Legal and ethical issues in drug admin

Drugs affecting the cns

Drugs affecting autonomic nervous system

Drugs affecting cardiova

Drugs affecting renal system/Fluids and electrolytes

Drugs affecting the endocrine system

LEGAL AND REGULATORY ISSUES IN DRUG ADMINISTRATION: LAWS AND LIFE

SPAN CONSIDERATIONS
NURSES AND MEDICATIONS
 Knowledge of nursing practice – defines, specifies, and limits the scope and
functions of the nurse
 limits of the nurses’ knowledge and skills – professional conduct and training

Under the law, nurses are RESPONSIBLE for their own actions regardless of whether
there is a written order.

Case: A doctor orders Morphine 500 mg instead of the standard Morphine 50 mg for a
patient post-surgery to relieve pain. The nurse administers it.

Analysis: - the doctor’s order was too high - the order was INCORRECT - the nurse
should have questioned the order

INTERNATIONAL DRUG LEGISLATIONS

LEGISLATION 1906 – Federal Food and Drug Act

➢protected the public from adulterated or mislabeled drugs
➢drug companies are to declare in the package label the presence of identified
dangerous and possibly addicting drugs

LEGISLATION 1912 – Sherley Amendment (to the Federal Food and Drug Act of 1906)
provided legislation prohibiting false therapeutic claims by drug companies in the
labelling of medication

LEGISLATION 1914 – Harrison Narcotic Act CONTENT

➢ established the legal term “NARCOTICS”
➢ regulated the manufacture and sale of habit-forming drugs

LEGISLATION 1938 – Federal Food, Drug and Cosmetic Act CONTENT

➢ prohibited marketing of new drugs before proper testing of their safety
application, submission, governmental investigation and review of a drug before it can
be sold

LEGISLATION 1951 – Durham - Humphrey Amendment (to the Federal Food, Drug and
Cosmetic Act)
CONTENT
➢ clearly differentiated PRESCRIPTION and NON-PRESCRIPTION drugs
➢ opioids, hypnotics and tranquilizers can not be refilled without a new prescription
from a doctor

LEGISLATION 1970 – Controlled Substance Act of 1970 (Comprehensive Drug Abuse

Prevention and Control Act)
CONTENT
➢ response to the growing misuse and abuse of drugs in the mid 60’s
➢ established government funded programs to prevent and treat drug dependence
➢ categorized and provided schedules for “controlled” substances

LEGISLATION 1983 – Orphan Drug Act CONTENT

➢ enabled the US Food and Drug Administration to promote research and marketing of
drugs used to treat rare diseases

1991 – Accelerated Drug Approval

➢ accelerated drug review processes in cases of life – threatening illnesses

DRUG LEGISLATIONS IN THE PHILIPPINES

Follows the International Standards
➢ World Health Organization (WHO)
➢ United States Pharmacopeia (USP)
➢ British Pharmacopoeia (BP)
➢ Canadian Drug Acts

❖ ensure PUBLIC SAFETY and the consumption of SAFE, QUALITY

medications
LEGISLATION Republic Act (RA) 3720 - "Foods, Drugs, Medical Devices and
Cosmetics Act" CONTENT
➢ Enabled the creation of the FOOD and DRUG ADMINISTRATION (FDA) in the Dept.
of Health
➢Established standards and quality measures for food, drugs, and cosmetics
➢Adopted measures to ensure pure and safe supply of food, drugs, and cosmetics in
the country
The FOOD and DRUG ADMINISTRATION (FDA)
➢ Inspection and Licensing Division - shall have charge of the inspection of food, drug,
and cosmetic establishments engaged in their manufacture and sale
➢ Laboratory Division - shall conduct all the tests, analyses and trials of products
covered by RA 3720

LEGISLATION Republic Act (RA) 9165 –the “Comprehensive Dangerous Drug Act of
2002“ (repealed RA 6425 – The Dangerous Drug Act of 1972) CONTENT
➢Enables the government to pursue an intensive and unrelenting campaign against the
trafficking and use of dangerous drugs and other similar substances through an
integrated system of planning, implementation and enforcement of anti-drug abuse
policies, programs, and projects
➢The government aims to achieve a balance in the national drug control program so
that people with legitimate medical needs are not prevented from being treated with
adequate amounts of appropriate medications, which include the use of dangerous
drugs

LEGISLATION Republic Act (RA) 6675 - “The GENERICS Act" CONTENT

➢ An act to promote, require and ensure the production of an adequate supply,
distribution, use and acceptance of drugs and medicines identified by their GENERIC
NAMES

LEGISLATION Republic Act (RA) 6675 - “The GENERICS Act" CONTENT

➢To promote, encourage and require the use of generic terminology in the importation,
manufacture, distribution, marketing, advertising and promotion, prescription and
dispensing of drugs;
➢To ensure the adequate supply of drugs with generic names at the lowest possible
cost and endeavor to make them available for free to indigent patients;
➢To encourage the extensive use of drugs with generic names through a rational
system of procurement and distribution;
➢To emphasize the scientific basis for the use of drugs, in order that health
professionals may become more aware and cognizant of their therapeutic effectiveness;
and
➢To promote drug safety by minimizing duplication in medications and/or use of drugs
with potentially adverse drug interactions.
LEGISLATION Republic Act (RA) 8203 - “Act Prohibiting Counterfeit Drugs" CONTENT
➢The rules and provisions regulate unregistered imported drug product without a
registered counterpart brand in the Philippines;
➢If the unregistered imported drug product has a registered counterpart brand in the
Philippines, the product shall be considered counterfeit;
➢Section 4 specifies the administrative sanctions
➢ A drug formulary is a list of brand-name and generic prescription drugs that are
approved to be prescribed by a particular in a specific health system or hospital.
➢ Drug formularies are developed based on the efficacy, safety and cost of the drugs.
➢It contains the Essential Medicines List (EDL)for the Philippines prepared by the
National Formulary Committee (NFC) in consultation with experts and specialists from
organized professional medical societies, medical academe and the pharmaceutical
industry.

LEGAL IMPLICATIONS Nurses must be aware of:

➢ the standards of medical, nursing care and nurse practice acts
defines the framework, scope and limits of nursing practice
➢ specific institutional policies and procedures
use and handling of narcotics
interpretation of medication orders
drug administration protocols
laws governing medical and nursing practice
international, local and institutional
➢the “Rights” of drug administration
➢the CODE of ETHICS
nurse
people
society
NURSES AND MEDICATIONS
➢One of the nurse’s main task/responsibility is to administer medications to patients
SAFELY and CORRECTLY.
➢Nurses must remember that medications once given or administered, CANNOT be
withdrawn.
➢Nurses must be very careful when administering medications.
➢Principles of drug administration must be observed.
➢Nurses must have the knowledge and skill to CALCULATE drug dosages in order to
avoid errors and complications.
•Doctors – prescribe medications by writing a drug order
•Pharmacists – prepare and dispense drugs
•Nurses – interpret and carry out drug orders

Parts of a drug order:

Drug labels and doctor’s orders
NURSES AND DRUG ORDERS
➢ Nurses administer medications only after a drug order is made by the physician.
➢ A drug order is WRITTEN on the client’s chart or file by the physician.
➢In some instances, nurses write the drug order on the chart/file when receiving verbal
or telephone order from the physician.
The physician must sign such order the soonest possible time – within 24 hours.

Nurses need to understand the drug order

 basic parts
 validity and nullity
 accuracy and veracity
responsibility and accountability
Drug orders must be
 clear and concise
 written by a licensed practitioner
 signed properly (with physician’s license number)
 clarified whenever needed

CULTURAL IMPLICATIONS
Nurses work in a diverse and multicultural environment.
➢ transcultural nursing practice
respect for patient’s values, beliefs, health practices, religion and spirituality
➢holistic nursing approach – integration of the patient’s mind, body and spirit in
providing care ➢influence of race, ethnicity and genetics – patients are unique and
respond differently to drug therapy

SPECIAL POPULATIONS and DRUG ADMINISTRATION

PREGNANT AND BREAST - FEEDING WOMEN
➢ Teratogenic effects may occur in the fetus secondary to drug exposure.
➢ Caution pregnant women to AVOID ALL DRUGS, including herbal and over-the-
counter drugs, except those approved by health care provider.
➢ Drugs may appear in breast milk – producing a pharmacologic effect on the infant.
➢ Weigh the potential risks and benefits to both mother and fetus before administering
drugs.

Drugs and Pregnancy Risk Categories

 Category A – studies indicate no risks to fetus
 Category B – studies indicate no risk to animal fetus; information in humans is not
available
 Category C – adverse effects reported in animal fetus; information in humans is not
available
 Category D – possible fetal risk in humans is reported; consider potential benefit vs.
risk may warrant use in pregnant women
 Category X – fetal abnormalities reported and positive fetal risk in humans is available
these drugs SHOULD NEVER be given to pregnant women

NEWBORNS AND CHILDREN CHILDREN

– pediatric dosing is based on milligram per kilogram of body weight (mg/kg) or body
surface area expressed as mg/m2
Pharmacokinetics – delayed metabolism and excretion due to immature liver and
kidneys
prone to overdose and toxicity

ELDERLY CLIENTS ELDERLY – absorb, distribute, and eliminate drugs less efficiently
 they require a decrease in drug dosage
 multiple diseases can exist – places increased risk for adverse drug reactions and
toxicities
 poor compliance to take medications
 patient teaching may be difficult due to sensory deficits and impairments
LEGAL AND REGULATORY ISSUES IN DRUG ADMINISTRATION

MEDICATION ERRORS AND RECONCILIATION ETHICAL CONSIDERATIONS AND

IMPLICATIONS

NURSES AND MEDICATIONS

Under the law, nurses are RESPONSIBLE for their own actions regardless of whether
there is a written order.

Knowledge of nursing practice – defines, specifies and limits the scope and functions
of the nurse
limits of the nurses’ knowledge and skills – professional conduct and training

MEDICAL ERRORS
➢ broad term used to refer to ANY ERROR in any phase of clinical patient care that
causes or has the potential to cause patient harm
➢ include
•Medications
•Medical or surgical procedures
•Patient monitoring
•Errors of commission
•Errors of omission

DEFINITION OF TERMS
• MEDICATION ERROR (ME) – refers to any PREVENTABLE adverse drug event
(ADE) involving inappropriate medication used by a patient or a health care professional
❖ may or may not cause patient harm

• ADVERSE DRUG EVENT (ADE) – refers to any injury caused by a medication or

failure to administer an intended medication
❖ it may or not be preventable
❖ may or may not cause patient harm
❖ expected side-effects are ADEs
DEFINITION OF TERMS
• ADVERSE DRUG REACTION (ADR) – refers to any unexpected, unintended,
undesired, or excessive response to a medication
❖ may or may not cause patient harm
❖ All ADRs are considered ADEs but not all ADEs are ADRs
• ALLERGIC REACTION – immunologic response resulting from an unusual sensitivity
of a patient to a certain medication
❖ may or may not be known or expected
• IDIOSYNCRATIC REACTION – an abnormal or unexpected susceptibility to a
medication (other than allergy) that is unique to the person
•MEDICATION MISADVENTURE (MM) – the broadest term for any undesirable
medicationevent in patient care that is usually iatrogenic in nature
• IATROGENIC HAZARD – any potential or actual patient harm that is caused by errant
or faulty actions of the health care staff

POINTS FOR REFLECTION: TYPES AND CAUSES OF MEDICATION ERRORS

FROM NURSE’S VIEWPOINT (AN IRANIAN STUDY, 2013)
➢Medication errors had been made by 64.55% of the nurses.
➢31.37% of the participants reported medication errors before occurrence.
➢Most common types of reported errors: wrong dosage and infusion rate.
➢Most common causes of errors: using abbreviations instead of full names of drugs
and similar names of drugs.
➢The most important cause of medication errors was lack of pharmacological
knowledge.
➢There were no statistically significant relationships between medication errors and
years of working experience, age, and working shifts.
➢Errors in oral administration were significantly related with number of patients.

ACTORS THAT CONTRIBUTE TO MEDICATION ERRORS

Staff – inexperience, fatigue, boredom, lax attitude, complacency
Patients - age, disease, attitudes, behaviors
Work environment – “safety” culture, design, protocols and guidelines, communication
Medication-design – packaging, labelling, “looking and sounding alike”

PREVENTING AND RESPONDING TO MEDICATION ERRORS

Medical Error (ME) is a PROFESSIONAL RESPONSIBILITY.
General Steps: (In case an error has been made)
o Check the patient/s by assessing all relevant parameters and DOCUMENTING them.
o Assess the patient/s for the EFFECTS of the drugs and consulting references and
professional experts when needed.
o Complete the ME reporting forms after contacting the physician, charge nurse or
supervisor. (For a student, report the matter immediately to the instructor.)
o INFORM the patient of the error. Monitor the progress of the patient closely.
o Modify the care plan as needed.
o Conduct a ROOT-CAUSE ANALYSIS of the medication error. Reflection is needed.
o Review and ESTABLISH easy to understand and consistent drug administration
guidelines.

PREVENTING MEDICATION ERRORS

➢Minimize verbal or telephone orders unless necessary.
➢Avoid use of medical shorthand, non-standard and unaccepted abbreviations and
acronyms.
➢DO NOT assume anything else not specified in a drug order.
➢DO NOT decipher illegibly written drug orders.
➢When in doubt about the correctness of a drug order, CLARIFY and DOUBLE-
CHECK.

PREVENTING MEDICATION ERRORS

➢ Follow the “rights” of drug administration.
➢ Always check the drug label 3 times and check against the medication order before
administration.
➢ Follow agency or hospital protocols on drug administration. DO NOT SHORTCUT the
process.
➢ DO NOT administer a medication prepared by someone else.
➢ Learn the nuances or details of unusual drug forms.
➢ Check patient’s allergies and drug history.
➢ Strive to be alert, inquisitive and keep on learning.
➢ EDUCATE patients and their families.
➢ Be humble to accept what you do not know – ASK HELP and clarify.

MEDICATION RECONCILIATION
➢ It refers to the FORMAL process in which health care professionals partner with
patients to ensure accurate and complete medication information transfer at interfaces
of care (WHO, 2007)
** Up to 67% of patients’ prescription medication histories recorded on admission to
hospital have one or more errors and 30 – 80% of patients have a discrepancy between
the medicines ordered in hospital and those they were taking at home.
➢ a PATIENT SAFETY initiative
➢ prevents omissions, duplications, incomplete, wrong drugs to be given

ETHICAL CONSIDERATIONS AND IMPLICATIONS OF MEDICATION ERRORS

Nurses are guided by the following ethical principles:
Beneficence – doing and promoting “goodness”
Nonmaleficence – the duty to “do no harm”; avoiding errors and mistakes
Autonomy – assisting patients in decisionmaking related to care; informed consent
Justice – fair distribution of resources; being fair in one’s actions
Veracity – telling the truth (drug effects; errors)
Confidentiality – respect for privacy and dignity

DRUGS AFFECTING THE CENTRAL NERVOUS SYSTEM (CNS) PART 1: OPIOID ANALGESICS GENERAL AND
LOCAL ANESTHETICS CNS DEPRESSANTS AND RELAXANTS

➢CNS – consists of the brain and spinal cord

•both are the main centers where correlation and integration of nervous information occurs
•composed of large numbers of excitable nerve cells and their processes – NEURONS

•controls most functions of the body and mind

PHYSIOLOGY OF PAIN AND OPIOID ANALGESICS

PHYSIOLOGY AND PSYCHOLOGY OF PAIN

➢PAIN – unpleasant sensory and emotional experience associated with actual or potential tissue
damage

•it is a highly PERSONAL and INDIVIDUAL experience

•“whatever the person says IT IS, existing whenever the person says IT DOES

PHYSIOLOGY AND PSYCHOLOGY OF PAIN

➢Pain acts as a protective mechanism that indicates an underlying physiologic or psychological problem

➢Pain is subjective and varies widely from person to person

➢Pain is based upon a person’s perception, emotional state, and ethnic, cultural, or religious influences

ANALGESIA

➢is a state of pain relief or absence of pain without loss of consciousness

➢ANALGESICS – medications that relieve pain without causing loss of consciousness

OPIOID ANALGESICS

➢ originated from the OPIUM plant

➢ very strong PAIN RELIEVERS

•Morphine

•Codeine

•Papaverine – smooth muscle relaxant

➢ OPIOID AGONISTS – drugs that bind to opioid pain receptors in the brain and cause an analgesic
response

example: Morphine sulfate, Codeine, Fentanyl

Opioid receptors

 high density on basal ganglia, amygdala, pre-botzinger complex

  middle density on brainstem, cerebral cortex, hippocampus

➢ OPIOID ANTAGONISTS – drugs that reverse the effects of agonists

•they bind to pain receptors and exert no response

•they compete with opioid agonists at receptor sites, hence blocking the effects of opioid agonists

example: Naloxone hydrochloride (Narcan), Naltrexone hydrochloride (Revia, Trexan)

Agonists- drugs that occupy receptors and activate them.

Antagonists- occupy receptors but do not activate them, antagonists block receptor activation by
agonists.

INDICATIONS:

➢ to alleviate MODERATE to SEVERE pain

➢ to treat pain unresponsive to non-opioid analgesics

• Examples: Butorphanol, fentanyl, meperidine, morphine, nalbuphine, and pentazocine are used as
adjuncts to anesthesia (used post-operatively)

• Morphine is also used to treat pain in ***sickle – cell crisis and those caused by myocardial infarction
and pulmonary edema

CONTRAINDICATIONS:

known drug allergy to opioids

severe asthma or other respiratory insufficiencies

conditions of increased intracranial pressure pregnancy

PHARMACODYNAMICS OF OPIOID ANALGESICS

◼ Many opioids have an AFFINITY for the CNS

They suppress the medullary cough center (medulla oblongata)

- cough suppression
- respiratory depression

ABSORPTION

•Oral doses are absorbed in the gastrointestinal (GI) tract

•IV administration produces the most rapid and reliable effect

•IM and subcutaneous routes delay absorption

DISTRIBUTION •distributed widely

METABOLISM:

•Metabolized extensively in the LIVER

EXCRETION: •Metabolites are excreted in the URINE

OPIOID SIDE-EFFECTS AND ADVERSE EFFECTS

Cardiovascular Central Nervous System (CNS)- HYPOTENSION, palpitation, flushing

Central Nervous System (CNS)- SEDATION, disorientation, euphoria, light headedness, dysphoria,
increased seizure threshold, tremors

•Gastrointestinal - Nausea, vomiting, constipation, biliary tract spasm

•Genito-urinary (GU)- Urinary retention

•Integumentary- Itching, rash, wheal formation

•Respiratory RESPIRATORY DEPRESSION and aggravation of asthma

•Others •Dependence physical •psychological

Opioid Side effects

“MORPHINE”

 myosis (pin-point pupils)

 out of it (sedation)
 respiratory depression
 physical dependence
 hypotension (orthostatic)
 infrequency (constipation, urinary retention)
 nausea
 emesis (vomiting)

“DESIGNER”

 Dry mouth
 Euphoria
 Sedation
 Itch
 Gastro constipation
 Nausea
 Eyes (papillary constriction)
 Respiratory depression

OPIOID TOXICITY AND MANAGEMENT

➢ use of OPIOD ANTAGONISTS

•NALOXONE (Narcan) – the drug of choice for complete or partial reversal of opioid-induced respiratory
depression

•the “antidote” for opioid overdose

•NALTREXONE – used as an adjunct treatment for opioid addiction

OPIOID INTERACTIONS

➢Concurrent use with alcohol, antihistamines, hypnotics or sedatives cause additional CNS depression.

➢Opioid agonist-antagonist may cause withdrawal symptoms in patients with physical dependence.

➢Concurrent use with non-opioid analgesics may enhance pain relief.

NURSING RESPONSIBILITIES IN OPIOID AGONIST ADMINISTRATION

➢Before starting therapy, the nurse should assess patient’s:

•allergies

•use of opioid and other drugs

•use of alcohol

•characteristics, duration and intensity of pain

➢Assess patient’s vital signs (BP, PR and RR) before administration and all throughout drug therapy.

➢To prevent withdrawal symptoms, discontinue opioid analgesics gradually after long-term use.

➢Instruct patient to take oral analgesics with food to minimize gastric irritation.

➢Teach the patient to change position slowly to minimize orthostatic hypotension.

➢Teach patient to avoid activities requiring alertness (ex: driving) until the response of the drug is
known.

➢Discuss ways to minimize dry mouth and constipation.

➢When administering Morphine and Meperidine, the nurse should withhold the dose and contact the
physician if the vital signs are abnormal, especially for a respiratory rate of <12 breaths/minute

➢follow agency protocol for administration of controlled substances.

GENERAL AND LOCAL ANESTHETICS

➢ ANESTHESIA – a drug-induced state in which the central nervous system is altered to produce

•varying degrees of pain relief

•depression of consciousness

•skeletal muscle relation

•diminished or absent reflexes

➢ ANESTHETICS – are the agents that depress the CNS to produce depression of consciousness, loss of
responsiveness to sensory stimulation and muscle relaxation

TYPES OF ANESTHESIA

GENERAL ➢ a drug-induced state of global or whole-body loss of consciousness

➢ drugs used for this purpose can be:

•inhaled

•intravenous

LOCAL

➢ a drug-induced state of insensitivity to pain in a specific area of the body without affecting
consciousness

➢ also referred as REGIONAL anesthesia

➢ can be given as:

• parenteral

• topical

EXAMPLES OF GENERAL ANESTHETICS

INHALED

➢ Nitrous oxide (laughing gas)

➢ Halothane

➢ Isoflurane

INTRAVENOUS

➢ Ketamine

➢ Propofol
➢ Thiopental

➢ Methohexital

ADJUNCT AGENTS

➢ Fentanyl

➢ Meperidine (Demerol)

➢ Morphine

GENERAL ANESTHETICS

➢ INDICATIONS – used mainly for surgical procedures

➢ CONTRAINDICATIONS – include

• known allergy

• pregnancy (intravenous agents)

• narrow angle glaucoma

➢ MAJOR SIDE EFFECTS

• respiratory depression

• cardiac depression

➢ DRUG TO DRUG INTERACTIONS

• Anti-hypertensives

• Beta-blockers

• Tetracycline

All produce additive effects

- Hypotension
- Myocardial depression
- Renal toxicity

➢ NURSING RESPONSIBILITIES

•Since anesthetics are given INTRA-OPERATIVELY, the responsibilities will be discussed in detail in LEVEL
3.

TYPE OF LOCAL ANESTHESIA

 Topical anesthesia (tetracaine, lidocaine, benzocaine)

 Infiltration anesthesia (procaine, chloroprocaine, lidocaine, bupivicaine)
 Nerve block anaesthasia (lidocaine, prilocaine, bupivicaine)
  Spinal anaesthesia (tetracaine, lidocaine, bupivacaine, articaine)
 Epidural anaesthesia (lidocaine, bupivacaine, articaine)

Types of Local Anesthesia (Local CNS)

➢ INDICATIONS – used for surgical, dental and diagnostic procedures

➢ CONTRAINDICATIONS – include

• known allergy

➢ MAJOR SIDE EFFECTS

• mostly allergic reactions

• for spinal and epidural – spinal headaches, hypotension, neural injury, transient back ache

• nerve blocks – urinary retention

➢ DRUG TO DRUG INTERACTIONS

• Bupivacaine

• Chloroprocaine

• Etidocaine

When given with epinephrine and gaseous anesthetics – cardiac dysrhythmias

CNS DEPRESSANTS AND RELAXANTS (SEDATIVES AND ANXIOLYTICS)

➢these are drugs that have a calming effect or depress the CNS

SEDATIVES – drugs that reduce nervousness, excitability and irritability without causing sleep

HYPNOTICS – sedatives given a much larger dose to induce or cause sleep

ANXIOLYTICS – drugs that basically effect calm and reduce panic or anxiety

Classifications:

➢Barbiturates – depress the brainstem (reticular formation area)

➢Benzodiazepines – depress hypothalamic, thalamic and limbic systems of the brain

• most commonly prescribed sedative-hypnotics

➢Non-benzodiazepines (miscellaneous agents) – usually short-acting agents for the short-term

treatment of insomnia
 1. Barbiturates
Long acting, phenobarbitone, pentobarbitone
Short acting- butobarbitone, methohexitone
Ultra short acting- thiopentone

2. Benzodiazepines
Hypnotic- diazepam, flurazepam, nitrazepam alprazolam, temazepam, triazolam
Antianxiety- diazepam, chlordiazepoxide, oxazepam, lorazepam, alprazolam
Anticonvulsant- diazepam, lorazepam, clonazepam, clobazam

3. Newer nonbenzodiazepine hypnotics

Zopicione, zolpidem, zaleplon

CNS DEPRESSANTS AND RELAXANTS INDICATIONS

•insomnia
•to induce sleep
•anxiety
•skeletal muscle relaxation
•adjunct to anesthesia in surgical procedures

CONTRA-INDICATIONS
allergies
pregnancy
respiratory depression
severe liver disease

SIDE and ADVERSE EFFECTS

•respiratory depression
•hypotension or hypertension
•arrhythmias
•elevated liver enzymes
•anemia
•blood dyscrasias
•urinary retention
•constipation
•withdrawal symptoms
•rebound insomnia
•dependence (physical and/or psychological)

SIDE and ADVERSE EFFECTS

•respiratory depression
•hypotension or hypertension
•arrhythmias
•elevated liver enzymes
•anemia
•blood dyscrasias
•urinary retention
•constipation
•withdrawal symptoms
•rebound insomnia
•dependence (physical and/or psychological)

DRUG to DRUG (and FOOD) INTERACTIONS

• BARBITURATES when they
➢ interact with antihistamines, benzodiazepines, opioids and alcohol to produce severe RESPIRATORY
DEPRESSION
➢ interact with MAOIs – prolong barbiturate effects
➢ are taken with anti-coagulants – reduce anti-coagulant effects and increase the risk for clot formation
➢ are taken with oral contraceptives – increase contraceptive metabolism

NURSING RESPONSIBILITIES
➢Assess the patient for allergies, blood and liver function studies.
➢Administer drugs with meals to decrease GI upset.
➢Administer the drugs before bedtime to facilitate sleep.
➢Put bed side rails up after drug administration.
➢Observe patients for side and adverse effects while on therapy.
➢Assist the patients (especially geriatric) during ambulation in the morning.

NURSING RESPONSIBILITIES
Teach and inform the patient of the following:
• Take medication ONLY as prescribed. DO NOT double-dose.
• Take only for a short period of time as prescribed.
•Avoid taking other CNS-altering medications such as opioids and alcohol.
• Do not take with over the counter (OTC) medications.
•Avoid driving or engaging in activities that require alertness.
•Keep all medications away from children’s reach.
•Inform that such medications can cause dependence and interfere with sleep if taken long-term.
• Non-pharmacological interventions to promote sleep.

➢CNS – consists of the brain and spinal cord

•both are the main centers where correlation and integration of nervous information occurs
•composed of large numbers of excitable nerve cells and their processes – NEURONS
•controls most functions of the body and mind

ANTI-CONVULSANTS (ANTI-EPILEPTICS)
ANTI-CONVULSANT DRUGS
➢these are also called “anti-epileptics”
➢used mainly for epilepsy and seizures
INDICATIONS:
•prevention and control of seizure activity
•maintenance therapy in patients with chronic seizures or epilepsy

MECHANISM of ACTION
•alter the movement of sodium, potassium, calcium, and magnesium ions resulting in stabilized and less
responsive cell membranes
•act to depress or limit the spread of a seizure discharge from its origin
•decrease the speed of nerve impulse conduction

ANTI-CONVULSANT DRUGS
Common examples: (on PRESCRIPTION ONLY)
➢ Benzodiazepines – 1 st line agents
•Diazepam – oral and parenteral forms
➢Hydantoins – management of tonic-clonic and partial seizures
•Phenytoin - oral and parenteral forms
•Carbamazepine – oral form
•Valproic acid – oral form
➢Barbiturates – prophylaxis for febrile convulsions
•Phenobarbital – oral and parenteral forms

CONTRA-INDICATIONS
•allergy
•pregnancy

SIDE and ADVERSE EFFECTS

•drowsiness
•bone marrow suppression
•thrombocytopenia

DRUG FOCUS: DIAZEPAM

➢ the drug of choice in the treatment of status epilepticus because of its quick onset
➢ has a longer half-life and has a longer duration of action
➢ stays in the CNS longer
➢IV and rectal administration have the most rapid onset of action

Side-effects: hypotension and apnea may occur with IV administration

NURSING RESPONSIBILITIES
•Oral drugs should be administered regularly at the same time each day.
•Administer oral drugs with meals to reduce GI upset.
•Give injections deep IM (usually in the gluteus).
•Give IV injections slowly and make sure IV line is patent or working well.
•DO NOT mix with other drugs and give IV injections separately.
•Monitor complete blood count (CBC) results as well as intake and output.
Teach and inform the patient of the following:
•Understand that drugs may be taken for life.
•Oral drugs should be taken regularly at the same time each day.
•Do not decrease dose or discontinue therapy without doctor’s order.
•Take the medication as ordered. DO NOT miss or double dose.
•Report any miss doses or problems immediately.
•The urine may turn pink when taking some of the drugs.
•Avoid driving or engaging in activities that require alertness.
•Encourage to always bring ID or medical bracelet.

ANTI-PARKINSONIAN DRUGS
•refer to the group of drugs that are indicated for the treatment and management of Parkinson’s
Disease (PD)

•PARKINSON’S DISEASE – a chronic, progressive degenerative disorder of the CNS affecting the
dopamine-producing neurons in the brain characterized by tremors or shaking

Classifications of Anti-Parkinsonian Drugs

Dopamine Receptor Agonists (Dopaminergics) Levodopa
Selective MONOAMINE OXIDASE (MAO) inhibitors Selegiline
Anticholinergic agents Benztropine mesylate (Cogentin)

DOPAMINE RECEPTOR AGONISTS – are used to provide exogenous (outside source) of lost dopamine or
enhance the function of neurons still capable of producing dopamine

➢ considered as the “cornerstone” of the treatment for PD

➢also called pre-synaptic or precursor drugs
•example: Levodopa Levodopa-carbidopa – given to prevent dysrhythmias

SELECTIVE MAO INHIBITORS – these drugs catabolize or breakdown catecholamines (dopamine,

epinephrine, etc…)
➢ increase the levels of dopaminergic stimulation in the CNS
•example:
Selegiline – used in combination with Levodopa or Levodopa-carbidopa
• it is an adjunctive agent used when a patient’s response to levodopa is fluctuating

ANTI-CHOLINERGIC AGENTS – these drugs block the effects of acethylcholine

➢they basically decrease salivation and relax smooth muscles

➢ helpful in relieving the muscle tremors and rigidity (extrapyramidal symptoms) of patients with PD

•examples: Benztropine mesylate (Cogentin)

 Biperiden (Akineton)

SIDE and ADVERSE EFFECTS

 Dopamine Receptor Agonists
 dizziness, impaired coordination, headache
 palpitations, orthostatic hypotension
 hemolytic anemia, agranulocytosis
 dark urine
 Selective MAO inhibitors
 dizziness, lightheadedness, confusion
 insomnia
 nausea, abdominal pain, dry mouth
 Anti-cholinergic agents
 drowsiness, confusion, hallucinations
 constipation, nausea, vomiting

NURSING RESPONSIBILITIES
 DOPAMINE RECEPTOR AGONISTS
 Assess history of patients for seizures, hypotension, PUD, MI or asthma. These are all
CONTRAINDICATIONS to receive the drugs.
 Assist the patient when walking because of dizziness at the start of therapy.
 Instruct to avoid foods high in Vitamin B6, increase fluid intake, and eat high fiber foods.
 SELECTIVE MAO INHIBITORS  Monitor blood pressure and pulse before and during treatment.
 Administer medicine at night or bedtime to avoid drowsiness at day time.
 Avoid administering MAOIs with tyramine containing food such as milk, tea, cardbonated drinks,
wheat bread and cheese.
 Observe mood swings during the treatment.

ANTI-CHOLINERGIC AGENTS
•Give the drugs or administer with meals or after meals to minimize GI upset.
•Facilitate intake of at least 2000 ml/day if not contraindicated.
•Instruct the patients on the following:
 Avoid driving or activities requiring alertness.
 Change positions slowly to prevent falling or injury due to orthostatic hypotension.
 DO NOT discontinue treatment without consultation.
 Avoid taking over-the-counter medications unless approved by the doctor.

PSYCHOTHERAPEUTIC DRUGS
➢these are also called “antipsychosis” or “neuroleptic agents”
➢used mainly for the treatment and management of mental and emotional disorders

Cannot be given to old patients

CNS STIMULANTS
➢these are drugs that stimulate a specific area of the brain and spinal cord
➢ elevate mood, produce a sense of energy and alertness, decrease appetite and enhance task
performance
➢ also called “sympathomimetic agents” because they have similar actions with the neurotransmitters
epinephrine and norepinephrine

➢examples of these drugs include

•Cocaine
• Amphetamines
• Caffeine (plant-derived)

➢ most of the drugs are considered CONTROLLED substances and follow the Scheduling Guidelines

DRUGS AFFECTING THE CARDIOVASCULAR SYSTEM

Types of Antianginal Drugs
01 Nitrates
 Therapeutic actions and indications
1. Relax and dilate, veins, arteries, capillaries
2. Prevention and treatment of attacks of angina pectoris

Includes:

a. Amyl nitrate
b. Isosorbide nitrate
c. Isosorbide mononitrate
d. Nitroglycerin

Pharmacokinetics

a. Sublingual tablet
b. Translingual spray
c. Intravenous solution
d. Transdermal patch

Contraindications, Adverse Effects, Drug-Drug Interactions

Contraindications:
1. Severe Anemia
2. Head trauma or Cerebral Hemorrhage
3. Pregnancy and Lactation

Caution:
*Hepatic and Renal Disease
*Hypotension & Hypovolemia
Adverse Effects:
1. CNS
2. G.I.
3. CV
4. Skin-related

Drug-Drug Interactions:
1. Heparin
2. Drugs that treat Erectile dysfunction

Nursing Considerations
1. Assess: kidney or liver function, pregnancy and lactation
2. Check for neurological status, cardiopulmonary status, lungs
3. Monitor for lab tests

02 Beta Blockers
Therapeutic actions and indications
1. Use to block stimulatory effects of sympathetic nervous system
2. Recommended use for angina

Includes:
a. Metropolol
b. Propanolol
c. Nadolol *drugs ending in “lol”

Pharmacokinetics (Routes of Administration)

Oral preparations
Peak – 60-90 minutes
Duration – 6-19 hrs

Contraindications, Adverse Effects, Drug-Drug Interactions

Contraindications:
1. Bradycardia, heart block, cardiogenic shock
2. Prinzmetal angina 3. Pregnancy and Lactation

Caution: *DM, Thyrotoxicosis *Asthma, COPD

Adverse Effects:
1. CNS
2. G.I.
3. CV
4. Respiratory
Drug-Drug Interactions:
1. Clonidine
2. NSAIDs
3. Insulin & Antidiabetics

NURSING CONSIDERATIONS:
1. Monitor ECG, heart rate
2. Monitor for I&O and weight gain
3. Teach patient not to abruptly stop taking the medication

03 Calcium Channel Blockers

Therapeutic actions and indications
1. For treatment of Prinzmetal angina, chronic angina, hypertension

Includes:

a. Amlodipine

b. Diltiazem

c. Nicardipine

d. Nifedipine

e. Verapamil

Pharmacokinetics

Oral preparations

Onset – 20 minutes

Duration – 2-4 hours

Contraindications, Adverse Effects, Drug-Drug Interactions

Contraindications:
1. Pregnancy or lactation Caution:
*Heart Block
*Sick sinus syndrome
*Heart Failure
*Renal or Hepatic Dysfunction

Adverse Effects:
1. CNS
2. G.I.
3. CV
4. Skin-related

Drug-Drug Interactions:
1. Cyclosporine
2. Digoxin

Nursing Considerations
1. Assess cardiopulmonary status, ECG
2. Check for liver function and renal function
3. Assess for respirations and auscultate lungs

Antiarrhythmic Drugs

Types:

1. Class I: antiarrhythmic
2. Class II: antiarrhythmic
3. Class III: antiarrhythmic
4. Class IV: antiarrhythmic

Class 1 antiarrhythmic

Therapeutic Actions and Indications

1. These are local anesthetics and membrane-stabilizing agents

2. For clients experiencing tachycardia

Includes:

a. Class Ia antiarrhythmics (Quinidine)

b. Class Ib antiarrhythmics (Lidocaine)

c. Class Ic antiarrhythmics (Propafenone)

Pharmacokinetics (Routes of Administration)

Oral preparation and IV/IM

Contraindications, Adverse Effects, Interactions

Contraindications:

1. Bradycardia or Heart Block

2. Heart Failure, Hypotension, or Shock

3. Electrolyte Imbalance

Caution:

*Hepatic and Renal Disease

Adverse Effects:

1. CNS

2. G.I.

3. CV

4. Respiratory

Interactions:

1. Digoxin

2. Oral Anticoagulants

3. Foods that alkalinize urine

4. Grapefruit

Class II Antiarrhythmic

Therapeutic Actions and Indications

1. Block beta-receptor sites in the heart and kidneys

2. Indicated for treatment of supraventricular tachycardia and PVCs

Includes:

a. Acebutolol

b. Esmolol

c. Propranolol
Pharmacokinetics

Oral Preparation and IV

Contraindications, Adverse Effects, Interactions

Contraindications:

1. Sinus Bradycardia and AV block

2. Heart failure, Asthma, Respiratory Depression

Caution:

*Diabetes

*Thyroid Dysfunction

Adverse Effects:

1. CNS

2. G.I.

3. CV

4. Respiratory

Interactions:

1. Insulin

Class III Antiarrhythmic

Therapeutic Actions and Indications

Drug of choice for treating ventricular fibrillation or pulseless ventricular tachycardia in cardiac arrest

Includes:

a. Amiodarone

b. Dofetilide
c. Ibutilide

d. Sotalol

Pharmacokinetics

Oral preparation and IV

Contraindications, Adverse Effects, Interactions

Contraindications:

1. AV Block

Caution:

*Shock, Hypotension, Respiratory Depression

Adverse Effects:

1. G.I.

2. CV

Interactions:

1. Antihistamines, TCAs

2. NSAIDs, aspirin, antacids

Class IV Antiarrhythmic

Therapeutic Actions and Indications

1. Block the movement of calcium ions across the cell membrane

Includes:

a. Diltiazem

b. Verapamil

Pharmacokinetics (Routes of Administration)

IV

Verapamil (administer via IV if used as an antiarrhythmic)

Contraindications, Adverse Effects, Interactions

Contraindications:

1. Hypotension Caution:

*Idiopathic Hypertrophic Subaortic Stenosis

Adverse Effects:

1. CNS

2. G.I.

3. CV Interactions:

1. Beta Blockers

2. Beta adrenergic drugs

Nursing Considerations

1. Assess: neurologic status, cardiac status, respiratory status

2. Inspect for the abdomen
3. Obtain baseline ECG

TYPES OF HYPERTENSIVES

1. ACE INHIBITORS
Therapeutic Actions and Indications
1. Prevent conversion of Angiotensin I to Angiotensin II (powerful vasoconstrictor and stimulator
of aldosterone)

Includes: “drugs ending in –pril”

a. Benazepril
b. Captopril
c. Enalapril d. Quinapril

Pharmacokinetics
Oral Administration and IV solution
Contraindications, Adverse Effects, Drug-Drug Interactions
Contraindications:
1. Impaired renal function
2. Pregnancy
3. Lactation

Caution: *Heart Failure

Adverse Effects:
1. CV
2. GI
3. Skin-related

*Captopril
*Moexipril

2. ANGIOTENSIN II – RECEPTOR BLOCKERS

Therapeutic Actions and Indications
1. Slows the progression of renal disease and in patients with HPN and type 2 DM

Includes:

a. Candesartan

b. Irbesartan

c. Losartan

d. Telmisartan

Pharmacokinetics

Oral preparations, unknown effects on lactation

Contraindications, Adverse Effects, Drug-Drug Interactions

Contraindications:

Pregnancy
Caution:
*Hepatic or renal dysfunction
*Hypovolemia

Adverse Effects:
1. CNS
2. G.I.
3. Respiratory
4. Skin
Drug-Drug Interactions:
1. Ketoconazole, fluconazole, Diltiazem
2. Phenobarbital, Indomethacin

3. VASODILATORS
Therapeutic Actions and Indications
1. Act directly on vascular smooth muscle to cause muscle relaxation
2. Treatment of severe hypertension

Includes:
a. Diazoxide
b. Hydrlazine
c. Minoxidil
d. Nitroprusside

Pharmacokinetics
Intravenous, Oral and IM

Contraindications, Adverse Effects, Drug-Drug Interactions

Contraindications:
1. Cerebral Insufficiency
Caution: *PVD, CAD, Heart Failure, Tachycardia
*Functional Hypoglycemia

Adverse Effects:
1. CNS
2. G.I.
3. CV
4. Skin-related
5. Endocrine
*CYANIDE TOXICITY

OTHER HYPERTENSIVES
1. Diuretic Agents
2. Ganglionic Blocker
3. Renin Inhibitor
4. Sympathetic Nervous System Blockers

Diuretic Agents
❑ Drugs that increase the excretion of sodium and water from the kidney
1. Thiazide and Thiazide-like Diuretics
2. Potassium-sparing Diuretics
 Ganglionic Blockers
❑ Used in severe or malignant HPN
❑ Monitor clients for loss of autonomic reflexes
1. Mecamylamine (Inversine)

Renin Inhibitor

❑ Inhibits RAS which may lead to decreased blood pressure, decrease aldosterone release, and
decreased sodium absorption

1. Aliskiren

Sympathetic Nervous System Blockers

1. Beta blockers

2. Alpha-adrenergic blockers

3. Alpha1- blockers

4. Alpha2- blockers

Nursing Considerations

1 Monitor for sudden drop in fluid volume

2 Assess for the following conditions: kidney and liver function, pregnancy and lactation

3 Administer on an empty stomach 1 hour before meals or 2 hours after meals

4 Assess: Baseline status

5 Encourage patient to implement lifestyle changes

6 Monitor: blood glucose and serum electrolytes

Types of Cardiotonic Agents

01 Cardiac Glycosides

Therapeutic Actions and Indications

1. They exert their effects on the cardiac muscles by affecting levels of intracellular calcium. Digoxin
(Lanoxin)

❑ Increases force of myocardial contraction (positive inotropic effect)

❑ Slow heart rate (negative chronotropic effect)

Pharmacokinetics

Oral preparation and parenteral

Contraindications, Adverse Effects, Interactions

Contraindications:

1. Ventricular Tachycardia or fibrillation

2. Heart block, sick sinus syndrome

3. IHSS

4. Acute MI

5. Electrolyte Imbalance

Adverse Effects:

1. CNS

2. CV

3. GI

*Digitalis Toxicity

02 Phosphodiesterase Inhibitors

Therapeutic Actions and Indications

1. Aid in increasing force of myocardial contractility through their enzyme-blocking effect.

Includes:

1. Inamrinone

2. Milrinone

Contraindications:

1. Severe aortic or Pulmonary Valvular Disease

2. Acute MI

3. Conditions with fluid volume deficit

Adverse Effects:

1. CV

2. GI

3. Hematology

4. Hypersensitivity Recations

Nursing Considerations

1. Assess: baseline weight, heart rate, blood pressure

2. Auscultate heart sounds and obtain ECG
3. Monitor: urinary pattern, serum electrolyte, renal function test