Calcium Carbonate:

Patient Assessment, Precautions

Patient Assessment: Note number and consistency of stools. Determin serum and urine calcium weekly in patients receiving prolonged therapy and in patients with renal dysfunction. Record Amelioration of Symptoms of hypocalcemia. Observe for S&S of hypercalcemia in patients receiving frequent or High doses, or who have impaired renal function.

Precautions: Decreased bowel motility (e.g., with anticholinergics, antidiarrheals, antispasmodics), Calcium acetate: pregnancy (category B).

Digoxin:

Administration, Toxicity and Risk Factors

Related to Same

Administration: 

Digitalization Dose- Give 1/2 dose initially followed by 1/4 at 8-12h intervals.

Give without regard to food. Crush and mix with fluid or food if patient cannot swallow it whole. IV-Direct: Give each dose over at least 5 min. Monitor IV frequently; Infiltration of parenteral drug into subcutaneous tissue can cause irritation and sloughing. 

Toxiticity & Risk Factors: 

Atenolol (Tenormin): 

Patient Teaching

Patient Teaching: Adhere rigidly to dose regimen. Sudden discontinuation of drug can exacerbate angine and precipitate tachycardia or MI in patients with Coronary Artery Disease, and Thyroid Storm in Patients with Hyperthyroidism. Make position changes slowly and in stages, particularly from recumbent to upright posture. If diabetic , closely monitor blood glucose values. 

Definition: Digibind aka Digoxin immune FAB is used as an antidote to treat a life-threatening overdose of digoxin or digitoxin. Digoxin immune FAB is not for treating a mild digitalis overdose. Digoxin immune FAB may also be used for other purposes not listed in this medication guide.

Definition: Propranolol (INN) is a sympatholytic nonselective beta 2 blocker. Sympatholytics are used to treat hypertension, anxiety, and panic. It was the first successful beta blocker developed. Propranolol is used to treat high blood pressure, abnormal heart rhythms, heart disease, pheochromocytoma (tumor on a small gland near the kidneys), and certain types of tremor. It is also used to prevent angina (chest pain) and migraine headaches. Propranolol is also used to improve survival after a heart attack. Propranolol is in a class of medications called beta blockers. It works by relaxing blood vessels and slowing heart rate to improve blood flow and decrease blood pressure.

Nitroglycerin:

Patient Teaching & Administration

Patient Teaching: Store tablet form in its original container. Sit or lie down upon First Indication of oncoming anginal pain. Relax for 15-20min after taking tablet to prevent dizziness or faintness. Be Aware that pain not relieved by 3 sublingual tablets over a 15min period may indicate acute MI or severe Coronary Insufficiency. Go to the ER when this happens. Keep record for prescriber of the number of angina attacks, amount of medication required and possible precipitating factors. Drug effects last 30-60mins. Remove transdermal unit or ointment immediately from skin and notify prescriber if faintness, dizziness, or flushing occurs following applications. Can use sublingual formulation while transdermal or ointment is in place. Report blurred vision or dry mouth; Both warrant withdrawal of drug. Change positions slowly to prevent postural hypotension, and avoid prolonged standing (occurs more frequently in the elderly). Report any increase in frequency, duration, or severity of anginal attack.

Administration: Sublingual Tablet: Give 1 tablet and if pain is not retrieved, give additional tablets at 5 min intervals, but NO More than 3 tablets in a 15 min period. Typically available for self-administration in their original container. Instruct in correct use, Request patient to report all attacks. Instruct to sit or lie down upon first indication of oncoming anginal pain and to place tablet under tongue or in buccal pouch (hypotensive effect of drug is Intensified in the Upright Position). Sustained-Release Tablet, Capsule: Give on a Empty Stomcah (1 h before eating or 2 h after meals), with a Full Glass of water. Ensure it is swallowed whole. Be Aware that sustained release form helps to Prevent Anginal Attacks; it is NOT Intended for Immediate Relief of Angina. Transdermal Ointment: Using dose-determing applicator supplied with package, squeeze prescribed dose onto this applicator in a thin, uniform layer to premarked 5.5 by 9 cm square. Place patch with ointment side down onto non-hairy skin surface (areas Commonly Used: Chest, Abdomen, Anterior Thigh, & Forearm). Cover with Transparent wrap and Secure with Tape. Avoid getting Ointment on Fingers. Rotate application site to prevent Dermal Inflimmation and sensitization. Remove ointment from previously used sites before reapplication. Transdermal Unit: Apply transdermal unit (transdermal patch) at the same time each day, preferably to skin site Free of Hair & not subject to Excessive Movement. Avoid Abraded, Irritated, or scarred skin. Clip hair if Necessary. Change Application site each time to prevent skin irritation and sensitization.

Captopril:

Benefits as a Non-Prodrug

Benefits as a Non-Prodrug: It gets through the body much faster, so it's good for something sudden such as an MI. Also, it has a shorter half-life since the body is able to process it so fast, it must be taken 3-4 times per day.

Guaifenesin:

Patient Teaching

Patient Teaching: Increase fluid intake to help loosen mucus; drink At Least 8 glasses of fluid daily. Contact prescriber if cough persists beyond 1 week. Contact prescriber if high fever, rash, or headache develops. 

Prilosec:

Indications & Patient Teaching

Indications: Duodenal & gastrid ulcer; Gastroesophageal reflux disease including severe erosive esophagitis (4-8 wk treatment). Longterm treatment of Pathologic Hypersecretory Conditions such as Zollinger-Ellison Syndrome, Mutliple Endocrine Adenomas, and Systemic Mastocytosis. In combination with Clarithromycin to treat Duodenal ulcers associated with Helicobacter Pylori. Dyspepsia occuring More Than Twice weekly. Prevention of NSAID-related ulcers; stress gastritis prophylaxis.

Patient Teaching: Report any changes in urinary elimination such as pain or discomfort associated with urination or blood in the urine. Report sever diarrhea, drug may need to be discontinued if this occurs.

Aldactone a.k.a. Spironolactone:

Monitoring Implications

Monitoring Implications: Check blood pressure before initiation of therapy and at regular intervals throughout therapy. Lab Tests: Monitor serum electrolytes (sodium and potassium) especially during early therapy; Monitor Digoxin Level when used concurrently. Assess for signs of fluid and electrolyte imbalance and signs of Digoxin Toxicity. Monitor daily I&O and check for Edema, may indicate tolerance to drug. Weigh patient under standard conditions before therapy begins and daily throughout therapy. Weight is a useful index for dosage adjustment. Observe for & report immediately the onset of Mental Changes, Lethargy, or Stupor in patients with Liver Disease. Monitor for the signs of Adverse Reactions and Gynecomastia.

Hydrochlorothiazide: 

Precautions when Given with Certain Drugs

Precations when Given with Certain Drugs: Amphotericin B, Corticosteroids Increase Hypokalemic effects; Sulfonylureas, Insulin may Antagonize Hypoglycemic effects; Bile Acid Sequestrants decrease Thiazide absorption; Diazoxide Intensifies Hypoglycemic & Hypotensive Effects; Increased Potassium & Magnesium loss may cause Digoxin Toxicity; Decreases Lithium Excretion and Increases Toxicity; Increases Risk of NSAID-induced renal failure and may attenuate diuresis. Do NOT use with Dofetilide. Withhold dose for 24 hr prior to Amifostine Usage. Monitor with Topiramate.

Heparin:

Monitoring Implications

Monitoring Implications: Lab Test: Baseline Blood Coagulation Tests, Hct, Hgb, RBC, and Platelet Counts Prior to Initiation of Therapy and at Regular Intervals throughout Therapy. Monitor aPPT levels closely. Dosage is adjusted to keep aPTT between 1.5-2.5 times normal control level. Draw blood for Coagulation Test 30 minutes Before each Scheduled Subcutaneous or Intermittent IV dose & approximately every 4 h for patients receiving Continuous IV Heparing during Dosage Adjustment Period. After dosage is established, Tests may be Done Once Daily. Patients vary widely in their reactions to heparin; risk of hemorrhage appears greatest in women, all patients older than 60 y, and patients with Liver Disease or Renal Insufficiency. Monitor Vital Signs, Report Fever, drop in Blood Pressure, Rapid Pulse, and other S&S of Hemorrhage. Observe all needle sites Daily for Hematoma & signs of Inflammation. Have on hand Protamine Sulfate (1% solution), specific Heparin Antagonist.

Reglan aka Metoclopramide:

Action, Side Effects, & Indication

Action: Potent Central Dopamine Receptor Antagonist that Increases resting Tone of Esophageal Sphincter and Tone & Amplitude of Upper GI Contractions. Thus gastric emptying & Intestinal Transit are accelerated. Antiemetic action results from drug-induced elevation of CTZ Threshold and Enhanced Gastric Emptying. Effective as an Antiemetic Agent as Part of a Chemotherapy Regimen. In Diabetic Gastroparesis, it Relieves Anorexia, Nausea, Vomiting, or Persistent Fullness after Meals.

Indication: Management of Diabetic Gastric Stasis (gastroparesis); to Prevent Nausea & Vomiting associated with Emetogenic Cancer Chemotherapy or Surgery; to Facilitate Intubation of Small Bowel; Symptomatic Treatment of Gastroesophageal Reflux. 

Side Effects: Mild sedation, Fatigue, Restlessness, agitation, headache, insomnia, disorientation, Extrapyramidal Symptoms (acute dystonic type), tardive dyskinesia; nausea, constipation, Diarrhea, dry mouth, alter drug absorption; urticarial or maculopapular rash; glossal or periorbital edema; methemoglobinemia; galactorrhea, gynecomastia, amenorrhea, impotence; Hypertensive Crisise (Rare). 

Atropine:

Clinical Indications & Side Effects

Clinical Indications: Bradycardia & Heart Block; Gastrointestinal Disorders related to Increased Motility and Secretion (Peptic Ulcers, Diverticulitis, Ulcerative Colitis); Urinary Spasms; Parkinson's Disease (may also be used to treat Extrapyramidal Symptoms Associated with Administration of Thorazine); Dilates Pupils of the eye; Preoperatively to Decrease Secretions & Vagal Stimulation.

Right Drug

Right Dose

Right Time

Right Route

Right Patient

Right Documentation

You Must have a Zero infront of a Decimal Point, because if the decimal point gets smudged off it will look like it's way more than your actually supposed to give the patient. i.e. 0.10 can be translated to 010 when the decimal pt. gets smudged off, where as .10 can be translated as 10 which is 10x the normal dose given. 

You Must NOT put an extra Zero Behind a number, this may lead people to think the dose is bigger than it actually is, plus it's just not necessary.  

Written Permission obtained from a Patient Consenting to a Specific Procedure (e.g., receiving an investigational drug), after the patient has been given Information Regarding the Procedure deemed Necessary for him or her to Make a Sound, "Informed" decision.

Nursing Process:

Phases

Assessment 

Diagnosis

Outcomes/Planning

Implementation

Evaluation

Laxatives:

Bulk Forming & Stimulant (Outcome/Patient Teaching):

Bulk-Forming- Outcome/Patient Teaching: Client will have Regular Bowel Movements with NO Constipation. Instruct patient to mix the drug in 8-10oz of water, stir, and drink Immediately. Do NOT Swallow in Dry Form. Follow Drug with 1 extra glass of water. Instruct client to Drink a Minimum of Eight 8oz glasses of water per day & to Increase Foods High in Fiber. Review the Nonpharmacologic Methods for Decreasing Constipation. Review the Importance of NOT becoming a Habitual User of Laxatives

Stimulant- Outcome/Patient Teaching: Client will have Regular Bowel Movements with NO Constipation or Straining. May take up to 3 days to Soften Stools. Take Tablets Whole. Do NOT Take for Long-Term Therapy. Report cramping, weakness, dizziness, and an increase in being thirsty. Inform provider if Constipation is Unrelieved or Symptoms of Electrolyte Imbalance occurs. Teach Family & Client that Normal Bowel Movements do NOT Always Occur Daily.

Antilipemic Drugs:

Patient Assessment & Potential Contraindications

Patient Assessment: Assess Patient's Diet, Excercise Level, Weight, Height, vs, Tobacco and Alcohol use, and Family hx. Assess baseline Liver Function, if there are problems Do NOT start patients on Antilipemic Drugs. 

Potential Contraindications: They may bind with acidic drugs in the GI tract, decreasing their absorption and effectiveness. Bile-sequestering drugs may reduce absorption of lipid-soluble vitamins, such as vitamins A, D, E and K. Poor absorption of vitamin K can affect prothrombin times significantly, increasing the risk of bleeding.

Lipoproteins:

HDL vs. LDL

HDL: High-Density Lipoprotein; "The Good Lipoprotein;" The Higher the better. They act as cholesterol scavengers, picking up excess cholesterol in your blood and taking it back to your liver where it's broken down. The higher your HDL level, the less "bad" cholesterol you'll have in your blood.

LDL: Low-Density Lipoprotein; "The Bad Lipoprotein;" The Lower the Better. These lipoproteins carry cholesterol throughout your body, delivering it to different organs and tissues. But if your body has more cholesterol than it needs, the excess keeps circulating in your blood. Over time, circulating LDL cholesterol can enter your blood vessel walls and start to build up under the vessel lining. Deposits of LDL cholesterol particles within the vessel walls are called plaques, and they begin to narrow your blood vessels. Eventually, plaques can narrow the vessels to the point of blocking blood flow, causing coronary artery disease.

 used to treat some people who are having a heart attack. They are typically given in a vein (intravenously, or IV). These drugs dissolve or break up blood clots that are blocking blood flow through a coronary artery. Clots cause most heart attacks. work best if they are given within 3 hours of a heart attack.

Patient Teaching: Report any signs of infection, bruising, or bleeding. Do NOT take Captopril, Moexipril, Quinapril, & Ramipril with Food, it reduces absorption; other ACE Inhibitors can be taken with food (i.e. no interaction). Do NOT use Potassium Supplements or Any Food or Substance Containing a Large Amount of Potassium. (i.e. low-sodium milk, salt substitutes, etc.)

Side Effects: Gastric Irritation, Headache, Dizziness, Tachycardia, Angioedema, Cough, maculopapular rash, Pruritus, Infection, Hyperkalemia.

Diuretics:

Patient Teaching & Monitoring Implications

Patient Teaching: Instruct the patient to take with or after meals if GI distress occurs; Must Change Positions Slowly, inorder to prevent Postural Hypotension; Clients should NOT eat a diet rich in Potassium; Do NOT take with Alcohol.

Monitoring Implications: Monitor the Heart Rate & BP. Evaluate for signs of Hypokalemia due to risk of Digoxin Toxicity. Evaluate adequate renal function; check the creatinine clearance in the elderly. Alcohol can cause sever low blood pressure, Never take with Alcohol.

Anticholinergic Drugs:

Site of Action; Patient Teaching (esp. the elderly); Side Effects, & Purpose:

Site of Action: They block the action of the neurotransmitter acetylcholine in the brain. The drugs help to block involuntary movements of the muscles associated with these diseases. They also balance the production of dopamine and acetylcholine in the body. Anticholinergics work by inhibiting parasympathetic nerve impulses. They do this by blocking the binding of acetylcholine to its receptor present in nerve cells. The parasympathetic nerve system is one of the two main parts of the automatic nervous system (ANS). It manages activities that occur when the body is at rest. The nerves in the parasympathetic system are responsible for involuntary movement of muscles in the gastrointestinal tract, lungs, urinary tract, and other parts of the body.

Patient Teaching: The elderly are usually more sensitive than younger adults to the effects of anticholinergics.  Be Aware of the S&S of Overdose. Do NOT eat or drink certain things while on certain medications. Do NOT drink Alcohol or Tobacco may interfere with the drug. Should be taken WithOut Food!

Side Effects: Dry mouth, blurred vision, constipation, drowsiness, sedation, Hallucinations, Memory Impairment, Difficulty Urinating, Confusion, Delirium, Decreased Sweating, and Decreased Saliva

Purpose: They are used to treat diseases like asthma, incontinence, gastrointestinal cramps, and muscular spasms. Parkinson's Disease. They are also prescribed for depression and sleep disorders. They can also be used to treat certain types of toxic poisoning, and are sometimes used as an aid to anesthesia.

1. When a person takes a dose of vancomycin, the amount in the blood rises for a period of time, peaks, and then begins to fall, usually reaching its lowest level, or trough, just before the next dose. The next dose is timed to coincide with the falling concentration of the drug in the blood.
2. The trough level is the lowest concentration in the patient's bloodstream, therefore, the specimen should be collected just prior to administration of the drug. The peak levelis the highest concentration of a drug in the patient's bloodstream.

A ratio that compares the blood concentration at which a drug becomes toxic and the concentration at which the drug is effective. The larger the therapeutic index (TI), the safer the drug is.

Onset refers to when the insulin starts to work. Peak refers to when the insulin works hardest. Duration refers to how long the insulin works.

Pharmacokinetics:

Basic Meaning & Basic Purpose of each Phase:

Definition: 

1. the branch of pharmacology concerned with the movement of drugs within the body.
2. Sometimes described as what the body does to a drug, refers to the movement of drug into, through, and out of the body—the time course of its absorption, bioavailability, distribution, metabolism, and excretion.
3. Purpose of Phases: 1) Absorption: 

   Elevation of gastric pH by antacids
   – Increases the absorbance of basic drugs;
   decreases that of acidic drugs
   • Laxatives
   – Increase peristalsis and decrease GI transit time
   • Drugs that are constipating may increase
   absorption of other meds
   • Adsorbents
   • Drugs that decrease GI blood flow
4. 2) Distribution: Competition for protein binding sites
   – Occasionally significant
   • Alteration of extracellular pH
   – Useful in cases of overdose, poisoning, etc.
   – Can alkalinize the urine to excrete acidic drugs
5. 3) Metabolism: Phase 1 metabolism involves chemical reactions such as 
   oxidation (most common), reduction and hydrolysis. There are 
   three possible results of phase 1 metabolism.
   The drug becomes completely inactive. In other words, the 
   metabolites are pharmacologically inactive. 
   One or more of the metabolites are pharmacologically active, 
   but less so than the original drug.
   The original substance is not pharmacologically active, but one of its metabolites is. The original is called a prodrug. 
6. Phase 2 metabolism involves reactions that chemically change the drug or phase 1 metabolites into compounds that are soluble enough to be excreted in urine. In these reactions, the molecule (drug or metabolite) is attached to an ionisable grouping. This is called conjugation and the product is called a conjugate. Metabolites formed in phase 2 are unlikely to be pharmacologically active.
7. 4) Excretion: There are three main sites where drug excretion occurs. The kidney is the most important site and it is where products are excreted through urine. Biliary excretion or fecal excretion is the process that initiates in the liver and passes through to the gut until the products are finally excreted along with waste products or feces. The last main method of excretion is through the lungs e.g. anesthetic gases.

   Excretion of drugs by the kidney involves 3 main mechanisms:

   • Glomerular filtration of unbound drug.
   • Active secretion of (free & protein-bound) drug by transporters e.g. anions such as urate, penicillin, glucuronide, sulfate conjugates) or cations such as choline, histamine.
   • Filtrate 100-fold concentrated in tubules for a favorable concentration gradient so that it may be secreted by passive diffusion and passed out through the urine.
8.  
9.  
10.  
11.  

Lifespan Considerations:

Pediatric, Elderly Pharmacokinetics:

Pediatrics: the younger the person the greater the percentage of the body water

First Pass Effect:

Routes Affected By This:

Routes Affected By This: also known as first-pass metabolism or presystemic metabolism is when an administered drug enters the liver and undergoes extensive biotransformation and thus decreasing the concentration rapidly before it reaches its target. 

Oral Route

Rectal Route (minimal)

Definition: agents and conditions, including viruses, drugs, chemicals, stressors, and malnutrition, which can impair prenatal development and lead to birth defects or even death

Polypharmacy:

Elderly

Definition: the use of large quantities of drugs (4 or more), incorrect combinations of drugs or prescription non indicated drugs. 

 Because they take more medications than younger patients, the elderly have a higher risk of adverse reactions. 

The most critical challenge for nurses is identifying the potential medication culprits in their older patient population. 

Medication Errors:

Prevention & Recognizing

Preventing Errors: 1) Multiple Systems of checks and balances should be implemented to prevent medication errors. 2) Prescribers should write legible orders that contain Correct Information, or orders should be written electronically if the technology is available. 3) Pharmacists or current drug book should be consulted if there is any area of concern, beginning with the medication order and continuing throughout the entire medication administration process. 4) Nurses should Always check the Medication Order Three times before giving the drug or consult with authoritative resources if any questions or concerns exist. 5) The Six Rights of Medication Administration should be used consistently, which has been shown to substantially reduce the likelihood of medication error. 

Recognition of Errors Being Made: 1) no error, although circumstances or events occured that could have led to an error. 2) Medication error that causes no harm. 3) Medication error that causes harm. 4) Medication error that results in death.

Medication Orders:

Components

1. DATE AND TIME THE ORDER IS WRITTEN 

2. DRUG NAME (GENERIC OR TRADE) 

3. DRUG DOSAGE 

4. ROUTE OF ADMINISTRATION 

5. FREQUENCY AND DURATION OF ADMINISTRATION, 

 SUCH AS TIME SEVEN DAYS, TIMES THEREE DOES, 

 QUID, ETC. 

6. ANY SPECIAL INSTRUCTIONS FOR WITHHOLDING OR 

 ADJUSTING DOSAGE BASED ON EFFECTIVENESS OR 

 LABORATORY RESULTS 

7. PHYSICIAN OR PROVIDER’S SIGNATURE OR NAME IF 

 TELEPHONE ORDER (T.O.)/VERBAL ORDER (V.O.), 

 WRITTEN ORDER 

8. SIGNATURE(S) OF LICENSED PRACTITIONER TAKING 

 WRITTEN ORDER, TELEPHONE ORDER, OR VERBAL 

 ORDER

Inotropic Positive: stimulate and increase the strength of heart muscle contraction causing the heart rate to increase

Inotropic Negative: agents weaken the force of muscular contractions.

Dromotropic Positive:  increase this rate of conduction.

Dromotropic Negative: decreases this rate of electrical conduction.

Chronotropic Positive: increases the heart rate by acceleration the rate of impulse formation in the SA node.

Chronotropic Negative: they slow down the heart rate by decreasing impulse formation.

Cholinergic Drugs:

Clinical Effects & Side effects:

Clinical Effects: They produce the same effects that the Parasympathetic Nervous System does. Cholinergic drugs produce the same effects as acetylcholine. Acetylcholine is the most common neurohormone of the parasympatheticnervous system, the part of the peripheral nervous system responsible for the every day work of the body. the parasympathetic system deals with everyday activities such as salivation, digestion, and muscle relaxation.

Side Effects: may cause vomiting, diarrhea, watery eyes, headache, dizziness, irregular heartbeat, wheezing, and/or breathing problems. Contact a doctor if these occur. 

Adrenergic Blockers:

Outcome, Action, Administration, Monitoring & Patient Teaching:

Action: Blocks Alpha1 Adrenergic Receptors resulting in vasodilation of Arteries & Veins. Decreases Peripheral Vascular Resistance, Relaxes smooth muscle of bladder/prostate. Binds to Beta 1-(cardiac) &/or Beta 2-(lungs) Adrenergic receptor sites that prevents the release of Catecholamine. Refer to page 58 to assist with this information. They include a decrease in Contractility, Decrease in Renin Release, and a Decrease in the Sympathetic Output.

Administration: If initial dose or increase in dose is During the Day, client Must Remain Recumbent for 3-4hours. 

Monitoring: Monitor BP frequently & protect from fallinig/injury after the first dose and with each increase due to first-dose syncope. Client Must remain recumbent for 3-4hours. Assess BP & Heart Rate Immediately Before each dose. Assist with Ambuating if client is dizzy.

Monitor Blood Sugar closely in clients with diabetes. Monitor Triglyceride and Cholesterol Level (LDL). Monitor BP & Pulse Prior to administering. If Pulse is less than 60 or SBP less than 90, withold and notify the provider. Monitor for any change in the cardac rhythm or any signs of CHF. 

Patient Teaching: Caution that the first-dose syncope may occur, and implement safety precautions. Report if edema is present in the AM. Sugarless gum, sips of tepid water, etc. may relieve dry mouth.

Instruct client regarding self-assessment of pulse, character, and rhythm; signs & symptoms of CHF. Avoid Heat, Excessive Exercise, Hot Showers, Baths & Hot Tubs.  

Outcome: Client's Blood Pressure will remain in Normal Limits with No Undesirable Effects from the medications.

The Blood Pressure will return to normal limits. If given for Arrhythmias, the ECG will record a Normal Sinus Rhythm.

Adrenergic Drug Effects:

Alpha vs. Beta Receptor Stimulation

Alpha Receptor Stimulation: 

Associated with vascular smooth muscle are a large number of alpha₁ receptors relative to beta₂ receptors. Activation of these receptors by sympathetic nervous system transmission or drugs will result in vasoconstriction and an increase in peripheral resistance and systemic arterial blood pressure.

Alpha₂ receptors also exist presynaptically associated with nerve terminals. Activation of these receptors inhibits the release of norepinephrine. 
Norepinephrine acts at presynaptic alpha₂ receptors to inhibit its own release.

Beta Receptor Stimulation: Activation of the beta₁ receptor leads to increases in contractile force and heart rate. Drugs that activate the beta₁ receptor can be used in heart failure to improve the contractile state of the failing heart. Drugs that activate the beta₁ receptor also increase heart rate. Indeed, excess stimulation the beta₁ receptor can induce significant increases in heart rate and arrhythmias. Arrhythmias are a major concern with drugs such as epinephrine that can be absorbed systemically after intra-oral injection.

 Activation of the beta₂ receptor leads to vascular and nonvascular smooth muscle relaxation. Drugs that activate the beta₂ receptor can be used to treat as asthma (by relaxing airway smooth muscle) and premature labor (by relaxing uterine smooth muscle).

Central sympatholytic drugs reduce blood pressure mainly by stimulating central α(2) -adrenergic receptors in the brainstem centers, thereby reducing sympathetic nerve activity and neuronal release of norepinephrine to the heart and peripheral circulation. •  This class of drugs, however, is currently used mainly as fourth-line (or beyond) drug therapy for hypertension because of side effects of drowsiness, fatigue, and dry mouth. •  Rebound hypertension is also another major concern in certain drugs with a short half-life, particularly in patients who are nonadherent to the regimen. Therefore, their use on a "PRN" basis for treatment of blood pressure surge in the absence of symptoms or acute target complications should also be avoided.

Drugs that inhibit nerve impulses in the sympathetic nervous system. They may block the effect of alpha-adrenergic receptors (e.g.thymoxamine, which is used to reverse pupillary blockage caused by a mydriatic) or the effect of beta-adrenergic receptors, called beta-blockers (e.g. betaxolol which block beta 1 receptors; timolol maleate, levobunolol, metipranolol and carteolol which block beta 1 and beta2 receptors). Beta-blockers are used in the treatment of glaucoma. Syn. adrenergic blocking agents. See alpha-adrenergic antagonist;betablocker.

Parasympathetic Stimulating Drugs:

Outcome & Muscurinic Receptors:

Outcome:

Muscarinic Receptors: 

 cholinergic receptors that are stimulated by the alkaloid muscarine and blocked by atropine; they are found onautomatic effector cells and on central neurons in the thalamus and cerebral cortex. cholinergic receptors of autonomic effector cells (and also on some autonomic ganglion cells and some central neurons) that arestimulated by muscarine and parasympathomimetic drugs and antagonized by atropine.

membrane bound proteins with an extracellular domain that contains a recognition site for acetylcholine (ACh); combination of Ach withthe receptor initiates a physiologic change (slowing of heart rate, increased glandular secretory activity, and stimulation of smoothmuscle contractions); changes are observed after treatment with the mushroom alkaloid muscarine. Muscarinic receptors are to bedistinguished from nicotinic receptors.

Ear Drops:

Pediatrics vs. Adult

Pediatrics: 

To instill otic medications in the ears of children younger than 3 years, gently pull the pinna down and back. It is often helpful to have the parents assist by asking them to hold the child in a supine position with the affected ear facing up. To help ensure that the medication is absorbed, keep the child in a supine position for a short period of time.

1. For Children over Age 3:
• Gently pull the outer flap of the affected ear UPWARD and backward to straighten the ear canal.
• Look for the ear canal to open.

Adult: For adults, pull the pinna up and back! 

IM Injection:

Pediatric vs. Adult

Pediatric: Infants < 18 months • Vastus lateralis muscle (_ <0.5 mL vol.) 7/8" - 1" 25 - 27 G 90˚

Children

(>18 months and walking

to 18 years)

• Deltoid muscle

• Ventrogluteal site

• Dorsogluteal site–not

recommended for <3 years

• Vastus lateralis muscle

7/8" - 1 1/4" 22 - 25 G 90˚

Adult: > 18 years

• Deltoid muscle, Ventrogluteal site–

may be best site for cachectic adults

• Dorsogluteal site–

avoid in obese adults

• Vastus lateralis muscle

1" - 1 1/2"

(up to 3" for

large adults)

19 - 25 G 90˚

Eye Drops:

Administration, Preventing Systemic Effects:

Administration: Insert the eyedrop into the lower conjunctival-sac. 

Preventing Systemic Effects: Apply gentle pressure to the patient's nasolacrimal duct for 30 to 60 seconds with a gloved finger wrapped in a tissue. This will help to reduce systemic absorption of the drug through the Nasolacrimal Duct and may also help to Reduce the Taste of the Medication in the Nasopharynx.

Metered Dose Inhalers:

Administration

Administration: 

Shake the MDI gently before using. Remove the cap; hold the inhaler upright and grasp with the thumb and first two fingers. Tilt the patient's head back slightly. If the inhaler is used without a spacer, do the followiing: 1) Have the patient open his or her mouth; position the inhaler 1 to 2 inches away from the patient's mouth. For Self-administration, some patients may measure this distance as 1 to 2 finger widths. 2) Have the patient exhale, then press down once on the inhaler to release the medication; have the patient breathe in slowly and deep for 5 seconds. 3) Have the patient hold his or her breath for approximately 10 seconds, then exhale slowly through pursed lips. 

Med. Preparation:

Ampule, Vial

Ampule: Ampules containing medications come in various sizes. The neck of the ampule Must be Broken Carefully Before the Medication is Withdrawn. Tapping an ampule to move the fluid below the neck. Carefully break the neck of the ampule in a direction away from you and away from others near you. Using a filter needle to withdraw medication from an ampule.

Vial: Insert air into a vial Before Withdrawing Medication. Withdraw medication from a vial, upside down with a tilt. Using a needle and syringe to remove medication from a vial hold in the same way as you would the needless method.

Sublingual Meds.

Administration:

Administration: Placed under the tongue. Be sure to wear gloves if you are placing the tablet into the patient's mouth. Instruct patient to let it dissolve completely before swallowing. This drug form is NOT taken with fluids. Instruct patient NOT to drink Anything, Until the Tablet has Dissolved Completely. Be sure to Instruct the Patient NOT to swallow the tablet; saliva should NOT be swallowed until the drug is Completely dissolved.