1. Putting Together Unit I NR33 Most of the slides in this presentation are in your previous powerpoints…. Profs D’Ambrosia & Winstanley

2. Where do I begin to study? http://www2.sunysuffolk.edu/mccabes/NR 33studyguidelines.htm http://www2.sunysuffolk.edu/mccabes/NR 33studyguidelines.htm

3. Approach to reading » » scan headings and subheadings before the start of reading session a heading when turned into a question is answered by the list of subheadings » » starting the reading session turn the heading into a question read the passage to answer the question highlight only information that answers the question repeat for each heading and subheading » » review your reading reread the highlighted information reading aloud reading into a tape recorder allows for review at a later time

4. Managing information that is not understood use of faculty resources appointment during office hours use of other resources patient resources learn topics from a patient perspective written in simpler language education sheets and online information from HON sites nursing references learn topics from other professional sources current med/surg nursing texts nursing journal articles

5. Managing information that is not understood participation in class – – review handouts prior to class – – seek clarification of information not understood » » submit a question in writing to professor debriefment after class – – review of lecture material » » compare lecture material to written references approach it slide by slide find reference in text book that correlates to lecture information helps to make connections develops use of multiple references

6. Content map for Medications What are the indications? What are the indications? What is the therapeutic effect? What is the therapeutic effect? What are the side effects? What are the side effects? What are the contraindications? What are the contraindications? What are the patient teaching points/nursing considerations? What are the patient teaching points/nursing considerations?

7. OH MY GOSH ? What does the nurse need to know to safely and competently give a medication? What does the nurse need to know to safely and competently give a medication? What does the nursing student need to say to the client about the medication that makes the client feel comfortable taking the medication? What does the nursing student need to say to the client about the medication that makes the client feel comfortable taking the medication?

8. Medications: Study them by class Study them by class Review the charts in Iggy Review the charts in Iggy Be familiar with the medications used in the case studies Be familiar with the medications used in the case studies

9. Evaluation of preparation Answering practice questions – – Practice question sources » » Website for text Self assessment quizzes organized according to chapter » » NCLEX review books organized according topic » » NCLEX software in computer lab – – take care of yourself » » rest, diet, exercise, relaxation techniques

10. Pharmacology Basics Pharmacokinetics; Definitions – –Pharmacokinetics is the study of drug movement throughout the body. There are 4 basic pharmacokinetic processes; 1) Absorption 2) Distribution 3) Metabolism 4) Excretion

11. Pharmacokinetics Events

12. Pharmacokinetics; 4 Processes 1. Absorption; movement from site of administration into the blood. 2. Distribution: movement from the blood into the tissue spaces andcells. 3. Metabolism: the enzymatically mediated change in drug structure. 4. Excretion: the movement of drugs and drug metabolites out of the body.

13. Clinical Relevance of Pharmacokinetics » The 4 processes act together to determine the drug concentration at its site of action. » Desired drug concentrations are achieved through control of dose, route and timing of drug administration.. » Understanding the reasons why a drug is administered by a particular route is essential for safe effective clinical practice.

14. Pharmacology and the Respiratory System » Obstructive Airway Disease Increased airway resistance can be due to: » Excess secretions (chronic bronchitis) » Pulmonary edema or aspiration » Contraction of bronchial smooth muscle (asthma) » Hypertrophy of mucous glands (chromic bronchitis) » Inflammation/edema (bronchitis and asthma) » Loss of lung parenchyma and radial traction (emphysema)

15. Pathophysiology of Asthma Reversible, intermittent airflow obstruction Reversible, intermittent airflow obstruction Can be fatal Can be fatal Airway obstruction can occur 2 ways Airway obstruction can occur 2 ways –Inflammation Obstructs the lumen of the airway Obstructs the lumen of the airway –Airway hyperresponsiveness Obstructs airways by constricting bronchial smooth muscle Obstructs airways by constricting bronchial smooth muscle Cell mediated factors involved in inflammatory response Components of a normal airway

16. Asthma:The Step System I: Mild or Intermittent Symptoms occur < =2x week, symptom free b/w episodes. Symptoms short lasting only few hours PFT normal b/w episodes II: Mild Persistent symptoms occur >2x week, not daily. symptoms occur >2x week, not daily. Present @ night 2x mos. Activity affected Present @ night 2x mos. Activity affected III: Moderate Persistent Symptoms occur daily. Persist for days. Symptoms present @ night at least once/week present @ night at least once/week IV: Severe Persistent IV: Severe Persistent Symptoms continuously present. Limited physical Symptoms continuously present. Limited physical activity. Episodes frequent. activity. Episodes frequent.

17. Education Education Drug therapy Drug therapy 1. Bronchodilators 2. Anti-inflammatory agents 3 Corticosteroids 5. Mast cell stabilizers 6. Leukotriene antagonists Exercise/activity Exercise/activity – aerobic exercise is encouraged to improve overall pulmonary function  Instruct patient to use inhaler prior to exercise prevention and early identification of complications airway remodeling prevention and early identification of complications airway remodeling Medical Management of Asthma Look @ chart 33-5 Drug Therapy

18. Where medications work 1998, Merck & Co. Inc. Mast cell stabilizers cromolyn Anti-inflammatory Anti-inflammatory agents agentscorticosteroids leukotriene antagonists leukotriene antagonists inhaled anti-inflammatories Bronchodilators beta 2 agonists methylxanthinesanticholinergics

19. Inhaled Therapy in Airway Disease Inhaled Therapy in Airway Disease Wide variety of devices available for drug delivery Wide variety of devices available for drug delivery –Metered Dose Inhalers (MDI) –Dry Powder Inhalers –Nebulizers Effective use requires patient effort Effective use requires patient effort and cooperation and cooperation Medical Management of Asthma

20. Major Drugs for Asthma (1) Bronchodilators Bronchodilators Beta2 adrenergic agonists Beta2 adrenergic agonists Inhaled-short-acting Inhaled-short-acting –Albuterol [Proventil, Ventolin] –Bitolterol [Tornalate] –Terbutaline [Brethaire] Inhaled-long-acting Inhaled-long-acting –Salmeterol [Serevent] –Formoterol [Foradil] Oral Oral –Albuterol [Proventil, Ventolin] –Terbutaline [Brethine]

21. Major Drugs for Asthma (2) Bronchodilators (Cont’d) Bronchodilators (Cont’d) Methylxanthines Methylxanthines –1. Theobromine –2. Theophylline –3. Caffeine Anticholinergics Anticholinergics –1. Ipratropium –2. Tiotropium

22. Major Drugs for Asthma (3) Anti-inflammatory Drugs Anti-inflammatory Drugs Corticosteroids Corticosteroids INHALED INHALED –Bechlomethasone dipropionate [Beclovent, Vandercil] –Budesonide [Pulmicort Turbohaler Flunisolide [Aerobid] –Flucicasone Propionate (Flovent) –Triamcolone acetonide ORAL ORAL –Prednisone –Prednisolone

23. Major Drugs for Asthma (4) Anti-inflammatory Drugs (Contd.) Anti-inflammatory Drugs (Contd.) Cromolyn and Nedocromil Cromolyn and Nedocromil –Cromolyn inhaled [Intal] –Nedocromil inhaled [Tilade] Leukotriene Modifiers Leukotriene Modifiers –Zafirlukast, oral [Accolate] –Zileuton, oral [Zyflo] –Montelukast, oral [Singulair]

24. Adrenergic agonists Most effective bronchodilator agents Most effective bronchodilator agents Primarily used via inhalation route Primarily used via inhalation route Many different agents available Many different agents available Non-selective adrenergic agonists Non-selective adrenergic agonists –Epinephrine Selective b-agonists Selective b-agonists –Isoproterenol Selective b2-agonists Selective b2-agonists –Albuterol –Metaproterenol –Bitolterol Long-acting b2-agonists Long-acting b2-agonists –salmeterol

25.  Beta 2 agonists relax bronchial smooth muscle & are used as first line therapy due to the rapid effect…..  Inhaled, PO, SC  Inhalers have particular rapid effect  short acting inhaled used for rescue  Proventil, albuterol  long acting inhaled used for maintenance  serevent  PO preparations associated with greater systemic side effect  terbulaline, proventil, repetabs  SC used in emergency management  brethine, epinephrine Drug therapy : Bronchodilators

26. Nursing Considerations for Methylxanthines  Used when other drug therapy is ineffective  PO, IV preparations  theodur, aminophylline  requires loading dose on initiation  monitor therapeutic blood levels (5-15 mcg/ml)  serum level > 20 mcg/ml is toxic  Therefore - Narrow therapeutic margin  side effects include:  restlessness, GI upset, tachycardia  caffeine potentiates side effects  Therefore - Poorly tolerated  methylxanthines  anticholinergics

27. Nursing Considerations for Anticholinergics Inhaled preparation Inhaled preparation –atrovent (ipratropium) used infrequently as an adjunct to rescue medication used infrequently as an adjunct to rescue medication –more often included in daily maintenance side effects: side effects: –dry mouth, headache, n/v, palpitations

28. Nursing Consideration with Anti-Inflammatories Corticosteroids / Glucocorticoids administered as PO, IV, Inhaled administered as PO, IV, Inhaled –Prednisone, Solumedrol, Beclomethasone –Side effects enhanced in PO and IV route –monitor for s/s of infection as it may be masked by medication inhaled steroids may cause candidiasis inhaled steroids may cause candidiasis –monitor for GI ulceration, impaired wound healing –monitor for hyperglycemia –monitor for weight gain, fluid retention Goal - prevent permanent structural damage to lungs.

29. CORTICOSTEROIDS Are the most effective anti-asthma drugs available Are the most effective anti-asthma drugs available Administration is usually by inhalation, but may also be oral or IV. Administration is usually by inhalation, but may also be oral or IV. Adverse reactions to inhaled glucocorticoids are minor, as contrasted with systemic use. Adverse reactions to inhaled glucocorticoids are minor, as contrasted with systemic use. Effective in improving all indices of asthma control— frequency and severity of symptoms, airway caliber and bronchial reactivity. Effective in improving all indices of asthma control— frequency and severity of symptoms, airway caliber and bronchial reactivity.

30. CORTICOSTEROIDS Mechanism of Anti-Asthmatic Action Mechanism of Anti-Asthmatic Action Glucocorticoids reduce symptoms of asthma by suppressing inflammation Glucocorticoids reduce symptoms of asthma by suppressing inflammation Specific anti-inflammatory effects include: Decreased synthesis & release of inflammatory mediators; (e.g., prostaglandins, leukotrienes, Specific anti-inflammatory effects include: Decreased synthesis & release of inflammatory mediators; (e.g., prostaglandins, leukotrienes, histamine) histamine) Decreased infiltration & activity of inflammatory cells (e.g., eosinophils, leukocytes) Decreased edema of the airway mucosa secondary to a decrease in vascular permeability).

31. CORTICOSTEROIDS By suppressing inflammation, glucocorticosteroids reduce bronchial hyperreactivity. By suppressing inflammation, glucocorticosteroids reduce bronchial hyperreactivity. In addition to reducing inflammation, glucocorticosteroids decrease airway mucus production, increase the number of bronchial b2 receptors and their responsiveness to b2 agonists In addition to reducing inflammation, glucocorticosteroids decrease airway mucus production, increase the number of bronchial b2 receptors and their responsiveness to b2 agonists Corticosteroid safety and adverse effects Corticosteroid safety and adverse effects Inhaled glucocorticosteroids are first line therapy for asthma. Inhaled glucocorticosteroids are first line therapy for asthma. Highly effective, very safe. Highly effective, very safe. Oral glucocorticosteroids are reserved for patients with severe asthma. Oral glucocorticosteroids are reserved for patients with severe asthma. Because of their potential for toxicity, these drugs are prescribed only when symptoms cannot be controlled with safer medications (inhaled glucocorticoids, b2 agonists, theophylline). Because of their potential for toxicity, these drugs are prescribed only when symptoms cannot be controlled with safer medications (inhaled glucocorticoids, b2 agonists, theophylline).

32. Inhaled Corticosteroids Beclomethasone (Vanceril ®) Beclomethasone (Vanceril ®) Initial agent, available since 1976 Initial agent, available since 1976 Prodrug, metabolized to beclomethasone mono- propionate Prodrug, metabolized to beclomethasone mono- propionate Budesonide (Pulmicort ®) Budesonide (Pulmicort ®) Most widely used agent in the world Most widely used agent in the world Nebulized form available Nebulized form available Triamcinolone (Azmacort®) Triamcinolone (Azmacort®) Flunisolide (AeroBid ®) Flunisolide (AeroBid ®) Fluticasone (Flovent ®) Fluticasone (Flovent ®) Most potent agent Most potent agent Mometasone (Asmanex ®) Mometasone (Asmanex ®)

33. Cromolyn & Nedocromil Prophylactic anti-inflammatory agents Prophylactic anti-inflammatory agents Less effective than inhaled corticosteroids Less effective than inhaled corticosteroids Function as mast cell degranulation inhibitors Function as mast cell degranulation inhibitors Useful to prevent exercise-induced asthma Useful to prevent exercise-induced asthma Poorly absorbed orally,used via inhalation Poorly absorbed orally,used via inhalation Cromolyn can also be used intranasally Cromolyn can also be used intranasally Both drugs “stabilize” mast cells by affecting the function of delayed chloride channels in the cell membrane to inhibit cellular activation. Both drugs decrease the severity and frequency of asthma episodes.

34. Leukotriene Modifiers Leukotrienes are chemical factors released by cells that cause inflammation, bringing about bronchoconstriction as well as eosinophil infiltration, mucus production, and airway edema Leukotrienes are chemical factors released by cells that cause inflammation, bringing about bronchoconstriction as well as eosinophil infiltration, mucus production, and airway edema Leukotriene inhibitors first became available in 1996 Leukotriene inhibitors first became available in 1996 –the first new drugs for asthma in over 20 years

35. Leukotriene Modifiers 5-lipoxygenase inhibitor 5-lipoxygenase inhibitor –Zileuton (Zyflo®) CAUTIONS CAUTIONS Hepatic toxicity Hepatic toxicity Drug interactions Drug interactions 4xday administration 4xday administration LTD4 receptor antagonists LTD4 receptor antagonists –Zafirlukast (Accolate®) –Montelukast (Singulair®) Leukotriene Pathway Inhibitors Leukotriene Pathway Inhibitors

36. Asthma Steps Step 1 Mild Intermittent Step 1 Mild Intermittent –Long-Term Control No daily medication needed –Quick Relief Short-acting bronchodilator: inhaled “b2-agonists as needed for symptoms

37. Asthma Steps Step 2 Mild Persistent Step 2 Mild Persistent –Long-Term Control One daily medication: Anti-inflammatory: either inhaled corticosteroid (low doses) or cromolyn or nedocromil –Quick Relief Short-acting bronchodilator: inhaled “b2- agonists as needed for symptoms.

38. Asthma Steps Step 3 Moderate persistent Step 3 Moderate persistent –Long-Term Control Anti-inflammatory: inhaled corticosteroid (medium dose) or Inhaled corticosteroid (low-medium dose) and a long- acting bronchodilator (long-acting inhaled “b2- agonist, sustained-release theophylline or longacting “b2-agonist tablets) Quick Relief Short-acting bronchodilator: inhaled “b2-agonists as needed for symptoms. Quick Relief Short-acting bronchodilator: inhaled “b2-agonists as needed for symptoms.

39. Asthma Steps Step 4 Severe persistent Step 4 Severe persistent –Long-Term Control Anti-inflammatory: inhaled corticosteroid (high dose) and Long-acting bronchodilator (inhaled “b2-agonist, sustained- release theophylline or long-acting !2-agonist tablets) corticosteroid tablets or syrup –Quick Relief Short-acting bronchodilator: inhaled “b2-agonists as needed for symptoms.

40. Nursing Consideration with Anti-inflammatories Leukotriene inhibitors Leukotriene inhibitors –PO preparation Accolate (Zafirlukast) & Singulair (Montelukast) Accolate (Zafirlukast) & Singulair (Montelukast) –usually added to clients unresponsive to inhaled steroids –Zafirlukast side effects: increased concentration if taken with Aspirin increased concentration if taken with Aspirin impaired absorption with food impaired absorption with food Tilade (Nedocromil) Tilade (Nedocromil) –inhaled therapy for maintenance only

41. Nursing Considerations with Mast Cell Stabilizers Cromolyn Sodium (Intal) Cromolyn Sodium (Intal) –inhaled preparations –preventative therapy in allergic/environmental triggers take several weeks before allergy season take several weeks before allergy season –requires consistent, regular use to be effective not used as a rescue drug not used as a rescue drug –causes throat irritation and coughing if powder is swallowed

42. Nursing Considerations for Beta 2 Agonists Monitor for s/s of toxicity especially with systemic preparations Monitor for s/s of toxicity especially with systemic preparations –palpitations, chest pain, hypertension Client teaching regarding use of short acting preparations as rescue medication Client teaching regarding use of short acting preparations as rescue medication

43. Interventions for Asthma Client Education Client Education – Self management Adjusting the frequency and dosage of prescribed drugs Adjusting the frequency and dosage of prescribed drugs Peak flow meters Peak flow meters – ↓PaCO 2 initially then PaCO 2 then later it may ↑ – Status asthmaticus Pharmacologic therapy Pharmacologic therapy – Step category for severity and treatment (See Chart 33 – 2) – Anti-Inflammatory Agents Exercise/Activity: Exercise/Activity: – Regular exercise with aerobics are recommended Oxygen Oxygen

44. Treatment for TB Disease Principles of therapy Principles of therapy – Induction phase 4 drug therapy for 2 months 4 drug therapy for 2 months – Continuation phase (after induction) 2 drug therapy for 4 months 2 drug therapy for 4 months Directly Observed Therapy (DOT) should be employed for suspected noncompliance……..therefore strict adherence is a must! Multiple drug regimens destroys the m/o quickly…. Reducing the emergence of MDR organisms!

45. Drug-Drug Interactions INH, RFB, PZA, EMB INH, RFB, PZA, EMB – Rifabutin is contraindicated with hard-gel saquinavir and delavirdine. – 20%-25% increase in the dose of PIs or NNRTIs might be necessary. – Patient should be monitored carefully for RFB drug toxicity (arthralgia, uveitis, leukopenia) if RFB is used concurrently with PIs or NNRTIs. – Evidence of decreased antiretroviral drug activity should be assessed periodically with HIV RNA levels. – No contraindication exists for the use of RFB with NRTIs. – RFB dosing may need to be increased or decreased with concurrent use of nelfinavir, indinavir, amprenavir, or ritonavir, or efavirenz. (protease inhibitors) –

46. Drug-Drug Interactions INH, SM, PZA, EMB INH, SM, PZA, EMB –Can be used concurrently with antiretroviral regimens that include PIs, NRTIs, and NNRTIs. INH, RIF, PZA, EMB or SM INH, RIF, PZA, EMB or SM –NRTIs may be administered concurrently with RIF. –If RIF is used with a client on antiretroviral therapy, the CDC site should be accessed to verify concurrent use of agents prior to administration

47. OK Now what do I really need to know???????? Remember we want you to study these drugs as classes. Remember we want you to study these drugs as classes. We want you to understand the nursing considerations regarding the classes of meds We want you to understand the nursing considerations regarding the classes of meds If the med is on a case study or several….. If the med is on a case study or several…..

48. ??????? Questions ????????