Pharm Reproductive and Genitourinary Study Guide Notes, Exams of Nursing

Download Pharm Reproductive and Genitourinary Study Guide Notes and more Exams Nursing in PDF only on Docsity! 1 Pharm Reproductive and Genitourinary Study Guide Notes Female Reproductive Tract - Consists of the ovaries, fallopian tubes, uterus, and vagina. Approximately every 28 days, a hormonal cycle occurs that stimulates an ovum in one of the ovaries to mature into a follicle and then rupture, releasing an ovum. - The pituitary gland produces hormones that govern this cycle - It produces follicle stimulating hormone, or FSH, during the first part of the cycle, which is responsible for the development of the follicle and release of estrogen. - The pituitary gland produces luteinizing hormone of LH, which causes the follicle to swell and split open mid cycle, releasing the ovum. - The empty follicle that remains becomes a corpus luteum and secretes estrogen and progesterone upon release of the ovum - The role of estrogen during the first part of the cycle is to stimulate the endometrium to thicken, so it can provide a need for fertilized ovum if pregnancy occurs. - The role of estrogen and progesterone during the last part of the cycle is to continue building up the endometrium - If pregnancy does not occur, the corpus luteum shrinks, stops its production of estrogen and progesterone, and sloughing of the endometrium occurs. - This is menstruation, or menses. If pregnancy does occur, the developing embryo and placenta produce the human chorionic gonadotropin hormone, or hCG, and helps maintain the follicle so that it continues to produce estrogen and progesterone. - Oxytocin is the hormone that stimulates uterine contractions during labor and delivery Male Reproductive Tract - The male reproductive tract consists of the testes, epididymis, vas deferens, seminal vesicles, prostate gland, and penis. - Sperm develops in the testes and then moves to the epididymis, where they mature - After maturation, the sperm moves through the vas deferens into its ampulla, where it is stored - During ejaculation, the seminal vesicles release fluid that mixes with the sperm as it moves through the prostate gland into the urethra. - Follicle stimulating hormone, or FSH, and luteinizing hormone of LH in men are as important to the production of sperm as they are to the development of an ovum- containing follicle in females. - FSH initiates the development of sperm in the testes, and LH regulates the production of testosterone by specialized cells in the testes. It’s the influence of testosterone in the epididymis that helps immature sperm mature - Exposure of testosterone to the enzyme 5-alpha reductase in the prostate, adrenal gland, and testes produces dihydrotestosterone. - Dihydrotestosterone is stronger than testosterone, and facilitates the evolution and maintenance of secondary sex characteristics. 2 - Its also responsible for male pattern baldness and contributes to the enlargement of the prostate gland as men age - The physiology behind the attainment and maintenance of an erection involves several chemical interactions and coordination of the sympathetic and parasympathetic nervous systems - Sexual arousal stimulates the parasympathetic nerves in male genitalia, causing the release of nitric oxide - Nitric oxide sets off a cascade of events, during which release of cyclic guanosine monophosphate, or cGMP, occurs causing dilation of the arteries in the penis that support an erection - The sympathetic nervous system is responsible for ejaculation - Phosphodiesterase type 5, or PDE5, is the enzyme that breaks down cGMP, terminating an erection. Urinary Tract - Only the lower structures of the urinary tract - After the kidneys produce urine, it drains into the bladder via the ureters. - The bladder is a storage vesicle for urine - Timing of the release is governed by voluntary relaxation of the external sphincter Goal of Drug Therapy • Prevent conception, treat premenstrual sydrome • Treat symptoms of menopause • Treat cause of endometrial hyperplasia and endometriosis • Treat infertility • Induce or stop uterine contractions • Accelerate fetal lung maturity in premature labor • Prevent and treat maternal seizure activity • Treat benign prostatic hypertrophy, outflow disorders, and erectile dysfunction • Treat incontinence, over-active bladder, and urinary retention • The goal of drug therapy for reproductive and urinary disorders is to prevent conception and/or treat premenstrual syndrome, symptoms of menopause, the cause of endometrial hyperplasia and endometriosis, and infertility. • In pregnancy, reproductive drugs induce or stop uterine contractions, accelerate fetal lung maturity in premature labor, and prevent and treat maternal seizure activity. • Other drugs for reproductive and urinary disorders provide androgen replacement therapy, treat benign prostatic hypertrophy and outflow disorders, erectile dysfunction, incontinence and overactive bladder, and urinary retention. • To understand how the drugs in this module affect the body, it’s important to understand the anatomy and physiology concepts that this lesson presents. • Remember to refer back to this lesson if you have difficulty remembering how one of the systems function or the effects of some of the hormones or enzymes. 5 • Oral contraceptives may also cause abnormal uterine bleeding and promote the growth of existing breast cancer. • Women with a certain gene mutation called BRC-A1 are at an increased risk for developing breast cancer if they take oral contraceptives. • Current research shows that the risk for breast cancer does not increase in women who do not have the BRC-A1 gene mutation. • Hypertension is another adverse effect of oral contraceptives in general. • Ethinyl estradiol drospirenone poses less risk for hypertension, due to the diuretic effect of this particular progestin. • But since drospirenone acts like a potassium-sparing diuretic, this contraceptive increases a patient’s risk for hyperkalemia or increased serum potassium levels. Check the safety alert to learn more about the hypertensive effects of oral contraceptives. Safety alert - Women taking oral contraceptives need to have their blood pressure checked regularly. Combination oral contraceptives can cause an increase in blood pressure by increasing blood levels of angiotensin and aldosterone. Angiotensin is a natural substance in the body released by the adrenal cortex and has vasoconstrictive properties. Aldosterone is also a natural substance in the body released by the adrenal cortex and promotes reabsorption of water in the kidneys. If the level of increase causes a woman's blood pressure to reach a level above 140/90, then the woman has hypertension. The provider either needs to have the woman stop taking the drug or prescribe an antihypertensive drug to counteract its effects. Intervention • Monitor indications of deep-vein thrombosis, pulmonary embolism, myocardial infarction, and cerebrovascular accident. • Encourage patients to quit smoking. • Monitor potassium levels and ECG periodically (ethinyl estradiol and drospirenone). • Monitor blood pressure. • Monitor the pattern and amount of uterine bleeding. • Recommend mammograms and breast examinations. • Discontinue the drug for any indications of breast cancer Administration • Confirm negative pregnancy status. • Use additional method of contraception during first cycle. • Give pills same time each day. • Give according to the precise dosing schedule: o 21 days of a drug-containing pill o 7 days of an inactive pill • Follow the manufacturer’s instructions for missed pills: o 1 missed pill: take one missed pill with the next pill o 2 missed pills: two pills for 2 consecutive days o 3 or more missed pills: start new cycle 7 days later Hypertension Diabetes mellitus Heart disease Migraines • • • • Precaution sPregnancy Category X History or other risk for thromboembolic events Suspected or confirmed breast cancer Altered liver function Altered renal or adrenal function (estradiol and drospirenone) Smokers above age 35 • • • • • • Contraindications 6 Patient instructions • Report pain, leg edema, sudden change in vision, severe headache, or shortness of breath. • Stop taking at least 4 weeks before any surgery that increases risk of thromboembolic events. • Do not smoke. • Report palpitations, paresthesias, weakness, or abdominal cramps. • Obtain regular blood pressure checks. • Report any menstrual issues. • Perform self-breast examination every month. • Obtain a mammogram and breast examination. Contraindications and Precautions Interactions • ACE inhibitors can cause hyperkalemia. • Rifampin, ritonavir, phenobarbital, carbamazepine, primidone, phenytoin, and St. John’s wort can reduce effectiveness of oral contraceptives. • Can reduce the effects of warfarin (Coumadin) and hypoglycemic drugs • Can increase levels of theophylline (Theo-24), diazepam (Valium), chlordiazepoxide (Librium), and tricyclic antidepressants Drug Therapy for Menopause Hormonal replacement therapy (HRT) used for the treatment of menopause: • Estrogen therapy • Estrogen and Progesterone Combination therapy • Menopause begins around 50 years of age, when the ovarian follicles, which produce most of a female patient’s estrogen, begin to decline. • This decrease in estrogen causes gradual menstrual irregularity and eventually a complete end to menses and fertility. • The loss of estrogen can cause many physical symptoms and body changes including hot flashes, insomnia, atrophy of the vagina and vulva, bone loss that can cause osteoporosis, and altered metabolism of lipids, which can cause high cholesterol levels. • There are two types of hormonal replacement therapy, known as HRT, that treat menopause. • One type is estrogen therapy alone, and the other is a combination of estrogen and progesterone therapy. 7 • Progesterone is included, along with estrogen, in therapy for females who still have a uterus in order to protect them from an increased risk of endometrial cancer of the uterus. Women who have had a hysterectomy, which is a surgical removal of the uterus, do not need to take progesterone as part of their hormone replacement therapy. Estrogen HRT • Relieves menopausal symptoms (vasomotor) • Prevents vulvar and vaginal atrophy • Prevents postmenopausal osteoporosis Prototype • Prototype drugs o oral: conjugated equine estrogen (Premarin) o transdermal estradiol (Estraderm, Climara, FemPatch) o estradiol intravaginal tablets (Vagifem) or estradiol cream (Estrace Vaginal Cream) Expected Pharmacologic Action • Estrogen binds to estrogen receptors in target tissues. • Hormone replacement therapy (HRT) substitutes a smaller, stable amount of estrogen for the previous fluctuating amounts. Side and Adverse Effects • Nausea • Hypertension • Endometrial hyperplasia, endometrial and ovarian cancer • Thromboembolism • Angiotensin causes vaso-constriction and aldosterone causes water retention. Both factors make an increase in blood pressure more likely. • Taking estrogen causes endometrial hyperplasia, or a buildup of the tissue that lines the uterus. • This increases a patient’s risk for endometrial and ovarian cancers. Some of the other adverse effects of estrogen use in menopause are more serious. • Estrogen increases the risk for thromboembolic disorders such as thrombophlebitis, pulmonary embolism, stroke, and myocardial infarction. • Click the safety alert to learn more about this increased risk. Interventions • Nausea diminishes with time. • Monitor for and report any indications of deep-vein thrombosis, pulmonary embolism, myocardial infarction, and cerebrovascular accident. • Encourage patients who smoke to quit smoking. • Advise use of HRT for no more than 3 to 4 years. • Monitor blood pressure. • Monitor for vaginal bleeding. • Check that patients with an intact uterus are prescribed progesterone. 10 • One of the functions of progesterone is to antagonize estrogen-influenced tissue growth in the uterine endometrium, and thus prevent hyperplasia or a buildup of the lining of the uterus. • In younger women, this monthly buildup of tissue is important to prepare the endometrium for possible ovum implantation. • In the menopausal woman, this growth is unnecessary. Continued growth can increase the chance for cancer cells to develop. • So, progesterone added to estrogen in HRT helps suppress tissue growth in the uterusdecreasing the development of endometrial cancer in the menopausal patient who has a uterus. Side and Adverse Effects • Nausea • Hypertension • Thromboembolism • Acute cardiac events • Vaginal bleeding and spotting • Edema and weight gain • Breast cancer Safety alert - Many studies have tried to determine if progesterone actually does increase a woman's risk for breast cancer. These studies found that progesterone does increase the risk for invasive breast cancer in relation to the dose and duration of the therapy, and in women previously treated for breast cancer. Women on estrogen/progesterone HST should perform monthly breast exams and get yearly mammograms. Interventions • Monitor and report deep-vein thrombosis, pulmonary embolism, myocardial infarction, or cerebrovascular accident. • Encourage patients who smoke to quit smoking. • Encourage temporary use of HRT for vasomotor symptoms. • Inform patients that nausea diminishes with time. • Monitor blood pressure. • Recommend mammograms and breast examinations. • Discontinue drug for any indications of breast cancer. • Monitor the pattern and amount of any vaginal bleeding. • Monitor for edema and weight gain. Administration • Oral o Give according to the precise dosing schedule o Give pills at the same time each day. • Transdermal o Apply patches at the recommended interval. o Apply to clean, dry, intact skin on the abdomen or trunk. Hypertension Gall bladder disease Diabetes mellitus Heart disease Migraines Kidney dysfunction • • • • • • Precautions History of or risk for thromboembolic events Suspected or confirmed canc r Liver disease Undiagnosed vaginal bleeding • • • • Contraindications 11 o Press firmly for 10 seconds. o Do not use the same site more than once per week. Patient Instructions • Report leg or chest pain, leg edema, sudden change in vision, severe headache, or shortness of breath. • Do not smoke. • Stop taking at least 4 weeks before any surgery that increases thromboembolic event risk. • Obtain regular blood pressure checks. • Exercise regularly and follow a healthy, low-fat diet. • Take oral forms with food; take pill or apply transdermal patch at bedtime. • Report vaginal bleeding or spotting to the provider. Contraindications and Precautions Interaction • Rifampin, ritonavir, phenobarbital, carbamazapine, primidone, phenytoin, and St. John's wort can reduce the effectiveness of estrogens. • Hormone replacement therapy can reduce the effects of warfarin (Coumadin) and hypoglycemic drugs. • Hormone replacement therapy can increase levels of theophylline (Theo-24), diazepam (Valium), chlordiazepoxide (Librium), and tricyclic antidepressants. • Ketoconazole may increase the adverse effects of progesterone. Drug Therapy for Endometrial Hyperplasia and Endometriosis • Symptoms include abdominal, back, or rectal pain, and abnormal bleeding. • Two types of drugs used for endometrial hyperplasia and endometriosis o GnRH Agonist o Progesterone o Endometrial hyperplasia, as discussed previously, is the overgrowth of tissue in the lining of the uterus, or the endometrium. o Endometriosis is a disorder in which tissue from the endometrium of the uterus extends and implants outside the uterus in surrounding areas such as around the ovaries, rectum, or outer wall of the uterus. o With each menstrual cycle, this tissue swells due to its normal response to estrogen. o Symptoms may include abdominal, back or rectal pain, and abnormal bleeding. 12 o Some patients may report no symptoms from the disorder and be unaware that they even have it. o Endometriosis is one of the leading causes of infertility in females and it also increases the risk for spontaneous abortion. o Treatment of endometriosis includes surgery to increase fertility and relieve symptoms and/or drug therapy. o 2 types of drugs that treat this disorder include GnRH agonists, and progesterone, which decreases hyperplasia. GnRH Agonist • Treats endometriosis • Treats uterine fibroids • Treats advanced prostate cancer in males Prototype • Prototype drug: leuprolide (Lupron, Lupron Depot) • Other drugs: nafarelin (Synarel) nasal spray Expected Pharmacologic Action • Initially, levels of LH and FSH increase. o Increased secretion of estrogen and progesterone • After a few weeks, LH and FSH decrease. o Decreased secretion of estrogen and progesterone o Chemically induced menopause o Overgrowth of endometrial tissue shrinks • Male patients who have prostate cancer o Levels of LH and FSH decrease o Less testosterone is produced and symptoms of cancer are relieved • The gonadotrophin-releasing hormone agonists, often referred to by their initials GnRH, act on the pituitary gland to affect the hormones LH and FSH secreted by the gland. • At first, the drug increases levels of LH and FSH, which stimulate increased secretion of estrogen and progesterone. • After a few weeks of constant administration, the GnRH agonists have the opposite effect, and levels of LH and FSH, as well as estrogen and progesterone levels, decrease in the female patient. • In fact, hormone levels decrease so much that the patient’s body is fooled into believing that menopause has occurred. • This effect causes the overgrowth of endometrial tissue to shrink, relieving the symptoms of endometriosis, which are caused by and depend on constant hormonal stimulation. The same effect occurs in male patients with prostate cancer. • As levels of LH and FSH decrease, much less testosterone is produced and symptoms of cancer are often relieved. Side and Adverse Effects 15 LH and FSH stimulant • Treats infertility • Promotes ovulation Prototype • Prototype drug: clomiphene (Clomid) Expected Pharmacologic Action • Blocks effect of estrogen receptors on pituitary gland • Increases secretion of gonadotropin-releasing hormone • Stimulates secretion of LH and FSH • Stimulates ovary to produce mature follicles • Ovulation occurs when follicle ruptures Side and Adverse Effects • Vasomotor instability (hot flashes) • Breast engorgement • Nausea, abdominal discomfort • Blurred vision, flashes of light, dizziness • Ovarian hyperstimulation • Multiple gestation Interventions • Vasomotor instability is a common effect. • Comfort measures include cold compresses and over-the-counter analgesics. • Monitor for worsening gastrointestinal symptoms and vomiting. • Monitor for and report vision alterations. • Recommend an ophthalmology examination if symptoms occur. • Discontinue therapy if visual symptoms occur/persist. • Monitor for indications of ovarian enlargement. • Multiple gestation, usually twins, may occur with clomiphene use. Administration • Give orally, beginning 5 days after onset of menses and continue therapy for 5 days. • Repeat the 5-day course at 30-day intervals as prescribed. • Give the drug at the same time each day. • For a missed dose, take it as soon as possible. • For two missed doses, consult the provider. • Stop taking the drug for any suspicion of pregnancy. Patient Instructions • Expect hot flashes as a side effect. • Apply cold compresses and take anti-inflammatory drugs. 16 • Wear a supportive bra. • Take the drug with food. • Report any visual disturbances; don't engage in driving or other activities if vision changes occur. • Report pelvic pain. • Be aware of the possibility of twins. Safety alert - Clomiphene stimulates the ovaries into developing follicles that release ovums at the appropriate time of a woman's cycle or after an injection of hCG. The ovaries can sometimes produce too many follicles, causing ovarian hyperstimulation syndrome, abbreviated OHSS. This syndrome manifests as significant weight gain of more than 10 lb in only 3 to 5 days, shortness of breath, edema of the lower extremities, increased abdominal girth, and decreased urination. Patients can treat minor cases at home with elevation of the legs, avoiding exercise and intercourse, and taking a mild analgesic. Severe cases require hospitalization due to the risk for ascites, pulmonary edema, and electrolyte imbalances, all of which can cause life-threatening complications. Patients at risk for OHSS should notify their provider immediately for a weight gain of 5 lb or more in one 24 hr period, nausea and vomiting, shortness of breath, dizziness, and decreased urination. Contraindications and Precautions Contraindications • Pregnancy Category X • Primary ovarian failure • Undiagnosed uterine bleeding • Liver disease • Uncontrolled thyroid disease • Thrombophlebitis Precautions • Polycystic ovarian enlargement Interaction • Tricyclic antidepressants, phenothiazines, and methyldopa (Aldomet) increase prolactin concentrations. • Black cohosh decreases effectiveness. • Drug interactions with clomiphene include tricyclic antidepressants, phenothiazine antipsychotic drugs, and methyldopa, also called Aldomet. • These increase prolactin concentrations, thus interfering with fertility. The herbal supplement black cohosh decreases the effectiveness of clomiphene. • For an overview of a LH and FSH stimulant prototype drug, click the button to access a drug information table. 17 Ovulation Stimulant 20 Interventions • Begin treatment at lowest therapeutic dose. • Monitor serum prolactin levels. • Monitor for worsening symptoms and vomiting. • Monitor for headache and other CNS effects. • Monitor blood pressure. Administration • Take orally twice per week on the same days. • Give with or without food. • Discontinue when prolactin levels are within the expected reference range. Patient Instructions • Take cabergoline with food. • Report headache or dizziness. • Do not engage in some activities if dizziness occurs or tends to recur. • Take over-the-counter analgesics to relieve headache. • Rise slowly to a sitting or standing position. Contraindications and Precautions Contraindications • Uncontrolled hypertension • Pregnancy-induced hypertension Precautions • Severe hepatic insufficiency Interaction • Avoid taking with phenothiazines, such as chlorpromazine (Thorazine); butyrophenones, such as haloperidol (Haldol), thioxanthenes, such as thiothixene (Navane), or metoclopramide (Reglan). • Cabergoline and these other drugs lose their effectiveness if taken concurrently. Drug Therapy that Induces Uterine Contractions There are three types of drugs that are used to induce uterine contractions • Oxytocin (Pitocin) • Dinoprostone (Cervidil) • Methylergonovine (Methergine) • These drugs induce uterine contractions during pregnancy in order to stimulate labor and promote its progression. • Uterine contractions are also under the influence of hormones, primarily oxytocin. • However, for uterine contractions to successfully propel a fetus through the birth canal, the cervix must be capable of dilating, so the head of the fetus can pass through. For this to happen, the cervix must be soft and thin, which is called effacement. • After the infant is born, oxytocin continues to exert its effect on the uterus, so postpartum hemorrhage does not occur. 21 • Based on this overview of events that surround labor and delivery, the drugs up for discussion next are oxytocin, also called Pitocin, dinoprostone, also called Cervidil, which promotes the “ripening” of the cervix, and methylergonovine, also called Methergine, which prevents postpartum hemorrhage. Oxytocin • Uterine stimulant • Induces or enhances labor near or post term • Treats postpartum hemorrhage Prototype • Prototype drug: oxytocin (Pitocin) Expected Pharmacologic Action • Stimulates smooth muscle to contract at the end of pregnancy • Responsible for milk ejection from milk channels • Causes water retention by the kidneys • As pregnancy progresses, the smooth muscle of the uterus develops more receptors to oxytocin. • At the end of pregnancy, known as term, the uterus is very receptive to oxytocin, • and synthetic oxytocin can be administered to stimulate the onset and progression of labor. • The exact role of natural oxytocin on labor and delivery is still largely unknown. • Natural oxytocin is also responsible for causing milk to be ejected from milk channels in the breasts after delivery. • It is related to the antidiuretic hormone known as ADH, which causes retention of water by the kidneys. Side and Adverse Effects • Uterine hyperstimulation • Hypertensive crisis • Water intoxication Interventions • Monitor risk factors such as multiple deliveries. • Monitor for headache, nausea, vomiting, and increasing blood pressure. • Monitor intake and output, and level of consciousness. • Monitor length, strength, and duration of contractions. • For hyperstimulation, turn the patient on her side, stop the infusion, and administer oxygen. • Be prepared to administer a uterine relaxant. • When administering oxytocin, it’s vital to monitor risk factors such as multiple deliveries, which may increase the danger of using oxytocin. Monitor patients for headache, nausea, vomiting, and increasing blood pressure during the use of oxytocin. Multiparity (multiple fetuses) Seizures Cardiac disease Polyhydramnios • • • • Precautions Unripe cervix, placental abnormalities Active genital herpes Uterine surgery Fetal distress Lung immaturity • • • • • Contraindications 22 • In order to recognize impending problems with water intoxication, monitor intake and output, and level of consciousness. • Monitor the length, strength, and duration of contractions carefully. For any indication of hyper-stimulation, • such as contractions lasting more than one minute, turn the patient on her side, stop the infusion, and administer oxygen to enhance delivery of oxygen to the fetus. Also, prepare to administer a uterine relaxant. • Check the safety alert to learn about the indications for hyperstimulation, and what you need to do if it happens to a laboring patient. Safety alert - Uterine hyperstimulation syndrome occurs in response to intravenous oxytocin, also called Pitocin, which causes contractions to last longer than 60 seconds, more frequently than every 2 to 3 min, or have a resting uterine pressure greater than 15 to 20 mm Hg. This type of uterine activity can cause uterine rupture, lacerations of the cervix and vagina, and postpartum hemorrhage in the laboring patient and hypoxia in the fetus. Since oxytocin also has antidiuretic properties, water intoxication can also occur and precipitate seizures. Take extreme care to monitor the rate, intensity, and duration of contractions of a laboring patient on a Pitocin drip, as well as the fetal heart rate. Make frequent adjustments of the rate in relation to any parameter almost outside the desired reference range. Uterine rupture requires an emergency cesarean section and possible hysterectomy if the uterus cannot be repaired before hemorrhage claims the new mother's life. In many institutions, only providers with special training can monitor a laboring patient on a Pitocin drip. Administration • Administer IV via infusion pump. • Gradually increase the flow rate by 1 to 2 milliunits/min every 30 to 60 min until o Contractions last 1 min or less o Contractions occur every 2 to 3 min • Monitor for uterine hyperstimulation. • Monitor fetal heart rate and rhythm, and report signs of fetal distress. • Stop the infusion for serious alterations in fetal heart rate or rhythm. Patient Instructions • Report increasing duration or strength of contractions. • Report headache, palpitations, nausea, or chest pain. • Report drowsiness. Contraindications and Precautions Hypo or hypertension Asthma Diabetes mellitus Seizure Glaucoma Uterine scarring from previous cesarean section • • • • • • Precautions Acute pelvic inflammatory disease Active cardiac disease Active lung disease Liver or kidney impairment Fetal malpresentation Nonreassuring fetal heart rate pattern Previous uterine surgery • • • • • • • Contraindications 25 • Be prepared to administer a uterine relaxant. • Monitor for nausea, vomiting, and diarrhea. • Pre-treat subsequent doses of gel with antidiarrheal and antiemetic agent. • Maintain hydration. • Monitor temperature. • Fever is an expected response within 15 to 45 min after instillation. Administration • Gel (Prepidil) o Have patients void prior to insertion. o Administer intracervically using a syringe and an endocervical catheter. o Have patients lie supine during instillation and remain supine for 30 min. o Repeat dosing every 6 hr twice if the desired therapeutic effect has not occurred. o Monitor uterine hyperstimulation. o Report hyperstimulation immediately. • Begin oxytocin 6 to 12 hr after the last dose. Vaginal insert (Cervidil) o Insert the pouch into the posterior fornix of the vagina. o Have patients lie supine for 2 hr. o Remove the pouch when active labor begins or 12 hr later. o Follow the monitoring precautions. o Patient Instructions • Report increasing duration or strength of contractions. • Report nausea, vomiting, diarrhea, and fever. • Increase clear fluid intake as needed. Contraindications and Precautions Interaction • Oxytocic agents increase the risk of uterine hyperstimulation Drug Therapy that Stops Uterine Contractions There is one type of drug that stops uterine contractions (tocolytics) • Beta2-adrenergic agonists Beta2-Adrenergic Agonists • Preterm labor inhibitor (off-label use) 26 • Beta 2 • adrenergic agonists relieve bronchospasm in respiratory disorders such as asthma. • However, they are also “off-label” during preterm labor to delay delivery. Preterm labor is delivery before 37 weeks gestation. • Since preterm delivery can be very dangerous for the fetus, uterine relaxants are valuable if they can delay labor even for 1 to 2 days. • This can be enough time to administer glucocorticoids, which improve the chance for a favorable outcome for the fetus. Prototype • Prototype drug: terbutaline (Brethine) • Other drugs o calcium channel blockers: nifedipine (Procardia) o cyclooxygenase inhibitors: indomethacin (Indocin) o nitric oxide donor: nitroglycerin transdermal (Minitran, Nitro-Dur) Expected Pharmacologic Action • Phosphorylated myosin light-chain kinase, an enzyme, interacts with actin to begin uterine contractions. • Beta adrenergic agonists and other classes of drugs stop labor by decreasing the availability of myosin light-chain kinase. Side and Adverse Effects • Respiratory effects: pulmonary edema, dyspnea, cough, tachypnea • Cardiac effects: tachycardia, myocardial ischemia, chest pain, palpitations, hypotension • Hypokalemia • Hyperglycemia Interventions • Monitor respiratory status, heart rate, and blood pressure. • Obtain baseline vital signs and an ECG prior to tocolytic therapy. • Stop tocolytic therapy for maternal tachycardia, dysrythmias, and chest pain. • Prepare to administer propranolol (Inderal) to counteract adverse cardiac effects. • Monitor cardiovascular status for 12 hr after discontinuation of tocolytic therapy. • Initiate fluid and electrolyte remediation or replacement. • Adjust dosages of insulin and hypoglycemic drugs accordingly. • Monitor fetal heart rate and rhythm, and report signs of fetal distress. • Interventions when administering terbutaline as a tocolytic agent include monitoring patients’ respiratory status, including oxygen saturation. • Initiate fluid restrictions if indicated. Stop the tocolytic therapy for any indication of pulmonary edema, • including symptoms of dyspnea, drop in oxygen saturation, and/or crackles in the lungs on auscultation. 27 • Monitor baseline vital signs and obtain an ECG prior to tocolytic therapy. • Monitor heart rate and blood pressure, as well as pattern and intensity of any chest pain patients experiences. • Stop the tocolytic therapy for any indication of maternal tachycardia, dysrhythmias, chest pain, or blood pressure below 90 over 60 millimeters of mercury. • Prepare to administer propranolol, also called Inderal, to counteract cardiac adverse events. • Continue to monitor cardiovascular status for 12 hours after tocolytic therapy is discontinued. • Initiate fluid and electrolyte remediation or replacement as indicated. Monitor blood glucose levels, especially for patients who have diabetes mellitus or gestational diabetes. Adjust doses of insulin and any hypoglycemic drugs accordingly. • Don't forget to monitor the fetal heart rate and rhythm, and report any signs of fetal distress immediately. • Stop the infusion for serious alterations in fetal heart rate, such as a rate greater than 180 beats per minute or rhythm changes. • Check the safety alert to learn more about the complications that can occur during tocolytic therapy with a beta 2-adrenergic agonist. Safety alert - You primarily give Beta2-adrenergic agonists for asthma, however, they have an "off-label" use as a tocolytic, or drug that stops uterine contractions during premature labor. Since they are beta2-adrenergic agonists, they activate the beta2 adrenergic receptors in a manner similar to that of norepinephrine. This causes uterine relaxation, bronchodilation, vasodilation with resulting hypotension, tachycardia, possible with dysrhythmias, and in rare cases, pulmonary edema and myocardial ischemia. Closely monitor the vital signs of patients receiving this type of therapy, to determine if excessive beta2-adrenergic stimulation is occurring. If so, stop the drug immediately. Administration • Confirm preterm labor and gestation between 20 and 35 weeks. • Usually administered subcutaneously (lateral deltoid area) o Every 20 min o Up to 3 hr o No longer than 48 hr • Less often administered by IV infusion • Monitor fetal heart rate and rhythm and report signs of maternal or fetal distress. • Stop the infusion for serious alterations in fetal heart rate (above 180 beats per min) or rhythm (non-reassuring). Patient Instructions • Shortness of breath, difficulty breathing, or cough • Palpitations or chest pain • Weakness, nausea, palpitations, or paresthesia • Polyphagia, polydipsia, and polyuria 30 • Depressed / absent DTRs • Altered level of consciousness • Decreased urine output • Magnesium toxicity • Pulmonary edema • Reduced variability of fetal heart rate Interventions • Monitor patient for burning at IV site. • Monitor patient for the adverse effects of warmth, flushing, diaphoresis, nausea and vomiting, drowsiness, headache, blurred vision, dizziness, and muscle weakness. • Monitor client for maternal hypotension, bradycardia, bradypnea, dpressed or absent DTRs, and altered level of conciousness. • Decreased urine output • Magnesium toxicity • Pulmonary edema • Monitor the patient for additional adverse effects, including warmth, flushing, diaphoresis, nausea, and vomiting. • Check the patient prior to and throughout therapy for drowsiness, headache, blurred vision, dizziness, and muscle weakness. • Monitor blood pressure, pulse, and respiratory rate every 15 to 30 minutes. • Stop the infusion and notify the provider if the patient's respiratory rate is 12 breaths per minute or fewer. • During therapy, assess the patient's patellar reflex. • Typically, you'll do this every 1 to 4 hours. • If deep-tendon reflexes are depressed or diminished, stop the magnesium sulfate infusion and notify the provider. • Because excretion of magnesium sulfate is dependent on adequate kidney function, maintain strict I&O. • Monitor urine output, and notify the provider if urine output is equal to or less than 30 milliliters per hour. • Therapeutic levels well above the normal range are essential for magnesium sulfate to prevent seizures. • So you need to closely monitor a patient for signs of toxicity, such as depressed respirations and diminished deep-tendon reflexes. • If the patient develops magnesium toxicity, you must act quickly to prevent respiratory arrest. • Remember that the target range is 4 to 7 milliequivalents per liter. • Report levels above this range to the provider, and prepare to stop the infusion. • Make sure you have IV calcium gluconate or calcium chloride IV antidotes readily available. • Magnesium sulfate therapy also places a patient at risk for pulmonary edema, so you need to monitor the patient's breath sounds. • If you hear crackles, discontinue the infusion and notify the provider. 31 Administration • Loading dose 4-6 g magnesium sulfate intermittent IV bolus over 15-30 min • Administer maintenance dose by continuous infusion at 2 g/hr • Monitor therapeutic levels (4-7 mEq/L) • Place patient on her left side Patient Instructions • Purpose of frequent monitoring for adverse effects • Purpose of strict I and O Contraindications and Precautions • Myasthenia gravis • Kidney failure • Hypocalcemia • Myasthenia gravis is a nervous system disease that causes muscle weakness, so don’t give magnesium sulfate to patients with this disease. • Also, don’t administer magnesium sulfate to patients with kidney failure, because the kidneys eliminate it. This can cause severe magnesium toxicity. • Lastly, don’t give magnesium sulfate to patients with hypocalcemia because hypocalcemia intensifies the suppression of acetylcholine and can contribute to adverse effects of the drug. • Kidney disease • Cardiac disease Interaction • Neuromuscular blocking agents Drug Therapy for Androgen Replacement Therapy There is one type of drug used in the treatment for androgen replacement therapy • Testosterone Testosterone • Treat male hypogonadism, delayed puberty, and testicular failure (males) • Treat breast cancer (females) • Testosterone treats male hypogonadism, which is when the level of testosterone secreted from cells in the testes is too low. • Testosterone also treats delayed puberty and testicular failure. • In females it can treat breast cancer, since testosterone antagonizes the effects of estrogen in estrogen-dependent cancers. • Note: Using androgens to improve athletic performance is illegal. Abuse of testosterone to increase muscle mass has serious side effects. • Check the safety alert to learn about these side effects and other dangers surrounding anabolic steroid abuse. Prototype 32 • Prototype drugs o testosterone (Androderm, AndroGel, Axiron) transdermal, transdermal, implantable tablets (Testopel), buccal tablets (Striant), and testosterone enanthate (Delatestryl) IM • Other drugs o methyltestosterone (Android): oral o oxandrolone (Oxandrin): oral • The prototype drug in this section is testosterone, also called Androderm. It’s available as a transdermal patch or gel called AndroGel, • a transdermal underarm liquid called Axiron, implantable pellets called Testopel, and buccal tablets called Striant. • Testosterone enanthate, also called Delatestryl, is available as an IM injection. Other types of testosterone include a category called 17-alpha-alkylated androgens. • These testosterone drugs are hepatotoxic. Two of these drugs include methyltestosterone, also called Android, which is available as an oral drug; • and oxandrolone, also called Oxandrin. Both of these drugs are only available in oral forms. • Oxandrolone is unique because it promotes weight gain in catabolic states and relieves the bone pain of osteoporosis. Safety alert - Anabolic steroid abuse involves the excessive use of testosterone-containing drugs to enhance development of muscles, strength, and athletic performance. There are several health consequences of anabolic steroid abuse. Minor consequences include the development of acne and gynecomastia in men and masculinization in women, including enlargement of the clitoris and hirsutism. The major consequences include testicular atrophy in men, suppressed growth in adolescents, and increased risk of heart attacks and strokes in both men and women. In relation to behavior, an increase in both irritability and aggression can occur, and is found to be a contributing factor in crimes, violence, and abuse. Psychological and physical withdrawal symptoms can also occur when an androgen is discontinued. Expected Pharmacologic Action • Binds to receptor cells in cell wall • The complex made by binding of testosterone with the receptor cell moves to the cell nucleus and acts on DNA. • Messenger RNA is synthesized, producing proteins that cause the androgenic and anabolic effects of testosterone on the body. Side and Adverse Effects • Virilization (females, children) • Increased growth of existing (undiagnosed) prostate cancer • Edema and weight gain • Premature epiphyseal closure • Gynecomastia (males) • Liver toxicity (17-alpha-alkylated androgens only) Interventions Precautions Liver impairment Obstructive uropathy Contraindications Pregnancy Category X Females and children 35 • PSA levels will decline with therapy • Increases in PSA level may indicate prostate cancer or nonadherence to therapy • Monitor for gynecomastia; concern for body image Administration • Give orally, with or without food. • Crush the tablets if needed. • Expect drug therapy to be lifelong. • Ensure that women do not handle the drug due to the possibility of transdermal absorption. • Expect therapeutic effects to take 6 to 12 months to develop. Safety alert - Women of child-bearing age or pregnant should not handle a crushed or broken 5- alpha reductase inhibitor, due to the potential for birth defects in male fetuses. The defect is hypospadias, in which the opening of the urethra is on the underside of the penis rather than the tip. These drugs are coated tablets to prevent incidental contact with the active ingredient. If a woman who is pregnant does come in contact with this drug, she should immediately contact her provider. Patient Instructions • Expect decreases in libido and ejaculate volume. • Undergo regular prostate cancer screenings. • Report breast enlargement. Contraindications and Precautions 5-Alpha Reductase Inhibitor • Saw palmetto may potentiate effects Alpha-Adrenergic Receptor Antagonists Treat benign prostatic hypertrophy Prototype • Prototype drug: tamsulosin (Flomax): specific alpha-adrenergic receptor antagonist • Other drugs o silodosin (Rapaflo): specific alpha-adrenergic receptor antagonist o alfuzosin (Uroxatral): nonspecific alpha-adrenergic receptor antagonist o terazosin (Hytrin): nonspecific alpha-adrenergic receptor antagonist o doxazosin (Cardura): nonspecific alpha-adrenergic receptor antagonist Expected Pharmacologic Action Precautions Hypotension Renal impairment History of syncope Contraindications Concurrent use of erectile dysfunction drugs such as sildenafil (Viagra) Females, children 36 • The prostate gland contains alpha-adrenergic receptors. • Tamsulosin antagonizes the alpha-adrenergic receptors. o Causes relaxation of smooth muscle in the prostate gland o Causes relaxation of smooth muscle in the outlet of the bladder • Increased urine flow and decreased BPH symptoms result. Side and Adverse Effects • Reduced ejaculate volume, ejaculation failure, retrograde ejaculation (tamsulosin and silodosin) • Headache • Hypotension, fainting, dizziness Interventions • Tell patients about the possibility of altered ejaculation. • Monitor for headache. • Monitor blood pressure. • Report a systolic pressure drop or a heart rate increase when rising from lying or sitting. Administration • Give orally once a day. • Give at the same time each day, 30 min after the same meal. • Swallow the capsules whole; do not crush or chew them. Patient Instructions • Expect decreases in ejaculate volume and ejaculation failure. • Report headache if not relieved by mild analgesic. • Have blood pressure checked regularly. • Rise slowly from a reclining or sitting position. • Report dizziness or fainting. • Do not engage in dangerous activities if dizziness occurs. • Plan to take this drug lifelong. Contraindications and Precautions Interaction • Drugs that lower blood pressure can increase hypotensive effects of nonselective alpha blockers. 37 • Erythromycin, itraconazole (Sporanox), nefazodone (Serzone), and HIV protease inhibitors increase levels of nonselective alpha blockers. • Cimetidine (Tagamet) may worsen orthostatic hypotension. Drug Therapy for Erectile Dysfunction There is one type of drug used in the treatment of erectile dysfunction • PDE5 inhibitors PDE5 Inhibitor Treat erectile dysfunction Prototype • Prototype drug: sildenafil (Viagra) • Other drugs o vardenafil (Levitra) o tadalafil (Cialis) Expected Pharmacologic Action • PDE5 makes an erection subside. • Sildenafil inhibits PDE5 within the penis. • The erection is sustained, made harder, and longer-lasting. Erections occur when the parasympathetic nervous system causes release of nitric oxide, which in turn activates an enzyme that makes cyclic guanosine monophosphate, or cGMP. Eventually, cGMP causes smooth muscles and arteries in the penis to relax, causing spaces in the corpus cavernosum to fill with blood. Because of the engorgement of blood, venous return is decreased, and arterial pressure within the arteries of the penis is increased. These factors cause and sustain an erection. The erection ends when another enzymatic reaction by phosphodiesterase type 5, or PDE-5, converts cGMP into another substance. The function of sildenafil is to inhibit PDE-5 within the penis. This sustains the erection, makes it harder, and longer-lasting. It exerts no therapeutic effect if the man is not sexually aroused. Side and Adverse Effects • Priapism (persistent erection) • Headache • Hypotension, fainting, and dizziness • Sudden loss of hearing (rare) • Irreversible loss of vision (rare Interventions • Tell patients about the risk of impotence following priapism. • Treatment involves aspirating blood from the corpus cavernosum and irrigating with a vasoconstrictor. Urinary tract infection Hiatal hernia with reflux Hyperthyroidism Hypertension Benign prostatic hypertrophy Autonomic hypertrophy Liver or renal disease • • • • • • • Precautions Narrow-angle glaucoma Myasthenia gravis Gastrointestinal obs ruction Genitourinary obs ruction Active cardiac dysfunction• • • • • Contraindications 40 • Monitor for headache. • Monitor for dizziness and somnolence. • Advise patients to use caution in hot weather. Administration • Give orally (either short-acting syrup or tablets) two to four times a day. • Give extended-release (ER) tablets once per day. • Swallow ER tablets whole; do not crush or chew them. • Expect excretion of the insoluble shell of the ER tablets in stool. • Apply the transdermal patch twice per week to dry and intact skin on the abdomen, hip, or buttocks. • Rotate patch adhesion sites. Patient Instructions • Suck on hard candy; sip water. • Increase fluid and fiber intake; increase activity levels. • Report undesirable changes in urinary elimination. • Use over-the-counter lubricating eye drops. • Obtain regular eye examinations. • Report headache not relieved by mild analgesic. • Report dizziness or fainting. • Do not engage in dangerous activities if dizziness occurs or tends to recur. • Avoid becoming overheated and seek medical attention if fever and signs of heat exhaustion. Contraindications and Precautions Interaction • CYP3A4 inhibitors: grapefruit juice, ketoconazole, erythromycin, and itraconazole (Sporanox) may increase toxicity. • CYP3A4 inducers: phenytoin (Dilantin), rifampin (Rifadin), and carbamazepine (Tegretol) decrease effectiveness. Drug Therapy for Urinary Retention 41 There is one type of drug used in the treatment of urinary retention • Cholinergics • Treat urinary retention Cholinergics Prototype • Prototype drug: bethanechol (Urecholine) Expected Pharmacologic Action • Activates muscarinic receptors in smooth muscle and other organs throughout the body • In the urinary bladder, cholinergic drugs o Contract the detrusor muscle/bladder o Relaxes internal sphincter Side and Adverse Effects • Hypotension, bradycardia • Excessive gastric acid and salivation, diarrhea, fecal incontinence • Bronchoconstriction • Dizziness, fainting Interventions • Monitor blood pressure and heart rate. • Monitor respiratory status. • Monitor for dizziness. • Monitor bowel elimination patterns. Safety alert - Acetylcholine, the neurotransmitter for the parasympathetic nervous system, stimulates the muscarinic receptors of the parasympathetic nervous system. When these receptors are stimulated, the parasympathetic nervous system slows the rate of the heart and dilates arterioles with a subsequent decrease in blood pressure. Cholinergic drugs, which stimulate muscarinic receptors, accentuate the effects of the parasympathetic nervous system on the heart and arterioles. Closely monitor patients taking a cholinergic drug for urinary retention for decreased cardiac output and postural hypotension. Administration • Give orally three to four times a day. • Give 1 hr before or 2 hr after meals. • For inpatient use, have a bedpan or urinal readily available. Patient Instructions • Report dizziness. • Increase fluid intake to maintain hydration. • Sit or lie down if feeling dizzy. • Report any difficulty breathing. • Report fainting. Precautions Bacteremia History of syncope Hypotension Hyperthyroidism Low cardiac output Asthma, COPD, gastric ulcers Urinary tract obstruction or bladder wall weakness Intestinal obstruction Recent intestinal surgery • • • • • • • Contraindications 42 • Do not engage in dangerous activities if dizziness occurs. Contraindications and Precautions Interaction • Cholinesterase inhibitors worsen cholinergic effects and increase the risk of toxicity. • Mecamylamine (Inversine) worsens abdominal symptoms and hypotension. • Procainamide (Pronestyl), quinidine, atropine, and epinephrine interfere with therapeutic effects. A patient is considering taking estrogen and medroxyprogesterone acetate (Prempro) to treat postmenopausal vasomotor symptoms. You explain to the patient that she would need to watch for which of the following possible indications of a serious adverse effect of this combination drug? - Swelling or pain in the calf Combination oral contraceptives, such as ethinyl estradiol and drospirenone (Yasmin), require cautious use with patients who have which of the following disorders? - Diabetes mellitus You are talking with a patient about beginning therapy with testosterone (Delatestryl) to treat testicular failure. Which of the following potential side effects should you tell the patient to watch for and report? - weight gain When talking with a patient about beginning therapy with finasteride (Proscar) to treat benign prostatic hypertrophy, you should instruct the patient to do which of the following? - Expected improvement in 6-12 months Match the drug in the left column with its therapeutic use in the right column by typing the appropriate letter in the center column.