Diphenhydramine(Benadryl), Dimenhydrinate(Dramamine), Promethazine(Phenergan)

Work both peripherally and centrally 

Astemizole(hismanal), Loratidine(Claritin), Fexofenadine(Allegra)

Don't have the CNS affects (drowsiness) that many older antihistamines have.

Work Peripherally to block the action of histamine. 

It is an Histamine blocker (antagonist)

Most beneficial when given early before the release of histamine.(timing is very important)

Allergic disorders

Parkinson disease

motion sickness

hypnotic/sedative 

Glaucoma

Peptic ulcer disease(ulcers in inner lining[mucosa] of the stomach or duodenum)

Benign prostatic hypertrophy (enlarged prostate) 

Avoid activities that require mental alertness

Client shouldnt consume alcohol or any CNS depressants

Always check the package inserts of OTC preps to determine drug interaction 

Act through sympathomimetic action

Constrict arterioles and reduce blood flow to area.

Headache

 Nervousness

Tremors

Tachycardia

Palpatations

Hypertension

Rebound effect 

Suppress the cough reflex

Only given if cough interferes with sleep or ADL's

narcotics (codine), Non-narcotics (dextromethorphan)

Guaifenesin (Robitussin)

Increases cAMP - exact the mechanism unkown

Cerebral stimulation, skeletal muscle stimulation, bronchodilation, pulmonary vasodilation, cardiac stimulation, diuresis 

Theophylline (Theodur)

Aminophylline 

acetylcysteine [mucomyst]

breaks mucoproteins in mucus into smaller strands, administered by inhalation, also given orally for treatment of tylenol overdose, have suction equipment at bedside to maintain open airway.

Para-aminophenol derivatives: acetaminophen[APAP] (tylenol)

Salicylates: aspirin

Nonsteroidal anti-inflammatory drugs (NSAIDs) 

Acetaminophen - Analgesic, antipyretic

NSAID's - Analgesic, antipyretic, anti-inflammatory, anti-platelet aggregation

ASA - Analgesic, antipyretic, anti-inflammatory, anti-platelet aggregation

blocks transmission of pain impulses to brain, inhibits prostaglandin synthesis

never take tylenol with alcohol 

blocks pain impulses and inhibits prostaglandins

always take ASA with food 

tinnitus, hearing loss, dizziness, and N/V/D that progresses to hyperventilation from metabolic acidosis.

High doses may cause GI bleeding/hemorrhagic gastritis 

Most widely used non-narcotic analgesic,

inhibits the activity of the enzyme cyclo-oxygenase, resulting in decreased formation of prostaglandin

 Decrease in prostaglandin synthesis and activity is responsible for the therapeutic effects

Cyclooxygenase - 2 inhibitors

Controversial - Vioxx

Celecoxib - Celebrex 

Anticoagulants: prolonged prothrombin time.

Adrenergic blockers: potential decrease in antihypertensive effects.

Loop diuretics: decreased diuretic effect.

Dont take NSAID's if on Lasix 

Check for history of peptic ulcer disease, GI bleeding

Overuse of NSAIDs can cause liver and renal damage

NSAIDs added with narcotics to achieve anti-inflammatory abilities 

ibuprofen (motrin)

naproxen (naprosyn)

ketrolac (Toradol) 

inhibit transmission of pain impulses

reduce cortical response to pain impulse (cortex)

After behavior response to (euphoric behavior) 

Reduce pain by stimulating opiate receptors in the CNS-endorphins

All narcotics cause constipation n/v, dizziness, and lightheadedness

Narcotics combined with antiemetics to potentiate analgesia and to prevent n/v

Onset of action for noarcotics: IV-immediate (peak in 5 min) IM - 20-30 minutes

Narcotics are either "natural" from the opium poppy or synthetic

Morphine is the "king" or "ruler" of potency. 

assess resp status (resp depression)

Drowsiness and sedation

Narcotics stimulate the chemoreceptor trigger zone

be alert for physical or psychological depenendence

Narcotics lower bp

They obsucre diagnosis of acute abdominal condition 

Dose depends on pain, response and pt size

Often prescribed PRN

Analgezia is more effective if given regularly around the clock

Oral drugs go through 1st pass effect 

Larger dose is needed for pain relief

Seen frequently with chronic pain

Observe for development of tolerence (lortab esp) 

Physical Dependence - results in withdrawal if stopped abruptly

 Psychological dependence - pattern of compulsive drug use, continued craving, used for effect not relief

 Less than 1% of clients become dependent

Respiratory depression

severe CNS depression

Acute alcoholism and delirium 

pump is controlled to not OD

Maintains constant blood level of narcotics

decreased total amount of narcotics used

Notice # of attempts to get meds 

Thiopental (Pentothal):

Ultrashort-acting barbituate

Produces hypnosis and anesthesia

Midazolam (Versed)

used as pre-medication or to supplement anesthesia and produce amnesia

Given in reduced dosages to debilitated or geriatric patients 

lidocaine (xylocain)

Renders a portion of the body insensitive to pain without affecting consciousness

Lidocaine without or lidocaine with epinephrine: 

Epinephrine may be added to cause local vasoconstriction-->decreased systemic absorption-->prolonged anesthetic duration (never use lidocane c epinephrine in finger, toes, penis ears and nose) 

Spinal Anesthesia

Used for surgery on lower abdomen, inguinal area or lower extremities

Anesthesia of choice for pt c resp, hepatic, or kidney disease 

Pt must be positioned in semi-folwler to prevent flow of anesthetic agent from flowing upward toward diaphragm else diaphragmatic paralysis and resp depression may result

Used for skin/tissue pain/discomfort

not systemically absorbed

ex - ointments for poison ivy and throat lozenges 

Contains lidocaine 

centrally acting - depresses the CNS or blocks the transmission of nerve impulses from the spinal cord to the skeletal muscle, causing skeletal muscle relaxation

Peripherally acting - muscle relaxants interfere with nerve impulses depolarization/repolarization 

central acting - releaves muscle spasms locally from trauma or inflammation. Also used to treat muscle spasm in multiple sclerosis

Peripherally acting agents - used in OR before induction with general anesthesia 

Centrally acting skeletal muscle relaxants

Indications for centrally acting skeletal muscle relaxants

used in treatment of spastic muscle conditions and pain in musculoskeletal diseases

Used in painful musculoskeletal conditions such as sprains and spasms 

MOA of Centrally acting skeletal muscle relaxants

Before administration document indications for therapy and onset and type of symptoms

Protect pt from injury

teach pt to abstain from other cns depressants including alcohol 

A pituitary hormone

increases water permeability in renal collecting ducts

Conserves body water by reducing water loss in urine

Stimulates vascular constriction and increases BP 

4 major indications:

Hypothalmic diabetes insipidus

gastrointestinal hemorrhage

to elevate blood pressure

nocturnal enuresis 

Use caution with pt c preexisting cardiac disease :

Angina

decreased cardiac output

increased peripheral resistance (hypertension)

arrhythmia 

bradycardia

Premature atrial contraction

heart block

fluid overhydration 

Assess for diabetes insipidus from head injury

perform neuro assessment

hypotention and check cardiac status

always assess vitals and serum sodium  (135-145)

replaces the thyroid hormones that are deficient in a pt with hypothyroidism(products replace T3 and/or T4)

T3 and T4 are critical for metabolic rate, cardiac output, protein synthesis, and glycogen utilization 

Used in pt's with mild to severe hypothyroidism

Used diagnostically in suppression test to differentiate suspected hyperthyroidism from euthyroidism 

symptoms of hyperthyroidism may occur

angina

tachycardia

palpitations

hypertension

cardiac dysrhythmia

n/v/d

cramping, insomnia, tremors, headache

nervousness

irritability

weight loss

fever 

Obtain baseline vitals to compare later.

Monitor weight

Instruct pt to take drug at the same time preferrably before breakfast

instruct client to avoid foods like strawberries, peaches, pears, cabbage, turnips, spinach, kale, brussel sprouts, cauliflower, radishes, and peas.

Dosages of insulin and oral antidiabetic drugs may need to be adjusted. 

drugs used for hyperthyroidism designed to block/antagonize the effects of hormones secreted from the thyroid gland

palpitations

heat intolerance

nervousness and insomnia

breathlessness

increased bowel movements

light/absent menstrual periods

 fast heart rate

trembling hands, muscle weakness

warm, moist skin

hair loss, staring gaze

weight loss

inhibits the formation of thyroid hormones by interfering with the incorporation of iodine into tyrosine

they also interfere with the oxidation of iodide ion

hyperthyroidism

thyrotoxicosis (thyroid storm) 

CNS: dizziness, neuritis, weakness, parasthesia, fatigue, headache

CV: bradycardia 

check serum t3/t4

check for symptoms of thyroid crisis

teach client S/S of hypothyroidism

Advise the client to contact the physician if a soar throat and feer occur while taking these drugs

 The most serious adverse effect of these drugs is agranulocytosis. Be aware that CBC should be checked for leukopenia

 Take drug c meals to decrease GI symptoms

 teach pt to take drug at regular intervals

advise about the effects of iodine and its presence in iodized salt, shellfish, and over-the-counter cough medicines 

rapid acting

intermediate acting

long acting 

restores ability of cells to use glucose

acts by stiulating cellular uptake of glucose, amino acids, nucleotide, and K

Promotes the synthesis of complex organic molecules, such as fatty acids, which are incorperated in tryglycerides 

Treatment of Type I (IDDM)

When Type II (NIDDM) is unresponsive to diet and oral antidiabetic agents

Treatment of hyperkalemia (insulin promotes cellular uptake of potassium) 

Absoprtion rate is related to:

type of insulin

injection site

volume of insulin given 

Humulin R

Novulin R 

NPH

Humulin N

Novulin N 

Developed to more closely stimulate the varying levels of endogenous insulin that occur normally in non-diabetic people

The first number represent the number of units of intermediate acting insulin, the second number represents the number of short acting insulin

Humulin 70/30, Novulin 50/50 

hypoglycemia

lipoatrophy/lipodystophy

lipohypertrophy

immunogenic insulin resistance 

sulfonylureas - stimulate the pancrease to secrete insulin

Biguanides - decreases hepatic glucose production and intestinal glucose absorption and increase peripheral glucose uptake and utilization

Glucoseidase inhibitors - delay the digestion of carbohydrates and absorption of glucose 

Chlopropamide(Diabenese)

Glipizide(Glucotrol)

Glyburide(Micronase) 

aka oral hypoglycemic agents (OHA's)

used to lower glucose levels

each group works differently that allows multiple drugs to be used at the same time to take advantage of each drugs properties 

Acarbose (Prandase) 

slows down absoroption of sugars from the gut

 oral glycemic agent

sulfonylureas - glyburide (Diabeta)

Metformin (Glucophage) 

Decreases glucose release from the liver

oral glycemic agent

Rosiglitazone (Avandia)

Increase glucose uptake by fat and muscle cells 

oral glycemic agent

Treatment of Type II diabetest (NIDDM) that is unresponsive to diet and exercise therapy

May also be used with insulin therapy in the client who requires large amounts of insulin, such as an obese client 

hypoglycemia*

GI: nausia, heartburn, diarrhea 

Avoid other meds (aspirin and alcohol esp)

teach signs of hypoglycemia and instruct to drink juice or candy if they occur and notify MD

if dose is missed, take as soon as remembered but dont double up dose

take med same time each day preferably 30 min before breakfast 

drugs that have a calming effect or that depress the CNS and are referred to as sedatives and hypnotics

classified as either a sedative or a hypnotic depending on the degree to which it inhibits the transmission of nerve impulses 

Medicines that act on the CNS and cause drowsiness and can control seizures

Increases the available amount of gamma-aminobutyric GABA in the CNS

GABA has a relaxing, anti-anxiety and anticonvulsive

Effect the amount of CNS sedatoin depends on dose 

hypnotics

sedatives

anticonvulsants

sedation before surgery 

Alcohol and other CNS depressants cause severe CNS depression that may lead to death.

Alcohol is the only way to O/D on barbiturates 

Phenobarbital (Luminal) 

antianxiety agents (aka anxiolytics)

Produce effect by depressing the CNS and by modulating the neurotransmitter GABA 

can cause several levels of CNS depression, ranging from sedation to general anesthesia (dose related)

These agents act on the CNS to produce varying degrees of depression 

treatment of chronic anxiety, anxiety related to a crisis event and panic disorder

To decrease anxiety accompanying surgical and diagnostic procedures

Treatment of alcohol and drug withdrawal, seizure disorders, and sleep disorders

Induction of anesthesia 

CNS: drowsiness, sedadtion, ataxia, diplopia, slurred speech, physical or psychological dependence

CV: hypotension, bradycardia, palpitations 

Diazepam (Valium)

Larazepam (Ativan)

administer IV slowly monitoring vitals

Tell client to avoide driving machinery

Tell client to avoid alcohol

If pain is present, prescribe pain meds because barbiturates dont releave pain

paradoxical effect can occur in elderly causing excitement and confusion

Sudden withdrawal could cause status epilepticus 

effect the conduction of ions across neurons particularly sodium and calcium channels

By altering these channels, the drug suppresses the irritable neurons and inhibits repetitive neuron firing. 

Antiepileptic 

Most commonly prescribed antiepileptic agent

affects ion conduction and action potentials to alter epileptogenicity, primarily in the motor cortex

Blocks NA channels and reduces calcium permeability which stabilizes the threshold against excitability 

Ataxia and gross mental changes

Nystagmus, diplopia

Gingival hyperplasia

Agranulocytosis, thrombocytopenia, leukopenia

peripheral neuropathy 

Management generalized tonic clonic seizures

Used in combination with phenytoin in clients who require polytherapy 

Antiepileptic 

(Antiepileptic)

absence seizures

myoclonic seizures

generalized tonic-clonic seizures

atonic seizures 

complete neuro assessment.

check for blood dyscraisias

Dental care is essential for dilantin therapy

assess the environment to ensure safety

stress importance of compliance

Avoid dehydration 

enhance the effects of dopamine by promoting dopamine synthesis of by activating doppamine receptors

increase dopamine levels in the CNS

Stimulate dopamine receptors in the brain

Inhibit dopamine breakdown in neurons 

avoid high protein/fat diets. it decreases effectiveness of levodopa

CV: postural hypotension

GI: dysphagia

GU: urinary retention of incontinence

Neuro: extrapyramidal symptems such as twitches and tremors specifically involuntary movements of eyelids or face, tongue, mouth 

antiviral agent effective in relieving symptoms of parkinsonism

increases release of dopamine from neuronal storage sites, thereby increasing CNS dopamine levels

note any insomnia. dont take at night. It may impair ability to drive

do not combine with non-prescription drugs esp cold medicines 

mimics the effects of dopamine by activating dopamine receptors in brain

Helps restore the dopamine-acetylcholine balance

Benztropine (cogentin)

benzodiazepines

Barbiturates

Antihistamines

Monamine Oxydase Inhibitors (MAOI) 

depression is caused by a decrease in neurotransmitters in the brain that are responsible for

mood.

Antidepressants stemulate chem. changes that increase the levels of these neurotransmitters

3 main neurotransmitters associated with mood are serotonin, norepinephrine and dopamine 

neurotransmitters released from nerve cells in the brain only have a short time to relay their message to another cell before enzymes destroy them

This process is called reuptake

Once reuptake occurs, the neurotransmitter ceases to have any affect on the brain

Ppl c depressive illnesses have fewer of the neurotransmitters being produced. 

Blocks re-uptake of all 3 neurotransmitters associated with mood serotonin, norepinephrine, and dopamine

Blockade of these receptors by the TCA's results in many undesireable side effects the most common being sedation, anticholinergic effects and opostural hypotention 

TCA overdoses are notoriously lethal. 70-80% of pts who die of TCA overdose do so before reaching the hospital. No known antidote 

Amitriptyline (Elavil)

increases levels of all 3 neurotransmitters by inhibiting an enzyme MAO

MAO is responsible for inactivating many of the important neurotransmitters in our nervous system

The most common side effect is postural hypotension 

There is a wide variety of drug interactions

Food containing the aminoacid tyramine(beer, chocolate, wine)

block the re-uptake of one neurotransmitter associated with mood: seratonin

SSRIs only work after they have achieved stady state

Side effects include GI upset, anorexia, and impotence 

Lithium (Li) - provides symptomatic control during both phases and when taken prophylactically

Li can reduce the frequency and severity of manic/depressive episodes

Li normally combined with a benzodiazepine or an antipsychotic when used for control of acute mania

When used during the depressive phase, Li is combined with an antidepressant 

GI symptoms can be minimized by taking c meals or milk

Monitor Li levels by checking blood 8-12hrs after last dose

Weigh daily and check ankles and wrist for edema

Li can cause renal damage - teach pt to have renal tests regularly

Drink 8-12 glasses per day.

Do not switch brand of Li carbonate because different brands have different Li fillers 

Antipsychotic agents dont provide a cure for psychosis but suppress or minimize the symptoms of psychosis. They cause a reduction in confusion and agitation and tend to normalize psychomotor activity.

No one agent is better than the other.The agent of choice would maximize therapeutic effects and minimize side effects

treatment of psychotic disorders

adjunct treatment in pain management

prevention and treatment of N/V

Intractable hiccups 

Abnormal movement disorders due to imbalances in the neurotransmitters dopamine and acetylcholine.

Higher incidence of EPS is noted with traditional high potency antipsychotic 

Acute dystonic reaction - characterized by spasm in major muscle groups of the neck and back and face

Akinesthesia - characterized by an uncontrollable inner restlessness and need to be in motion

Drug induced PD - characterized by maks-like face - drooling, tremor, pill rolling, shuffling gait and stooped psoture

Tardive dyskinesia - characterized by orofacial dyskinesis such as tongue protrusion, lip smacking puckering, chewing and blinking 

monitor for decreased anxiety, agitation, psychotic behavior

photosensitivity instruction

assess for EPS and anticholinergic effects (dryness) 

Check for signs of postural hypotension

increase fluid and fiber intake 

Drug-drug interactions - alcohol, antacids, anticonvulsants, antihypertensives, tobacco, and antidepressants

Drug-food-interaction - acaffein, High doses of Vit C may decrease antipsychotic effect

Sedation

Drowsiness

Postural hypotention

palpitation

tachycardia

Chlorpormazine (Thorazine)

Fluphenazine (Prolixin) 

Haloperidol (Haldol) 

Clozapine (Clozaril)

Risperidone (Risperdal) 

Drug of choice for cardiac pain and pt with CHF

administer as small 2mg dose q5min until CP relieved

causes vesodilation->reducing preload euphoric effect-> reduction in anxiety/catecholamines

Cuases biliary spasms and should be avoided for pt c gall bladder or pancreatic disease 

Manages moderate to severe pain

used as an adjunct to anesthesia, for preop sedation and for obstetric analgesia

causes less biliary spasms than morphine

can be used with gal-bladder disease 

suppresses cough, same as morphine

used in treatment of mild-moderate pain

antitussive in low doses

most appropriate for pain in head (injury/post-op)  because of less CNS depression

Has maximum analgesic effect regardless of dose

Tylenol#3 with gr 1/2 of codeine

Tylenol #4 with gr 3/4 of codeine 

B&O suppository (used for bladder spasm because it has belladonna which is a anticholinergic to decrease bladder tonicity and prevent spasms)

can have an adverse effect which causes oliguria and dry mouth 

Naloxone (Narcan) - reverses the effects of opiods, including resp depression, sedation and hypotension

use if: suspected narcotic overdose, 

cv andor resp depression after narcotic administration

Action: displaces opiate agonists and binds with opiate receptors 

Administered in IV and may be repeated q5min 

Morphine Sulfate

Meperidine (Demerol)

Codeine

Hydrocodone (Vicodin) 

Hydromophone (Dilaudid)

Propoxyphene (Darvocet)

Belladonna and opium suppositories (B&O)