects:
Skin rash, loss of taste, neutropnea, nausea, vomiting, hypotension, proteinuria, renal
failure and hyperkalemia.
Dosage:
Tablets: - 12.5 mg 2-3 time per day.
- If there is no response, after 1-2 weeks, increase dose
to 25 mg 2-3 times per day.
Nursing considerations:
1. In case of overdose, give normal saline to restore BP.
2. Should not be discontinued without Dr. order.
3. Obtain baseline hematological studies, liver & renal functions
tests prior to beginning the treatment.
4. Determine client’s understanding of the therapy and if he/she
takes other medications.
5. Observe client closely for hypotension 3 hours after the initial
dose.
6. In case of hypotension, place client in supine position and give
IV saline infusion.
7. Withhold potassium sparing diuretics and consult with
physician (hyperkalemia may occur).
8. Take captopril 1 hour before meal or on an empty stomach.
9. Report skin rash, heartburn, and chest pain to physician.
10. Explain to client that he may develop loss of taste for 2-3
months, if it persist, notify the physician.
ATENOLOL:
Trade name: Normatin.
Classification: Beta-adrenergic blocking agent/ Antihypertensive
INDICATIONS
-Hypertension
-angina pectoris.
Dosage:
Tablets: 50 mg or 100 mg daily
Initial dose is 50 mg, if there is no response, increase dose to 100 mg daily.
VALOLOL:
Trade name: Corgard
Class: Beta-adrenergic blocking agent.
Action: manifests both beta 1 and beta 2 adrenergic blocking.
Uses: hypertension, angina pectoris.
Dose: 40-80 mg daily.
PROPRANOLOL HYDROCHLORIDE
Trade name: Inderal, Deralin
Classification: beta-adrenergic blacking agent.
Action: manifests both beta1 and beta 2 adrenergic blocking activity.
Indication:
1. . Angina pectoris. 4. . Prophylaxis of
migraine.
2. Hypertension. 5. . Prophylaxis of MI.
3. . Cardiac arrhytmias.
6. . Pheochromocytoma
TEMOLOL MALEATE:
P a g e | 52
Trade name: Blocadren, Timpotic.
Classification: Ophthalmic agent, beta-adrenergic agent.
Action: both beta1 and beta 2 receptors blocking activity.
Uses:
Tablets: for hypertension.
Ophthalmic solution:- chronic open angle glaucoma.
METHYLDOPA :-
-Trade name:-( Aldomin/ Aldomet )
-Classification:- Antihypertensive ( centrally acting antiadrenergic agent )
-Action:- The active metabolite alphamethylenorepinephrine lowers
BP by stimulating central inhibitory alpha-adrenergic
receptors.
-Uses:- Hypertension & hypertension crises (parenteral).
-Contraindications:-
1.Hypersensitivity,
2.Active hepatic diseases.
3.Pregnancy.
4.Pheochromocytoma.
-Side effects:-
- Headache, dizziness, general weakness, depression and sedation(c.n.s).
- Bradycardia, orthostatic hypotension.
- Dry mouth, nausea, vomiting, sore (black) tongue
- Jaundice, liver disorders.
- Hemolytic anemia, & leukopenea.
- Male impotence.
-Dosage:-
Tabs. :- initially 250 mg bid or tid.
-NURSING CONSIDERATIONS:-
1. Avoid activities that need mental awareness such as driving.
2. Note any evidence of jaundice and do liver function test on intervals..
3. Advise pt. to rise from the bed slowly.
4. Instruct pt. about reportable Signs & Symptoms
5. Explain to pt. that urine rarely may be turn into dark / blue color.
6. 6.Advise client to carry a card detailing current medication regimens always.
HYDRALAZINE HYDROCHLORIDE:-
-Trade name:- ( Apresoline )
-Classification:- Antihypertensive, direct action on vascular smooth muscles.
-Action:- directly affect vascular smooth muscles vasodilation, cardiac output and finally
blood flow to the brain and kidneys.
- Uses:- used with combination therapy to treat hypertension.
-Given parenterally in hypertension emergencies.
P a g e | 53
CONTRAINDICATIONS:-
Angina pectoris.
Rheumatic heart disease.
Chronic glomerulonephritis.
Systemic lupus erthymatosis (S.L.E.)
Side effects:-
-Orthostatic hypotension,
tachycardia,
nausea, vomiting.
-Headache, dizziness, constipation and male impotence.
-Dosage:-
-Tabs. : initially 10 mg qid for 2-4 days, then 25 mg bid
-I.V, I.M :-10 mg (IV slowly) repeated as necessary,( may decrease Bp minutes.)
BARBITURATES:
Phenobarbital :
Class: sedative- anticonvulsant- barbiturate.
-Barbiturates are absorbed orally and distributed widely throughout the body.
-All barbiturates redistribute in the body from the brain to the splanchnic areas, to
skeletal muscle, and adipose tissue.
-They readily cross the placenta and can depress the fetus.
-Barbiturates do not raise the pain threshold and have no analgesic properties.
They may even exacerbate pain.
-. Chronic use leads to tolerance
Excretion and metabolism
-Barbiturates are metabolized in the liver, and inactive metabolites are excreted in the urine.
Action:
- The sedative-hypnotic action of the barbiturates is due to their interaction with GABA A
receptors, which enhances GABAergic transmission.
- The binding site is distinct from that of the benzodiazepines.
- Long-acting barbiturate- act as a sedative- hypnotic and anticonvulsant by producing
CNS depression.
- It increase the inhibitory activity of the nerve synapses.(enhances effect of GABA.
EFFECTS OF BARBITURATES
1. Depression of CNS:
At low doses, the barbiturates produce sedation (calming effect, reducing
excitement).
At higher doses, the drugs cause hypnosis, followed by anesthesia (loss of feeling
or sensation), and finally, coma and death.
Thus, any degree of depression of the CNS is possible, depending on the dose
2. Respiratory depression:
P a g e | 54
Barbiturates suppress the hypoxic and chemoreceptor response to CO2, and
overdosage is followed by respiratory depression and death.
3. Enzyme induction:
Barbiturates induce P450 microsomal enzymes in the liver. Therefore, chronic
barbiturate administration diminishes the action of many drugs that are dependent
on P450 metabolism to reduce their concentration
USES:
1- Pre-anesthetics medication.
2- Sedation
3- Hypnotic
4- Epilepsy
5- in tetanus & eclampsia ( as anticonvulsant) .
N.B.: should be given parenteral for anticonvulsant effect.
CONTRAINDICATION: Hypersensitivity.
SIDE EFFECTS:
1. Headache 5. hypotension
2. fever 6. nausea
3. megaloblastic anemia 7. vomiting
4. dizziness 8. epigastric pain
Forms and Dose:
Tablets 30mg,100mg,ampules 60, 130mg in 1 cc
Sedation: 30-120 mg daily in 2-3 divided doses.
For adults: Hypnotic 100-320 mg at bed-time.
Anticonvulsant: I.V. 100-320 mg, repeated as necessary.
Preoperative sedation: I.M. only 130-200 mg – 60-90 minutes before surgery.
N.B: Luminal can be used in neonates as antihyper- bilirubinemia.
Over dose:
Manifested by tachycardia , hypothermia, coma, respiratory
depression , absent reflexes & circulatory collapse respiratory
relaxation unseals and vascular collapse.
TREATMENT OF OVERDOSE TOXICITY( BARBITUARATE POISONING):
1. Maintain & assist respiration as indicated.
2. Support circulation by vasopressor & I.V. fluids as required.
3. Aspirate stomach content, take care to avoid pulmonary aspiration.
4. Diuretics may be given as ordered.
5. Intake & output measurement.
6. Dialysis if indicated.
Nursing considerations:
1. .If given I.V, closely monitor the rate of flow. Rapid administration may lead to respiratory
depression.
2. Monitor the site of I.V. for signs of extravasations which cause severe pain, nerve damage &
necrosis.
3. .Avoid the use of alcoholic beverages.
4. .Instruct the client not to drive a car or operate other hazardous machinery after taking the
medication .
5. .Take the medication only as prescribed.
6. If used for hypnotic effect, give ½ hr before bedtime.
7. Teach patient about sings and symptoms of toxicity, and instruct patient to report them to
treating physician.
P a g e | 55
8. If taken for 8 weeks or more, instruct patient not to stop it suddenly to avoid withdrawal
symptoms as convulsion.
9. Keep the drug out of reach of the children.
Other barbiturates:- Thiopental, secobarbital, pentobarbital, Amobarbital
DIAZEPAM:
Trade name: Valium
Class: anti-anxiety agent, benzodiazepine.
Action:
-inhibit CNS neurotransmitter.
-The anxiolytic effect is believed to be mediated through the action of benzodiazepine to
increase the inhibitory action of GABA “Gamma aminobutyric acid”
.-The drug is metabolized in the liver & excreted through urine.
Indications:
1. Symptomatic relief 6. Before gastroscopy
of anxiety & tension. or esophagoscopy.
2. Alcohol withdrawal. 7. Treatment of status
3. Muscle relaxant. epilepticus .
4. Anticonvulsive. 8. Relief of facial
5. Preoperatively. muscle spasm
NOTE
CONTRAINDICATIONS:
1. Hypersensitivity.
2. Acute narrow angle glaucoma.
3. Pregnancy.
4. Shock, coma.
5. Alcoholic intoxication (to avoid respiratory of depression).
SIDE EFFECTS:
-
1. Drowsiness 5. visual disturbances
2. fatigue 6. headache
3. ataxia 7. phlebitis at injection site
4. hypotension
P a g e | 56
8.Anterograde amnesia:- The temporary impairment of memory( mediated by GABAA
receptors). This also impairs a person's ability to learn and form new memories
DOSAGE:
Ampules of 2 ml containing 10 mg.
-Tablets 2 mg, 5 mg or 10 mg.
-I.V. or I. M. 2-20mg depenoling on the indication.
-Tablets 2-10 mg 2-4 times daily.
Nursing Considerations:
- Stress that drug may reduce pt’s ability to handle dangerous equipment.
- Avoid alcohol ingestion.
- Don’t stop taking the medication suddenly, withdraw drug gradually.
- Monitor B.P. before & after administration.
CHLORPROMAZINE:
Trade name: largactil
Class: Antipsychotic, phenothiazine.
ACTION:
-Act by blocking dopamine receptors.
-It has significant antiemetic effect, hypotensive, sedative & anticholenergic effect.
USES/ INDICATION
- Acute & chronic psychosis (such as schizophrenia, mania & manic depression.
- Pre-anesthetic .
- Intractable coughs.
- Nausea & vomiting.
CONTRAINDICATION:
- Severe depression, coma.
- Bone marrow depression.
- Patients with history of seizures & on anticonvulsant therapy.
- Hepatic & renal diseases.
- Prostatic hypertrophy.
- Dehydration - glaucoma , measles.
SIDE EFFECTS:
-Depression -hypotension -leukopnea
- dizziness -bronchospasm -aplastic anemia
- seizures - larngospasm -dry mouth.
- gynaecomastia. - tardive dyskinesia
-Orthostatic - photosensitivity,
DOSE:
Tablets 10-25 mg 2-4 times a day.
I.M. 25-50 mg repeated after 1 hour if needed.
NURSING CONSIDERATIONS:
- Shouldn’t be used to treat nausea & vomiting in children less than 6 months of age.
- Should avoid getting solution on hands or clothing (it will cause dermatitis).
- Solutions with marked discoloration should be discarded.
- Note any history of seizures.
- Take liver & kidney function test periodically.
P a g e | 57
- Document & rotate injection sites.
- Report side effects immediately.
- Determine age of male patients & assess for prostatic hypertropty.
FLUPHENAZINE DECANOATE:
Trade name: modicate.
Class: antipsychotic, phenothiazine.
ACTION:
- is accompanied by a high incidence of extra-pyramidal symptoms &
low incidence of sedation, anticholenergic, antiemetic & orthostatic
hypotension.
USES:
- Psychotic disorders.
- For chronic pain in conditions such as diabetic neuropathy & patients trying to withdraw
from narcotics.
DOSES:
P.O. or I.M.
Tablets : 2.5 – 10 mg / day in divided doses (3-4 times).
I.M.: 12.5 –25 mg can be repeated /1-4 weeks.
HALOPERIDOL
Trade name: Haldol
Class.: antipsychotic.
Action:
- Block dopamine receptors ( sedation ).
- Alpha-adrenergic blockade ( the release of growth hormone & the release of prolactine).
- Anticholenergic effect, sedation & orthostatic hypotension.
USES:
- Psychotic disorders such mania, schizophrenia
- Drug induced psychosis.
- Agressive & agitated patients. (mental retardation)
SIDE EFFECTS
-ECG changes - nausea - leukocytosis
- anorexia - vomiting - slurred speech .
- dry mouth - polyuria
- In case of toxication (blood level over 2.0 mmol/L): hyper-reflexia and
hyperextension of limbs, convulsions, toxic psychosis, syncope, oliguria, circulatory
failure, and coma.
CONTRAINDICATIONS:
- Cardiovascular - Pregnancy & - Patients receiving
- renal diseases. lactation. diuretics.
-Brain damage. - Dehydration. - Sodium depletion
NURSING CONSIDERATIONS:
- Monitor serum level of lithium every 1-2 weeks to prevent toxicity (normal level is 0.4 -
1.0 mmol/L and toxic level is above 1.5 mmol/L).
- Monitor for pulse irregularities & changes in B.P.
- Provide diet adequate in sodium.
- Monitor for signs & symptoms of toxicity.
P a g e | 58
- Avoid factors that enhance toxicity: dehydration, renal failure, infection, co-
administration of diuretics, and sodium depletion (may occur with diuretics).
- Maintain adequate fluid and sodium levels.
- Withdrawal (stopping) drug should be gradual (over weeks)
ANTIDEPRESSANTS
TRICYCLIC ANTIDEPRESSANTS
ANTICONVULSANTS
1.PHENYTOIN SODIUM:
Trade name: Dilantin
Class: anticonvulsant .
Action: acts in the motor cortex of the brain to reduce the spread of electrical
P a g e | 59
discharges from the rapidly firing epileptic foci in this area. Also activity of
centers in the brain stem responsible for the tonic phase of grand mal seizures.
USES:
-Chronic epilepsy.
Contraindications:
Hypersensitivity.
SIDE EFFECTS:
-Drowsiness - measles-like rash -Hirsutism (excessive
-ataxia -gingival hyperplasia hair growth)
-dizziness - hypoglycemia.
N.B : - rapid I.V. administration Hypotension & arrhythmia.
DOSE:
Tabs 200-400 mg daily in divided doses.
I.V. 100 mg every 5 minuets up to a maximum of 1g.
NURSING CONSIDERATIONS:
1. I.V. phenytoin may forms a precipitate, so flush tubing by saline (not dextrose)
before & after administration.
2. Assess for hypersensitivity.
3. If a pregnant woman takes this drug, tell her not to breast-feed her baby.
4. Obtain liver & kidney function studies.
5. Monitor serum drug levels on a routine basis.
6. During I.V. therapy, monitor B.P. for signs of hypotension .
7. Takee food to minimize GI upset.
8. If the patient is diabetic, monitor for signs of hypoglycemia.
9. Oral hygiene to minimize bleeding from the gum.
10. Report any excessive growth of hair
2 CARBAMAZEPINE:
Trade name: tegretol
Class.: anticonvulsant.
Action:
- semilar to Trcyclic antidepressant.
- antimanic , antidiuretic, anticholinergic & antipsychotic effects.
- nticonvulaant action unknown.
USES:
-Epilepsy - tonic-clonic seizures
-alcohol-withdrawal
- resistant schizophrenia.
- trigeminal neuralgia.
DOSE :
-P.O. 200 mg bid.
-Trigeminal neuralgia : 100-200 mg bid.
SIDE-EFFECTS:
-Photosensitivily
- Drowsiness - unsteadiness. -nausea& vomiting
-dizziness -Aplastic anemia - blurring of vision
.
CONTRAINDICATIONS:
- Bone marrow - Hypersensitivity - Patients taking
depression. - Lactation - MAO inhibitor
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.
NURSING CONSIDERATIONS:
- Should be taken with food.
- Obtain baseline liver & kidney function.
- Protect tablet from moisture.
- Obtain baseline eye examination.
- Blood cells evaluation weekly .
- Monitor intake & out put.
- Use safety measures.
- Advise client to avoid sunlight. (photosensitivity)
4 MAGNESIUM SULFATE
Class: Anticonvulsant, electrolyte.
ACTION:
- Magnesium depresses CNS & control convulsion by blocking the release of
acetylcholine at the myeloneural junction
- It is an important cation present in the extracellular fluid.
- It is an essential electrolyte for muscle contraction, certain enzyme system & nerve
transmissions.
USES:
- Seizures associated with toxemia of pregnancy.
- Epilepsy
- laxative
- Hypomagnesemia
- In total parenteral nutrition
CONTRAINDICATIONS:
- In the presence of heart block.
- In the presence of myocardial damage.
SIDE EFFECTS:
Magnesium hypotension muscle
intoxication respiratory paralysis
depression paralysis respiratory
flushing failure
P a g e | 61
- Check with the physician before administering magnesium if any of the following
conditions exist:
1. Absent patellar or knee jerk reflex.
2. R.R. less than 16\m
3. Urinary output less than 100 ml\4 hrs .
4. Patient has a history of heart block or myocardial damage.
- Have available I.V. calcium gluconate .
- Don’t administer drug 2 hrs preceding delivery of the baby.
- If mother has received I.V. therapy of this drug 24 hours prior to delivery, assess the
newborn for neurologic & respiratory depression.
- Drugs such as aspirin and acetaminophen are available without a prescription, thus
consumed in large quantities for the relief of pain and fever.
- If they were used improperly, their administration may cause serious effects.
- They are responsible for accidental poisoning in small children.
ACETAMINOPHEN: “PARACETAMOL”
Trade names: acamol, panadol
Class. : non-narcotic analgesic, para-aminophenol type.
Action:
- Acetaminophen decrease fever by an effect on hypothalamus leading to sweating &
vasodilation.
- It also inhibits the effect of pyrogens on the heat-regulating center on the hypothalamus.
- It may cause analgesia by inhibiting CNS prostaglandin syntheses -
has no anti-inflammatory effect .
- It doesn’t manifest any anticoagulant effect or any ulceration of GIT.
USES:
- Pain due to Headache, dysmenorrhea, arthralgia, myalgia, muscluoskletal pain,
immunization, teething, tonsillectomy.
- To reduce fever due to bacterial & viral infection .
- As a substitute for aspirin when contraindicated .
CONTRAINDICATIONS: renal insufficiency, anemia.
SIDE EFFECTS:
- Skin rashes - jaundice
- fever - hypoglycemia
- Chronic & even acute toxicity can occur after long symptom-free usage.
- Heamolytic anemia, neutrotopnea, thrombocytopnea
.
P a g e | 62
1. Induction of emesis
2. Gastric lavage.
3. Activated charcoal.
4. Oral N-acetylecystine (mucomyst) is said to reduce or prevent hepatic damage by
inactivating acetaminophen metabolites which cause liver effects.
Dose: Tab. 500 mg Q 4 hrs or up to 1g Q 6 hrs.
Nursing considerations:
1- Suppositories should be stored below 27c .
2- Liver function studies for long term therapy.
3- Note signs of met-hemoglobinemia: bluish discoloration of gum & fingernails.
4- Have mucomyst available for signs of toxicity.
5- Teach patient signs of toxicity to be reported immediately.
ACTION:
-Inhibition of the enzyme cyclo-oxygenase which results in decreased prostaglandin
synthesis ,so it is effective in :
Reducing joint swelling, pain & morning stiffness.
Increasing the mobility in arthritic patients.
Antipyretic action due to decreased production of prostaglandin from the
hypothalamus.
Having irritating effect on the GIT.
USES :
Rheumatoid arthritis
Osteoarthritis.
Gout
Other musculoskeletal diseases.
Dental pain
Strains & sprains.
Contraindications:
1- Children less than14 years of age.
2- Lactation.
3- Hypersensitivity (asthma, rashes, rhinitis).
Uses with caution in patients with a history of GI disease & reduced renal functions.
Side effects:
1. Peptic, duodenal ulcer, GI bleeding nausea, vomiting, dyspepsia.
2. Dizziness, drowsiness.
3. Hypo + hyperglycemia.
4. Bronchospasm, rhinitis.
5. Blurring of vision.
6. Tinnitus , loss of hearing.
7. Bone marrow depression
8. C.H.F.
NURSING CONSIDERATIONS:
1. Note any history of allergic responses to aspirin or non-steroidal anti-inflammatory
agents. {NS.AID.}
2. Note the age of the client.
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3. Determine if patient is taking oral hypoglycemic or insulin and document it.
4. Take these agents with milk or meal or antacids as prescribed.
5. Encourage patient to take drug regularly.
6. Report signs of GI irritation.
7. Instruct client to report signs of bleeding, blurring of vision, tinnitis , rashes – etc.
8. If the client has Diabetes Mellitus, explain the possible in increasing hypoglycemic
effect of the drugs, to test urine & blood for glucose. To adjust dose of these agents.
1) DICLOFENAC SODIUM:
Trade name: Voltaren
Class. : Non steroidal anti-inflammatory analgesic.
Dose: Suppositories, tabs or injection of 150-200 mg daily in 2-4 divided doses.
NURSING CONSIDERATIONS:
1. Give on full stomach to avoid GIT irritation.
2. When given IM, Give it deep into a large muscle because drug is very
irritant.
2) INDOMETHACIN:
Trade name : Indocid.
Class. : Anti-inflammatory, analgesic, antipyretic.
Dose: suppositories & caps.
25mg – 50 mg bid-tid.
3) NAPROXEN:
Trade name: Naprex.
Class.: Non- steroidal anti-inflammatory analgesic.
Dose: 500 mg bid.
4) IBUPROFEN:
Trade names: Brufen, artofen.
Class.: non-steroidal anti-inflammatory analgesic.
Dose: 400 mg bid.
SALICYLATES:
Acetylsalicylic Acid:
Trade name: Aspirin
Classification:
Non-narcotic analgesic, antipyretic, anti-inflammatory, anti-Rheumatic, anti-platelet,
NSAID.
Action:
- inhibition of the enzyme cyclo-oxygenase (COX. 2) which results in decreased
prostaglandin synthesis.
- The antipyretic effect is due to an action on the hypothalamus that results in heat loss by
vasodilation of peripheral blood vessels & promoting sweating.
- The anti-inflammatory effects probably by decreasing prostaglandin synthesis & other
mediators of the pain response.(inhibit COX. 2)
- The analgesic action is not fully known but may be due to improvement of the
inflammatory condition .
N.B. : Aspirin also produces inhibition of platelet aggregation.
P a g e | 64
USES:
- Pain
- Myalgia
- Arthralgia
- Headache
- Dysmenorrhea
- Antipyretic (reduce fever)
- Anti-inflammatory (arthritis, gout, rheumatic fever)
- To reduce the risk of recurrent ischemic attacks & strokes.
- Reduction of risk of death or non-fatal MI in patients with history of infarction or
unstable angina pectoris.
DOSE:
- In minor conditions: 325-600 mg every 4 hours.
- May reach up to 6 grams /day in divided doses in arthritis and rheumatic conditions.
CONTRAINDICATIONS:
- Hypersensitivity to salicylates.
- Asthma in conjunction with anticoagulant therapy.
- Vitamin deficiency (risk for bleeding increase with Vitamin K deficiency).
- Chickenpox or influenza (potential risk for Reye’s syndrome among children and
teenagers).
- Pregnancy and lactation.
- One week before & after surgery.
- Patients receiving anticoagulants.
- Patients with bleeding disorders (ie, hemophilia)
- GI bleeding or hemorrhage from other sites.
- History of GI ulcers.
SIDE EFFECTS:
1. Children with chicken pox 4. Bronchospasm.
( reyes syndrome). 5. Anaphylaxis
2. Heartburn, nausea, anorexia, 6. Skin rashes.
occult blood loss.. 7. Increase bleeding time
3. GI bleeding, potentation of
peptic ulcer.
SALICYLATE TOXICITY
- SALICYLISM : nausea, vomiting, dizziness, tinnitus, difficulty hearing, diarrhea,
mental confusion.
- Acute aspirin poisoning: Respiratory alkalosis, hypercapnea, tachypnea, hemorrhage,
confusion, pulmonary edema, convulsion, tetany, metabolic acidosis..
NURSING CONSIDERATIONS:
1. Take drug with or after food or with milk to decrease GI irritation.
2. Assess for history of asthma and history of hypersensitivity.
3. Do not use with other anticoagulants.
4- Note any history of peptic ulcer.
5- Report signs of side effect e.g. gastric irritation if occurs.
6- Aspirin is not given 1 week before & after surgery to prevent bleeding.
7- If patient is diabetic, discuss the possibility of hypoglycemia occurring-
patients should monitor their blood glucose level frequently.
P a g e | 65
8- Teaches patient about the toxic symptoms (ringing in the ears dizziness,
mental confusion-etc) and ask him/her to report it to physician.
Narcotic Analgesics:
- It include opium such as morphine, codeine & opium derivatives such as Meperidine.
- These substances have similar pharmacological properties.
DEPENDENCE & TOLERANCE:
- Remember that all drugs of this group may lead to addiction.
- Psychological & physical dependence & tolerance develop even when using clinical
doses.
- Tolerance usually develops because the patient requires shorter periods of time between
doses or larger doses for relief of pain.
EFFECTS OF NARCOTIC ANALGESICS:
ON C.N.S:
- Alteration of pain perception (analgesia)
- Euphoria
- Drowsiness
- Change in mood
-Mental clouding
- Deep sleep
TREATMENT OF ACUTE OVERDOSE:
1- Induce vomiting or gastric lavage.
2- Artificial respiration.
3- Give narcotic antagonist (Narcan).
ACTION OF NARCOTIC ANALGESICS:
- Narcotic analgesics attach to specific receptor in the CNS resulting in analgesic action
- Action exactly is unknown but may be by decreasing cell membrane permeability to
sodium transmission of pain impulses.
USES:
- Severe pain
- Hepatic & renal colic .
- Pre-anesthetic medication
- Post-surgical pain.
- Pain from MI, carcinoma.
- Postpartum pain & burns.
- Antitussive.
CONTRAINDICATIONS:
- Asthmatic conditions
- Emphysema
- Severe obesity
- Convulsions
- Diabetic acidosis
- Myxeodema
- Addisson's disease
- Hepatic cirrhosis
- Children less than age of 6 months.
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SIDE EFFECTS:
-Respiratory -headache - dry mouth
depression -mental clouding -skin rashes
-apnea -insomnia nausea & - laryngospasm
-dizziness vomiting - urinary retention
-euphoria - constipation - decreased libido.
NURSING CONSIDERATIONS:
- Use supportive nursing measures as relaxation techniques to relieve pain before using
nacrotics.
- Explore the source of pain, use non-narcotic analgesia if possible.
- Administer the medication when needed, prolonging the medication administration will
decrease the effect of the medication.
- Monitor vital signs & mental status.
- Monitor Respiratory rate (drug may lead to respiratory depression).
- Monitor blood pressure ( hypotension may occur)
- Monitor pulse rare (if 60\m withhold the drug).
- Watch for constricted pupils. Document it and notify the physician.
- Monitor bowel function, since drug may cause constipation .
- Encourage client to empty bladder every 3-4 hrs (since drug may cause urinary
retention).
- If client is bed ridden, use side rails.
- Inform the client\family that the drug may become habit forming and leading to
addiction.
- Document any history of asthma or other contraindications.
- Have emergency equipment and narcotic antagonist available .
1. CODEINE SULFATE:
Class. : Narcotic analgesic, morphine type.
Action: -
- Resembles morphine pharmacologically but produce less effect on
respiratory system, less nausea & less vomiting.
- In high doses (more than 60 mg), it will irritate the cough center, but in lower doses, it is
a potent antitussive and is an ingredient in many cough syrups.
USES:
- Relief of mild to moderate pain.
- Antitussive.
DOSE:
- Analgesic: 15-60 mg q 4-6 hrs.
- Antitussive: 10-20 mg q 4-6 hrs.
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- In minor surgeries.
- Spasm of GI tract, uterus.
- Prior to some diagnostic procedures e.g. cystoscopy.
- Post operative pain.
ADD. CONTRAINDICATIONS:
- Hypersensitivity. - Convulsive states.
- Children less than 6 months. - Head injuries.
- Diabetic acidosis.
ADD. SIDE EFFECTS: Transient hallucinations, hypotension.
DOSE:
Drug is available in the form of tablets, syrup, I.M, S.C.
Dose is 50-100 mg Q 3-4 hr.
It can be given as I.V. continuous infusion on a concentration of 1 mg\ml.
It also can be given IV slowly, and should be diluted in a concentration of 10mg/ml.
4. MORPHINE SULFATE:
Class.: Narcotic analgesic, morphine type.
Action: See narcotic analgesic.
USES:
-Acute & chronic Pain- Given, Intrathecally, epidurally, orally or I.V. infusion.
- Pre-operative medication.
- To facilitate induction of anesthesia or to decrease the dose of anesthesia.
N.B. :
It is given in lower doses for continuous pain & in higher doses in sharp intermittent & all
kinds of pain.
ADDITIONAL CONTRAINDICATIONS:
1. It is given epidural or intrathecal, if infection is present at injection site.
2. In patients on anticoagulant therapy .
3. Bleeding disorders.
4. If patients have received parenteral corticosteroids within the past 2 weeks.
DOSE:
- Oral: 10-30 mg Q 4 hr.
- I.M.: 5-20 mg\70 kg Q 4 hr as needed.
- I.V.: bolus of 2.5-15 mg for a person of average weight of 70 kg over 4-5 minutes
(slowly).
- Continuous infusion: 0.1-1 mg\ ml in 5% dextrose in water by a controlled infusion
pump.
NARCOTIC ANTAGONISTS:
- The narcotic antagonists are able to prevent or reverse many of the pharmacological
actions of morphine-type analgesics & meperedine (Pethidine) as respiratory depression
induced by these drugs within minutes.
NALOXONE HYDROCHOLRIDE:
Trade name: Narcan.
Class.: Narcotic antagonist.
Action:
P a g e | 68
- Block the action of narcotic analgesic by displacing previously given narcotics from their
receptor sites or preventing them from attaching to opiate receptors.
- The duration of action of naloxone is shorter than that of the narcotic analgesic so the
respiratory depression may return when the narcotic antagonist has washed off the body.
USES:
Respiratory depression induced by narcotics.
Drug of choice when the depressant drug is unknown.
Diagnosis of acute opiate overdose.
N.B. : Naloxine is not effective when respiratory depression is induced by
hypnotic, sedative or other non-narcotic drugs.
CONTRAINDICATIONS:
- Sensitivity to drug.
- Narcotic addicts since it will cause severe withdrawal symptoms.
- Neonates.
SIDE EFFECTS:
1. GIT Nausea, vomiting
2. sweating
3. hypertension
4. tremors.
5. If used postoperatively: tachycardia, pulmonary edema, hypo or hypertension.
Dose: 0.4-2 mg I.V. , S.C. or I.M.
NURSING CONSIDERATIONS:
1. Determine the etiology of respiratory depression.
2. Assess & obtain baseline vital signs.
3. Monitor respiration closely after the duration of action.
4. Have emergency drugs & equipment available.
5. If the patient is comatose, turn him to his side to avoid aspiration .
6. Maintain safe environment (side rails & soft support).
BRONCHODIALATORS
1. SALBUTOMOL
Trade name: ventolin
Class.: sympathomimetic agent, bronchdialtor
ACTION:
stimulate β 2 receptors of the bronchi leading to bronchodilation.
USES:
- Bronchial asthma.
- Bronchospasm due to bronchitis or emphysema.
- Parenteral for treatment of status asthmaticus.
-Use in premature labor
DOSAGE:
Aerosol for inhalation: 0.18 – 0.2 mg (2 inhalations) Every 4 – 8 hours.
Solution for inhalation: 1.25 mg in 2 – 5 ml.
Oral syrup, tablets: 2 – 6 mg tid – qid.
SIDE EFFECTS:
-Tachycardia - Dizziness - weakness
-arrythmias - sweating - vertigo
-anginal pain. -Hot flushes. - insomnia.
-Nausea & vomiting. -Headache
P a g e | 69
NURSING CONSIDERATIONS:
- Don’t exceed the recommended dose.
- The contents of the container are under pressure, don’t store near heat or open flames.
- When given by neubilization, use facemask or mouth-piece.
- Compress O2 or air at 6 – 10 L\min for 5-15 minutes.
- Observe client for evidence of allergic response.
- NEVER give the solution prepared to be given as inhalation by the IV route. It may
cause severe tachycardia.
A. SYMPATHOMIMETICS
1) EPINEPHRINE/ADRANALINE
Trade name: Adrenaline
Class. : Direct acting-adrenergic agent.
Action:
-They relax airway smooth muscle and inhibit release of bronchoconstricting mediators
from mast cells.
-A natural hormone produced from adrenal medulla, induce marked stimulation of alpha,
β1 + β2 receptors causing cardiac stimulation, bronchodilation & decongestion.
USES:
1- Relief of respiratory distress due to bronchospasm.
2- Rapid relief of hypersensitivity reactions.
3- Cardiac arrest.
4- Open- angle glaucoma.
5- To prolong the action of anesthesia.
6- Topically to stop bleeding.
Contraindications:
- Narrow angle glaucoma.
- Shock
- Lactation.
- Tachycardia
- During labor (it may delay the 2nd 8 loge do labor).
SIDE EFFECTS:
1. Fatal ventricular fibrillation. 5. necroses at injection side
2. Cerebral hemorrhage 6. blurring of vision
3. urinary retention 7. photophobia.
4. headache
DOSE:
Available in ampoules of 1ml containing 1 mg adrenaline
Can be given by I.M injection., I.V. & S.C.
0.2 – 0.5 mg, IM or S.C. + Q 20 min – 4 hr as needed.
N.B. : For cardiac resuscitation 0.5 mg diluted to 10 ml with normal saline
may be administered I.V. or intracardiac to restore myocardial
contractility.
NURSING CONSIDERATIONS:
- Never administer 1 : 100 solution IV., use 1 : 1000 mg sol. For I.V. use.
- Use tuberculine (1cc) syringe to measure adrenaline.
- Administer adrenaline using piggyback set to adjust the rate of infusion.
- Administer infusion by electronic infusion device for safety & accuracy.
- Closely monitor patients receiving I.V. adrenaline infusion.
P a g e | 70
- Note the client for signs of shock “loss of consciousness, clammy, cold skin, cyanosis….
etc.).
- Briskly massage site of S.C. or I.M. injection to hasten the action of the drug.
SIDE EFFECTS:
Nausea & drowsiness flashing
vomiting headache euphoria
dry mouth insomnia hallucination
constipation blurring of flushing of the
heartburn vision skin
dizziness photophobia
.
1) ATROPINE SULFATE:
Class.: Cholinergic blocking agent.
Action:
It is a parasympatholytic agent which cause relaxation of smooth muscles & inhibition of
secretary glands:
USES:
- Adjunct in peptic ulcer treatment.
- Irritable bowel syndrome.
- Treatment of spastic disorders of biliary tract .
- During anesthesia to control salivation & bronchial secretions.
- Parkinsonism.
- Anti-arrhythmic (prophylaxis).
- Prophylaxis and treatment of toxicity due to cholinesterase inhibitor including
organophosphate pesticides poisoning.
P a g e | 71
- Ophthalmologic treatment of uveitis.
Contraindications: See parasympatholytics
Side effects: See parasympatholytics
Dose:
Tablets: 0.3 – 1.2 mg Q 4-6 hr
Available in 1ml-ampoule containing 1 mg atropine.”
IM, I.V. & S.C. 0.4 – 0.6 mg Q 4-6 hour for anticholinergic action.
N.B. :
For treatment of toxicity from cholinesterase inhibitors
“ organophosphophate poisoning”, give 2-4 mg IV initially then 2 mg every 5-10
minutes until muscarinic symptoms disappear and signs of atropine toxicity
begins to appear like dilation of pupils, flushing of face & tachycardia.
NURSING CONSIDERATIONS:
- Check dosage & measure the drug exactly.
- Assess for history of asthma, glaucoma, ulcer .. etc.
- Determine the age of the client.
- Frequent mouth care.
- Assess client for change in pulse rate.
- In case of blurring of vision, assist on ambulating & give safety measures.
2) SCOPOLAMINE HYDROBROMIDE :
Trade name: Hyoscine.
Class.: cholinergic blocking agent.
ACTION :
It is a parasympatholytic agent, depress the cerebral cortex, especially the
motor area, act as a powerful hypnotic.
USES:
1- Motion sickness ( prevention and control of nausea and vomiting).
2- Pre-anesthetic.
3- Anti-arrhythmic.
4- Mydriatic and cycloplegic ( paralysis of the ciliary muscle of the eye, resulting in loss
of accommodation.)
5- Adjunctive with other drugs to treat GIT ulcers.
6- With other narcotics to treat biliary colic.
CONTRAINDICATIONS:
- Hypersensitivity. - Glaucoma
- Bronchial asthma - Cardiac arrhythmias
- Pregnancy - Lactation.
DOSE:
Oral: O.25 mg I hour before travel ( for motion sickness).
Parenteral: 0.32-0.6 mg SC or IM.
SIDE EFFECTS:
-Pupil dilation -Dry mouth -Suppression of
- photophobia -constipation lactation
-blurred vision - nausea & vomiting. -flushing
- headache -tachycardia - nasal congestion.
-drowsiness. - arrhythmia
NURSING CONSIDERATIONS:
As atropine.
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ANTI-HISTAMINES - H1 RECEPTOR BLOCKERS /ANTAGONISTS
USES:
- Treatment of seasonal allergic rhinitis
- allergic conjunctivitis .
- Treatment of urticarial transfusion reactions.
- Treatment of Atopic dermatitis.
- Treatment of insect bites.
- Sneezing & rhinorrhea due to common cold.
- Prophylaxis & treatment of motion sickness “nausea & vomiting” eg Scopolamine a
first-generation H1 antagonists.
- Night – time sleep aid.
CONTRAINDICATIONS:
- Hypersensitivity.
- Pregnancy.
- Glaucoma
- Prostatic hypertrophy
- CNS depression (phenothiazine type).
- Bone marrow depression
- Comatose patients.
P a g e | 73
SIDE EFFECTS:
Sedation - deep sleep - Dizziness - Headache - muscle weakness - disturbed
coordination - epigastric distress - dry mouth - nausea - vomiting - urinary frequency,
anemia ( pancytopnea) .
Paradoxical excitation (especially in children & elderly) Restlessness, irritability,
insomnia , hysteria, tremors euphoria, nervousness, hallucinations , disorientation &
convulsion.
Usually caused by overdose (acute toxicity).
TREATMENT OF OVERDOSE:
- Symptomatic & supportive.
- Vomiting is induced with syrup of ipecac.
- Gastric lavage .
- Vasopressors (to treat hypotension) –e.g. Dopamine , adrenaline.
- Phenytoin for treatment of convulsion.
N.B. : Don’t use CNS depressants including diazepam.
NURSING CONSIDERATIONS:
- Inject I.M. preparations deep into muscles.
- Oral preparations may cause gastric irritation, so give drug with meals.
- Note if the client has any medical history of ulcer, glaucoma & if the client is pregnant.
- Obtain a baseline B.P. , Pulse & respiration .
- Note signs of CNS depression (signs of overdose so induce vomiting).
- If in hospital, use side rails (safety measures).
- Advice client to report signs of side effects immediately.
- Instruct client to avoid undue exposure to sun.
- If the drug is being used for motion sickness, it should be taken 30 minutes before
transporting.
- Caution the client not to drive a car or operate other machinery.
1- CHLORPHENIRAMINE MALEATE:
Trade name: ahiston.
Class. : Antihistamine.
Action: It has little sedative effect.
Dose: each tablet contains 4 mg
1-2 tablets 3-4 times daily.
injection- 10mg
2- PROMETHAZINE HCL:
Trade name: phenergan, prothiazine.
Class: It is a phenothiazine derivative. It is a potent antihistamine with prolonged
ACTION. It may cause severe drowsiness. It also provides antiemetic effect.
-It also has a sedative action, effective in vertigo vestibular apparatus
USES:
- Motion sickness.
- Nausea & vomiting due to anesthesia.
FORMS:
Syrup: 5ml contains 5 mg , 25 mg.
Ampoule: 50 mg \2ml.
DOSE:
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Antihistamine: 125 mg 4 times daily.
Sedative: 25 mg – 50 mg.
Anti-vertigo: 25 mg 2 times daily.
PREPARATIONS AVAILABLE
Azelastine
Nasal (Astelin): 137 mcg/puff nasal spray
Ophthalmic (Optivar): 0.5 mg/mL solution
Brompheniramine (generic, Brovex)
Oral: 6, 12 mg extended release tablets; 12 mg chewable tablets; 8, 12 mg/5 mL
suspension
Buclizine (Bucladin-S Softabs)
Oral: 50 mg tablets
Carbinoxamine (Histex, Pediatex)
Oral: 4 mg tablets; 8 mg timed-release tablets; 10 mg extended release capsules;
1.5, 4 mg/5 mL liquid; 3.6 mg/5 mL oral suspension
Cetirizine (Zyrtec)
Oral: 5, 10 mg tablets; 5, 10 mg chewable tablets; 5 mg/5 mL syrup
Chlorpheniramine (generic, Chlor-Trimeton)
Oral: 2 mg chewable tablets; 4 mg tablets; 2 mg/5 mL syrup
Oral sustained-release: 8, 12, 16 mg tablets; 8, 12 mg capsules
Clemastine (generic, Tavist)
Oral: 1.34, 2.68 mg tablets; 0.67 mg/5 mL syrup
Cyclizine (Marezine)
Oral: 50 mg tablets
Cyproheptadine (generic)
Oral: 4 mg tablets; 2 mg/5 mL syrup
Desloratadine (Clarinex)
Oral: 5 mg regular or rapidly disintegrating tablets; 2.5 mg/5 mL syrup
Dexchlorpheniramine (generic)
Oral: 4, 6 mg extended release tablets; 2 mg/5 mL syrup
P a g e | 75
mL suspension
Parenteral: 25, 50 mg/mL for injection
Ketotifen (Zaditor)
Ophthalmic: 0.025% solution
Levocabastine (Livostin)
Ophthalmic: 0.05% solution
Loratadine (generic, Claritin, Tavist)
Oral: 10 mg tablets; 10 mg rapidly disintegrating tablets; 1 mg/mL syrup
Meclizine (generic, Antivert)
Oral: 12.5, 25, 50 mg tablets; 25 mg capsules; 25 mg chewable tablets
Olopatadine (Patanol)
Ophthalmic: 0.1% solution
Phenindamine (Nolahist)
Oral: 25 mg tablets
Promethazine (generic, Phenergan)
Oral: 25, 50 mg tablets; 6.25 mg/5 mL syrups
Parenteral: 25, 50 mg/mL for injection
Rectal: 12.5, 25, 50 mg suppositories
Triprolidine (Zymine)
Oral: 1.25 mg/5 mL liquid
INSULIN:
1- Rapid- acting insulin.
a) Insulin injection ( regular, crystalline zinc insulin) .
b) Prompt insulin zinc suspension.
2- Intermediate- acting insulin
a) Isophane insulin suspension (NPH- Neutral protamine hagedorn )
b) Insulin zinc suspension (lente)
3- Long-acting insulin
Un) Protamine zinc insulin suspension (PZI)
Deux) Extended insulin zinc suspension (ultralente)
N.B. : Insulin preparations with various times of onset & duration of action are often
mixed to obtain optimum control in diabetic patients.
P a g e | 76
ACTION:
1- Facilitates the transport of glucose into cardiac & skeletal muscles & adipose tissue.
2- Increases synthesis of glycogen in the liver .
3- Stimulates protein synthesis & lipogenesis.
4- Inhibits lipolysis & release of free fatty acids from fat cells.
5- Causes intracellular shifts of potassium.
N.B. : Since insulin is a protein , it is destroyed in the GIT thus it must be administered
parenterally.
- It is metabolized mainly in the liver.
USES:
- Replacement therapy in type I diabetes.
- Indicated in type II diabetes when other measures have failed or with surgery , trauma,
infection, fever , endocrine dysfunction , pregnancy , gangrene , kidneys or liver disease .
- Regular insulin is used in I.V. dextrose to treat severe hyperkalemia.
CONTRAINDICATIONS:
Hypersensitivity to insulin.
SIDE EFFECTS:
1- Hypoglycemia due to overdose , decreased food intake or hard exercise, “
S& S OF HYPOGLYCAEMIA
-Hunger -profuse - tingling in the
-weakness sweating fingers
- fatigue - headache - blurred vision
-nervousness -Confusion - hypothermia
pallor or flushing - numbness of - loss of
mouth consciousness.
NB/-“Sever prolonged hypoglycemia may cause brain damage.”
2- Allergic urticaria , lymphadenopathy.- “ Use human Insulin product”.
3- In site of injection :- developing of swelling , itching , atrophy or hypertrophy of
S.C. fat tissue - so rotate site of injection to minimize the problem.
4- Insulin resistance caused by obesity, infection, trauma ,surgery ….etc.
5- Hyperglycemic rebound (somogyi effect) in patients who receive chronic
overdose.
Diabetic coma is usually precipitated by the patient’s failure to take insulin.
TREATMENT OF DIABETIC COMA:
20 – 30 units of insulin, then 20 units every 30 minutes.
To avoid hypoglycemia give 1 g dextrose for each unit of insulin is administered
with supplemental electrolytes ( K+ ) & fluids .
Monitor vital signs.
Urine samples for analysis.
***
TREATMENT OF HYPOGLYCEMIA:
- Mild hypoglycemia: relieved by oral administration. of CHO as orange juice.
- In comatosed patients : administer 10 –30 ml of 50% dextrose solution I.V.
DOSE:
Usually administered S.C.
NB-/Regular insulin is the ONLY preparation that may be administered. I.V
-This route should be used only for patients with severe ketoacidosis or
diabetic coma.
- Always expressed in units.
P a g e | 77
- Dosage is individualized, it is established & monitored by blood glucose, urine glucose
& acetone test.
Insulin antagonists:
1- Growth hormone elevates glucose level & decreases glycogen synthesis.
2- Glucocorticoids enhance conversion of protein to glucose.
3- Adrenaline decreases insulin release & enhance glycogenolysis.
4- Thyroid hormone promote gluconeogenesis.
5- Glucagon.
NURSING CONSIDERATIONS:
1- Read the product information & any important notes inserted into the package.
2- Refrigerate stock supply of insulin but avoid freezing.
3- Follow the guidelines with respect to mixing the various types of insulin.
4- Invert the vial several times to mix before the material is withdrawn “avoid
vigorous shaking”.
5- Assist patient for self-administration of insulin.
6- Rotate the sites of S.C. injections to prevent the problem of hypertrophy or
atrophy at injection site.
7- Allow insulin to remain at room temperature 1 hour before administration.
8- Apply pressure for 1 minute, don’t massage since it may interfere with rate of
absorption.
9- If breakfast must be delayed, delay the administration of morning dose of insulin.
10-Obtain a thorough nursing history from the client / family.
11-If the client has symptoms of hyperglycemia reaction:
- Have regular insulin available for administration.
- Monitor client closely after administration.
- Check blood glucose, urine glucose, and acetone.
12-Check for early symptoms of hypoglycemia.
13-Assess diabetic more closely for infection or emotional disturbances that
may increase insulin requirements.
14-Explain the necessity for close regular medical supervision.
15-Explain to patient how to test the urine for sugar & acetone.
16-Explain the use & care of equipment & the storage of medication.
17-Explain the importance of exercise & adhering to the prescribed diet.
18-Explain the importance of carrying candy or sugar at all times to counteract
hypoglycemia should it occur.
19-Provide the client & family with a printed chart explaining symptoms of
hypoglycemia , hyperglycemia & instructions concerning what to do for
each.
20-Instruct client that blurring of vision will subside within 6-8 weeks.
21-Advise client to check vials of insulin carefully before each dose. Regular
insulin should be clear, where as other forms may be cloudy.
P a g e | 78
USES
- suitable for treatment of diabetic coma,
- acidosis/ketoacidosis (diabetic) or other
emergency situations.
DOSE:
- individualized, initial 5-10 units 15-30 minutes before meals & at bedtime.
-Diabetic acidosis 0.1 unit / kg given by continuous I.V. infusion.
- Several oral antidiabetic agents are available for patients with non-insulin dependent
diabetes.
Nursing considerations:
- See nursing considerations for insulin.
- Drugs may be taken with food to minimize GI upset.
- Stop the medication if signs of side-effects or ketoacidosis appear.
1- CHLORPROMIDE:
Trade name : Diabenase.
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Class: first generation sulfonylurea.
Dose: initial 250 mg daily as a single or divided doses.
Maintenance 100-250 mg daily as a single or divided doses.
Doses: More than 750 mg are not recommended.
2- GLYBURIDE:
Trade name : Micronase.
Class: Second-generation sulfonylurea .
Dose: Initial 2.5-5 mg daily given with breakfast ( or the first main meal ) then
increased by 2.5 mg weekly to achieve the desired response.
3- TOLBUTAMIDE :
Trade name : Orinase.
Class: First-generation sulfonylurea.
Dose: Initial 0.5 – 2 g daily , so adjust the dose depending on response (Maintenance
0.25 –3 g daily) ( not exceed 3g ) .
4- GLIBENCLAMIDE :
Trade name: daonil.
Class: First generation sulfonylurea .
Dose: ½ -1 tablet (5mg) daily , increased by 2.5 – 5 mg weekly to achieve the desired
response.
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(1) Glucocorticoids e.g. cortisone & hydrocortisone:- regulate the metabolism of
CHO, protein & fat .
(2) Mineralocorticoids e.g. Aldosterone & deoxycorticosterone.:- increase
reabsorption of Na+ (+water ) & excretion of potassium & hydrogen.
USES:
Therapy with glucocorticoids is not curative & many situations should be
considered as adjunctive rather than primary therapy:-:
1- Replacement therapy : adrenal insufficiency (Addison’s disease) .
2- Rheumatic disorders : rheumatoid arthritis & osteoarthritis.
3- Collagen diseases: systemic lapus erythematosus, rheumatic cardiac.
4- Allergic diseases: drug hypersensitivity , urticarial transfusion reaction.
5- Respiratory diseases: bronchial asthma , rhinitis.
6- Ocular diseases : allergic & inflammatory conjunctivitis, keratitis … .
7- Dermatological diseases: psoriasis, contact dermatitis, urticaria.
8- Diseases of the GIT: ulcerative colitis.
9- Nervous system : Myasthenia gravis.
10-Malignancies: leukemia, lymphoma.
11-Nephrotic syndrome.
12-Hematological diseases: hemolytic anemia, thrombocytopenic purpura.
13-Miscellaneous: septic shock, liver cirrhosis, stimulation of surfactant
production, prevention of organ rejection.
CONTRAINDICATIONS:
1- If infection is suspected (Mask signs & symptoms).
2- Peptic ulcer.
3- Acute glomerulonephritis.
4- Cushing’s syndrome .
5- Congestive heart failure.
6- Hypertension.
7- Hyperlipidemia.
SIDE EFFECTS:
Prolonged therapy may cause cushing-like syndrome & atrophy of the adrenal cortex &
subsequent adrenocortical insuficiency.
N.B: steroid withdrawal syndrome may lead to : anorexia, nausea, vomiting, weight loss ,
headache , myalgia & hypotension.
Side effects include:
Edema osteoporosis amenorrhea
alkalosis nausea & depression.
hypokalemia vomiting. DM in
hypertension Headache prolonged use
CHF muscle hypercholester-
wasting olema
weakness hirsutism
Dose: Highly individualized according to the condition & response of the patient.
N.B.: It is most important that therapy not be discontinued abruptly.
NURSING CONSIDERATIONS:
1- Administer oral forms with food to minimize ulcerogenic effect.
2- For chronic use, give the smallest dose possible.
3- Corticosteroids should be discontinued gradually if used chronically.
P a g e | 81
4- Document baseline weight , B.P. , Pulse & temperature.
5- Frequently take BP, monitor body weight (signs of Na+ & H2O retention).
6- Periodic serum electrolytes, blood sugar monitoring.
7- Report signs & symptoms of side effects (cushing-like syndrome).
8- Discuss with female client potentials of menstrual difficulties.
9- Instruct the client to take diet high in protein & potassium.
10-Instruct the client to avoid falls & accidents (osteoporosis causes
pathological fracture).
11-Remind the client to carry a card identifying the drug being used.
12-Stress the need for regular medical supervision.
13-Advise the client to delay any vaccination while taking these medications
(weakened immunity).
14-Explain the need to maintain general hygiene & cleanliness to prevent
infection.
1- BETAMETHASONE:
Trade name : celestone.
Class: Adrenocorticosteroid, synthetic, glucocorticoid type.
Tabs,tubes
2- DEXAMETHASONE:
Trade name : dexacort.
Class : adrenocorticosteroid –synthetic , glucocorticoid type.
Forms : Tablets 0.5 mg.
Ampoule 4mg , 20 mg.
ADDITIONAL USES: prevention of respiratory distress syndrome in premature infants
3- HYDROCORTISONE:
Trade name: hydrocort.
Class: adrenocorticosteroid , naturally occuring, glucocorticoid.
Forms: Vials 100 mg, 500 mg. ,tubes
4- PREDNISONE :
Trade name : deltasone.
Class: adrenocorticostewid , synthetic.
Forms: Tablets 5mg, 20mg., injection( arhritis)
5- FLUDROCORTISONE ACETATE:
Trade name : florinef.
Class: adrenocorticosteroid , synthetic , mineralocorticoid.
Uses: Mainly used for treatment of addison’s disease .
Forms: 0.1 mg tablet.
OTHERS-diprofos injection
1-METHYLERGONOVINE MALEATE:
Trade name: Methergine.
Class: Oxytocic agent.
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Action: Is a synthetic agent stimulates the rate, tone & amplitude of uterine
contractions. It also stimulates smooth muscles surrounding certain blood vessels by
interacting with adrenergic & dopaminergic receptors.
Uses:
Management & prevention of postpartum & postbortal hemorrhage by producing
firm contraction & decrease uterine bleeding.
Incomplete abortion.
Migraine headache
CONTRAINDICATIONS:
- Pregnancy - To induce labor - Prior to delivery of
placenta
- Hypertension - - Toxemia
SIDE EFFECTS:
Nausea, vomiting, diarrhea, allergic reaction, Dizziness, headache, tinnitus.
N.B.: use of this substance during labor may result in uterine tetany with rupture, cervical
laceration, embolism of amniotic fluid & intracranial hemorrhage in infant.
DOSE:
Forms: Tablet 0.2 mg (0.2- 0.4 mg /6-12 hr for 48 hrs).
I.V. in emergency situations.
2-OXYTOCIN:
Trade name: Pitocin
Class: oxytocic agent.
Action:
- It has uterine stimulant, vasopressive & antidiuretic properties.
- Mimics uterine contractions of normal labor.
- Facilitates ejection of milk from the breasts by stimulating smooth muscles.
Onset: I.V. immediately , I.M 3-5minutes.
Peak 40m,
duration I.V. 20m. I.M. 30-60 m.
USES:
- Antepartum induction or stimulation of labor.
- Uterine inertia (hypotonic contractions).
- For induction of labor in case of preeclampsia, eclampsia ,maternal diabetes & other
conditions.
- To hasten uterine involution .
- Intravenously in sol. for postpartum hemorrhage & uterine atony.
CONTRAINDICATIONS:
- Hypersensitivity
- cephalopelvic disproportion (C.P.D. )
- Malpreresentation
- undilated cervix
- History of cesarean delivery.
N.B.: Oxytocin should never be given I.V. undiluted in high concentration .
SIDE EFFECTS:
-Tetanic uterine contraction
- rupture uterus
-Hypertension
- tachycardia.
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-To Fetus :- it may cause death, intracranial hemorrhaye, brady or tachycardia
Dose: I.M. or I.V. infusion for induction or stimulation of labor.
I.V. infusion 10 units (1ml) diluted in 500 ml of normal saline or 5% dextrose
Initial 0.001 – 0.002 unit /minute, increased by small increments after 15
minutes intervals
NURSING CONSIDERATIONS:
1- The physician should be available during administration of the drug.
2- Use Y-tubing for I.V. administration (one bottle contain oxytocin & another free) .
3- Note any history of hypersensitivity & other contraindications.
4- Check for cervical dilation & uterine contractions patterns.
5- Remain with the client throughout the administration of medication.
6- Monitor fetal heart rate at least every 10 minutes.
7- Check vital signs every 15minutes.
8- Prevent uterine rupture & fetal damage by clamping off I.V. oxytocin , start
medication – Free fluid , provide O2 & notify the physician in case of hypertonic uterine
contraction & abnormal fetal heart rate patterns.
DIURETICS
1- Loop Diuretics:
Furosemide
Trade name : Fused , Lasix
Class: Loop diuretic.
Action :
- It inhibits the reabsorption of sodium and chloride in the ascending loop of Henle
resulting in the excretion of sodium, chloride & to a lesser degree potassium &
bicarbonate ions. Also it decrease the reabsorption of sodium & chloride & increase the
excretion of potassium in the distal tubule.
- It has a slight antihypertensive effect.
Uses:
- Edema associated with:
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- Congestive heart failure
- Liver cirrhosis .
- Nephrotic syndrome.
- Acute pulmonary edema.
- Hypertension.
Contraindications:
- Hepatic coma associated with electrolyte depletion.
- Anuria
- Sever renal diseases.
- Hypersensitivity.
Side effects:
- Dehydration, hypovolemia.
- Hypokalemia ,hyperglycemia, Hyponatremia
- Nausea, vomiting, diarrhea, anorexia.
- Tinnitus, blurring of vision, headache, orthostatic hypotension, rashes &
photosensitivity.
*After I.V use: Thrombophlebitis & cardiac arrest.
*After I.M use: pain at injection site.
N.B.:
Because the drug potentates the effects of muscle relaxants, it is recommended to
discontinue oral medication 1 week before surgery & the I.V. 2 days before surgery
Forms:
Tablets 40 mg.
Ampoules 20 mg /2ml , 250 mg /10 ml.
Dose: oral: 20-80 mg as a single dose.
I.V: 20-40 mg as a single dose.
For hypertensive crisis:100-200 mg.
Nursing considerations:
1- When high doses are required, administer lasix by infusion.
2- Store in a light-resistant container.
3- Monitor serum electrolytes & for signs of hypokalemia.
4- Observe client for signs of dehydration & circulatory collapse.
5- Monitor pulse & blood pressure.
6- Advise the client to take medication in the morning to avoid interruption of sleep.
7- Discuss the need for a diet high in potassium.
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