THE FIVE PLUS FIVE RIGHTS OF DRUG

ADMINISTRATION Parasympathetic Nervous System

THE RIGHT CLIENT
Verify client by checking ID bracelet and nametag
Ask the client to state his/her name
Have high-lighted warning tools for clients with same last name
Address the client by name before administering the drug
Ask for allergies
innervates primarily the gastrointestinal tract, eye, heart,
respiratory tract, glands, and bladder
uses acetylcholine as preganglionic and postganglionic
neurotransmitter
Muscarinic Agonists-
Agonists- produce the same response as that obtained
by stimulating the parasympathetic nervous system

THE RIGHT DRUG Acetylcholinesterase- produce their pharmacologic action by

The client receives the drug that was prescribed by a physician, blocking the enzymatic hydrolysis of acetylcholine
dentist or any authorized prescriber.

THE RIGHT DOSE Neostigmine, Pyridostigmine, and Edroponium and

Be familiar with measurement conversion process and drug
preparation. Calculate the dose correctly.
Check drug reference books for recommended dosage
range
Measure liquid preparation at the lowest part of the
meniscus
Physostigmine
Therapeutic Uses
Pupillary constriction in the treatment of glaucoma
Increase muscle strength in client with myasthenia gravis
Reversal of neuromuscular blockade

THE RIGHT TIME Adverse effects:

The nurse should adhere as closely as possible t the scheduled
times.
Nurses must check whether the client is for surgery or diagnostic
procedures and determine the need for withholding the
drugs
Expiration dates must be checked
Antibiotics are administered at even intervals
effects: Bradycardia, asthma, peptic ulcer
Nursing Considerations
Administer IV drug slowly
Administer with foods BUT better BEFORE meals
Maintain atropine sulfate as antidote
Discontinue the drug if excessive salivation, diarrhea, vomiting,
and muscle weakness (cholinergic crisis)

THE RIGHT ROUTE Muscarinic Blocking Agents- competitively block the actions of
Be sure to know the prescribed route by which as medication is to acetylcholine at both central and peripheral muscarinic
be administered receptors
Assess the client’s ability to swallow before the administration of
oral medications
Stay with the client after administering the medications to ensure Atropine, Ipratropium, Scopolamine, and Glycopyrrolate
intake and to monitor acute effects.
Therapeutic Uses
THE RIGHT ASSESSMENT Pre-op medication to decrease salivary secretions and pupil
Requires that appropriate data is collected before administering the dilatation
medications. Anti-spasmodic drug to treat peptic ulcer
Agent to increase the heart rate when bradycardia is present
THE RIGHT DOCUMENTATION
Be sure to document the medication and time administered on the Antidote for cholinergic agonists poison (betanechol)
chart Motion sickness — use scopolamine
Document site location after administration of IM, ID and SQ Asthma — use ipratropium
injection
Adverse effects:
Dry mouth, blurred vision, tachycardia, constipation, urinary
THE RIGHT TO EDUCATION retention
The client receive correct and complete information about the Contraindications-
Contraindications- Glaucoma, Urinary and GI obstruction,
medication and how it relates to his/her particular situation. ileus
It requires that the patients have the knowledge to make the
decision to take the drug (informed
(informed consent)
consent) .

Nursing Considerations
THE RIGHT EVALUATION Provide comfort measures
Ensure adequate hydration to prevent hyperpyrexia
THE RIGHT TO REFUSE Protect eyes form lights
Provide appropriate information and explanation why the Advise to avoid hazardous activities
medication is ordered. Provide high-fiber diet and laxative
Instruct to void before administering the drug
Document if the client refuses medication, client’s reason and
report the refusal to the physician
Sympathetic Nervous System
modulates the activity of smooth muscle, cardiac muscle, and
AUTONOMIC NERVOUS SYSTEM glandular cells
transfer of information from terminals of most sympathetic
NEUROHUMORAL TRANSMISSION
neurons to the effector organs is mediated by norepinephrine
 except those few anatomically sympathetic neurons that
project to sweat glands and some blood vessels in the neck,
face, and skeletal muscles that use acetylcholine as a
transmitter
α¹-Receptors-
α¹-Receptors- located in the smooth muscle throughout the body ,
in the eye, lung, blood vessels (arteries), uterus, gut, and
genitourinary system
α²-Receptors-
α²-Receptors- located chiefly on the presynaptic nerve terminals
create a negative feedback that inhibits NE release
vascular smooth muscle contains postsynaptic α²-receptors
that produce vasoconstriction (veins)
ß¹-Receptors-
ß¹-Receptors- located in the postsynaptic membranes in the heart
ß²-Receptors-
ß²-Receptors- located in smooth muscle and gland cells
Direct-acting Sympathomimetics
receptor agonists mimic the effects of sympathoadrenal discharge
by combining directly with postjunctional receptors
Eg: Norepinephrine (Levophed), Epinephrine, Dopamine
(Intropin), Phenylephrine
Epinephrine (Adrenalin)-increases
(Adrenalin)-increases BP and HR, pupil dilatation
and bronchodilatation
Therapeutic use:
use: Asthma, Anaphylactic shock and cardiac arrest
Adverse reaction:
reaction: palpitations, tachycardia and dyspnea. High
doses can result in cardiac dysrhythmias.
Albuterol (Ventolin) - purely bronchodilatation, affect the ß¹
causing increased in HR at high doses
Note for adverse effects of adrenergic drugs
Check the IV insertion site for any tissue necrosis
Sympatholytics
inhibits the synthesis, storage, or release of norepinephrine
α¹-Adrenergic Receptor Antagonists -inhibits
the contraction of arterial and venous smooth muscle
eg: Prazosin (Minipress), Terazosin (Hytrin)
α²-Adrenergic Receptor Antagonists
-involved in advocating sympathetic output
-decrease vagal tone
-delays platelet aggregation
-facilitating the release of NE and Ach from nerve
endings
-promotion of insulin secretion and initiation
of lipolysis
eg: Yohimbine
Therapeutic Uses
Hypertension= prompt vasodilatation which causes decreased BP
Decrease the symptoms of benign prostatic hypertrophy
Peripheral vascular disease (Raynaud’s disease) — vasodilatation
increase the blood flow to the extremities
Adverse effects: reflex tachycardia and orthostatic hypotension

Nursing consideration
Clonidine and Methyldopa- treat hypertension by regulating the Monitor heart rate and BP
release of nor-epinephrine leading to decreased blood pressure Caution to change position slowly
Advise to avoid hazardous activities
Provide supportive measures like quiet environment, rest and
Indirect-acting Sympathomimetics analgesics
do not activate receptors directly but facilitate the release of Monitor response to the drug — improvement of blood pressure
norepinephrine from sympathetic neuronal varicosities, or readings and urination
block the reuptake transporter in the neuronal membrane
Eg. Amphetamine, Ephedrine, Phenylpropanolamine Selective ß-Adrenergic Antagonists -therapeutic effects
are on the cardiovascular system by slowing the
heart rate and decreasing myocardial
contractility
eg: Metoprolol, atenolol, esmolol,
Therapeutic effects acebutolol, betaxolol
Vasoconstriction in hypotension Nonselective ß-Adrenergic Antagonist
Attention deficit disorder - block the ß¹-adrenergic receptor of the heart and the
Narcolepsy ß²-adrenergic receptor in bronchial smooth muscle
Appetite control, obesity (bronchoconstriction)
eg: Propranolol (Inderal), Nadolol, Timolol,
Adverse effects:
effects: Pindolol, Labetolol
Nausea, tremors, hyperactivity and headache Therapeutic Uses
Hypertension
Mixed acting Sympathomimetics Glaucoma= it decreases the secretion of aqueous humor
stimulate the adrenergic receptor sites and stimulate the release of Migraine= induces vasodilatation in brain vasculature
nor-epinephrine from terminal nerve endings Hyperthyroidism
Eg: Ephedrine, Metaraminol Angina and Myocardial infarction= reduces the chest pain upon
exertion
Therapeutic use Contraindications (Non selective)
Hypotension- the drug increases systolic and diastolic BP by Allergy
cardiac stimulation Heart blocks
Treat mild form of bronchial asthma Bradycardia
Shock (Metaraminol)- It enhances cardiac activity and mild COPD
vasoconstriction CHF

Adverse effects: Adverse effects

tremors, headache, hyperactivity and insomnia CVS- bradycardia,
bradycardia, hypotension, heart block
CNS- fatigue, dizziness, unsteadiness
Nursing Considerations: Respi- bronchospasm, pulmonary edema
Check for the vital signs and ECG GI- nausea, vomiting, diarrhea, hypoglycemia
GU- decreased libido, impotence, dysuria
ANTIPARKINSONS
Nursing Considerations Enhance the effects of DOPAMINE by promoting dopamine
Emphasize NOT to stop abruptly the drug intake production or by activating the dopamine receptors in the brain
Give with FOODS to improve absorption Eg: Levodopa, Bromocriptine, Amantadine, Pergolide,
Provide comfort measures Selegiline
Adequate rest periods
Avoidance of hazardous activities Precautions:
Change position slowly Renal and hepatic disorders
CNS STIMULANTS Psychosis
Stimulate the cortical and reticular activating system (RAS) of the Interactions:
brain releasing neurotransmitters from the nerve cells Alcohol and Phenytoin will decrease the effect of levodopa
leading to increased stimulation of the post-synaptic MAOIs can cause hypertensive crisis
neurons.
FOOD interactions:
These are drugs used to treat certain disorders With HIGH proteins
Exogenous obesity- Dextroamphetamine Impair drug transport to the brain
Attention-deficit hyperactivity disorders- Methylphenidate With PYRIDOXINE (Vitamin B6)
Narcolepsy- Modafinil These can cause DECREASED effectiveness of the drug
Exaggerate the drug reactions
Contraindications
Marked anxiety, agitation, extreme tension, severe tension and
glaucoma- exacerbated by the CNS stimulation.
Adverse Effects
CNS= nervousness, insomnia,
insomnia, headache, and blurred vision
GIT= anorexia,
anorexia, nausea and weight loss
CVS= HPN, tachycardia, arrhythmias, and angina
Nursing Considerations
Administer the drug before 6 pm to reduce the effect of insomnia
BEST given AFTER meals to prevent the effect of anorexia
Provide safety measures such as side-rails and assisted ambulation

ANTIEPILEPTICS
Affect the entire brain and reduce the chance of sudden electrical
outburst that causes seizures

Agents for treating TONIC-CLONIC SEIZURES

Hydantoins (Phenytoin)
Benzodiazepines (Diazepam, Clonazepam)
Barbiturates (Phenobarbital)

Agents for treating ABSENCE SEIZURES

Succinimides (Ethosuximide)
Valproic Acid
Zosinamide

Agents for treating Partial FOCAL SEIZURES

Carbamazepine
Gabapentin

HYDANTOINS
STABILIZE the nerve cell membrane throughout the brain
reducing and limiting the excitability and conduction
through nerve pathways.
Clinical Uses
Tonic-clonic seizures and Status epilepticus
Prevention of seizures in neurosurgery
Muscle relaxation

Adverse effects
CNS effects- depression, confusion, drowsiness, lethargy, fatigue
GIT- GINGIVAL HYPERPLASIA and severe liver toxicity which
are all related to cellular toxicity.
SKIN- hirsutism and coarsening of the facial skin
Bone Marrow depression

Nursing Considerations
Administer the drug with food to alleviate GI irritation
Provide meticulous mouth oral care
1. Therapeutic class: anti-inflammatory agents
a. type: non-steroidal anti-inflammatory agents
b. type: steroidal anti-inflammatory agents
i. action: powerful suppression of inflammation by inhibiting the mobilization leukocytes,
fibroblasts, and inflammatory mediators, prevents increased capillary permeability
ii. examples
• short-acting
o hydrocortisone (Hydrocortone 20-240 mg by mouth daily in
divided doses)
o hydrocortisone sodium succinate (Solu-Cortef 20-120 mg/m2 IV
every 12-24 hours)
• intermediate-acting: predniSONE (Deltasone 5-60 mg by mouth daily in 1-4
doses)
• long-acting: dexamethasone (Decadron 0.75-90 mg/kg by mouth daily every
6-12 hours, IV 1-6 mg every 2-6 hours for 72 hours)
iii. uses
• gold standard for anti-inflammatory action
• septic shock, allergy, neoplasms, cerebral edema
• inflammatory diseases such as RA, severe COPD
iv. adverse effects
• suppression of hypothalamic-pituitary-adrenal axis
• opportunistic infections, hyperglycemia, hemorrhage, gastritis, HTN,
thromboembolic disorders, edema
• emotional lability, seizures, insomnia
• osteoporosis, poor wound healing, fragile skin
• hidden infection: client may not display expected findings associated with
infection including fever and leukocytosis
v. contraindications
• active infection, psychosis
• children < 2 years-old, AIDS, TB
• idiopathic thrombocytopenia, acute glomerulonephritis
vi. nursing care
• establish baseline data and monitor
o occult infection
o serum glucose, potassium, cortisol level, WBCs
 o temperature, blood pressure, urine output, mental status
• frequently monitor for infection
• administration
o undiluted IV push
o suspension: give deep IM injection, do not give suspension IV
o oral: administer with food or milk
• client teaching
o take daily therapy in AM
o report infection, fever, surgery, anorexia, fatigue, dizziness, joint
pain
o need for follow-up care and testing
o do not abruptly discontinue therapy
o wear Medic Alert tag, take only as directed
o protect skin and avoid sick people, hand washing
o injection technique for insulin to control hyperglycemia
o avoid OTC drugs and herbal remedies including aloe and licorice
2. Therapeutic class: antihistamines
a. first generation (associated with drowsiness)
i. type: H1-receptor blockers
• action: compete with histamine for receptor sites to decrease allergic response
• examples
o brompheniramine (Dimetane, Dimetapp 4 mg by mouth every 4-6
hours)
o clemastine (Tavist 1.34 mg by mouth twice daily)
o diphenhydrAMINE (Benadryl 12.5-50 mg by mouth every 4-6
hours)
o promethazine (Phenergan)
o see Therapeutic class: typical antipsychotic drugs

• uses
o allergy, pruritus, allergic rhinitis
o motion sickness, antiparkinson, infant colic
 o ameliorate allergic response during invasive procedures using
contrast medium
• adverse effects
o anaphylaxis, thrombocytopenia, hemolytic anemia
o drowsiness, poor coordination
o blurred vision, dry mouth, urinary retention, seizures
o nightmares when used as hypnotic, especially with older clients
• contraindications: acute asthma
• nursing care
o establish baseline data and monitor breath sounds and respiratory
secretions, temperature, level of consciousness
o assist for ambulation
o do not confuse with dimenhyDRINATE
o client teaching
1. may take with food
2. drink 2000 ml fluids daily
3. use sunscreen, ask for help when getting up
4. avoid alcohol, OTC drugs, CNS depressants
5. do not drive or engage in hazardous activities
b. second generation (associated with less drowsiness and anticholinergic effects)
c. type: mast cell stabilizers
3. Therapeutic class: immune modulators, stimulants
a. type: interferons
i. action: prevent viral replication in host cells, stimulate production of antiviral proteins,
inhibits tumor growth, and increases aggressiveness of phagocytes
ii. examples
• interferon beta-1a (Avonex)
• interferon alfa-n 1 lymphoblastoid (Wellferon)
• interferon alfa-2a/interferon alfa-2b (Roferon-A)
iii. uses: chronic hepatitis C, malignant melanoma, Kaposi’s sarcoma, leukemia in clients >
18 years-old
iv. adverse effects
• myelosuppression, seizures, MI, heart failure, edema, blood pressure
changes
• flushing, photosensitivity, flu-like symptoms
• GI upset, weight loss, xerostomia, impotence
v. nursing care
• establish baseline data and monitor
o vital signs, EKG, breath sounds: very frequently
o CBC, weight
o bleeding, oral mucosa, mental status
• avoid contact with skin
• clients may become hemodynamically unstable during therapy
• different interferons are not interchangeable: each has individual indications,
dosing, and administration guidelines
• administer at bedtime with acetaminophen
• administration
o given subcutaneously, IM, and intralesional
o reconstitute and mix gently, solution may be stored for 30 days
o only by qualified personnel, in controlled conditions, wearing
gown, gloves, and mask
• client teaching
o avoid hazardous activity
o report signs of infection
b. type: interleukins (IL)
i. action: stimulates cellular immunity of helper T cell to inhibit tumor growth
• acts on lymphocytes to stimulate mitogenesis and cytotoxicity initiates killer
T cell
 • activity and interferon-γ production
ii. examples
• aldesleukin (IL-2, interleukin-2)
• oprelvekin (Neumega)
iii. uses
• renal cell carcinoma, melanoma
• in combination with zidovudine for HIV
iv. adverse effects
• MI, cardiopulmonary arrest, capillary leak syndrome, CVA,
myelosuppression, pulmonary edema, intestinal perforation or ileus,
renal dysfunction
• muscle and joint pain, change in mood and mental status, dizziness, impaired
motor function
v. contraindications: abnormal thallium stress test, pulmonary function test, organ allografts
vi. nursing care
• establish baseline data and monitor
o continuous blood pressure, EKG, SaO2, PAP, RAP
o RFT, urine output, LFT, bleeding, acidosis
o CBC, differential, platelets; maintain platelets > 75,000/mm3 and
leukocytes > 2,000/ mm3
o clients may become hemodynamically unstable during therapy
• do not confuse with Prokine
• may store unused solution in refrigerator within 48 hours, do not freeze
• administration
o do not shake
o infuse over 15 minutes without inline filter in plastic IV bag
o be prepared to administer
1. hydrocortisone for extravasation
2. DOPamine for blood pressure support
• client teaching
o report changes in breathing, cough
o watch for infection avoid pregnancy
o avoid shaving, aspirin, ibuprofen, alcohol
c. type: T- and B-cell modulator
i. action: stimulates B-cells leading to increased antibody formation which enhances T-cell,
monocyte, and macrophage activity
ii. example: levamisole (Ergamisol)
iii. use: colon cancer in combination with fluorouracil
iv. adverse effects
• myelosuppression
• GI upset, taste perversions, alopecia
• flu-like symptoms, dizziness, headache
v. nursing care
• establish baseline data and monitor CBC and differential
• avoid concurrent administration of phenytoin or alcohol
• client teaching
o avoid pregnancy
o injection technique
4. Therapeutic class: immune modulators, immunosuppressants
a. information common to immunosuppressive agents
i. action: impair an aspect of the immune system most responsible for or likely to stimulate
allograft rejection while exposing the individual to risks of immunosuppression
ii. adverse effects
• susceptibility to opportunistic infections and malignancies, masks signs of
infection, stimulates latent infection
• nephrotoxicity, hepatic dysfunction, hyperglycemia, hyperlipidemia,
thrombocytopenia, dysrhythmias, embryotoxic and teratogenic
• anorexia, nausea, diarrhea
• potentiates the action and adverse effects of other immunosuppressants
 iii. contraindications: when risk of immunosuppression outweighs benefit of drug; tolerance
iv. nursing care
• establish baseline data and monitor
o drug levels, RFT, LFT, CBC, immune markers, tissue biopsy,
CXR
o allograft function
1. cardiac: cardiac output, blood pressure, EKG, PAP,
PCWP
2. pulmonary: SaO2, PaCO2, PFT
3. renal: creatinine, creatinine clearance
4. hepatic: bilirubin, ALT, AST, prothrombin time
o search for infection
o client teaching
1. need for follow-up care and testing
2. avoid pregnancy, promptly report signs of infection
3. follow manufacture’s instructions on mixing and
administration, take only as directed, and take until
instructed to stop
4. hand-washing and infection control
1. wear tight fitting mask on windy days
2. cook meat, poultry, and fish until well-done
3. avoid sick people, ceiling fans and room
fans
4. avoid digging in dirt, cat litter box, birds and
bird cages
5. restrict fresh fruits and vegetables to items
that are easily peeled or washed in soap and
water such as bananas, oranges, apples,
carrots, tomatoes, potatoes

b. type: T- and B-cell suppressants

i. action: suppress antibody production, suppressor and helper T-cells, and release of
interleukins
ii. examples:
• cyclosporine (Sandimmune, Neoral)
• mycophenolate mofetil (CellCept)
• sirolimus (Rapamune) (macrolide)
• tacrolimus (Prograf)
iii. uses:
• prevention and treatment of transplant allograft rejection in combination with
other immunosuppressants and glucocorticoids
• prevention of allograft vasculopathy
• autoimmune disorders, non-Hodgkin’s lymphoma, Crohn’s disease
 • adverse effects
• lower risk of hyperlipidemia with tacrolimus (Prograf)
iv. nursing care
c. type: monoclonal antibodies
i. action: impairs the effects of tumor necrosis factor alpha, competes with IL-2 for receptor
sites, and impairs immunological response to antigens
ii. examples
• muromonab-CD3 (Orthoclone OKT3)
• basiliximab (Simulect)
• infliximab (Remicade)
iii. uses
• prevention and treatment of transplant allograft rejection in combination with
other immunosuppressants and glucocorticoids
• Crohn’s disease, rheumatoid arthritis
iv. adverse effects
• increased susceptibility to infection, heart failure, anaphylaxis, pulmonary
edema, hemodynamic instability
• GI upset, bleeding, gingival hyperplasia
• fever, chills, headache, insomnia, muscle and joint pain
• impaired metabolism of uric acid, K+, Ca++, P

v. nursing care
• establish baseline data and monitor
o drug levels
o RFT, LFT, CBC, CXR, hidden infection
o cardiac allograft: cardiac output, blood pressure, EKG, PAP,
PCWP
o pulmonary allograft: SaO2, PaCO2, PFT
o renal allograft: creatinine, creatinine clearance
o hepatic allograft: bilirubin, ALT, AST, prothrombin time
vi. administration
• oral route preferred
• IV: reconstitute by gently inverting 50 ml bag of 5% dextrose or 0.9% NaCl,
do not shake
vii. client teaching
• avoid pregnancy
• promptly report signs of infection
• need for follow-up care and testing
• hand-washing and infection control
• wear tight fitting mask on windy days
• cook meat, poultry, and fish until well-done
• avoid sick people, ceiling fans and room fans
• restrict fresh fruits and vegetables to items that are easily peeled or washed in
soap and water such as bananas, oranges, apples, carrots, tomatoes, potatoes
• avoid digging in dirt, cat litter box, birds and bird cages

d. type: glucocorticoids

used in combination with cyclosporine and other immunosuppressants