Drugs for Bacterial Infections

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Cholinesterase Inhibitors

* Neostigmine (Prostigmin)

        ACTION: Prevent the enzyme cholinesterase (CHE) from inactivating acetycholine (ACh),
       thereby increasing the amount of ACh available at receptor sites. Transmission of nerve
       impulses is increased at all sites responding to ACh as a transmitter

Therapeutic Use (TU)

  increases muscle strength by increasing ACh effects at motor neurons in Myasthenia Gravis
  Causes reversal of nondepolarizing neuromuscular blocking agents (tubocurarine) following surgery

Side Effects/Adverse Effects

  Increased GI motility and secretion, bradycardia & urinary Urgency due to excessive muscarinic
          * 1) If effects become intolerable notify primary care provider, Side effects can be treated
                with ATROPINE

  Cholinergic Crisis- excessive muscarinic stimulation and respiratory depression from neuromuscular
         * Treat with Muscarinic effects with ATROPINE

         * Provide resp. support through mechanical ventilation

       Contraindications (CI) :

              In clients with obstruction of GI and GU system
              Pregnancy Risk Category C

       Med food/ Interaction

  Atropine : counteracts the effects of Neostigmine (Nursing interventions: ATROPINE is used to
      treat NEOSTIGMINE TOXICITY……….if no recovery is noted apply mechanical ventilation
      until full muscle function is regained)
  Tubocurarine : Neostigmine reverses neuromuscular blockade after surgical procedures and
  Succinylcholine (increase neuromuscular blockade) : Avoid concurrent use

        Client Education : Start at low dosages and titrate until desired muscle function is achieved,
Encourage the client to keep track of self doasage administration, recognize signs of INADEQUATE
DOSING, such as difficulty swallowing and signs of overmedication, such as urinary urgency, Advise
the client to wear a medical alert bracelet 

Effectiveness : Decreased fatigued, improved muscle strength as demonstrated by chewing,
swallowing and performing hygiene

Neuromuscular blocking agent

Drug : Tubocuraine (non-depolarizing) & Succinycholine (Depolarizing)

       Action: Neuromuscular blocking agents block Ach at the neuromuscular junction resulting in
       muscle relaxation and hypotension. They d/n cross the blood-brain barrier so complete
       paralysis can be achieved w/o loss of consciousness or decreased pain sensation


       Used as adjuncts to general anesthesia to promote muscle relaxation
       Used to control spontaneous respiratory movements in clients receiving mechanical ventilation
       These Meds are used to diagnosis MYASTHENIA GRAVIS
       Succinycholine is preferred for : Seizure contol during electroconvulsive therapy, endotracheal
       tubation, endoscopy


  Respiratory Arrest from paralyzed respiratory muscles (NI: monitor respirations and vitals
      continuously, equipment ready for resuscitation)
  Hypotension resulting from HISTAMINE RELEASE and GUANGLIONIC BLOCKADE,
      Bradycardia and dysrhythmias


       Malignant hyperthermia: 109.4 F (NI: Monitor vitals, stop med, ice or ice saline to cool the
       client, Administer Dantrolene: decreases metabolic activity of the skeletal muscle)
       Prolonged Apnea due to low Pseudocholinesterase (NI : Test clients blood and hold med if
       pseudo levels are low)

    Med/food Int

  General anesthetics are often used concurrently in surgery
  Aminoglycosides, tetracyclines : increase effects of neuromuscular blockade
  Neostigimine & Prostigmin) and other Cholinesterase inhibitors : decrease the effects of non-
      depolarizing neuromuscular blockers, such as Tubucurarine; increase the effects of
      depolarizing neuromuscular blockers, such as Succinylcholine

       Education: Continous Cardiac and respiratory monitoring (have life support equipment handy)

      Effectiveness: Muscle relaxation during surgery, absence of seizures in EC Therapy, Successful
      Endotracheal intubation, No spontaneous respiratory movements
Classification : Adrenergic Agonist
Drug : Epinephrine (Adrenaline) other drugs Dopamine and Dobutamine

       Action : Catecholamine adrenergic agonists c/n be taken by the oral route, d/n cross the blood
       brain barrier and the duration is short


       Alpha1 : Activation of receptors in arterioles of skin, viscera ad mucous membranes, and
       veins lead to vasoconstriction

       Beta1 : Heart stimulation leads to increased HR. increased Myocardial contractility, increased
       rate of conduction through the AV node, Activation of receptors in the kidney lead to release of

       Beta2 : Activation of receptors in the arterioles of the heart, lungs, and skeletal muscles
       leading to vasodilation, Bronchial stimulation leads to bronchodilation, activation of receptors
       in the uterine smooth muscles causes relaxation, activation of receptors in the liver causes
       glycogenesis, activation of skeletal muscles leads to muscle contraction

       Dopamine : activation of receptors in the kidney cause the renal blood vessels to dilate

       Estrogen acting on Alpha1

  TU: Increases B/P, decreases congestation of nasal mucosa, Manages superficial bleeding, slows
       absorption of local anesthetics

       Estrogen acting on Beta 1

  Increases HR, Myocardial contractility, rate of conduction through the AV
  Tx: AV Block and Cardiac Arrest

Estrogen acting on Beta2

  Tx : Asthma

       S/E :

       Hypertensive crisis : Due to Vasoconstriction of Alpha 1 receptors (NI: Continuous Cardiac
       monitor).Dysrhythmias : Do to activating Beta1 receptors which increases the workload of the
       heart and the oxygen demand of the heart

Contraindications- Pregnancy Risk C, In clients with Tachydysrhythmias and v.Fib
      Med/Food Int- Avoid use of MAOI’s in clients receiving Epinephrine.Tricylic Antidepressants
      increase the effects of epinephrine, may need to lower epinephrine dosage.General Anesthetics
      and epi can cause Dsyrhythmias so monitor ECG and notify primary care provider for signs of
      chest pain, increased HR

  Phentolamine Treats Epinephrine Toxicity
  Propranolol treats Chest Pain and dysrhythmias

      Education- Must be administered IV by continuous infusion, continuous ECG monitoring

      Effectiveness- urine output greater than 30ml/hr, improved mental status, systolic blood
      pressure maintained at greater than equal to 90mm hg

Classification : Alpha Adrenergic Blockers (Sympatholytics)


      Action: Venous and arterial dilation. Smooth muscle relaxation of the prostatic capsule
      and bladder neck

      TU: Tx: HTN

        Doxazosin mesylate (Cardura) may be used to decrease symptoms of benign prostatic
      hypertrophy (BPH) (e.g urgency, frequency, dysuria)


             First-Dose Orthostatic Hypotension (NI: first dose may be given at night, monitor
      blood pressure for 2hr after the initiation of tx, instruct clients to avoid activity for the first 12-
      24hr, encourage pt. to change positions slowly)

      Contraindications (CI) : Pregnancy risk C. CI in clients with hypersensitivity to

      Med/Food Int
      Anti-hypertensive Medications
            NSAID’s and Clonidine decrease Anit-HTN effects


      *decrease in b/p, reduction in benign prostatic hypertrophy symptoms 

Classification : Centrally Acting Alpha2 Agonists

Drug : Clonidine (Catapres)
       Action :

  Act in the CNS to decrease sympathethic outflow. This results in a decrease of norepinephrine
       (NE) released from sympathetic nerves, thereby decreasing the amount of NE that is available
       to stimulate the adrenergic receptors (both alpha and beta receptors) of the heart and peripheral
       vascular system
  decreases sympathetic outflow to myocardium, results in bradycardia and decrease cardiac
       output (CO)
  decreases in synmpathetic outflow to peripheral vasculature results in, vasodilation, which leads to
       decrease blood pressure


  Drowsiness and Sedation
  Dry Mouth (encourage the client to chew gum or hard candy, symptoms resolves in 2 to 4 weeks)
  Rebound HTN: Discontinue CLONIDINE gradually over the course of 2 to 4 days

       Med & Food Int

  Antihypertensive Meds (may have hypotensive additive effects)
  Prazosin, MAOI’s and Tricyclic Antidepressants (May counteract anti-hypertensive effects)
  Alcohol : CNS Depressants

       Education- Pregnancy must be ruled out before treatment is begun

  Administer Twice a day in divided doses
  Transdermal patches applied every seven days

       Effectiveness- decreased blood pressure, absence of pain

Classification : Adrenergic Neuron-Blocking Agents

Drug: Reserpine

       Action- Depletion of NE from postganglionic symphathetic neurons which decreases the
       activation of alpha and beta adrenergic receptors…………..This slows HR and Reduces
       Cardiac Output

       TU: Tx HTN and Can be, but is less commonly used to treat Psychotic States

       Severe Depression (NI: educate about signs of depression such as early morning insomnia,
       decreased appetite, change in mood

  Cardiovascular Effects : Bradycardia, orthostatic hypotension, nasal congestion ((due to depletion of
       Noreepinephrine (NE))………Bradycardia caused by decreased activation at the beta1
       receptors, hypotension and nasal congestion caused by dec. activation at alpha receptors
  GI Effects : Increase secretion of gastric acid causing Ulcer Formation

       CI: Patients who have a hx of Depression 

Classification : Beta Adrenergic Blockers (Sympatholytics)

Drugs : Propranolol and Metoprolol

       Action : decrease HR, Myocardial contractility (inotropic), rate of conduction through the
       AV.Metoprolol blocks at Beta1 receptor, Propranolol (Inderal) blocks at Beta 2 receptor

       TU: Angina Pectoris, HTN, Cardiac Dysrhythmias, MI, Heart Failure,
       Other uses : hyperthyroidism, migraine headache, stage fright, glaucoma

       S/E of Metoprolol (lopressor): Bradycardia (Administer Atropine and Isoproterenol)
       Decrease In Cardiac output (Metoprolol may take like 1 to 3 months for effects to work) AV
       Block (D/n administer beta-blocker) Orthostatic hypotensive, rebound myocardium
       excitation (use of beta blockers shouldn’t be abruptly stopped, discontinue over 1 to 2 weeks)

       S/E of Propranolol (Inderal) : Bronchoconstriction (Avoid in asthmatic clients),
       Glycogenolysis is inhibited (Contraindicated in Diabetic pt.s treat diabetic pt.s with Beta1


  Beta adrenergic blockers are contraindicated in clients with AV block and Sinus BradyCardia
  Non-Selective beta-adrenergic blockers are contraindicated in clients with asthma, bronchospasms
       and heart Failure
  Use cardioselective Beta-adrenergic blockers cautiously in clients with heart failure, asthma,
       bronchospasm, diabetes, hx of allergies and depression

       MED and Food Int

  CCB’s (Verapamil &Diltiazem (Cardizem) : intensifies the effects of beta-
       blockers………monitor closely
  Antihypertensive Meds : Increases Hypotensive effects……monitor b/p
  Insulin- prevents glycogenolysis: may need to adjust dosage of insulin when using Propranolol

       Education- Self monitor HR and B/p, D/N crush or chew extended release tablets, avoid
       sudden changes in position

       Effectiveness- Absence of chest pain, cardiac dysrhythmias, normal b/p, control of signs of
Classification : Muscarinic Agonists

Drug : Bethanechol (Urecholine)

       Action : Binds reversibly to muscarinic cholinergic receptors and causes activation, the
       principal structures affected by muscarinic activation are the heart, exocrine glands, smooth
       muscles, and eye

       At the heart : Causes Bradycardia
       At Exocrine Glands : Causes increase sweat, salivation, bronchial secretions, and secretion of
       gastric acid
       In the Smooth muscles of the lung and GI Tract : Promote contraction
       In the bladder : contracts the detrusor muscle and relaxs the trigone and sphincter causeing

      TU : Tx for Urinary Retention in post opt and post pardum pt. NOT urinary retention caused by
      physiological obstruction…..b/c it cam cause injury due to increased pressure

      S/E : Hypotension and bradycardia. Excessive salivation ,increased sec. of gastric acid,
      abdominal cramps and diarrhea

       CI : Patients with low blood pressure, gastric ulcers, intestinal obstruction (can rupture the
      bladder) patients with asthma (it causes bronchoconstriciton), hyperthyroid patients (Can cause

Classification : Muscarinic Antagonists (Anticholinergic Drugs)

Drug: Atropine

       Action : completely block the action of acetylcholine at muscarinic receptors. Exerts it’s
       influence primarily on the heart, exocrine glands, smooth muscles, and eye, just like the
       muscarinc agonist

       At the heart : increase HR
       Exocrine Glands : decrease secretion of salivation, bronchial glands, sweat glands and
       decreases gastric secretions
       Smooth muscles: Atropine causes relaxation of the bronchi, decreased tone of the urinary
       bladder detrusor and decreased tone and motility of the GI
  Eye : Dilates the pupil (mydriasis) focuses the lens for far vision (cycloplegia)
  CNS: can cause mild excitation at therapeutic doses, Toxic doses can causes delirium &

       TU:Helps during eye examinations for disorders of the eye. Tx Bradycardia. Tx : diverticulitis
       by decreasing tone and motility in the smooth muscles of the intestine. Used to Reverse
       Muscarinic Poisioning, Can treat Peptic Ulcers disease, Asthma (by bronchodilating)
       S/E : Xerostomia (Dry Mouth), Blurred Vision (paralyze ciliary muscle focus on far objects
       causes blurred vision) photophobia (paralysis of iris sphincter prevents constriction of the
       pupil) (NI: where glasses 4photophobia-when unable to adapt to bright light)

       Urinary Retention and Constipation (blockade of muscarinic receptors increase the pressure
       w/in bladder and increases the tone of the urinary sphincter and trigone)
       Anhidrosis (absence of sweat), Tachycardia, Asthma(cause thickening and drying of bronchial

   Drug Interactions : Anti-histamines, phenothiazines, antipsychotics, tricyclic
   antidepressants…have anticholinergic effects and can enhance the effects of Atropine

Note : Anti-cholinergic means blockade at Muscarinic Receptors-not blockade at all cholinergic

Classification : Ganglinic Blocking Agents

Drugs : Mecamylamine

       Action : Blocks transmission through the ganglia of the ANS by completing with Ach for
       binding to nicotinic receptors

       TU : Are used ONLY to decrease blood pressure, treats primary HTN in selected patients, only
       used when b/p c/n be reduced by all other medications
       S/E :

       Antimuscarinic effects (dry mouth, blurred vision, photophobia, urinary retention,
       constipation, tachycardia, anhidrosis)

       Orthostatic hypotension (by dilating veins causes pooling of blood decreasing blood return to
       the heart, reducing CO and subsequent fall in b/p)
      CNS Effects ( tremor convulsions, and mental aberrationds)

                          Central Nervous System Drugs
                       Drugs for Parkinson’s disease
Dopaminergic Drugs:
Anti-Parkinson’s Medications
Dopaminergics: Levodopa (increases dopamine [DA] synthesis)
       -levodopa plus carbidopa (Sinemet)
       -Carbidopa (blocks levodopa destruction)
Dopamine agonists: pramipexole (Mirapex)
Centrally acting anticholinergics: Benztropine (Cogentin)
Dopamine releaser (Antiviral): Amantadine (Symmetrel)
Medications: Levodopa (Dopar, Larodopa), levodopa plus carbidopa (Sinemet)
       -Levodopa crosses the blood brain barrier and is taken up by dopaminergic nerve terminals and
converted to dopamine (DA). This newly synthesized DA is released into the synaptic space and
causes stimulation of DA receptors
       - Carbidopa does not possess any therapeutic effects, but is used to augment levodopa.
Carbidopa inhibits conversion of levodopa to DA in the intestine and periphery, and thereby allows for
increase amounts of levodopa to reach the CNS

Dopamine agonists:
Medications: Pramipexole (Mirapex), Ropinirole (Requip), bromocrptine (Parlodel)
      -Act directly on DA receptors

Centrally Acting Anticholinergics:
Medications: Benztropine (Cogentin), Trihexyphenidyl (Artane)
Actions: These medications block acetylcholine at muscarnic receptors, which assists in maintaining
the balance between dopamine and acetylcholine in the brain.

Dopamine releaser (Antiviral):
Medications: Amantadine (Symmetrel)
Actions: Antiviral stimulate DA release, prevent dopamine reuptake, and may block cholinergic and
glutamate receptors

Therapeutic Uses:
   - These medications do not halt the progression of Parkinson’s disease (PD): however, they do
      offer symptomatic relief from dyskinesias (e.g., bradykinesis, resting tremors, and muscle
   - Levodopa may be used as a first-line medication for PD treatment
   - Pramipexole (Mirapex) is used as monotherapy in early-stage PD, and used in conjunction with
      levodopa in late- stage PD. It is used often in younger clients who are more able to tolerate
      daytime drowsiness and postural hypotension
Side/Adverse Effects: Nursing Interventions and Client Education
                        Dopaminergics: levodopa- usually dose dependant
   - N&V, drowsiness
          o Administer in small doses at the start of treatment and with food
   - Dyskinesias (e.g.), head bobbing, tics, grimacing, tremors)
          o Decrease dosage of medication, but the decrease may result in resumption of PD
   - Orthostatic hypotension
          o Monitor the clients b/p
          o Instruct the client about signs of postural hypotension
   - Cardiovascular effects from beta1 stimulation (e.g., tachycardia, palpitations, irregular
          o Monitor the clients vital signs
          o Use cautiously in clients with cardiovascular disorders
          o Monitor ECG
   -   Psychosis (e.g., visual hallucinations, nightmares)
           o Administer antipsychotic medications such as clozapine (Clozaril) if symptoms occur.
   -   Discoloration of sweat and urine
           o Advise the client that this is a harmless side effect
   -   Activation of malignant melanoma
           o Avoid use of medication in clients with skin lesions that have not been diagnosed
                                    Dopamine Agonists: Pramipexole (Mirapex)
   -   Sleep attacks
   -   Daytime sleepiness
           o Advise the client to avoid the use of other CNS depressants such as alcohol
   -   Orthostatic hypotension
   -   Psychosis
   -   Dyskinesisas
   -   Nausea
                     Centrally acting anticholinergics: benztropine (Cogentin)
   -   N&V
   -   Atropine-like effects (e.g., dry mouth, blurred vision, mydriasis, urinary retention, constipation)
           o Advise the client to chew sugarless gum, eat foods high in fiber, and increase water
               intake to at least 8 to 10 glasses of water/day
   -   antihistamine effects (e.g. sedation, drowsiness)
                                    Antiviral: amatadine (Symmetrel)
   -   CNS effects (e.g., confusion, dizziness, restlessness)
   -   Atropine-like effects\
   -   Discoloration of skin, also called livido, reticularis
           o Advise the client that discoloration of the skin will subside when the medication is

                             Levodopa plus cardidopa (Sinemet)
- Abnormal movements, psychiatric disorders

   - Pregnancy Risk Category C
   - Contraindicated in clients with malignant melanoma
   - Do not use w/in 2 weeks of MAOI use
   - Use cautiously in clients with heart disease and psychiatric disorders
Pramipexole (Mirapex)
   - Pregnancy Risk Category C
   - Use cautiously in clients with liver and kidney impairment
Anticholinergic agents
   - Contraindicated in clients with narrow-angle glaucoma
   - Use cautiously in older adults, the very young, clients with enlarged prostate glands, and a
      history of urinary retention

Medication/Food Interactions
                                     Dopaminergics: levodopa
   -   Proteins interfere with levodopa absorption and transport across the blood-brain barrier. High
       protein meal decrease therapeutic effects.
           o Proteins trigger an “off episode”
           o Advise the client to eat protein in several portions during the day
   -   Conventional-antipsychotic agents (e.g., chlorpromazine [Compazine], haloperidol [Haldol]
       decrease therapeutic effects.
           o Avoid use with levodopa
           o To treat levodopa-induced psychosis, use the atypical antipsychotic clozapine (Clozaril)
   -   Pyridoxine decrease therapeutic effects
           o Advise client to avoid vitamin preparations that contain pyridoxine
   -   MAOIs cause hypertension
           o Avoid concurrent use
   -   Carbidopa, dopamine agonists, anticholinergics, COMT inhibitors, and dopamine
       releasers increase therapeutic effects
           o These medications can be used concurrently to increase the beneficial effects of

                             Dopamine agonists: pramipexole (Mirapex)
   -   Levodopa- concurrent use has beneficial and harmful interactions. Use with levodopa can
       decrease motor control fluctuations and allow for lower dosage of levodopa. Concurrent use
       can also increase the risk of orthostatic hypotension and dyskinesias
                                   Levodopa plus carbidopa (Sinemet)
   -   Beneficial interactions include allowing for lower dosage of levodopa, decrease cardiovascular
       responses to dopamine in the periphery, and decrease nausea.

                                        Cholinesterase Inhibitors
Prototype Medication: Neostigime (Prostigmin)
Action: Prevent the enzyme cholinesterase (ChE) from inactivating acetylcholine (Ach), thereby
increasing the amount of Ach available at receptor sites. Transmission of nerve impulses is increased
at all sites responding to Ach as a transmitter.
Therapeutic Uses:
    - Neostigmine (Prostigmin) increase muscle strength by increasing Ach effects at motor neurons
         in myasthenia gravis
    - Neostigmine causes reversal of nondepolarizing neuromuscular blocking agents (tubocurarine)
         following surgery
Side/Adverse Effects:
    - Excessive muscarine stimulation as evidenced by increased GI motility, increased GI
         secretions, bradycardia, and urinary urgency
              o Side effects may be treated with atropine
    - Cholinergic crisis –excessive muscarnic stimulation and respiratory depression from
         neuromuscular blockade
              o Muscarinic effects can be treated with atropine
              o Provide respiratory support through mechanical ventilation and oxygen
    - Pregnancy Risk Category C
    - Contraindicated in clients with obstruction of GI and GU system
    - Use cautiously in clients with seizure disorders, hyperthyroidism, peptic ulcer disease, asthma,
         bradycardia, and hypotension.
Medication/Food Interactions
Atropine-counteracts the effects of neostigmine
    - Used to treat neostigmine toxicity
   -   Monitor the client closely and provide mechanical ventilation until the client has regained full
       muscle function
   - Neostigmine reverses neuromuscular blockade after surgical procedures and overdose.
   - Monitor the client for return of respiratory function. Support respiratory function as necessary.
       If used to treat overdose, provide mechanical ventilation until the client has regained full
       muscle function
Succinylcholine: increase blockade
   - Avoid concurrent use
                               Drugs for Epilepsy (Antiepileptics) AEDs
   Select Prototype Medications:
   Barbiturates: Phenobarbital (Luminal)
   Hydantoins: phenytoin (Dilantin)
   Benzodiazepines: diazepam (Valium)
   Lorazepam (Ativan)
   Carbamazepine (Tegretol)
   Ethosuximide (Zarontin)
   Valproic acid (Depakote)
   Gabapentin (Neurontin)
   Action: AEDs control seizure disorders by various mechanism, which include
   - Slowing the entrance of sodium and calcium back into the neuron and, thus extending the time
       it takes for the nerve to return to its active state
   - Suppressing neuronal firing, which decreases seizure activity and prevents propagation of
       seizure activity into other areas of the brain
   - Potentiating the inhibitory effects of gamma butyric acid (GABA) and thereby suppressing
       seizure activity.

Therapeutic Uses
   - Treatment of generalized seizures
          o Tonic clonic ( Grand mal)
          o Absence seizures (Petit mal)
          o Atonic seizures
          o Myoclonic seizures
          o Status epilepticus
          o Febrile seizures
   - Treatment of partial seizures
          o Simple partial
          o Complex partial
   - Complete eradication of seizure activity
Medications/ Therapeutic Uses
Phenobarbital (Luminal)
   - Used for partial seizures and generalized tonic-clonic seizures
   - Not effective against absence seizures
Phenytoin (Dilantin)
   - Is effective against all major forms of epilepsy except absence seizures
   - Use IV route for status epilepticus
   - Antidysrhythmic
Carbamazepine (Tegretol)
   -  Used for the treatment of partial (simple and complex) seizures, tonic-clonic seizures, bipolar
      disorder and trigeminal and glossopharyngeal neuralgias
Ethosuximide (Zarontin)
   - Only indicated for absence seizures
Valproic acid (Depakote)
   - Used for partial, generalized and absence seizures, bipolar disorder and migraine headaches.
Gabapentin (Neurontin)
   - Used a single agent for control of partial seizures. The medication is also used for neuropathic
      pain and the prevention of migraine headaches.
Diazepam (Valium)
   - Status epilepticus

Side/Adverse Effects: Nursing Interventions and Client Education
Barbiturates: Phenobarbital (Luminal)
   - CNS effects in adults manifest as drowsiness, sedation, confusion, and anxiety; in children,
      CNS effects manifest as irritability and hyperactivity
   - Toxicity (e.g., nystagmus, ataxia, respiratory depression, coma, pinpoint pupils, hypotension,
          o Stop medication. Administer oxygen and maintain respiratory function with ventilatory
          o Monitor clients vital signs
Hydantoins: phenytoin (Dilantin)
   - CNS effects (e.g., nystagmus, sedation, ataxia, double vision)
   - Gingival hyperplasia- softening and overgrowth of gum tissue resulting in tenderness and
      bleeding gums
          o Advise the client to maintain good oral hygiene
   - Skin rash
          o Stop medication
   - Teratogenic (e.g. cleft palate, heart defects)
          o Avoid use in pregnancy
   - Cardiovascular effects (e.g. dysrhythmias, hypotension)
          o Administer at slow IV rate and in dilute solution to prevent adverse CV effects
   - Endocrine and other effects (e.g., coarsening of facial features, hirsutism, and interference with
      vitamin D metabolism)
          o Encourage the client to consume adequate amounts of calcium and vitamin D
Carbamazepine (Tegretol)
   - Cognitive function is minimally affected, but CNS effects can occur
          o Administer in low doses initially and then gradually increase dose
          o Administer dose at bedtime
   - Blood dyscrasias (e.g., leucopenia, anemia, thrombocytopenia)
          o Obtain the clients baseline CBC and platelets. Perform ongoing monitoring of CBC and
          o Observe the client for signs of bruising and bleeding gums
   - Teratogenesis
   - Hyo-osmolarity – promotes secretion of ADH which inhibits water excretion by the kidneys,
      and places the client with heart failure at risk for fluid overload
          o Monitor serum sodium periodically.
          o Monitor the client for edema, decrease urine output and hypertension.
   - Skin disorders (e.g., dermatitis, rash, Stevenson-Johnson syndrome
          o Treat mild reactions with anti-inflammatory or antihistamine medications
          o Medications should be discontinued if there is a severe reaction
Ethosuximide (Zarontin)
   - Gastrointestinal effects N&V
   - CNS effects
Valproic acid (Depakote)
   - Gastrointestinal effects
   - Hepatoxicity (e.g., anorexia, abdominal pain, jaundice)
          o Medication should be prescribed in lowest effective dose
   - Pancreatits as evidenced by nausea, vomiting, and abdominal pain
          o Monitor amylase level
          o Medication should be discontinued if pancreatitis develops
   - Thrombocytopenia
          o Monitor platelet count
          o Advise client to observe for signs of bruising
Gabapentin (Neurotin)
   - CNS effects
   - Respiratory depression
          o Monitor client’s vital signs
          o Have resuscitation equipment ready
          o Administer oxygen\
   - Anterograde amnesia
          o Monitor clients memory loss
   - Teratogenic (e.g., cleft palate, heart defects)

Barbiturates- contraindicated in clients with intermittent porphyria
Phenytoin contraindicated in clients with sinus bradycardia, sinoatrial blocks, second- and third degree
AV block, or stokes-Adam syndrome
Carbamazepine- contraindicated in clients with bone marrow suppression or with bleeding disorders
Valproic Acid- contraindicated in clients with liver disorders.

Medication/Food interactions
Phenytoin (Dilantin)
   - Oral contraceptives, warfarin (Coumadin), and glucocorticoids- phenytoin causes a
      decrease effects of these medications due to the stimulation of hepatic drug-metabolizing
          o Advise the client to increase dose of oral contraceptives
   - Alcohol, diazepam (valium), cimetidine (tagamet), and valproic acid increase phenytoin
   - Carbamazepine (Tegretol), Phenobarbital, and chronic alcohol use decrease phenytoin
   - CNS depressants (e.g., barbiturates, alcohol)
          o Additive CNS depressant effects can occur with concurrent use
Carbamazepine (Tergretol)
   - Oral contraceptives and warfarin (Coumadin) – carbamazepine causes decrease in the
      effects of these medications due to stimulation of hepatic drug-metabolizing enzymes
   - Grapefruit juice –inhibits metabolism, and thus increase carbamazepine levels
   - Phenytoin and phenobarbital- decrease the effects of carbamazepine
Valproic acid (Depakote)
   - Phenytoin and Phenobarbital –concurrent use with valproic acid increase the levels of these

Drugs for migraines:
Nonsteroidal Anti-inflammatory drugs
aspirin (Ecotrin):
Prevents platelets from clumping together by inhibiting enzymes and factors that normally lead to
arterial clotting
      Primary prevention of acute MI
      Prevention of reinfarction in clients following acute MI
      Prevention of stroke

Side effects:
GI effects such as bleeding, hemorrhagic stoke
Nsaids, heparin, warfarin
Local Anesthetics
Ester-type Local anesthetics: procaine (Novocain)
Amide-type Local anesthetics: lidocaine (Xylocaine)
Decrease pain by blocking conduction of pain impulses in a circumscribed area. Loss of consciousness
does not occur
     Dental procedures
     Minor surgical procedures
     Labor and delivery
     Diagnostic procedures
Side effects:
CNS excitation (seizures, followed by resp. depression, leading to unconsciousness), Hypotensiins,
cardio suppression aeb bradycardia, heart block, and cardiac arrest, allergic rxn’s, spinal headache and
urinary retention

General Anesthetics
Inhalation Anesthetics: halothane (Fluothane)
Produces loss of consciousness, loss of all sensations, relaxation of muscles, and memory loss
    Anesthesia for surgery
    Diagnostic procedures
    Cardiological procedures
    Relief of pain
    Muscle relaxation
Side effects:
Hypotension, respiratory and cardiac depression, malignant hyperthermia, hepatotoxicity
Interactions: CNS depressants (barbiturates, benzodiazepines, alcohol), CNS stimulants
(amphetamines, cocaine), Opioid analgesics (morphine), succinylcholine
Intravenous Anesthetics: thiopental (Pentothal)
Produce loss of consciousness and elimination of response to painful stimuli
     Adjunct to inhalation anesthetics
     Induction and maintenance of anesthesia
     Amnesia
Side effects:
Respiratory and cardiovascular depression (hypotension)
CNS depressants (barbiturates, benzodiazepines, alcohol), CNS stimulants (amphetamines, cocaine),
Opioid analgesics (morphine),
Opioid (narcotic) Analgesics and Antagonists
Pure Opioid Agonists: Morphine sulfate
Act on mu receptors and to lesser degree on kappa receptors. Activation of mu receptors produces
analgesia, respiratory depression, euphoria, and sedation.
     Relief of moderate to sever pain
     Sedation
     Reduction of bowel motility
Side effects:
Respiratory depression, constipation, orthostatic hypotension, urinary retention, coughs suppression,
CNS depressants (barbiturates, benzodiazepines, Phenobarbital, alcohol), anticholinergic agents
(antihistamines and tricyclic depressants, MAIO’s, antihypertensive
Agonist-Antagonist Opioid: pentazocine (Talwin)
Compared to pure opioid agonists, these have a low potential for abuse causing little euphoria and less
respiratory depression
     Relieve mild to moderate pain, not severe pain
Side effects:
Abstinence syndrome (cramping, hypertension, vomiting)
Pure Opiod Antagonists: naloxone (Narcan)
Interfere with the action of opioids by competing for opioid receptors. Opioid antagonists have no
effect in the absence of opioids.
     Treatment of opioid overdose
     Reversal of effects of opioids, such as respiratory depression
      Reversal of respiratory depression in an infant
Side effects:
Tachycardia and tachypnea, abstinence syndrome (cramping, hypertension, vomiting)

Antipsychotic drugs
Traditional antipsychotic: chlorpromazine (Thorazine), haloperidol (Haldol)
Dopamine, acetylcholine, histamines, and norepinephrine receptors in the brain and periphery are
     Schizophrenia
     Bipolar disorders
     Tourette’s syndrome
     Delusional disorders
     Schizoaffective disorder
     Dementia and other organic mental syndromes
     Huntington’s chorea
Side effects:
Early extrapyramidal symptoms: acute dystonia (severe spasms of the tongue, neck, face, and back),
parkinsonism tremors, akathisia (inability to stand still or sit). Late extrapyramidal symptoms: (tardive
dyskinesia). Neuroleptic malignant syndrome ( sudden high grade fever, blood pressure fluctuations,
dysrhythmias), anticholinergic effects.
Anticholinergic agents, CNS depressants (barbiturates, benzodiazepines, Phenobarbital, alcohol),

Atypical Antipsychotics: clozapine (Clozaril)
Block serotonin and dopamine receptors
    Severe schizophrenia
    Psychosis induced by levodopa therapy
Side effects:
Agranulocytosis, seizures, new onset diabetes, weight gain, inflammation of the heart muscles
Immunosuppressive medications
Tyicyclic Antidepressants: imipramine (Tofranil)
Block reuptake of norepinephrine and serotonin
     Depression
     Bipolar disorders
Side effects:
Orthostatic hypotension, anticholinergic effects, cardiac toxicity, sedation
MAOI’s, antihistamines, epinephrine, ephedrine, alcohol, benzodiazepines, opioids
Selective Serotonin Reuptake Inhibitors: fluoxetine (Prozac)
Block reuptake of serotonin
     Major depression
     OCD
     Bulimia nervosa
     PMDD
     Panic disorders
     PTSD
Side effects:
Sexual dysfunction, weight gain, serotonin syndrome (mental confusion, agitation, anxiety),
withdrawal syndrome, hyponatremia, rash
MAIO’s, Coumadin, tricyclic antidepressnats and lithium, NSAID’s and anticoagulants
Monoamine Oxidase Inhibitors: phenelzine (Nardil)
Block MAO-A in the brain thereby increasing the amount of norepinephrine and serotonin available
for transmission
     Atypical depression
     Bulimia nervosa
     OCD
Side effects:
CNS stimulation, orthostatic hypotension, hypertensive crisis
Ephedrine, amphetamine, tricylic antidepressants, SSRI’s antihypertensices, Demerol, Tyramine rich

Atypical Antidepressants: bupropion HCL (Wellbutrin)
Inhibit dopamine uptake
     Treatment of depression
     Aid to quit smoking
Side effects:
Headache, dry mouth, constipation, increase heart rate, nausea, restlessness, weight loss, seizures
Drugs for Bipolar Disorder
Lithium carbonate, carbamazepine (Tegrertol), valproic acid (Depakote)
Produces neurochemical changes in the brain including serotonin receptor blockade
    Treatment of bipolar (they control episodes of acute mania, and help to prevent the return of
      mania or depression)
    Alcoholism
    Bulimia
    Schizophrenia
    Side effects:
    GI effects, tremors, polyuria, renal toxicity, goiter and hypothyroidism, teratogenesis
    Diuretics, NSAID’s, anticholinergics

CLASS: Adrenergic Agonists
PRO: epinephrine and dopamine (catecholamine)
ACTION: vasoconstriction (up BP), bronchodialation, increase heart rate
SE: hypertensive crisis, dysrythmias
CONTRA: tachydysrhythmia and ventricular fibrillation
IINTERACT: MAOIS and general anesthetics
INTERVENTIONS: IV only and ECG monitoring

CLASS: Alpha Adrenergic Blockers
PRO: prazosin (minipress)
ACTION: dilate arteries and veins
USES: hypertension
SE: orthostatic hypertension (first dose at night, change position slow)
INTERACT: antihypertensive meds (hypotension), NSAIDS counteract the effects
INTERVENTIONS: take with food and first dose at night

CLASS: centrally acting alpha2 agonist
PRO: clonidine (catapres)
ACTION: lower sympathetic outflow, lower nowepinephrine, lower BP
USE: hypertension
SE: drowsiness (will diminish), dry mouth (resolves in 2-4 wks)
INTERACT: antihypertensive meds (hypotension), prazosin (counteract effects), alcohol
INTERVENTIONS: take large dose at night to lower drowsiness, transdermal patches changed every 7d

CLASS: beta adrenergic blockers (beta blockers)
PRO: metoprolol (lopressor), propranolol (inderal)
ACTION: lower HR, lower myocardial contractility, lower conduction through AV node
USE: angina pectoris, hypertension, dysrythmias, MI, heart failure
SE: bradycardia, lower cardiac output (1-3 months for beneficial effects), bronchoconstriction (avoid
                                                                                         asthma pt)
INTERACT: pt with AV block and sinus bradycardia, calcium channel blockers (intensifies), insulin
INTERVENTIONS: avoid sudden position changes

CLASS: ACE inhibitors
PRO: captopril, enalapril
ACTION: block production of angiotensin II, vasodilation (arteries), excrete NA, retain K
USES: heart failure, hypertension, MI
SE: 1st dose orthostatic hypotension (stop med for 2-3 days if taking diuretic), cough, hyperkalemia
CONTRA: 2nd and 3rd trimester pregnancy
INTERACT: diuretics (stop med for 2-3 d), K supplements, lithium (can up lithium levels), NSAIDS
                                                                  (decrease andtihypertensive effect)
INTERVENTIONS: captopril taken 1h before meals

PRO: losartan
ACTION: blocks action of angiotensin II, vasodialation, excrete NA, retain K
USES: reduce hypertension
SE: angioedema
CONTRA: 2nd and 3rd trimester pregnancy
INTERACT: antihypertensive med (additive effect)
INTERVENTIONS: take with or w/o food
*(ARB’s not as effective as ACE inhibitors because they only block the action and not the production of
angiotensin II)

CLASS: Calcium Channel Blockers

PRO: verapamil (affect heart and vessels)
ACTION: blocks vasodilation in arteries, lower contraction force, lower HR, slower AV conduction
USES: angina pectoris, hypertension, cardiac dysrythmias
SE: Orthostatic hypertension, peripheral edema, constipation
INTERVENTIONS: weigh daily, prescribe diuretic for edema, up fluid intake and fiber, IV admin over 2-3 min
CONTRA: cautiously use digoxin, beta blockers, and grapefruit juice
PRO: nifedipine (affect only vessels)
ACTION: blocks vasodilation in arteries

USES: angina pectoris, hypertension, cardiac dysrythmias
SE: reflex tachycardia, peripheral edema

INTERVENTIONS: administer beta blocker if tachy, prescribe diuretic for edema, IV admin over 2-3 min
CONTRA: cautiously use digoxin, beta blockers, and grapefruit juice

CLASS: organic nitrates
PRO: nitroglycerine
ACTION: lower cardiac O2 demand, dilating veins and decreasing preload
USES: angina, periop (control BP or produce hypotension), heart failure
SE: headache (take aspirin), tolerance
CONTRA: traumatic head injury (increase intracranial pressure)
INTERACT: alcohol, cautiously use with CCB, beta blockers, diuretics, Viagra (hypotension)
INTERVENTIONS: angina attack 1) take rapid-acting 2) wait 5 min 3) can take 2 more doses at 5 min intervals if

CLASS: cardiac glycosides
PRO: digoxin
ACTION: increase force of contraction, decrease HR
USE: heart failure, dysrhythmias (A Fib)
SE: dysrhythmias if toxic
INTERACT: thiazide diuretics, ACE and ARB, dopamine
INTERVENTIONS: take same time daily, avoid OTC drugs, do not take potassium-sparing diuretics, treat
dysryhthmias with lidocaine, trear bradycardia with atropine

CLASS: antidysrythmic meds

PRO: Sodium Channel Blockers 1A (procainamide)
ACTION: decrease electrical conduction, decrease rate of repolorization
USE: Afib, Aflutter
SE: lupus, cardiotoxicity
INTERACT: antichollinergics
PRO: Sodium Channel Blockers 1B (lidocaine)

ACTION: decrease electrical conduction, increase rate of repolorization
USE: short term dysrhythmias
SE: CNS effects, resp. arrest
INTERACT: cimetidine, beta blockers phenytoin
INTERVENTIONS: do not crush

INTERVENTIONS: never administer with epinephrine, administrations is usually loading dose followed by
maintenance dose of 1-4 mg

CLASS: statins
PRO: Lipitor, lovastatin
ACTION: increase LDL receptors to remove greater amt of LDL, increase HDL
USES: hypercholesterolemia
SE: hepatotoxicity (up in serum tranaminase), myopathy
CONTRA: pregnancy
INTERACT: fibrates (up myopathy), grapefruit juice
INTERVENTION: lovastatin take with evening meal, increase med dose if taking erythromycin

CLASS: bile-acid sequestrants
PRO: cholestyramine (questran)
ACTION: increase LDL receptors to remove more LDL
USES: use adjunct with HMG CoA reductase inhibitors (atorvastatin)
SE: so systemic effects, constipation
INTERACT: digoxin, warfarin, thiazide (all interfere with absorption)
INTERVENTION: take other med 1hr before or 4hr after

CLASS: loop diuretics
PRO: furosemide (lasix)
ACTION: block reabsorption of Na, Cl, and H2O in loop of henle
USE: pulmonary edema, conditions not responsive to other diuretics, renal impairment
SE: dehydration, hypotension, ototoxicity, hypokalemia
CONTRA: diabetes (cautious)
INTERACT: digoxin, antihypertensives, lithium, NSAIDS
INTERVENTION: weigh in morning, avoid administering late in day

CLASS: thiazide diuretics
PRO: hydochlorothizaide
ACTION: block reabsorption of Na, Cl, and H2O in early distal convoluted tubule
USE: essential hypertension, edema, liver and kidney disease
SE: dehydration, hypokalemia, hyperglycemia
CONTRA: lower kidney function
INTERACT: digoxin, lithium
INTERVENTION: monitor K levels, eat foods high in K

CLASS: potassium-sparing diuretics
PRO: spironolactone
ACTION: block aldosterone, potassium retension, Na and H20 secretion
USES: combined with other diuretics for K sparing effects, heart failure
SE: hyperkalemia
INTERACT: ACE and K+ supplements (hyperkalemia)
INTERVENTION: only given orally, avoid K+ salt substitutes

Gastrointestinal Drugs: Start on p. 891 in Lehne
Drugs for Peptic Ulcer Disease
An example antibiotic regiment for H pylori would include:
       Omeprazole + Amoxicillin + Clarithromycin for 10 days-remember that none is effective
alone and a multi-drug regiment is to prevent development of resistance to H pylori. Other
options listed in p. 894

H2 Receptor Antagonists-Cimetidine [Tagamet], Ranitidine hydrochloride [Zantac]
      Action: blocks receptor H2 receptor sites in PARIETAL cells lining the stomach
      Therapeutic Use: GERD
      Sides/Adverse Effects: Decreased libido and impotence (keep away from your partner)
      Contraindications/Precautions: Pregnancy Cat. B. Careful with older folks can cause
      antiadrenergic effects like impotence and CNS effects like confusion.
      Interactions: Increases the levels of Warfarin and Phenytoin (anticonvulsant).
      Interventions/Education: remember the drugs ending in –tidine can be administed IV in
      acute situations. Also eat 6 small meals.

Proton Pump Inhibitor Omeprazole [Prilosec]
      Action: reduce gastric acid secretion by irreversibly inhibiting the enzymes that produces
      gastric acid so it stays in the system for a few weeks. They also reduce basal and stimulated
      acid production.
      Therapeutic Use: Ulcers, GERD, and hypersecretory conditions like Zollinger-Ellison
      Sides/Adverse Effects: Insignificant with short term use.
      Contraindications/Precautions: Preg C. Caution in children and women who are
      breastfeeding. Increase risk for pneumonia.
      Interactions: delayed absorption of ampicillin, digoxin, iron and ketocanazole
      Interventions/Education: Do not crush, crew or break sustained-release capsules.

Mucosal Protectants Sucralfate [Carafate]
       Action: uses acidic environment of stomach and duodenum into a viscous substance that
       adheres to an ulcer and protects from further injury.
       Therapeutic Use: Acute duodenal ulcers and maintained therapy.
       Sides/Adverse Effects: increase dietary fiber to decrease constipation.
       Contraindications/Precautions: Preg B and contraindicated in those with hypersensitivity
       Interactions: May interfere with absorption of phenytoin, digoxin, warfarin and
       ciprofloxacin so spread out meds by 2h.
       Interventions/Education: empty stomach 1h before meals

Antacids Aluminum hydroxide gel [Amphojel]
      Action: neutralize gastric acid and inactivate pepsin—mucosal protection may come into
      play by stimulating the production of prostaglandins.
      Therapeutic Use: PUD by promoting healing and relieving pain. Symptomatic relief for
      Sides/Adverse Effects: Can cause constipation. Can lead to hypophosphatemia.
      Contraindications/Precautions: Preg Cat. C. DO not administer to clients with perforation
      or obstruction
      Interactions: Al binds with warfarin and tetracycline which interferes with absorption
      Interventions/Education: Chew it up real good and drink 8oz of H20 or milk.

Drugs for NSAID-- Induced Ulcers
       Action: works on the GI tract to decrease acid secretion, increase the secretion of
       bicarbonate and protective mucous and promote vasodilatation to maintain submucosal
       blood flow.
       Therapeutic Use: to prevent gastric ulcers in clients using NSAID long-term
       Sides/Adverse Effects: Diarrhea and abdominal pain—notify provider the dose may need
       to be reduced.
       Contraindications/Precautions: remember this drugs causes contractions of the uterus
       which could lead to spontaneous abortion.
       Interactions: NONE it’s a miracle!!!
       Interventions/Education: Besides ensuring contraception use teach client to take with
       meals and at bedtime.

Surfactants Docusate Sodium [Colace]
       Action: lower surface tension of the stool to allow penetration of H20
       Therapeutic Use: short term use r/t pregnancy or opoid use. To relieve painful elimination
       (hemorrhoids)., prevent straining, decrease risk of fetal impaction of immobile, promote
       peristalsis due to aging
       *other info below

Stimulant Laxatives Bisacodyl [dulcolax]
       Action: stimulate intestinal peristalsis-act on the colon by reducing water and electrolyte
       absorption and increasing the secretion of water and ions into the intestine.
       Therapeutic Use: prior to surgery, short term treatment caused by high opoid use.
       Sides/Adverse Effects: discourage clients from using suppositories on a regular basis as it
       may cause burning and can lead to proctitis.
       *other below

Osmotic Laxatives-magnesium hydroxide [Milk of Mag]
      Action: Osmotic lax draw H2O into the mass of stool stretching musculature and
      stimulating peristalsis
      Therapeutic Use: used in clients to prevent painful elimination, prep for surgery of
      diagnostic test, evacuate bowel after ingestion of poison or antihelminthic to rid body of
      dead parasites.
      Sides/Adverse Effects: Can lead to accumulation of toxic level of Mg (avoid in folks with
      renal dysfunction). Osmotics can also cause dehydration.

       *General Information for this group:
       Sides/Adverse Effects: GI irritation-do not crush or chew enteric-coated tablets.
       Contraindications/Precautions: Contraindicated in clients with fecal impaction, bowel
       obstruction, and acute surgical abdomen to prevent perforation-also in clients with nausea,
       cramping and abdominal pain. Warn clients with heart disease to avoid laxatives that
       contain sodium.
       Interactions: Milk and antacids can destroy enteric coating of bisacodyl.
       Interventions/Education: Obtain a complete history of laxative use and provide teaching as
       appropriate. Teach client that chronic laxative use can lead to fluid and electrolyte
       imbalances. Promote fiber food so that normal bowel function may be resumed.

Serotonin Antagonists Ondansetron [Zofran]
      Action: blocks serotonin receptors in the chemoreceptor trigger zone (CTZ)
      and antagonizing the serotonin receptors on the afferent vagal neurons that
      travel from the upper GI tract to CTZ
      Therapeutic Use: Sides/Adverse Effects: prevents emesis related to chemo, radiation
      therapy and postoperative recovery
      Sides/Adverse: Headache, diarrhea, dizziness
      *see below

Dopamine Antagonists Prochlorperazine [Compazine]
      Action: Anitemetic effects result from blockade of dopamine receptors in the CTZ.
      Therapeutic Use: prevents emesis r/t chemo, opoid and postoperative recovery
      Sides/Adverse Effects: EPS Extrapyramidal symptoms i.e. restlessness, anxiety, spasms of
      the neck and face—treat with an anticholinergic like benadryl
      *See below
Cannabinoids; dronabinol [Marinol]
      Action: unknown
       Therapeutic Use: Control vomiting and nausea(CINV) in chemo
       Sides/Adverse Effects: Potential for dissociation, dysphoria
       Contraindications/Precautions: avoid using in clients with mental health disorders
       * See Below

       *General information for this group:
       *General Contraindications/Precautions- Use cautiously with children and older adults due
       to EPS sides.
       Interactions: CNS depressants such as opoid medications can intensity CNS depression of
       antiemetics; antihypertensives concurrent use can intensify hypotensive effects of
       antiemetics; anticholinergics like antihistamines concurrent use can intensify
       anticholinergic effects of antiemetics.
       Nursing Interventions: Antiemetics prevent or treat nausea and vomiting from various
       causes match with cause. Using a combination allows for lower dosage and decrease the
       risk of side effects i.e. EPS system.

Drugs for Adrenal insufficiency (Not in ATI-found in pharm)
       Hydrocortisone (a glucocorticoid)
              Prototype glucocorticoids
                      Key function replacement therapy used for acute adrenal
              insufficiency/nonendocrine applications used to treat a broad spectrum of nonendocrine
                      Adverse Effects When taken in large doses to treat nonendocrine disorders,
              glucocorticoids are highly toxic. High dose therapy include adrenal suppression and
              productive cushing syndrome.

       Fludrocortisone (mineralocorticoid)
              Prototype mineralocorticoid
                     Key function treats addison’s disease, primary hypoaldosteronism, and
              congenital adrenal hyperplasia. (In most cases used with glucocorticoid)
                     Adverse Effects When dosage is too high, salt and water are retained in excess,
              while excessive amounts of potassium are lost. Expansion of blood volume,
              hypertension, edema, cardiac enlargement, hypokalemia.
                     Intervention monitor weight gain, elevation of b/p, and hypokalemia.

       Women’s Health
       Estrogen (ATI pg 488-490)
              Prototype Conjugated equine estrogens (Premarin)
              Estradiol (Estrace)
                       Action: estrogens are hormones needed for growth and maturation of the female
              reproductive tract and secondary sex characteristics. Estrogens block bone resorption
              and reduce low density lipoprotein levels. At high levels, estrogens suppress the release
              of follicle stimulating hormone needed for conception.
                       Uses: contraception, relief of potmenopausal symptoms (hot flashes, mood
              changes), prevention of postmenopausal osteoporosis, treatment of dysfunctional
              uterine bleeding and endometriosis, treatment of prostate cancer.
        Side Effects: Endometrail and ovarian cancers occur when prolonged estrogen is
the only potmenopausal therapy, potential risk for estrogen-dependent breast cancer,
embolic events, impotence, and decrease libido in males
        Nursing interventions: Give the client progestins alson with estrogen, instruct
the client to report persistent vaginal bleeding, encourage regular self-breast exams and
mammograms, discourage smoking, monitor pain, swelling, warmth of legs for emboli
(make sure pt takes the med at the same time each day)
        Interaction: estrogens can decrease the effectiveness of warfarin. (monitor INR)
Use of phenytoin with estrogen can increase the risk of toxicity (monitor signs of

Contraceptive Agents (ATI pg 493-494)
Combination Oral Contraceptives
        Ethinyl Estradiol/norethindrone
Progestin-Only Oral Contraceptives
Long-Acting Contraceptives
        Subdermal progestin implant (Norplant)
        Depot medroxyprogesterone acetate
Drugs for Emergency Contraception
        Leveonorgestrel alone
        Ethinyl estradiol/levonorgestrel (the Yuzpe Regimen)
PROTOTYPE: OVCON 35 (Necon 1/35, ortho-novum)
        Action: Oral contraceptives decrease fertility by inhibiting ovulation, thickening
cervical mucus, and making the lining of the endometrium less favorable for
        Uses: Oral contraceptives are used to prevent pregnancy.
        Side Effects: Thromboembolic events, hypertension, breakthrough or abnormal
uterine bleeding, cervical cancer
        Nursing Interventions: Discourage smoking, report warmth, edema, etc, may be
emboli, monitor b/p, evaluate pt for possibility of pregnancy if two or more periods
missed, routine pap smear.
        Interactions: Carbamazephine, Phenobarbital, phenytoin, rifampin, tetracyclines,
and ampicillin-oral contraceptive effectiveness decreases with concurrent use of these
medications (Use additional contraceptive measures). Warfarin and oral
hypoglycemics-oral contraceptives decrease the effects of these meds(check INR)

Drugs for infertility(NOT FOUND IN ATI)
Drugs for controlled ovarian stimulation
       Human chorionic gonadotropin
Drugs for hyperporlactinemia
       Cabergoline (dopamine agonist)

Uterine Stimulatns and Relaxants
       Uterine Stimulatns (Oxytocics) (ATI pg 481-483)
              Prototype Oxytocin (Pitocin, Syntocinon)
              Other med (Methylergonovine (Methergine)
                      Action: Uterine stimulants increases the strength, frequency, and length of
              uterine contractions.
                      Uses: Induction of labor, enhancement of labor, delivery of afterbirth, to control
              postpartum bleeding, fetal stress testing, intranasal promotion of milk let down.
                      Side Effects: Uterine rupture, hypertensive
                      Nursing intervention: Monitor the length, strength, and duration of contractions,
              have magnesium sulfate on standby to relax the myometrium, monitor the pt for
              symptoms of hypertension (headache, nausea, vomiting)
                      Interactions: vasopressors-can lead to hypertension (avoid use of oxytocin and
              vasopressors, monitor b/p)

                      Uterine Relaxants (Tocolytics)
                              Prototype terbutaline sulfate (brethine)
                              Magnesium sulfate
                      Action: Terbutaline selectively activates beta2 adrenergic receptors, resulting in
              uterine smooth muscle relaxation.
                      Uses: IV or SC terbutaline can be used for up to 48 hr to delay preterm labor.
                      Side Effects: tachycardia, palpitations, chest pain, tremors, anxiety, headache.
                      Nursing Interventions: Monitor the pt for these beta1 side effects, intervene
              based on tolerance and physiological impact, monitor the pt for beta2 skeletal muscle
              stimulant side effects.
                      CAUTION: Lactation enters breast milk
                      Interactions: adrenergic agonists-concurrent use can cause additive effects,
              MAOIs-concurrent use can lead to hypertension, Beta blockers-concurrent use can blunt
              effect (monitor for tachycardia, tremors, b/p)
                      ***Terbutaline should be administered IV or SC due to high first pass effect
              with oral administration.

             Prototype Testosterone enanthate (Delatestryl)
                     Action: Androgens are a hormone needed for growth and maturation of male sex
             organs and secondary sex characteristics. This hormone promotes skeletal muscle
             growth in sexually mature males.
                     Uses: Androgens are used for treatment of hypogonadism in androgen deficient
             men, treat delayed puberty, treat androgen-responsive breast cancer.
                     Side Effects: Hepatotoxicity, Cardiovascular risk high LDL, lower HDL, edema,
             virilism effects, males- acne, facial hair, gynecomastia, impotence, priapism, females-
             deeper voice, unusual hair growth, clitoral enlargement, menstrual irreg, acne.
                     Nursing interventions: Liver function test, check cholesterol levels, edema, low
             sodium diet, hypercalcemia
                     Interactions: Warfarin, oral hypoglycemic, and glucocorticoids-androgen effects
             on metabolism can increase med levels of these meds. Heaptotoxic drugs can increase
             the risk of liver damage. (monitor INR, signs of bleeding, infection, liver function)
                     ***Instruct pt to report weight fain of more than 2 pounds in a week.

Drugs for Erectile Dysfunction
              Prototype sildenafil (Viagra)
                     Action: augments the effects of nitric oxide released during sexual stimulation
             resulting in enhanced blood flow to corpus cavernosum and penile erection.
                     Uses: treat erectile dysfunction
                     Side effects: MI, sudden death, priapism
                     Nursing Interventions: Monitor pt risk factors and history with regard to
             cardiovascular health, notify dr if erection lasts more than 4 hr.
                     **Do not take with Nitroglycerine
                     Interaction: Organic nitrates (nitroglycerin)-can lead to fatal hypotension,
             Ketoconazole, erythromycin, grapefruit juice-inhibit metabolism of sildenafil thereby
             increases plasma level of med
                     **Instruct pt to take 1 hr before sexual activity and limit use to once a day

      Drugs for Benign Prostatic Hyperplasia (NOT IN ATI)

Drugs for IBS

Alosetron (Lotronex)

 Only approved for treating women with severe, diarrhea-predominant IBS that has lasted for 6 or
      more months. Causes selective blockade of type 3 serotonin receptors, which are found
      primarily on neurons that innervate the viscera. It decreases abdominal pain, increases
      colonic transit time, reduces intestinal secretions, and increases absorption of H2O and Na.

 Side Effects—Most common complication is constipation, which can be complicated by
     impaction, bowel obstruction, and perforation. Can also cause ischemic colitis (intestinal
     damage secondary to reduced blood flow).

 Drug Interactions—No known adverse interactions with other drugs.

Drugs for Bacterial Infections
 Penicillin G (Bicillin LA)

 Destroys bacteria by weakening the bacterial cell wall. Med of choice for gram-positive cocci, such
      as streptococcus pneumonia, meningitis.

 Side Effects—Allergies/anaphylaxis, renal impairment, hyperkalemia/dysrhythmias with high
     doses of penicillin G.

 Interventions—interview client for prior allergy, observe client for 30 min following
      administration of parenteral penicillin. Monitor client’s kidney function and I&O. Monitor
      client’s cardiac status and electrolyte levels.

 Drug Interactions—
 Aminoglycosides—penicillin inactivates aminoglcyosides when missed in the same IV solution. Oral

 Apicillin—decreases oral contraceptive efficacy.

 Cephalosporins (use cautiously in pts with renal impairment)

Cephalothin—Not in ATI,Pharm,Mosby’s drug book.

 Cephalosporins are similar to penicillins, they destroy the bacterial cell wall.

 Side Effects—allergic/hypersensitivity/anaphylaxis. Bleeding tendencies, Thrombophlebitis,
     Cross allergy to penicillin.

 Interventions—If signs of allergy appear, stop immediately, observe for signs of bleeding, if
      bleeding administer parenteral vitamin K and stop cephalosporin, to avoid thrombophlebitis
      rotate injection sites and administer slowly over 3-5min. Also assess patient for allergy to

 Drug Interactions—

 Disulfiram reaction (intolerance to alcohol) occurs with combined use of some cephalosporins with
      alcohol, but not cephalotin.

 Probenecid delays renal excretion


Imipenem (Primaxin) (use cautiously in pts with renal impairment)

 Destroys bacterial cell walls causing destruction of micro-organisms.

 Primarily used with other antibiotics for broad spectrum with serious infections.

 Side Effects—Allergy/hypersensitivity, GI symptoms(nausea,vomiting,diarrhea), Suprainfection

 Interventions—Monitor the patient for signs of allergic reactions. Observe client for any GI signs,
      notify primary caretaker, and watch I&O. For suprainfection, monitor patient for signs of
      colitis (e.g., diarrhea, oral thrush, vaginal yeast infection) and intervene accordingly.

 Drug Interactions—None listed.

 Vancomycin (Vancocin) (use cautiously in pts with renal impairment)
Destroys bacterial cell walls.

Primarily used for serious infections caused by MRSA. Also used in antibiotic-associated
    pseudomembranous colitis.

Side Effects—Ototoxicity, Infusion reaction (e.g., rashes, flushing, tachycardia, hypotension), and

Interventions—Assess client for signs of hearing loss, obtain a baseline hearing test prior to
     administration, tell pt. to inform care provider if hearing loss occurs. To avoid infusion
     reactions, infuse vancomycin slowly over 60 min. To avoid thrombophlebitis, rotate injection
     sites and monitor infusion site for redness, swelling, and inflammation.

Drug Interactions—None listed.

Bacteriostatic Inhibitors of Protein Synthesis


Tetracycline Hydrochloride (Sumycin)

Broad-spectrum antibiotics that inhibit micro-organism growth by preventing protein synthesis

Medication of choice topically and orally for acne vulgaris.

Side Effects—GI discomfort (cramping, nausea, vomiting, diarrhea, esophageal ulceration),
    Yellow/brown tooth discoloration and/or hypoplasia of teeth enamel can occur,
    Hepatotoxicity, Photosensitivity, Suprainfection of the bowel. Should be avoided by pregnant

Interventions—Monitor client for signs of GI upset. To avoid tooth discoloration and enamel
     problems, avoid giving to children under 8 years of age. To avoid hepatotoxicity, avoid giving
     high doses via IV. For photosensitivity, avoid long exposure to sun. For suprainfection,
     monitor GI system.

Drug Interactions—

Milk products, calcium supplements, iron supplements, magnesium-containing
    laxatives, and most antacids. Tetracyclines should be taken on an empty stomach with
    water. Give 1 hour before and 2 hours after meals and/or supplements containing

Oral contraceptives. Instruct the pt to report signs of reduced levels, such as breakthrough
    bleeding. Dose of oral contraceptive may need to be increased.

Erythromycin (E-Mycin)

   Slows the growth of micro-organisms by inhibiting protein synthesis.

   Used primarily to treat infections in patients with a penicillin allergy.

   Side Effects—GI discomfort (nausea, vomiting, epigastric pain), Thrombophlebitis.

 Interventions—To avoid GI discomfort, administer with meals. To avoid thrombophlebitis,
      administer slowly and in a dilute solution

 Drug Interactions—

 Antihistamines, theophylline (asthma med), carbamazepine (anticonvulsant), and
     warfarin—concurrent use with these meds could result in toxicity so avoid use
     of these with erythromycin.


Linezolid (Zyvox)

 Works well against MRSA and vancomycin-resistant enterococci (VRE). Inhibits bacterial protein

 Side Effects—Generally well tolerated. Most common side effects are diarrhea, nausea, and
     headache. Can cause myelosuppression, manifesting as anemia, leucopenia,
     thrombocytopenia, or pancytopenia.

 Interventions—Monitor for GI upset signs, and if pt. is receiving Linezolid for more than 2 weeks,
      CBC should be done weekly.

 Drug Interactions—

 Linezolid is a weak inhibitor of monoamine oxidase (MAO), and hence poses a risk for hypertensive
      crisis. Can also cause hypertensive crisis in conjunction with foods high in tyramine.


Tigecycline (Tygacil)

 A tetracycline derivative designed to overcome resistant bacteria. Active against a broad spectrum
      of bacteria, including many resistant strains.
  Side Effects—Because it is a tetracycline derivative, side effects are very similar to those of
      tetracyclines. Most common side effects were nausea and vomiting. Should be avoided by
      pregnant women.

  Interventions-- Monitor client for signs of GI upset. To avoid tooth discoloration and enamel
       problems, avoid giving to children under 8 years of age. To avoid hepatotoxicity, avoid giving
       high doses via IV. For photosensitivity, avoid long exposure to sun. For suprainfection,
       monitor GI system.

  Drug Interactions—Minimal interactions, can delay the clearance of warfarin so coagulation
      should be monitored.


  Clyndamycin (Cleocin)

  Inhibits bacterial protein synthesis. Effective against most anaerobic bacteria and most gram-
       positive aerobes.

  Side Effects—Antibiotic-associated pseudomembranous colitis (AAPMC). This is the most severe
      toxicity. The cause is suprainfection of the bowel with C.difficile. AAPMC is characterized by
      profuse, watery diarrhea (10-20 stools /day), abdominal pain, fever, and leukocytosis. Stools
      often contain mucous or blood.

  Interventions—Watch for signs of AAPMC, or other GI problems. If AAPMC is present, vigorous
       replacement therapy with fluids and electrolytes is usually indicated. Drugs that decrease
       bowel motility should NOT be used because they may worsen the symptoms.

Drug Interactions—The site at which clyndamycin binds overlaps the binding sites for
erythromycin and chloramphenicol. As a result, concurrent use of these with clyndamycin is not

Drugs for Bacterial Infections

Class: Aminoglycosides (Bactericidal Inhibitors of Protein Synthesis)
Pro Drug- Gentamicin
Uses: Medication of choice for aerobic gram negative bacilli ( escherichia coli, pneumoniae, etc)
Side Effects: Ototoxicity (discontinue if this occurs), Nephrotoxicity (Monitor BUN, Creatinine and
Do not mix Aminoglycosides with penicillins in the same IV solution.

Class: Fluoroquinolones
Pro Drug- Ciprofloxacin
Uses: A broad spectrum antimicrobial, can be used on gram positive or negative bacteria. Medication
of choice for clients who have inhaled anthrax.
Side Effects: GI discomfort, Achilles tendon rupture ( observe for swelling, redness or pain and to
report to primary care provider and stop med).
Do not give to children < 18, Warfarin levels can be increased with Ciprofloxacin, Do not use dairy
products, antacids or salts until 1 hr before or 2 hrs after med is administeed.

Class: Cyclic Lipopeptides
Pro Drug- Daptomycin
Uses: Can kill all gram positive bacterias.
No need to monitor plasma level, Only side effect may be muscle injury due to IV. Does not have any
significant interactions. Can be used for MRSA

Class: Sulfonamides and Trimethoprim
Pro Drug- Trimethoprim/Sulfamethoxazole (Bactrim)
Drug- Sulfisoxazole
Drug- Trimethoprim
Uses: inhibit bacterial growth by preventing synthesis of folic acid, med of choice for UTI’s.
Side Effects: Do not administer to patients allergic to sulfa, thiazide diuretics, loop diuretics. Can cause
crystalluria so increase fluid intake, photosensitivity, if sore throat or pallor notify provider.

Drugs for TB
Pro Drug- Isoniazid (INH)
Drug- Rifampin
Drug- Pyrazinamide
Drug- Ethambutol
Uses: Inhibits growth of mycobacteria, indicated for latent TB. INH daily for 6 months.
Side Effects: Peripheral neuropathy (give 50-200mg of vitamin B6 daily), Hepatotoxcity
Interacts with Phenytoin and levels may need to be adjusted, Avoid alcohol. Take on an empty

Drugs for Funal Infections
Pro Drug- Polyene Macrolides (Amphotericin B)
Drug- Azoles (Itraconazole)
Drug- Echinocandins (Caspofungin)
Uses: Used for systemic fungal infections, Azoles are used for superficial fungal infections.
Side Effects: Infusion reactions (pretreat with diphenhydramine), Nephrotoxicty (monitor I&O, BUN),
Give 1 Liter of saline on day of amphotericin infusion. Contraindicated in renal failure patients. Avoid
use with antimicrobials such as aminoglycosides.

Viral Infections
Drugs for Cytomegalovirus Infection
Action: prevents the reproduction of viral DNA
       - medication of choice for herpes simplex virus, varicella zoster virus, and
       - Ganciclovir is treatment choice for CMV retinitis in immunocompromised pts with
              HIV, and transplant pts at risk for CMV infection

Pro drug: acyclovir (Zovirax)
          - phlebitis and inflammation at site of injection
          - Nephrotoxicity
          - mild discomfort
          - should be used cautiously in pts with renal impairment, dehydration, and pts taking
               nephrotoxic meds
          - administer slowly over 1 hr
          - ensure adequate hydration during infusion and 2 hr after to minimize nephrotoxicity

Other: Ganciclovir (Cytovene), ribavirin (Rebetol)
          - granulocytopenia and thrombocytopenia
          - reproductive toxicity
          - pregnancy
          - pts with neutrophils count <500/mm3
          - obtain baseline CBC and platelet count and monitor
          - if neutrophils count is <500/mm3, stop treatment, cell counts improve within 3-5
          - advise women to avoid pregnancy during coarse of therapy and for 90 days after end
                of therapy
          - inform men of risk for sterility

       - use rubber gloves for topical administration to avoid transfer of virus to other parts of
       - acyclovir diminishes symptoms but does not cure virus
       - refrain from sexual activity when lesions are present
       - pts with healed lesions should continue to use protection during sexual activity to
                prevent transmission of virus
Childhood Immunizations
 Hepatitis B: doses given at birth, 1-2 mo, and 6-18 mo
       ~ SE: local reaction (anorexia, soreness, fatigue), anaphylaxis
       ~ Contraindicated in pts with a prior history of anaphylactic reaction and/or and allergy to
               Baker’s yeast
 Diptheria and tetanus toxoids and pertussis vaccine (DTaP): doses at 2, 4, 6, 15-18mo, and at 4-6
       ~ SE: encephalopathy (fever, irritability, persistent crying that can’t be consoled),
               seizures, and/or local reaction at site of injection
       ~ Contraindicated in children with: severe febrile illness, history of prior anaphylactic
               reaction to DTaP, occurrence of encephalopathy 7 days after administration of
               DTaP immunization
Tetanus and diphtheria toxoids and pertussis vaccine (Tdap): 11-12 years
Tetanus and diphtheria (Td) booster: every 10 years following DTaP
Haemphilus influenza Type B (Hib): doses at 2, 4, 6, and 12-15 mo
Inactivated poliovirus vaccine (IPV): doses at 2, 4, 6-18mo, and 4-6 years
       ~ SE: vaccine associated paralytic poliomyelitis and/or local reaction
Measles, Mumps, Rubella vaccine (MMR): doses at 12-15 mo and at 4-6 years
       ~SE: local reactions (fever, rash, swollen glands), anaphylaxis
       ~ Contraindicated in:
               - pregnant women and children who are allergic to eggs, gelatin, and neomycin
               - history of thrombocytopenia
               - immunocompromised children
               - pts with advanced HIV
               - pts who just received blood products or immunoglobulins
Varicella vaccine: single dose at 12-18 mo or 2 doses administered 4 wks apart after age 13
       ~ SE: varicella like rash
       ~ Contraindicated for:
               - women who are pregnant
               - clients with cancer
               - pts with history of allergy to neomycin and/or gelatin
               - immunocompromised pts
               - children with congenital immunodeficiency
               - pts taking immunosuppressive meds
Pneumococcal conjugate vaccine (PCV): doses at 2, 4, 6, and 12-15 mo
       ~SE: mild local reaction, fever
Hepatitis A: 2 doses 6 mo apart after 12 mo
Influenza vaccine: annually beginning at 6 mo (Oct thru Nov is ideal time)
       ~ SE: Guillain-Barre syndrome, local reaction, fever
       ~ Contraindicated in pts with:
               - acute febrile illness
               - hypersensitivity to eggs
Meningococcal vaccine (MCV4): dose at age 11-12
       ~ SE: mild local reaction
Uses: prevention of childhood of infectious diseases and their complications
Action: Immunizations produce antibodies that provide active immunity. May take
       months to have an effect but confer long-lasting protection against infectious
Nursing interventions:
       ~ in infants and young children, IM vaccinations are given in the vastus lateralis
       ~ for older children, adolescents, and adults, vaccinations are given in the deltoid
       ~ avoid administering aspirin to children to treat fever following immunization
               due to the risk of the development of Reye syndrome
Adult Immunizations
Influenza Vaccine: given one dose annually after age 50 (earlier if specific risk factors such as
         chronic disease)
Pneumococcal polysaccharide vaccine (PPV): one dose at age 65, and revaccinated every 6-8 years
after initial vaccination
Meningococcal vaccine: students entering college and living in college dormitories if not
         previously immunized
Tetanus diphtheria (Td) booster: every 10 years

Action: Prevent infectious diseases through the production of antibodies that provide
        active immunity
Uses: prevention of infectious diseases and their complications
Side effects: local reaction (redness, swelling, pain) at injection site, low grade fever,
        risk of systemic allergic reaction (urticaria, anaphylaxis), small risk of Guillain-
        Barre syndrome
        ~ acute febrile illness- don’t give until symptoms resolve
        ~ hypersensitivity to eggs
Nursing Interventions:
        ~ administer IM deep in the deltoid muscle
                ~ have emergency meds and equipment on standby in case of the occurrence of an
                        allergic reaction

Anticancer Drugs
Alkylating Agents
       - Nitrogen mustards: cyclophosphamide (Cytoxan, Neosar)
Platinum compounds:
       - cisplatin (Platinol AQ)
       - Folic acid analog: methotrexate (Rheumatrex, Trexall)
       - Pyrimidine analog: cytarabine (Cytosar-U)
       - Purine analogs: mercaptopurine (Purinethol)
Antitumor Antibiotics:
       - doxorubicin (Adriamycin, Rubex)
Mitotic Inhibitors:
       - vincristine (Oncovin)
       - paclitaxel (Taxol, Onxol)
Topoisoomerase Inhibitors:
       - topotecan (Hycamtin)
       - irinotecan (Camptosar)
Cytotoxic Medications:
       - asparaginase (Elspar)
       - hydroxyurea (Hydrea)
       - procarbazine (Matulane)
Breast Cancer: antiestrogen:
       - tamoxifen (Nolvadex)
Prostate Cancer:
       - leuprolide (Lupron)
       - megestrol acetate (Megace)

Action: Destroy cancer cells, as well as healthy cells, by preventing the replication of DNA
Uses: Used in the treatment of a variety of cancers
Side Effects:
       - Bone marrow suppression
               ~ monitor CBC
               ~ assess for bruising and bleeding gums
               ~ instruct pt to avoid crowds and contact with infectious individuals
       - GI discomfort
       - Alopecia
               ~ advise that hair loss will occur 7-10 days after beginning of treatment and will
                       last for a maximum of 2 mo after last administration of chemo agent
       - Muscositis (GI tract)
               ~ assess for mouth sores
       - Reproductive toxicity such as congenital abnormalities, amenorrhea, menopausal
               symptoms and atrophy of vaginal epithelium, and sterility in males
               ~ advise females against becoming pregnant while taking meds
               ~ advise male clients to consider sperm banking prior to treatment
       - Hyperuricemia
               ~ monitor kidney function, BUN, and creatinine
               ~ increase fluid intake and monitor I&O
               ~ administer allopurinol if uric acid level is elevated
Nursing interventions:
       - dosage of agents should be individualized

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