Adverse Effects/Contraindications/Side Effects/Interactions

by Diana Shenefield, PhD

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    00:00 Today we're going to talk about adverse effects, contraindication, side effects, and interactions of pharmacological meds again. So, we've talked about what are expected. Now, we're talking about all of the things that are either expected but aren't good or unexpected. My name is Diana Shenefield. Let's get started.

    00:23 Again, why do we need to know this? Because on NCLEX, you need to know your medications, not only why they're given, but you need to be prepared for side effects, adverse effects, and any other contraindications that might be going on with the patient. One, so that I can be watching forward as the nurse, but two, so that the patient can be educated on what to watch for at home. Look at your learning outcomes.

    00:47 Make sure that you understand each one of the outcomes and make sure that you're prepared educationally to answer any questions that deal with those outcomes.

    00:55 If you have questions, make sure you'd go back to your pharmacology book, and make sure you'd go to your NCLEX review books. So, we're going to start with a question to get you thinking. A patient is admitted for pulmonary embolism, receives heparin 1500 units per hour IV. In case of a serious bleeding reaction, what are you going to give? You need to know antidotes. You need to know antidotes of all your medications, especially the ones that can be life-threatening. And we know bleeding from heparin can be life threatening. So, what are you going to give? Are you going to give vitamin K? Are you going to give protamine sulfate? Are you going to give promethazine? Or are you going to give protamine? So think back to your heparin and what is the antidote? And hopefully, you picked protamine sulfate. Again, if you can't remember, go back and review that because it's very important to know. Second question, we've got a 14-year-old prescribed amphetamine, again, a combination, Adderall.

    01:58 How many kids do you know that are on amphetamine kind of medications for ADHD? What does a nurse need to watch for? What is the adverse effect? Is it weight gain? Is it depression? Is it somnolence? Or is it bradycardia? Again, it's really important. You're going to have a lot of patients that are going to come in for other reasons but are on ADHD meds.

    02:21 And so, what do you need to watch for? And the answer to this question is somnolence.

    02:25 If you've got a child that's on that medication, it seems very sleepy and doesn't respond, or just wants to sit and talk to nobody. We need to be concerned about that. So let's dive into what is the review of unintended responses.

    02:41 We know there's lots of things to be watching for. And so let's review some of our terminologies. Side effects.

    02:48 Lot of people get side effects and adverse drug reactions mixed up. But as a nurse, you need to know what those are. A side effect is unavoidable secondary things that happen. When you take a medication, unfortunately, it doesn't just go to the part of the body that needs to be fixed. It affects the whole body. The things that happen because of that are side effects.

    03:10 Some side effects can be very mild. Some side effects can be more severe. But again, it's something that happens because the body is going systemically.

    03:20 Adverse effects, we need to watch for those, whether it's toxic, and toxicity means that they have too much of the drug. Allergic reaction. Are they developing anaphylaxis? Or is it just kind of a weird effect that happens just because of their genetic makeup? Again, side effects are things that happen just because the medicine is going systemic. Adverse effects are things that are happening that we didn't plan on.

    03:45 And then you have iatrogenic, which are medications that cause disease. One thing we think of is diseases that are caused from medications that cause birth defects. That would fall underneath that, or teratogenic. Again, if it causes a birth defect or it causes another kind of effect to happen, that is not good at all. And then carcinogenic. We usually think of chemotherapy drugs may treat one kind of cancer, but in the treatment, cause another kind of cancer.

    04:16 Again, these are all terminology that the nurse needs to know and that you need to understand so when you're talking to your patient about the side effects or the adverse effects, that you can speak intelligently and be able to watch for the different effects, and what to warn them about, and maybe what to just keep an eye on. So, side effects.

    04:37 Again, they're unavoidable. Some of the common side effects are things like nausea, vomiting, maybe dizziness, things that once they've been on the medication for a while will probably go away. Those are things that want the body get used to getting that medication. You can adjust to that. Or maybe it's just something that the patient is going to have to get used to. One of the things that come to mind is your ACE inhibitors. And if you remember, one of the side effects for an ACE inhibitor is that nagging dry cough. That would be a side effect. Some patients can't tolerate that, and we need to switch. But that's a common side effect. We need to educate our patients. Now sometimes, nurses will say, "Oh, but if I tell patients everything that could happen, they'll imagine it." And that's not really true. So make sure that you educate them on common side effects.

    05:28 And then, they also need to know when do they need to call the doctor. If they're dizzy all the time after taking a medicine, it may be a common side effect, but you can't drive and you can't work when you're dizzy. So you need to let them know when do they need to notify the physician, just because it's an explained side effect or an expected side effect, when do they need to call the physician.

    05:52 Unintended responses. Now, we're talking about adverse effects. We're going to start with CNS kind of problems. You know, if your CNS is over-stimulated or under stimulated, can cause seizures. We know a lot of depression medications. One of the side effects or the adverse things that happen if some people feel like they need to commit suicide, they would need to make sure that the physician knew about that. If it's a medication that could cause seizures, even though we kind of know that in the back of our mind, seizures are a serious adverse effect, so we'd want to be prepared for that.

    06:30 EPS. Hopefully, you remember what that is, extrapyramidal symptoms.

    06:34 That's when you get those tremors. If you got a patient that develops that, one of the medications that comes to mind and should come to your mind is raglan.

    06:43 If they're on that, again, that can cause a lot of problems, the tremors, you know if they have a job, that will affect their job or just self-esteem.

    06:51 What about anticholinergic effects? Things like falls. Falls are a big thing. We don't want our patients falling. We need to watch for them. Or vision changes. If they're having blurred vision, we want to make sure that we know that before we send them out driving or if they work somewhere where that's going to be detrimental. Cardiovascular changes. Again, you give a patient a medication. If it drops their blood pressure, we worry about falls. Those are all things that we need to make sure that we're keeping in mind, especially for our beta blockers and our ACE inhibitors, the first time they take a dose. Those are adverse effects that don't happen to everybody. But if they do, we need to know about those.

    07:33 And then GI problems. People always think about nausea and vomiting, but don't forget a lot of the antibiotics cause diarrhea. And so if you have a patient that's already, maybe emaciated or malnourished, you're going to want to know if they're having severe diarrhea. So make sure you review that. And then you got hematological.

    07:52 Blood. A lot of the medications will cause a decrease in blood cells. And so we need to be watching our labs. Hepatic system. Because of that first past effect that we talked about, if their liver is compromised either from cirrhosis or hepatitis or just age, we want to make sure that we know that there's going to be a build up of drugs. What about the kidneys? We know that all of our medications are excreted through the kidneys. So, what do we need to watch for in our patients with normal kidneys and our patients that are already in kidney failure? And then the skin. We're always watching for rashes. We're always watching for infection. So again, what do I need to be thinking about with this patient that could happen because of the adverse effects of their medications? So, toxicity. Some drugs should commonly come to your mind on what are common drugs that people get into little trouble with by taking too many, acetaminophen right at the top. We know that a daily dose of acetaminophen is 4000 grams.

    08:57 We need to teach our patients that anything over that causes toxicity to the liver. It's not the Tylenol itself, it's the too much Tylenol that causes the problem. What about digoxin? You need to review to make sure that you remember what a digitoxic patient looks like. And one of the easy ones to remember is the halo. Do they see the halo when they look into the lights? Do they have nausea? Because dig has such a small therapeutic response, it's important that we don't have our patients become toxic. NSAIDS and aspirin, again, too much can cause a lot of GI bleeding. So make sure you're reviewing that and you're looking through your drugs and seeing which ones become toxic the easiest. And then allergic reactions. Sometimes, people are just allergic to medications. But just remember, if they've only had the dose one time, they can still have a reaction the second time. So, if you have drugs like penicillins or sulfa drugs that are more commonly causing problems with allergic reactions, make sure you're staying with your patient. But know what those are and know how do I spot if somebody is having an allergic reaction. You know, if they start complaining of their lips tingling, if they start complaining like it feels like their tongue is swelling, that should send up red flags. And remember, what's the first thing you do? You stop the medication and then you assess your patient.

    10:24 You know, do they have a runny nose? Do they have sneezing? Are their eyes watering? All those things you need to be watching for because maybe it's not a full-blown anaphylactic shock. But any kind of allergic reaction should send up red flags that maybe the next dose could be anaphylactic shock. Looking for skin, you know, hives. Are they itching? Do they have blistering? Are they weeping? Do they have wheezing? Again, if you can hear them breathing when you come into the room and they're wheezing, you need to stop the medication. And then, pain, nausea, diarrhea. We need to evaluate, is this an allergic reaction or is this a side effect of the medication? So again, doing a good thorough assessment and making sure that you know whether it's an allergic reaction or not before you give that next dose. Carcinogenic. We can't always know which drugs are going to cause cancer or which drugs cause birth defects. But you want to make sure that you're looking in your drug book and know that each drug is categorized for birth defects.

    11:26 Again, they're never going to ask you what the level is of a certain drug, but you need to understand that there are drugs out there and how you would know.

    11:34 So make sure you review your drug book for that. So not only do I need to understand as a nurse and you need to understand as a nurse what the benefits and the detriments are to medications. We need to make sure we're telling our patients for them to make informed decisions about what's going to happen to them, what's going to happen to their unborn children. They need to have all the information.

    11:55 And sometimes, it can be kind of scary talking about secondary cancers or birth defects. But again, my job as a nurse and your job as a nurse is to make sure that your patient understands the pros and cons of that medication. Not all medications are detrimental to the point of causing birth defects or causing cancer, but as a nurse, I need to know which ones are, and I know that by reading in my drug book. Chemotherapy, again, causing cancer. We know that a lot of chemotherapeutic drugs cause secondary cancers. Why? Because it goes to stomach, and it can't just target the cancer cells. It targets other cells. So again, before your patient starts chemotherapeutic meds, you need to make sure that they know the consequences, that they know what the outcomes could be. And then, drug and food interactions. The big one that should come to your mind is Coumadin, Warfarin.

    12:50 Can't be taken with green leafy vegetables, a lot of the medicines you can't take with grapefruit juice. If there are certain medications that point out in the drug book of what they can and can't be eaten or drink with, you need to make sure that you make note of those because those are easy questions on NCLEX to make sure that you catch that. Drug interactions. We know we've studied polypharmacy. We know there is a lot of people out there that are on a lot of different meds. When you're taking a lot of different medications, they have to interact one way or another. So, which ones are big no no's to put together? Again, you'll know that from your drug book. And the incompatibilities. When we think about incompatibilities, usually, we think about IV medications. You need to make sure you know which IV medications can't be mixed.

    13:35 And what's the danger there? Crystallization. We don't want crystals going into the bloodstream. So again, there are some drugs that are common drugs that can't be mixed. So make sure you're looking in your drug book for that.

    13:48 Okay. So we talked a little bit about grapefruit juice. You want to make sure you know that. We talked a little bit about Coumadin and vitamin K. But don't forget your tyramines, your cheeses that go with MAOIs. So again, you want to review your drug book and review the drugs that very commonly say, don't take it with this food or take it with that drink. Again, it's not all of them, but certain ones, I know that you've learned in nursing school and you need to make sure you keep those in mind. Again, combination drugs. You know, you can't give a drug that's going to raise a blood pressure and a drug that's going to lower a blood pressure at the same time. That's an easy one to figure out, but just remember that you're watching the medications that you're giving. And you need to have enough of an understanding to know are they going to contradict each other. And then, don't forget your over-the-counter medicines. Don't forget your herbal remedies. Again, many patients don't think that if you can buy it at the local grocery store that it's a medication.

    14:45 And we need to do good education to make sure that they are telling us what they're on and that they are medications and that they can contraindicate with other the medications that they're already on. So make sure you're checking on that as well.

    14:59 Again, make sure what you can mix into syringes and IVs, very very important.

    15:04 Review your body systems.

    15:08 Again, patients with liver and kidney disease, lot of the side effects and adverse reactions are going to be multiplied if their liver isn't working right in metabolism and their kidneys can't excrete. So, you need to make sure you know the history of your patient and you need to make sure you're looking at your liver labs and your kidney labs to see if they're going to be able to clear these medicines out, because again, especially drugs that cause toxicity, if they can't clear it out of their body, the toxicity level is going to go up a lot faster. And I as a nurse and you as a nurse, we need to keep that in mind so that we're watching for those side effects.

    15:47 Looking at some of your drugs, you'll notice that some of them aren't approved for pediatric patients, and it's because of their livers and their kidneys.

    15:57 Other drugs you need to really watch in your older client. Again, just because of the normal aging process, the liver and the kidneys don't function like they did before.

    16:06 So make sure you're watching for these adverse effects in the little ones and in the older patients as well. So, we talked about a lot, a lot of review. And a lot of times, students, I know, my students as well, think that there's no way that they can know every drug in the drug book.

    16:25 Remember, NCLEX doesn't expect you to know every drug in the drug book.

    16:29 What they're looking for is, are you safe in giving your drugs? And the way that you're safe is, is that you understand how drugs are given, and you understand side effects and adverse reaction so that you can watch for those in your patient and you can either prevent them or you can catch them in time that it doesn't cause injury to your patient. So make sure you're reading your pharmacology book and good luck on NCLEX. I'm Diana Shenefield. See you later.

    About the Lecture

    The lecture Adverse Effects/Contraindications/Side Effects/Interactions by Diana Shenefield, PhD is from the course Physiological Integrity. It contains the following chapters:

    • Review of Unintended Responses to Medications
    • Side Effects and Adverse Medication Effects
    • Toxicity and Allergic Reactions
    • Iatrogenic, Teratogenic and Carcinogenic
    • Medication Interactions

    Included Quiz Questions

    1. Tachycardia
    2. Bradycardia
    3. Lethargy
    4. Tachypnea
    1. Nausea and vomiting
    2. Patient complains of decreased hearing or hearing loss
    3. Elevation of serum BUN and/or creatinine
    4. Urine output of less than 600 ml daily
    1. To reduce side effects of the Thorazine
    2. To decrease the incidence of seizures
    3. To potentiate the action of Thorazine
    4. To improve and stabilize mood
    1. Evaluate patient’s intake of grapefruit juice
    2. Assess for evaluation of body temperature
    3. Evaluate rate, depth, and regularity of respirations
    4. Assess for weight loss by obtaining a daily weight
    1. “This is an expected side effect of the drug, and you should use caution and move slowly when standing up.”
    2. “You may be experiencing a toxic effect of the drug, and I will notify the physician”
    3. “Dizziness is not related to the drug, but I will need to ask you a few more questions.”(
    4. “Episodes of dizziness when moving are common symptoms of elevated blood pressure.”

    Author of lecture Adverse Effects/Contraindications/Side Effects/Interactions

     Diana Shenefield, PhD

    Diana Shenefield, PhD

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