pharm test 5

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pharm test 5
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  1. Histamines
    • There are 2 types of histamines = H1 and H2
    • - H1:
    • }H1receptors mediate smooth muscle contraction (allergic
    • symptoms)
    • }Dilation of capillaries
    • -H2:
    • }Accelerate HR
    • }Accelerate gastric acid secretion
  2. Allergic Response:
    • why it is when there is an excessive amount of histamine released- this can lead to allergic reaction and even anaphylaxis!
    • Both H1 and H2 dilate vessels = inflam. response
    • }There can be an in crease in body secretions
    • }There can be dilation of the vessels causing fluid to move OUT OF the vessels and into the tissue causing a drop in the Bp and excessive
  3. Antihistamines
    • }They are “antagonists”
    • }Those that compete with histamine for the H2 receptors are “ H2 antagonists” or H2 BLOCKERS
    • }Think about cimetadine and rantadine- they act on the GI system
    • }Those that compete with histamine for the H1 receptors are called “H1 BLOCKERS”- these help out with environmental allergies
    • }Allergies due to- molds, mold spores, dust, etc… that can cause hay fever, ithy eyes, uticaria, sneezing, cough, etc…
  4. How do allergens produce this effect:
    • }Histamines and other substances are released by mast cells, basophils b/c they are reacting to the circulating antingens( foreign substances) in the blood.
    • }Binds and activates specific receptors in the eyes, nose, skin, resp. tract
    • }How- in the skin? Histamines bind to nerve endings causing pruritis
  5. Focus on H1 Blockers
    • }H1 BLOCKERS will block histamines attempting to bind to receptor sites- that is why early treatment is needed!
    • }If there is histamine already attached to the receptor sites- the H1 blockers can’t help!
    • }These have an anticholinergic effect- so they DRY secretions (Think about the opposite of SLUDGE
  6. Non-sedating Antihistamines
    • 1) FEXOFENADINE- Allegra and Seldane*
    • }Seldane has serious interactions- off market.
    • }EES- antibiotic and Ketokonozole (antifungal)- can
    • lead to Seldane build-up in the blood- can cause cardiac dysrythmias and can be life-threatening
    • }Allegra used for the relief of symptoms of seasonal allergic rhinitis- OTC
    • }Safe in children 12 and older
  7. 2) Claritin
    • }Also non-sedating
    • }Not used in those with lower resp-tract diseases
    • }Not for those with an acute asthma attack
    • }Why?
    • }Also now available OTC
    • }Fairly inexpensive
  8. Traditional Antihistamines
    • 1) Diphenhydramine- Benadryl
    • }Used for allergies as well as motion sickness and a sleep aid (think safety ed.)
    • }Very safe (few s/e’s)
    • }Anticholinergic properties… so now what?
    • }Not used in nursing mothers and neonates
    • }Is available in PO (tabs, elixir and topical)
    • }Topical- available alone or in combo with other drugs- calamine, camphor
    • 2) Meclizine-
    • }For the treatment of vertigo
    • }For dizziness
    • }Can be used for motion sickness
    • }May cause sleepiness
    • }Safety if sleepiness
    • }Educate
    • }Rx.
    • 3) Promethazine- Phenergan
    • }Antihistamine, used basically for antiemetic
    • }Rx only- may be po, IV, IM, and rectal formula
    • }Uusually ordered q4-6hours prn for nausea
    • }Given in conjunction with Demerol if Demerol is the drug of choice for pain
    • }How does this work as an antiemetic?
    • 4) Astelin-
    • }Only nasal spray antihistamine
    • }Used for adults and children over age 12
    • }May have rebound effect- educate
    • 5) Zyrtec-
    • }Used for year round allergy sufferers
    • }Used for chronic uticaria also
    • 6) Chlor-trimeton-
    • }Available OTC in tab form
    • 7) Dramamine-
    • }Used for motion sickness
    • }Can be used starting at age 6 and greater
    • }Causes sleepiness
    • 8) Unisom-
    • }OTC for sleep aid
    • }Take with a full glass of water
    • 9) Atarax/Vistaril
    • }Has sedative and mild antianxiety properties
    • 10) Antivert-
    • }Used for the treatment of vertigo
  9. Adverse antihistamine
    reactions
    • }Can cause dysrythmias/palpitations
    • }Hypotension, syncope
    • }Dizziness, blurred vision
    • }Sedation
    • }Paradoxical excitement, insomni
    • }Nervousness, headache
    • }Seizure
    • }N/V/D/anorexia
    • }Rarely-Leukopenia, pancytopenia
  10. Cold Medications
    • }Decongestants:
    • }Used to decrease the nasal mucosa inflammation
    • }3 types:
    • }a) Adrenergics-
    • }b) Anticholinergics
    • }c) Corticosteroids-
    • }Can be taken orally, inhaled, topical
  11. Oral/Inhaled Decongestants
    • }Neo-synephrine
    • }Sudafed
    • }These give the longest effect because they are distributed systemically
    • }Onset is delayed
    • }Caution in handing out sudafed- why?
    • }Better have some ID on ya!
    • Inhaled decongestants: Vicks inhaler, Benzedrex
  12. Topical Decongestants
    • }Adrenergics and intranasal steroids
    • }Prompt onset
    • }Use after several days can cause “rebound congestion”
    • }What kind of education do you need to provide?
    • }ADRENERGICS-
    • }Ephedrine- Vicks
    • }Afrin
    • }Neo-senephrine
    • }INTRA-NASAL STEROIDS:
    • }Beconase
    • }Decadron Phosphate Turbinase
  13. How do these work?
    • }They relieve nasal stuffiness (vasocinstrict)
    • }Shrink engorged nasal mucous membranes
    • }If these inadvertently enter the blood stream- they can cause:
    • -Hypertension
    • -Palpitations
    • -HA, dizziness
    • }Adrenergics- specifically constrict the small blood vessels that supply the UR tract-especially those around the sinus cavity
    • }These can cause nervousness, tremors, palpitations,
    • insomnia
    • }Nasal steroids- reduce inflammation
    • }Can cause mucosal irritation and dryness
    • }Nasonex, Flonase, Nascort
  14. Antitussives- what is this?
    • }Cough reflex – stimulated when the receptors in the bronchi, alveoli, and the lining of the lungs (pleura) are stretched due to excessive secretions of foreign
    • substance invasion.
    • }Stimulated in the medulla
    • }Usually beneficial, but can be harmful- after surgery, after hernia repair, if there is IOP or ICP
    • }There are Opioid and Non-opioid antitussives
    • }Non-opioid are less effective-
    • Dextramethrephan/Benzonatate
    • }Non-opioids have no analgesic effect- does not have addictive properties or cause CNS depression
    • }Fairly safe to use short term
    • }BENZONATATE- non-opioid, but it anesthetizes the cough reflex by causing numbing of the stretch receptors
    • }Codiene, hydrocodone (opioids) and dextramethorephan (non-opioid) directly suppress the cough reflex
    • }Most of these drugs can cause dizziness, drowsiness, sedation
    • }Cause dry mouth, nausea, constipation
    • The Drugs- }Benzonatate- Tesselon
    • -Non-opioid
    • -Numbs cough receptors
    • -Rx only
    • -100 mg capsules only, orally
    • -Looks like a small vitamin E
    • -Tesselon Perle’s
    • }Codeine- antitussive- opioid
    • }Addictive properties
    • }Usually in combo with a cough med- Robitussin AC
    • }Can depress RR and CNS!!!
    • }Controlled substance- Rx only
    • }Not for severe respiratory disorders, seizures, ICP
    • }Detramethoraphan- Vicks
    • 44, Robitussin DM
    • }Non-opioid
    • }Safe
    • }Non-addicting*
    • }Not with persistent head aches (why?)
    • }Not with asthma, emphysema
  15. Expectorants
    • }Expectorate? Cough up and out by thinning secretions
    • }Reduces viscosity of secretions
    • }Commonly- Robitussin, Guifenesen, Guiatuss
    • }Help suppress cough b/c secretions thin
    • }Can worsen hyperkalemia with K+ sparing diuretics = cardiac dysrhythmias
  16. Nursing process with all of these meds:
    • }Assess- s/s, allergic reactions, allergies
    • }If patient has URI symptoms- many safe
    • }If Lower RI- not so much! Assess and get a Dx.
    • }ICP, IOP, Asthma, Emphysema, Cardiac problems, HTN
    • }Renal or liver disease- caution!
    • }Get a really good hx. & drug hx.
  17. Implementations:
    • }Many taken with food to avoid GI upset
    • }May make mouth dry- gum/hard candy if ok
    • }Frequent oral care
    • }No other meds with antihistamines – why?
    • }Increase po fluids with expectorants
    • }If a liquid or chewable med- no food/drink 30 minutes after
    • }Drowsiness? SAFETY ED…
    • }Many antihistamines can interact with antibiotics like EES, ketokonozole so discuss with Dr. or dentist
    • }Fever or cough > 1 week- Dr…
    • }Avoid caffeine- why?
    • }Watch for any s/s of allergic reactions
  18. H2 Blockers
    • }We started so I will add to the info- but we will cover in GI meds…
    • }Histamine blockers reduce acid like in GERD
    • }Tagamet, Pepcid, Zantac
    • }These all decrease stomach secretions = decrease in stomach acid = decrease in esophogeal irritation
    • }Allows for healing to begin
  19. A&P first:
    • }Used for URI’s and LRI’s
    • }UR: common cold, rhinitis, hay fever
    • }LR: asthma, emphysema, chronic bronchitis
    • -So your COPD’s (LR)
    • -All of the URI and LRI’s will cause obstruction in airflow through the airway
    • -CF will also affect the LR tract as well! (FYI)
  20. Bronchial Asthma
    • }Recurrent/reversible, bronchi and brochioles narrow, bronchospasm, inflame causing viscous mucous
    • }Wheezing and SOB is the main complaint
    • }Asthma attacks are sudden- (status asthmaticus)*- can last days to weeks
    • }Both can be deadly!
  21. Chronic Bronchitis
    • }Continuous inflammation of the brochi or bronchioles
    • }Common causes:
    • -Chemicals
    • -Smoke
    • -Pet dander
    • -Air irritants
  22. Emphysema
    • }Enlarged air spaces in the lungs
    • }Results in destroyed alveolar walls
    • }O2 and CO2 exchange becomes impaired
    • }This effects respirations!
    • }Lungs become less elastic and SOB ensues, especially on exertion
    • }Smoke and irritants can exacerbate
  23. Brochodilators -2 classes
    Xanthine derivitives & Beta-agonists
    • Xanthine Derivitives-}Plant alkaloids- caffeine, theophylline, theobromine
    • }Only theophylline is the bronchodilator!
    • }Others include: aminophylline (less potent & shorter acting than theophylline)
    • }XD’s used primarily for asthma attacks
    • }Amynophyliine usually used for status epilepticus*
    • }Xanthines increase cardiac contractility increasing HR
    • }Causes increased blood flow to kidneys
    • }So diuretic effects
    • }Educate
    • }Inhaled medications- 100% bioavailability
    • Side effects- }N/V/ anorexia
    • }GI reflux during sleep
    • }Tachy, palpitations, V dysrhythmias
    • }Increased urination
    • }Hyperglycemia
    • }Nervousness/tremors
    • Interactions- }Oral contraceptives
    • }EES
    • }Allipurinol
    • }Flu vaccine
    • }Cimetadine
    • }Often a drug-drug interaction so the drugs become less effective or ineffective
  24. Theophylline
    • }Slo-bid, theodur, Uniphyl
    • }Used for chronic respiratory disorders
    • }Oral, rectal, IV, topical
    • }Monitor theo levels
    • }WNL = 10.0-20.0 mcg/ml
    • }Absorbed best on an empty stomach
    • }Metabolized about 70% in the LIVER!
    • toxicity- }Increased restlessness, irritability, N/V, tremors
    • }Restlessness and anxiety may be due to hypoxia
    • }ASSESS!!!
    • }Never omit doses or double-up on doses
    • }Elderly and pedi can have increased s/e’s
  25. Beta Agonists
    • }Smooth muscle relaxants
    • }Used most commonly for an acute asthma attack to quickly reduce airway constriction
    • }They stimulate the SNS receptors (beta and alpha adrenergic receptors)
    • }They imitate effects of epi and norepi in receptors
    • }Dilate smooth muscle and airway
    • }They vasoconstrict- reduces swelling in muc. membranes and limits secretions
    • }FYI- one of the meds is called terbutaline
    • }This stimulates beta 1’s and 2’s
    • }Beta 1’s are on the uterus
    • }Terbutaline (Brethine) relaxes the uterus
    • }Used in preterm labor
  26. The Drugs
    • 1) Albuterol (proventil, Servent*- longer acting)
    • }Beta 2 specific bronchodilators
    • }Relieves bronchospasms
    • }Albuterol- commonly with acute asthma attacks
    • }Not for the patient with tachy or cardiac disease
    • }Tends to increase HR and cause tremors
    • 2) Epinephrine, ephedrine
    • •(Primatene, Adrenalin, Bronchaid)
    • •Causes bronchodilation
    • •Can also easily cause tachy
    • •Ephedrine no longer OTC
    • •Epi used primarily as a first line drug- code
  27. Anticholinergics
    • }Atrovent- the only one used
    • }Como drug- Albuterol and atrovent = COMBIVENT
    • }Inhaled causes bronchodilation
    • }Used mainly for COPD management
    • }Not for acute attacks
    • side effects-}It’s an anticholinergic!
    • }Dries everything
    • }Cough
    • }HA
    • }Anxiety
    • }Not with a hypersensitivity to atropine
  28. Antileukotreine agents
    • }What is a leukotreine? Substance in the body that causes inflammation, bronchial constriction and mucous
    • }Causes wheeze, cough, SOB
    • }Newer class of asthma medication
    • }Affects primarily the lungs
    • }Antileukotreine? Blocks this effect
  29. The drugs
    • 1)Singulair- FDA ok for children 2 +
    • •Fairly safe with few side effects
    • 2) Accolate- asthma prophylaxis, 12 +
    • •PO tabs
    • •Interacts with ASA, EES, Dilantin, coumadin
    • 3) Zyflo- 12 +, not with liver disease!
    • •PO tabs
    • •Interacts with inderal, coumadin, theophylline
    • Contraindications:}All can cause N/V,
    • dyspepsia, insomnia, dizziness
    • }Accolate can cause liver dysfunction as well
    • }Toxicity of any of these:
    • -Support the systems
    • -Educate to report any side effects and do not stop abruptly
  30. Corticosteroids
    • }Commonly used for chronic asthma
    • }Potent antiinflammatories
    • }Not for acute asthma attacks
    • }Prophylaxis for asthma prevention
    • }PO or inhaled? Inhaled decreases systemic effects
    • }Systemic corticosteroids- reduces immunities, can cause F&E imbalances, nervous system effects, dermatological effects
    • }Can cause pharyngeal irritation, cough, dry mouth, oral fungal infections
    • }Not for patients with candida already, not in the patient with any systemic fungal/yeast infections
    • }Who might these patient’s be?
    • }Can exacerbate psychosis! FYI
    • }Educate
  31. Assessment
    • }Baseline VS and lung sounds
    • }Skin color and cap refill (RR <12 or > 24 = uh oh)
    • }Cough, dyspnea, SOB, orthopnea, distress?
    • }Cardiac symptoms? Restlessness? O2 sats…
    • }Use of accessory muscles?
    • }Allergies?
    • }Cough- color, viscosity of sputum
    • }Other meds?
  32. Education
    • }Stop smoking!
    • }Avoid known allergens
    • }OTC’s? Check with Dr. first
    • }Id card or bracelet
    • }Wean most drugs over 1-2 weeks
    • Corticosteroids can cause Cushingoid symptoms
    • }Weight gain > 3-5 lbs per week may mean trouble
    • }No doubling doses if missed
    • }Review MDI use (Timby)
    • }Store upright, activate into air first…
    • }Clean mouth piece frequently
    • }Never share
    • }Store as directed
    • }Do not run out of Rx.
  33. The Drugs
    • 1)Prednisone-is an immunosuppressant
    • •Can be used for many diseases:
    • -Inflammatory diseases
    • -Lupus
    • -Arthritis
    • -Chron’s disease
    • -To prevent organ rejection
    • -Can cause cushingoid symptoms
    • 2) Hydrocortisone
    • •Also an immunosuppresant, can also treat many skin conditions
    • 3) Bexamethasone- topical, used for many skin conditions
    • 4) Dexamethasone-antihistamine, antiinflammatory, immunosuppresant
    • * Can be given with antibiotics for those with bacterial meningitis
  34. Mast Cell Stabilizers
    • }Chromolyn and Tilade
    • -Suppress the release of mast cells
    • -What are mast cells?
    • -Cells in the body rich in histamines, allergens can bind to them causing an allergic reaction!
    • -They also release vasocontrictor’s = SOB
    • -Most meds here go directly to the lung and have little
    • systemic effect
    • •Mast cell stabilizers used for COPD management and used
    • solely for prohylaxis
    • •What does this mean then?
    • •Chromylyn can be used for allergic rhinitis and allergic eye disorders
    • •Used to prevent….
    • •Also used for those with Chron’s and Ulcerative colitis
  35. Chromolyn
    • }Less potent then Tilade
    • }If patient is lactose intolerant- chromolyn can exhibit similar
    • GI symptoms
    • }Oral
    • }Opthalmic drops (Alomast, Alocril)
    • }Nasal spray
    • }No longer available in oral inhalation formula!
    • }May take up to 4 weeks to start working…
  36. Pediatric considerations any Resp. drugs:
    • }One spray per nostril, no more than 6 doses/24 h
    • }Educate parents about the meds
    • }Review inhaler/nebulizer education!
    • }Any capsules- not chewed
    • }Many meds can take several weeks for results
    • }Some nebs have filters- change when indicated
    • }Can clean tubing and mouth pieces with H2O and vinegar solution
  37. Antiemetic Agents
    • }Why talk about these in respiratory???
    • }Many are antihistamines and anticholinergics- that’s why!!
    • }How do they work?
    • }By relieveing n/v by blocking Ach receptors so nauseous stimuli is not transmitted
  38. The drugs
    • 1) Scopolamine- has anticholinergic properties
    • }Works on inner ear for balance
    • }DO NOT use for glaucoma patients…
    • }72 h patch- behind the ear
    • }Rotate patch
    • }4 hours to start working
    • }Wash hands after administration
    • }NOT for those already on anticholinergics
    • }Not with antidepressants
    • 2) meclazine/Antivert (antihistanmines)
    • •H1 blockers
    • •Inhibits Ach by binding to histamine1 receptors
    • •Used for motion sickness or vertigo
    • •Very safe antiemetic
    • }Compazine-Dopamine blocking agent “neuroleptic agent’
    • }For nausea and vomiting, motion sickness
    • }Not for those with bone marrow supression
    • }Not for seizure patients or those with encephalopathy
    • }Parkinson’s patients- Levadopa effects are decreased if given with Compazine!
    • }Zofran- Seratonin Blocker (blocks in GI tract)
    • }Very safe for adults
    • }No contraindications unless allergic to it specifically
    • }Increases chemo tolerance
    • }Not good for kids or elderly or pregnancy
    • }Can cause HA
    • }Take and OTC analgesic

    • }THC/Marinol
    • }This alters mood and releives n/v
    • }Especially in those cancer patients with chemo
    • }Can cause hypotensive effects
    • }Better head to Cali for this one legally!
  39. Assessment
    • }n/v? why and for how long?
    • }All of these drugs have effect CNS receptors so SAFETY
    • }They can all dry so educate and monitor (i/o)
    • }Some work on smooth muscle and can reduce spasms, anxiety and aggitation
    • }Daily weights, baseline vs, electrolytes
    • }IV- give SLOOOOW… the irritate the vein especially phenergan
    • }Oral medications- only if no active n/v- if they throw it up you cannot redose!
    • }Start all meds low and slow…
    • }Peppermint and ginger can reduce n/v
    • }Ginger interacts with NSAIDS, ASA, antiplatelet drugs and Digoxin!
    • }If only taking for impending travel- take the med 30-60 hours prior
    • }NO DRIVING
    • }Phenergan (promethazine)- (antihistamine) often given for nausea
    • }May be given with demerol
    • }Will dry secretions- educate and assess
    • }Benadryl- Diphenhydramine (antihistamine)
    • }Commonly used for allergies and pruritis
    • }Again dries secretions so educate
    • }These still act on CNS so educate about safety
  40. The Immune System
    • }The IMMUNE SYSTEM- fights off the foreign invaders that are constantly attacking the body
    • }Also fights against its own cells that can become cancerous
    • }The system can also attack itself and cause autoimmune diseases or immune-mediated diseases
  41. Immunosupressant drugs
    • }Agents that decrease or prevent an immune response and suppresses the immune system
    • }Used for rejection therapy after an organ transplant**
    • }They suppress certain lymphocyte (T-cells) cell lines
    • }Used for the treatment of rheumatoid arthritis
  42. Cyclosporine
    • }Has a profound interaction with many drugs and GRAPEFRUIT JUICE
    • }Increases serum levels
    • }May be given together to achieve therapeutic levels
    • }Used for the prevention of organ rejection
    • }Can be used for arthritis, psoriasis, IBD
  43. Imuran and Cellcept
    • }Used for prophylaxis for organ rejection
    • }May be given in combo with cyclosporine and corticosteroids
    • }Side effects can be numerous
    • }As with any in this class, they suppress the immune system making the patient prone to infection
  44. Common adverse reactions
    • FYI: ECHINACEA- commonly taken OTC to prevent colds, can interfere with immunosuppressant therapy
    • }IMURAN:
    • }Leukopenia
    • }Thrombocytopenia
    • }Hepatotoxicity
    • }CYCLOSPORINE:
    • }Moderate hypertension
    • }Neurotoxicity including tremors
    • }Hepatotoxicity with cholelithiasis and hyperbilirubiemia
    • }Nephrotoxicity
    • }Gingival hyperplasia
  45. Nursing Assessment
    • }Check renal function and urinary function
    • }Liver function, is there jaundice, edema or ascites
    • }Check cardiofunction, any history of dysrythmias, hypertension
    • }CNS baseline, seizure history
    • }Respiratory assessment
    • }Check labs before, during and after therapy, if WBC’s drop below 3K, stop medication
    • }Oral antifungals should be given together with immunosupressants to treat oral candidiasis which is
    • common
    • }Oral before IM- to decrease risk of infection that is common with IM injections
    • }Avoid crowds
    • }Any early signs of cold or flu- call your Dr.
    • }Women on immunosupressants- use birth control for up to 12 weeks after therapy is completed
    • }ORAL cyclosporines- to avoid GI upset- take with CHOCOLATE MILK or with MEALS!!
    • }Organ transplant? = life-long therapy


    • }METHOTREXATE-considered a cancer med,but…
    • }Used for solid tumors in the breast, head, neck, lungs, and for lymphocytic leukemia
    • }Also has immunosuppressant activity- can be used for rheumatoid arthritis, SLE

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