Thsalbutamol eplerenone should bepby 50%.

NSAIDs
maypantihypertensive effects.
● Decrease in BP. Concurrent use of ACE inhibitors or
● Decrease in frequency and severity of Angiotensin II receptor blockers
anginal attacks. mayqrisk of hyperkalemia.
● Decrease in need for nitrate therapy.
● Increase in activity tolerance and sense INDICATIONS:
of well-being. Hypertension (alone, or with other
agents). LV systolic dysfunction and
evidence of
CLASSIFICATION: ALDOSTERONE HF post-MI.
RECEPTOR ANTAGONIST
GENERIC NAME: Eplerenone CONTRAINDCIATIONS:
BRAND NAME: Inspra Serum potassium _5.5 mEq/L; Type 2
diabetes with microalbuminuria
(for patients with HTN;qrisk of
RECOMMENDED DOSAGE, ROUTE, AND hyperkalemia); Serum creatinine
FREQUENCY:
Hypertension SIDE EFFECTS/ADVERSE REACTIONS:
PO (Adults): 50 mg daily initially; may CNS: dizziness, fatigue.
beqto 50 mg twice daily; Patients GI: abnormal liver function tests,
receiving abdominal pain, diarrhea.
concurrent moderate CYP3A4 inhibitors GU: albuminuria.
(erythromycin, saquinavir, verapamil, Endo: abnormal vaginal bleeding,
fluconazole)—25 mg once daily initially. gynecomastia.
HF Post-MI F and E: HYPERKALEMIA.
PO (Adults): 25 mg daily initially;qin 4 wk Metab: hypercholesterolemia,
to 50 mg daily; subsequent dose hypertriglyceridemia.
adjustmentsmay Misc: flu-like symptoms.
need to be made based on serum
potassiumconcentrations. NURSING RESPONSIBILITIES:

DRUG ACTION: Assessment

Blocks the effects of aldosterone by ● Monitor BP periodically during therapy.
attaching to mineralocorticoid receptors. ● Monitor prescription refills to
Therapeutic determine adherence.
Effects: Lowering of BP. Improves survival ● Lab Test Considerations: May cause
in patients with evidence of HF hyperkalemia. Monitor serum potassium
post-MI. levels prior to starting therapy, within the
Pharmacokinetics first wk, at 1 mo fol lowing start of
A: Well absorbed following oral therapy or dose adjustmentand
administration. periodically thereafter.
D: Unknown. Monitor serum potassium and serum
M: Half-life: 4–6 hr. creatinine in 3-7 days in patients who
E: Mostly metabolized by the liver start taking a moderate CYP3A4 inhibitor.
(CYP3A4 enzyme ● May causepserum sodium andqserum
system);_5%excreted unchanged by the triglyceride, cholesterol, ALT, GGT,
kidneys. creatinine, and uric acid levels.
Pharmacodynamics:
O: PO, UNKNOWN Potential Nursing Diagnoses
P: 1wk Decreased cardiac output (Indications)
D: 24hr Noncompliance (Patient/Family
Teaching)
DRUG-DRUG DRUG-FOOD Implementation
INTERACTIONS: ● Do not confuse Inspra with Spiriva.
Drug-Drug: Concurrent use of strong ● PO: Administer once daily. May be
inhibitors of the CYP3A4 enzyme system increased to twice daily if response is
(ketoconazole, itraconazole, nefazodone, inadequate.
clarithromycin, ritonavir, or nelfinavir)
significantlyqeffects of eplenerone; Patient/Family Teaching
concurrent use contraindicated. ● Instruct patient to take medication as
Concurrent directed at the same time each day, even
use of weak inhibitors of the CYP3A4 if feeling well.
enzyme system (erythromycin, ● Encourage patient to comply with
saquinavir, additional interventions for hypertension
fluconazole, verapamil) mayqeffects of (weight reduction, discontinuation of
eplerenone; initial dose of smoking, moderation of alcohol
consumption,regular exercise, stress

Page | 1
management). Medication controls, but Subcut (Adults): 5000 units IV, followed
does not cure, hypertension. by initial subcut dose of 10,000–20,000
● Instruct patient and family on correct units, then 8000–10,000 units q 8 hr or
technique for monitoring BP. Advise 15,000–20,000 units q 12 hr.
them to monitor BP at least weekly, and Prophylaxis of Thromboembolism
notify health care professional of Subcut (Adults): 5000 units q 8–12 hr
significantchanges. (may be started 2 hr prior to surgery).
● Inform patient not to use potassium Cardiovascular Surgery
supplements, salt substitutes containing IV (Adults): At least 150 units/kg (300
potassium, or other Rx, OTC, or herbal units/kg if procedure _60 min; 400
products without consulting health care units/kg if_60 min).
professional. Intraarterial (Neonates , Infants, and
● May cause dizziness. Caution patient to Children): 100–150 units/kg via an artery
avoid driving or other activities requiring prior to cardiac catheterization.
alertness until response to medication is Line Flushing
known. IV (Adults and Children): 10–100 units/mL
● Advise patient to notify health care (10 units/mL for infants _10 kg, 100
professional if dizziness, diarrhea, units/mL for all others) solution to fill
vomiting, rapid or irregular heartbeat, heparin lock set to needle hub; replace
lower extremity edema, or difficulty after each use.
breathing occur. Total ParenteralNutrition
● Advise patient to inform health care IV (Adults and Children): 0.5–1 units/mL
professional of treatment regimen prior (final solution concentration) to maintain
to treatment or surgery. line patency.
● Advise patient to notify health care Arterial Line Patency
professional if pregnancy is planned or Intraarterial (Neonates): 0.5–2 units/mL.
suspected. Advise patient to avoid breast
feeding during therapy. DRUG ACTION:
● Emphasize the importance of follow-up Potentiates the inhibitory effect of
exams to check serumpotassium. antithrombin on factor Xa and thrombin. In
Evaluation/Desired Outcomes low doses, prevents the conversion of
● Decrease in BP without appearance of prothrombin to thrombin by its effects on
side effects. factor Xa.
● Improvement in survival in patients Higher doses neutralize thrombin,
with evidence of HF post-MI. preventing the conversion of fibrinogen to
fibrin.
H. ANTICOAGULANT, ANTIPLATELET, Therapeutic Effects: Prevention of
AND THROMBOLYTIC DRUGS thrombus formation. Prevention of
extensionof existing thrombi (full dose).
A. ANTICOAGULANTS Pharmacokinetics:A Erratically absorbed
following subcut or IM administration.
CLASSIFICATION: DRUGS THAT D: Does not cross the placenta or enter
ACTIVATE ANTITHROMBIN; breast milk.
UNFRACTIONATED PB: Very high (to low-density
GENERIC NAME: Heparin lipoproteins, globulins, and fibrinogen).
BRAND NAME: Hepalean, Hep-Lock, Hep- M: T ½ : 1–2 hr
Lock U/P E: Probably removed by the
reticuloendothelial system (lymph nodes,
RECOMMENDED DOSAGE, ROUTE, AND spleen).
FREQUENCY: Pharmacodynamics:
Therapeutic Anticoagulation O: , UNKNOWN
IV (Adults): Intermittent bolus—10,000 P: 1wk
units, followed by 5000–10,000 units q4–6 D: 24hr
hr. Continuous infusion—5000 units (35–
70 units/kg), followed by 20,000–40,000 DRUG-DRUG DRUG-FOOD
units infused over 24 hr (approx. 1000 INTERACTIONS:
units/hr or 15–18 units/kg/hr). Heparin is frequently used concurrently
IV (Children 1 yr): Intermittent bolus—50– or sequentially with other agents
100 units/kg, followed by 50–100 units/kg affecting coagulation. The risk of
q 4 hr. Continuous infusion—Loading potentially serious
dose 75 units/kg, followed by 20 interactions is greatest with full
units/kg/hr, adjust to maintain aPTT of anticoagulation
60–85 sec. Drug-Drug: Risk of bleeding may beqby
IV (Neonates and Infants 1 yr): concurrent use of drugs that affect
Continuous infusion—Loading dose 75 platelet function, including aspirin,
units/kg, followed by 28 units/kg/hr, NSAIDs, clopidogrel, dipyridamole, some
adjust to maintain aPTT of 60–85 sec. penicillins, ticlopidine, abciximab,
eptifibitide, tirofiban, and dextran.

Page | 2
Risk of bleeding may beqby concurrent THROMBOSIS), anemia. Local: pain at
use of drugs that cause injection site. MS: osteoporosis (long-
hypoprothrombinemia, including term
quinidine, cefoperazone, cefotetan, and use).
valproic acid. Misc: fever, hypersensitivity.
Concurrent use of thrombolyticsqrisk of
bleeding. Heparins affect the NURSING RESPONSIBILITIES:
prothrombin time used in assessing the
response to warfarin. Digoxin, Assessment
tetracyclines, nicotine, ● Assess for signs of bleeding and
and antihistamines maypanticoagulant hemorrhage (bleeding gums; nosebleed;
effect of heparin. Streptokinase may be unusual bruising; black, tarry stools;
followed by relative resistance to hematuria; fall in haematocrit or BP;
heparin. guaiac-positive stools). Notify health care
Drug-Natural Products: increase risk of professional if these occur.
bleeding with arnica, anise, chamomile, ● Assess patient for evidence of
clove, dong quai, fever few, garlic, additional or increased thrombosis.
ginger, and Panax ginseng. Symptoms will depend on area of
involvement.
INDICATIONS: ● Monitor patient for hypersensitivity
Prophylaxis and treatment of various reactions (chills, fever, urticaria).
thromboembolic disorders including: ● Subcut: Observe injection sites for
Venous thromboembolism, Pulmonary hematomas, ecchymosis, or
emboli, Atrial fibrillation with inflammation.
embolization, Acute and chronic ● Lab Test Considerations: Monitor
consumptive coagulopathies, Peripheral activated partial thromboplastin time
arterial thromboembolism. (aPTT) and hematocrit prior to and
Used in very low doses (10–100 units) to periodically during therapy. When
maintain patency of IV catheters (heparin intermittent
flush) IV therapy is used, draw aPTT levels 30
min before each dose during initial
CONTRAINDCIATIONS: therapy and then periodically. During
Hypersensitivity; Uncontrolled bleeding; continuous administration, monitor aPTT
Severe thrombocytopenia; levels every 4 hr during early therapy.
Open wounds (full dose); Avoid use of For Subcut therapy, draw blood 4–6 hr
products containing benzyl alcohol in after injection.
premature infants. ● Monitor platelet count every 2–3 days
Use Cautiously in: Severe liver or kidney throughout therapy.
disease; Retinopathy (hypertensive or ● May cause hyperkalemia andqAST and
diabetic); Untreated hypertension; Ulcer ALT levels.
disease; Spinal cord or brain injury; ● Toxicity and Overdose: Protamine
History sulfate is the antidote. Due to short half-
of congenital or acquired bleeding life, overdose can often be treated by
disorder; Malignancy; OB: May be used withdrawing the drug.
during
pregnancy, but use with caution during Potential Nursing Diagnoses
the last trimester and in the immediate Ineffective tissue perfusion (Indications)
postpartumperiod; Risk for injury (Side Effects)
Geri: Women_60 yr haveqrisk of Implementation
bleeding. ● High Alert: Fatal hemorrhages have
Exercise Extreme Caution in: Severe occurred in pediatric patients due to
uncontrolled hypertension; Bacterial errors in which heparin sodium injection
endocarditis, bleeding disorders; GI vials were confused with heparin flush
bleeding/ulceration/pathology; vials. choice prior to administration.
Hemorrhagic Have second practitioner independently
stroke; Recent CNS or ophthalmologic check original order, dose calculation,
surgery; Active GI bleeding/ulceration; and infusion pump settings. Unintended
History of thrombocytopenia related to concomitant use of two heparin products
heparin (unfractionated heparin and LMW
heparins) has resulted in serious harm or
SIDE EFFECTS/ADVERSE REACTIONS: death. Review patients’ recent
GI: drug-induced hepatitis. Derm: (emergency department, operating room)
alopecia (long-term use), rashes, and current medication administration
urticaria. records before administering any heparin
Hemat: or LMW heparin product. Do not confuse
BLEEDING, HEPARIN-INDUCED heparin with Hespan (hetastarch in
THROMBOCYTOPENIA (HIT) (WITH OR sodium chloride). Do not confuse vials of
WITHOUT heparin with vials of insulin.

Page | 3
● Inform all personnel caring for patient ● Prevention of deep vein thrombosis
of anticoagulant therapy. Venipunctures and pulmonary emboli.
and injection sites require application of ● Patency of IV catheters.
pressure to prevent bleeding or
hematoma formation. Avoid IM injections
of other medications; hematomas may
develop. CLASSIFICATION: LOW-MOLECULAR-
● In patients requiring long-term WEIGHT HEPARIN
anticoagulation, oral anticoagulant
therapy should be instituted 4–5 days GENERIC NAME: Enoxaparin
prior to discontinuing heparin therapy. BRAND NAME: Lovenox
● Solution is colorless to slightly yellow.
RECOMMENDED DOSAGE, ROUTE, AND
IV Administration FREQUENCY:
● pH: 5.0–8.0. VTE Prophylaxis
● Subcut: Administer deep into subcut Subcut (Adults): Knee replacement
tissue. Alternate injection sites between surgery—30 mg q 12 hr starting 12–24 hr
arm and the left and right abdominal wall after surgery for 7–10 days; Hip
above the iliac crest. Inject entire length replacement—30 mg q 12 hr starting 12–
of needle at a 45_- or 90_-angle into a 24 hr postop or 40 mg once daily starting
skin fold held between thumb and 12 hr before surgery (either dose may be
forefinger; hold skin fold throughout continued for 7–14 days; continued
injection. Do not aspirate or massage. prophylaxis with 40 mg once daily may
Rotate sites frequently. Do not be continued for up to 3 wk); Abdominal
administer IM because of danger of surgery—40 mg once daily starting 2 hr
hematoma formation. Solution should be before surgery and then continued for 7–
clear; do not inject solution containing 12 days or until ambulatory (up to 14
particulate matter. days); Medical patients with acute illness
● Direct IV: Diluent: Administer loading —40 mg once daily for 6–14 days.
dose undiluted. Concentration: Varies Subcut (Infants and Children 2mo—18
depending upon vial used. Rate: yr): 0.5 mg/kg/dose every 12 hr.
Administer over at least 1 min. Loading Subcut (Infants 1–2mo): 0.75 mg/kg/dose
dose given before continuous infusion. every 12 h
● Continuous Infusion: Diluent: Dilute
25,000 units of heparin in 250–500 mL of
0.9% NaCl or D5W. Premixed infusions DRUG ACTION:
are already diluted and ready to use. Potentiates the inhibitory effect of
Admixed solutions stable for 24 hr at antithrombin on factor Xa and thrombin.
room temperature or if refrigerated. Therapeutic Effects: Prevention of
Premixed infusion stable for 30 days thrombus formation.
once overwrap removed. Concentration: Pharmacokinetics
50–100 units/mL. Rate: See Absorption: 100% absorbed after subcut
Route/Dosage section. Adjust to maintain administration.
therapeutic aPTT. Use an infusion pump Distribution: Unknown.
to ensure accuracy. Metabolism and Excretion: Metabolized
in the liver, primarily renally eliminated
Patient/Family Teaching Clearancepby 30% in renal impairment
● Advise patient to report any symptoms (CCr_30 ml/min).
of unusual bleeding or bruising to health Half-life: Single dose: 4.5 hr; Repeat
care professional immediately. dosing: 7 hr.
● Instruct patient not to take medications Pharmacodynamics:
containing aspirin or NSAIDs while on O: , UNKNOWN
heparin therapy. P: 3-5hr
● Caution patient to avoid IM injections D: 12hr
and activities leading to injury and to use
a soft toothbrush and electric razor DRUG-DRUG DRUG-FOOD
during heparin therapy. INTERACTIONS:
● Advise patient to inform health care Drug-Drug: Risk of bleeding may beqby
professional of medication regimen prior concurrent use of drugs that affect
to treatment or surgery. platelet function and coagulation,
● Patients on anticoagulant therapy including warfarin, aspirin, thrombolytic
should carry an identification card with agents, NSAIDs, dipyridamole, some
this information at all times. penicillins, clopidogrel, abciximab,
eptifibatide,
Evaluation/Desired Outcomes tirofiban, ticlopidine, and dextran.
● Prolonged partial thromboplastin time
(PTT) of 1.5–2.5 times the control, INDICATIONS:
without signs of hemorrhage.

Page | 4
Prevention of venous thromboembolism
(VTE) (deep vein thrombosis (DVT)
and/or pulmonary embolism (PE)) in
surgical or medical patients. Treatment
of DVT with or without PE (with warfarin).
Prevention of ischemic complications
(with aspirin)
from unstable angina and non-ST-
segment-elevation MI. Treatment of acute
ST-segment- elevation MI (with
thrombolytics or percutaneous coronary
intervention)
CONTRAINDCIATIONS:
Contraindicated in: Hypersensitivity to
benzyl alcohol (multidose vial); Positive
in vitro test for antiplatelet antibody in
the presence of enoxaparin;
Active, major bleeding.
Use Cautiously in: Severe hepatic or
renal disease (adjust dose if CCr _30
mL/min); Retinopathy (hypertensive or
diabetic); Uncontrolled hypertension;
Recent
history of ulcer disease; History of
congenital or acquired bleeding disorder;
Women_45 kg and men _57 kg
(qexposure to enoxaparin withqrisk of
bleeding; weightadjusted dosing
recommended); Malignancy; Geri: May
haveqrisk of bleeding due to age-
relatedpin renal function; OB, Lactation,
Pedi: Safety not established; should not
be used in pregnant patients with
prosthetic heart valves without careful
monitoring. Exercise Extreme Caution in:
Severe uncontrolled hypertension;
Bacterial endocarditis;
Bleeding disorders; GI
bleeding/ulceration/pathology;
Hemorrhagic stroke; Recent CNS or
ophthalmologic surgery; History of
thrombocytopenia related to heparin;
Spinal/epidural anesthesia or spinal
puncture (qrisk of spinal/epidural
hematoma that may lead to long-termor
permanent paralysis).
SIDE EFFECTS/ADVERSE REACTIONS:
CNS: dizziness, headache, insomnia.
CV: edema.
GI: constipation,qliver enzymes, nausea,
vomiting.
GU: urinary retention. Derm: alopecia,
ecchymoses, pruritus, rash, urticaria.
F and E: hyperkalemia. Hemat: bleeding,
anemia, eosinophilia, thrombocytopenia.
Local: erythema at injection site,
hematoma, irritation, pain.
MS: osteoporosis.
Misc: fever.
NURSING RESPONSIBILITIES:
Assessment
● Assess for signs of bleeding and
hemorrhage (bleeding gums; nosebleed;
unusual bruising; black, tarry stools;
hematuria; fall in haematocrit or BP;
guaiac-positive stools); bleeding from
surgical site. Notify health care
professional if these occur.
● Assess patient for evidence of
additional or increased thrombosis.
Symptoms depend on area of
involvement.
● Assess location, duration, intensity,
and precipitating factors of anginal pain.
● Monitor patient for hypersensitivity
reactions (chills, fever, urticaria). Report
signs to health care professional.
● Monitor patients with epidural
catheters frequently for signs and
symptoms of neurologic impairment.
Delay placement or removal of catheter
for at least 12 hours after administration
of lower doses (30 mg once or twice daily
or 40 mg
once daily) and at least 24 hours after
administration of higher doses (0.75
mg/kg twice daily, 1 mg/kg twice daily, or
1.5 mg/kg once daily) of enoxaparin.
Monitor for signs and symptoms of
neurological impairment (midline back
pain, sensory and motor deficits
[numbness or weakness in lower limbs],
bowel and/or bladder dysfunction)
frequently if epidural or spinal anesthesia
or lumbar puncture is done during
therapy.
● Subcut: Observe injection sites for
hematomas, ecchymosis, or
inflammation.
● Lab Test Considerations: Monitor CBC,
platelet count, and stools for occult
blood periodically during therapy.
thrombocytopenia occurs, monitor
closely. If hematocrit decreases
unexpectedly, assess patient for
potential bleeding sites.
● Special monitoring of clotting times
(aPTT) is not necessary in most patients.
Monitoring of the aPTT may be
considered in certain patient populations
(such as obese patients or patients with
renal insufficiency).
● Monitoring of Antifactor Xa levels may
be necessary to titrate doses in pediatric
patients Therapeutic range 0.5–1 unit/mL.
● May causeqin AST and ALT levels.
● May cause hyperkalemia.
● Toxicity and Overdose: For overdose,
protamine sulfate 1 mg for each mg of
enoxaparin should be administered by
slow IV injection.
Potential Nursing Diagnoses
Ineffective tissue perfusion (Indications)
Risk for injury (Side Effects)
Implementation
● Do not confuse Lovenox with Levemir.
● Cannot be used interchangeably (unit
for unit) with unfractionated heparin or
other low-molecular-weight heparins.
● Subcut: Administer deep into subcut
tissue. Alternate injection sites daily
between the left and right anterolateral
Page | 5
and left and right posterolateral mg) for 2–4 days then adjust daily dose
abdominal wall. Inject entire length of by results of INR, use 0.1 mg/kg if liver
needle at a 45_ or 90_ angle into a skin dysfunction
fold held between thumb and forefinger; is present. Maintenance dose range—
hold skin fold throughout injection. Do 0.05–0.34 mg/kg/day.
not aspirate or massage. Rotate sites
frequently. Do not administer IM because DRUG ACTION:
of danger of hematoma formation. Interferes with hepatic synthesis of vitamin
Solution should be clear, colorless to K-dependent clotting factors (II, VII, IX, and
pale yellow; do not inject olution X). Therapeutic Effects: Prevention of
containing particulatematter. thromboembolic events.
● If excessive bruising occurs, ice-cube Pharmacokinetics
massage of site before injection may A: Well absorbed from the GI tract after
lessen bruising. oral administration.
● To avoid the loss of drug, do not expel D: Crosses the placenta but does not
the air bubble from prefilled syringes enter breast milk.
before the injection. Use a tuberculin Protein Binding: 99%.
syringe when using multidose vials to M: Half-life: 42 hr.
ensure correct dose. E: Metabolized by the liver.
● To minimize risk of bleeding after Pharmacodynamics:
vascular instrumentation for unstable O: PO, IV, 36-72hr
angina, recommended intervals between P: 5-7days
doses should be followed closely. Leave D: 2-5days
vascular access sheath in place for 6–8
hr after enoxaparin dose. Give next DRUG-DRUG DRUG-FOOD
enoxaparin dose _6–8 hr after sheath INTERACTIONS:
removal. Observe site for bleeding or Drug-Drug: Abciximab, androgens,
hematoma formation. capecitabine, cefotetan,
Patient/Family Teaching chloramphenicol,
● Advise patient to report any symptoms clopidogrel, disulfiram, fluconazole,
of unusual bleeding or bruising, fluoroquinolones,
dizziness, itching, rash, fever, swelling, itraconazole,metronidazole (including
or difficulty breathing to health care vaginal use), thrombolytics, eptifibatide,
professional immediately. tirofiban, ticlopidine, sulfonamides,
● Instruct patient not to take aspirin, quinidine, quinine, NSAIDs, valproates,
naproxen, or ibuprofen without and aspirin mayqthe response to
consulting health care professional while warfarin andqthe risk of bleeding.
on enoxaparin therapy. Chronic use of acetaminophen mayqthe
Evaluation/Desired Outcomes risk of bleeding. Chronic alcohol
● Prevention of deep vein thrombosis ingestion maypaction of warfarin; if
and pulmonary embolism. chronic alcohol abuse results in
● Resolution of acute deep vein significant liver damage, action
thrombosis. of warfarin may beqdue topproduction of
● Prevention of ischemic complications clotting factor. Acute alcohol ingestion
(with aspirin) in patients with unstable mayqaction of warfarin. Barbiturates,
angina or non-Q-wave MI. carbamazepine, rifampin, and hormonal
● Treatment of acute ST-segment contraceptives containing estrogen
elevation myocardial infarction maypthe anticoagulant response to
warfarin. Many other drugs may affect the
activity of warfarin.
CLASSIFICATION: VITAMIN K Drug-Natural Products: St. John’s
ANTAGONIST wortpeffect.qbleeding risk with anise,
GENERIC NAME: Warfarin arnica, chamomile, clove, dong quai,
BRAND NAME: Coumadin, Jantoven fenugreek, feverfew, garlic, ginger,
ginkgo, Panax ginseng, licorice, and
RECOMMENDED DOSAGE, ROUTE, AND others.
FREQUENCY: Drug-Food: Ingestion of large quantities
PO, IV (Adults): 2–5 mg/day for 2–4 days; of foods high in vitamin K content
then adjust daily dose by results of may antagonize the anticoagulant effect
INR. Initiate therapy with lower doses in of warfarin
geriatric or debilitated patients or in
Asian INDICATIONS:
patients or those with CYP2C9*2 and/or Prophylaxis and treatment of: Venous
CYP2C9*3 alleles or VKORC1 AA thrombosis, Pulmonary embolism, Atrial
genotype. fibrillation with embolization.
PO, IV (Children 1 mo): Initial loading Management of myocardial infarction:
dose—0.2 mg/kg (maximum dose: 10 Decreases risk of

Page | 6
death, Decreases risk of subsequent MI, acceptable when risk is lower. Heparin
Decreases risk of future thromboembolic may affect the PT/INR; draw blood for
events. Prevention of thrombus PT/INR in patients receiving
formation and embolization after both heparin and warfarin at least 5 hr
prosthetic valve after the IV bolus dose, 4 hr after
placement. cessation of IV infusion, or 24 hr after
subcut heparin injection. Asian patients
CONTRAINDCIATIONS: and those who carry the CYP2C9*2 allele
Contraindicated in: Uncontrolled bleeding; and/or the CYP2C9*3 allele, or those with
Open wounds; Active ulcer disease; VKORC1
Recent brain, eye, or spinal cord injury or AA genotype may requiremore frequent
surgery; Severe liver or kidney disease; monitoring and lower doses.
Uncontrolled ● Monitor hepatic function and CBC
hypertension; OB: Crosses placenta and before and periodically throughout
may cause fatal hemorrhage in therapy.
the fetus. May also cause ● Monitor stool and urine for occult blood
congenitalmalformation. before and periodically during therapy.
Use Cautiously in: Malignancy; Patients ● Toxicity and Overdose: Withholding 1 or
with history of ulcer or liver disease; more doses of warfarin is usually
History sufficient if INR is excessively elevated
of poor compliance; Women with or if minor bleeding occurs. If overdose
childbearing potential; occurs or anticoagulation needs to be
); Pedi: Has been used safely but may immediately reversed, the antidote is
require more frequent PT/INR vitamin K (phytonadione,
assessments; AquaMEPHYTON). Administration of
Geri: Due to greater than expected whole blood or plasma also may be
anticoagulant response, initiate and required in severe bleeding because of
maintain at lower doses the delayed onset of vitamin K.
Potential NursingDiagnoses
SIDE EFFECTS/ADVERSE REACTIONS: Ineffective tissue perfusion (Indications)
GI: cramps, nausea. Risk for injury (Side Effects)
Derm: dermal necrosis. Hemat: Implementation
BLEEDING. ● High Alert: Medication errors involving
Misc: fever. anticoagulants have resulted in serious
harm or death from internal or
intracranial bleeding. Before
NURSING RESPONSIBILITIES: administering, evaluate recent INR or PT
Assessment results and have second practitioner
● Assess for signs of bleeding and independently check original order.
hemorrhage (bleeding gums; nosebleed; ● Do not confuse Coumadin (warfarin) with
unusual bruising; tarry, black stools; Avandia (rosiglitazone) or Cardura
hematuria; fall in haematocrit or BP; guaiac- (doxazosin). Do not confuse Jantoven
positive stools, urine, or nasogastric (warfarin) with Janumet
aspirate). (sitagliptin/metformin) or Januvia
● Assess for evidence of additional or (sitagliptin).
increased thrombosis. Symptoms ● Because of the large number of
depend on area of involvement. medications capable of significantly altering
● Geri: Patients over 60 yr exhibit greater warfarin’s effects, careful monitoring is
than expected PT/INR response. Monitor recommended when new agents are started
for side effects at lower therapeutic or other agents are discontinued. Interactive
ranges. potential should be evaluated for all new
● Pedi: Achieving and maintaining medications (Rx, OTC, and natural
therapeutic PT/INR ranges may be more products).
difficult in pediatric patients. Assess ● PO: Administer medication at same
PT/INR levels more frequently. time each day. Medication requires 3–5
● Lab Test Considerations: Monitor PT, INR days to reach effective levels; usually
and other clotting factors frequently begun while patient is still on heparin.
during therapy. Therapeutic PT ranges ● Do not interchange brands; potencies
1.3–1.5 times greater than control; may not be equivalent.
however, the INR, a standardized system Patient/Family Teaching
that provides a common basis for ● Instruct patient to take medication as
communicating and interpreting PT directed. Take missed doses as soon as
results, is usually referenced. Normal INR remembered that day; do not double
(not on anticoagulants) is 0.8–1.2. An INR doses. Inform health care professional of
of 2.5–3.5 is recommended for patients at missed doses at time of checkup or lab
very high risk of embolization (for tests. Inform patients that anticoagulant
example, patients with mitral valve effect may persist for 2 5 days following
replacement and ventricular discontinuation. Advise patient to
hypertrophy). Lower levels are

Page | 7
readMedication Guide before starting
therapy and with each Rx refill. DRUG ACTION:
● Review foods high in vitamin K. Patient Acts as a direct inhibitor of thrombin.
should have consistent limited intake of Therapeutic Effects: Lowered risk of
these foods, as vitamin K is the antidote thrombotic sequelae (stroke and systemic
for warfarin, and alternating intake of embolization) of non-valvular atrial
these foods will cause PT levels to fibrillation.
fluctuate. Advise patient to avoid Pharmacokinetics
cranberry juice or products during Absorption: 3–7% absorbed following oral
therapy. administration.
● Caution patient to avoid IM injections Distribution: Unknown.
and activities leading to injury. Instruct Metabolism and Excretion: Of the amount
patient to use a soft toothbrush, not to absorbed, mostly excreted by kidneys
floss, and to shave with an electric razor (80%); 86% of ingested dose is
during warfarin therapy. Advise patient eliminated in feces due to poor
that venipunctures and injection sites bioavailability.
require application of pressure to prevent Half-life: 12–17 hr.
bleeding or hematoma formation. Pharmacodynamics:
● Advise patient to report any symptoms of O: within hours
unusual bleeding or bruising (bleeding P: unknown
gums; nosebleed; black, tarry stools; D: 2 days
hematuria; excessive menstrual flow) and
pain, color, or temperature change to any DRUG-DRUG DRUG-FOOD
area of your body to health care professional INTERACTIONS:
immediately. Patients with a deficiency in Drug-Drug: Concurrent use of other
protein C and/or S mediated anticoagulants, antiplatelet agents,
anticoagulant response may be at greater antifibrinolytics, heparins, prasugrel,
risk for tissue necrosis. clopidogrel, or chronic use of NSAIDs
● Instruct patient not to drink alcohol or take increase risk of bleeding. Concurrent use
other Rx, OTC, or herbal products, of P-gp inducers including rifampinplevels
especially those containing aspirin or and effectiveness; avoid concurrent use.
NSAIDs, or to start or stop any new P-gp inhibitors, including dronedarone and
medications during warfarin therapy without ketoconazole (systemic) mayqlevels and
advice of health care professional. the risk of bleeding; concomitant use
● Advise patient to notify health care should be avoided in patients with CCr
professional if pregnancy is planned or 15–30 mL/min
suspected or if breast feeding.
● Instruct patient to carry identification INDICATIONS:
describing medication regimen at all To reduce the risk of stroke/systemic
times and to inform all health care embolization associated with non-
personnel caring for patient on valvular
anticoagulant therapy before lab tests, atrial fibrillation
treatment, or surgery.
● Emphasize the importance of frequent lab
tests to monitor coagulation factors. CONTRAINDCIATIONS:
Evaluation/Desired Outcomes Hypersensitivity; Active pathological
● Prolonged PT (1.3–2.0 times the bleeding; Concurrent use of P—
control; may vary with indication) or INR glycoprotein (P-gp) inducers; Prosthetic
of 2–4.5 without signs of hemorrhage heart valves (mechanical or
bioprosthetic).
Use Cautiously in: Concurrent
CLASSIFICATION: DIRECT THROMBIN medications/pre-existing conditions
INHIBITORS thatqbleeding risk (other anticoagulants,
GENERIC NAME: Dabigatran antiplatelet agents, antifibrinolytics,
BRAND NAME: Pradaxa heparins, chronic NSAID use, labor and
delivery); Renal impairment; Surgical
RECOMMENDED DOSAGE, ROUTE, AND procedures (discontinue 1–2 days prior if
FREQUENCY: CCr _50 mL/min or 3–4 days prior if CCr
PO (Adults): 150 mg twice daily. _50 mL/min; Geri: increase risk of
Renal Impairment bleeding; Lactation: Use cautiously during
PO (Adults): CCr 30–50 mL/min and breast feeding;
taking dronedarone or systemic Pedi: Safety and effectiveness not
ketoconazole— established.
75 mg twice daily; CCr 15–30 mL/min—75
mg twice daily; CCr 15–30 SIDE EFFECTS/ADVERSE REACTIONS:
mL/min and taking P-gp inhibitor—Avoid GI: abdominal pain, diarrhea, dyspepsia,
concomitant use; CCr_15 mL/min— gastritis, nausea. Hemat: BLEEDING,
Not recommended thrombocytopenia. Misc: ANGIOEDEMA,
hypersensitivity reactions including

Page | 8
ANAPHYLAXIS.
NURSING RESPONSIBILITIES:
Assessment
● Assess .for symptoms of stroke or
peripheral vascular disease periodically
during therapy.
● Assess for symptoms on bleeding and
blood loss; may be fatal.
● Lab Test Considerations: Use aPTT or
ECT, not INR, to assess anticoagulant
activity, if needed.
● Monitor renal function prior to and
periodically during therapy. Patients with
renal impairmentmay require dose
reduction or discontinuation.
Potential NursingDiagnoses
Activity intolerance
Implementation
● When converting from warfarin,
discontinue warfarin and start dabigatran
when
INR is_2.0.
● When converting from dabigatran to
warfarin, adjust starting time based on
creatinine clearance. For CCr _50
mL/min, start warfarin 3 days before
discontinuing dabigatran. For CCr 31–50
mL/min, start warfarin 2 days before
discontinuing dabigatran. For CCr 15–30
mL/min, start warfarin 1 day before
discontinuing dabigatran. For CCr _15
mL/min, no recommendations can be
made.
INR will better reflect warfarin’s effect
after dabigatran has been stopped for at
least 2 days.
● When converting from parenteral
anticoagulants, start dabigatran up to 2
hrs before next dose of parenteral drug is
due or at time of discontinuation of
parenteral therapy.
● When converting to dabigatran from
parenteral anticoagulants, wait 12 hrs
(CCr _30 mL/min) or 24 hr (CCr _30
mL/min) after last dose of dabigatran
before initiating parenteral anticoagulant
therapy.
● For surgery, discontinue dabigatran 1–
2 days (CrCL _50 mL/min) or 3–5 days
(CCr _50 mL/min) before invasive or
surgical procedures; consider longer
times for major surgery, spinal puncture,
or placement of a spinal or epidural
catheter.
If surgery cannot be delayed, bleeding
risk isq. Assess bleeding risk with ecarin
clotting time (ECT) or aPTT is ECT is not
available.
● PO: Administer twice daily without
regard to food. Swallow capsule whole;
do not open, crush, or chew;may result
in increased exposure.
● If dabigatran is discontinued, consider
starting another anticoagulant;
discontinuation of dabigatran increases
risk of thrombotic events.
Patient/Family Teaching
● Instruct patient to take dabigatran as
directed. Take missed doses as soon as
remembered within 6 hrs. If _6 hr until
next dose, skip dose and take next dose
when scheduled; do not double doses.
Do not discontinue without consulting
health care professional. If temporarily
discontinued, restart as soon as
possible. Store dabigatran at room
temperature. After opening bottle, use
within 4 mo; discard unused dabigatran
after 4mo.
● Inform patient that they may bleed
more easily or longer than usual. Advise
patient to notify health care professional
immediately if signs of bleeding (unusual
bruising, pink or brown urine, red or
black, tarry stools, coughing up blood,
vomiting blood, pain or swelling in a
joint, headache, dizziness, weakness,
recurring nose bleeds, unusual bleeding
from gums, heavier than normal
menstrual bleeding, dyspepsia,
abdominal pain, epigastric pain) occurs.
● Advise patient to notify health care
professional of medication regimen prior
to treatment or surgery.
● Instruct patient to notify health care
professional of all Rx or OTC
medications, vitamins, or herbal
products being taken and consult health
care professional before taking any new
medications.
● Advise female patient to notify health
care professional if pregnancy is planned
or suspected or if breast feeding.
Evaluation/Desired Outcomes
● Reduction in the risk of stroke and
systemic embolism.
CLASSIFICATION: DIRECT FACTOR Xa
INHIBITORS
GENERIC NAME: Rivaroxaban
BRAND NAME: Xarelto
RECOMMENDED DOSAGE, ROUTE, AND
FREQUENCY:
Prevention of Deep Vein Thrombosis
Following Knee or Hip Replacement
Surgery
PO (Adults): 10 mg once daily, initiated
6–10 hr post-operatively (when
hemostasis
is achieved) continued for 35 days after
hip replacement or 12 days after knee
replacement.
Reduction in Risk of Stroke/Systemic
Embolism in Nonvalvular
Atrial Fibrillation
PO (Adults): 20 mg once daily with
eveningmeal.
Renal Impairment
PO (Adults): CCr 15–50mL/min—15 mg
once daily with evening meal.
Page | 9
Treatment of and Reduction in Risk of (atrial fibrillation)]; Prosthetic heart
Recurrence of Deep Vein valves;Moderate to severe hepatic
Thrombosis or PulmonaryEmbolism impairment (Child-Pugh B or C) or any
PO (Adults): 15 mg twice daily for 21 liver pathology resulting in
days, then 20 mg once daily for altered coagulation; Lactation: Avoid
remainder of breast feeding;
treatment period Use Cautiously in: Neuroaxial spinal
anesthesia or spinal puncture, especially
DRUG ACTION: if
Acts as selective factor X inhibitor that concurrent with an indwelling epidural
blocks the active site of factor Xa, catheter, drugs affecting hemostasis,
inactivating the cascade of coagulation. history
Therapeutic Effects: Prevention of blood or traumatic/repeated spinal puncture or
clots and subsequent pulmonary emboli spinal deformity (increase risk of spinal
following knee/hip replacement surgery. hematoma); Use of feeding tube (proper
Pharmacokinetics placement of tube must be documented
A: Well absorbed (80%) following oral in insure absorption);OB: Use only if
administration; absorption occurs in the potential benefit outweighs potential risk.
stomach and decreases as it enters the
small intestine. SIDE EFFECTS/ADVERSE REACTIONS:
D: Unknown. CNS: syncope. Derm: blister, prutitus.
M: Half-life: 5–9 hr. Hemat: BLEEDING. Local: wound
E: 51% metabolized by the liver; 36% secretion.
excreted unchanged in urine. Metabolites MS: extremity pain,muscle spasm.
do not have anticoagulant activity.
Pharmacodynamics: NURSING RESPONSIBILITIES:
O: PO, unknown Assessment
P: 2-4hr ● Assess for signs of bleeding and
D: 24hr hemorrhage (bleeding gums; nosebleed;
unusual bruising; black, tarry stools;
DRUG-DRUG DRUG-FOOD hematuria; fall in haematocrit or BP;
INTERACTIONS: guaiac-positive stools); bleeding from
Drug-Drug: Rivaroxaban acts as a surgical site. Notify health care
substrate of these subsets of the professional if these occur.
ketoconazole, itraconazole, ● Monitor patients with epidural
lopinavir/ritonavir, ritonavir, catheters frequently for signs and
indinavir/ritonavir, and conivaptan symptoms of neurologic impairment.
mayqlevels; avoid concomitant use. Epidural catheter should not be removed
carbamazepine, phenytoin, or rifampin earlier than 18 hrs after last
may decrease levels; avoid concomitant administration of rivaroxaban; next dose
use. Concurrent use with aspirin or should be at least 6 hrs after catheter
NSAIDs may increasethe risk of bleeding. removal.
Concurrent use of clopidogrel or other ● Lab Test Considerations: May
anticoagulants mayqrisk of bleeding and causeqserum AST, ALT, total bilirubin
should be avoided. and
Drug-Natural Products: St. John’s GGT levels.
wortplevels of rivaroxaban and should be Potential NursingDiagnoses
avoided. Ineffective tissue perfusion (Indications)
Risk for injury (Side Effects)
INDICATIONS: Implementation
Prevention of deep vein thrombosis that ● When switching from warfarin to
may lead to pulmonary embolism rivaroxaban, discontinue warfarin and
following knee or hip replacement start rivaroxaban as soon as INR _3.0 to
surgery. Reduction in risk of avoid periods of inadequate
stroke/systemic embolism in anticoagulation. When switching from
patients with nonvalvular atrial anticoagulants other thanwarfarin to
fibrillation. Treatment of and reduction in rivaroxaban, start rivaroxaban 0 to 2 hr
risk of recurrence prior to next scheduled evening dose and
of deep vein thrombosis or pulmonary omit dose of other anticoagulant. For
embolism. continuous heparin, discontinue heparin
and administer rivaroxaban at same time.
CONTRAINDCIATIONS: When switching from rivaroxaban to
Contraindicated in: Hypersensitivity; warfarin or other anticoagulants, No data
Active major bleeding; Severe renal is available. May discontinue rivaroxaban
impairment and begin both parenteral anticoagulant
[CCr _30 mL/min (deep vein and warfarin at time of next rivaroxaban
thrombosis/pulmonary embolism dose.
treatment or prevention); CCr _15 mL/min

Page | 10
● Discontinue at least 24 hr prior to
surgery and other interventions. Restart
as soon as hemostasis has been
restablished.
● If rivaroxaban must be discontinued for
other than bleeding, consider replacing
with another anticoagulant;
discontinuation increases risk of
thrombotic events.
● PO: Administer first dose 6–10 hrs after
surgery, once hemostasis has been
established. 10 mg tablet may be
administered without regard to food; 15
mg and 20 mg tablet should be taken
with food.
● If unable to swallow tablet, 15 mg and
20 mg tablets may be crushed, mixed
with applesauce, and administered
immediately after mixing. Follow dose
immediately with food. Tablets are stable
in applesauce for up to 4 hr.
● If administering crushed tablet via GI
feeding tube, check placement of tube.
Rivaroxaban is absorbed from the GI
tract, not the small intestine. Suspend
crushed tablet in 50 mL water and
administer. Follow administration of 15
mg or 20 mg tablet immediately with
food.
Patient/Family Teaching
● Instruct patient to take medication as
directed. Take missed doses as soon as
remembered that day. If taking 15 mg
twice daily, may take two 15 mg tablets to
achieve 30 mg daily dose, then return to
regular schedule. If taking 10 mg, 15 mg,
or 20 mg once daily, take missed dose
immediately. Inform health care
professional of missed doses at time of
checkup or lab tests. Inform patients that
anticoagulant effect may persist for 2–5
days following discontinuation. Advise
patient to read Medication Guide before
starting therapy and with each Rx refill in
case of changes. Caution patients not to
discontinue medication early without
consulting health care professional.
● Advise patient to report any symptoms
of unusual bleeding or bruising (bleeding
gums; nosebleed; black, tarry stools;
hematuria; excessive menstrual flow)
and symptoms of spinal or epidural
hematoma (tingling;
numbness, especially in lower
extremities; muscular weakness) to
health care professional immediately.
● Instruct patient not to drink alcohol or
take other Rx, OTC, or herbal products,
especially those containing aspirin or
NSAIDs, or to start or stop any new
medications during rivaroxaban therapy
without advice of health care
professional.
● Advise female patients to notify health
care professional if pregnancy is planned
or suspected or if breast feeding.
Evaluation/Desired Outcomes
● Prevention of blood clots and
subsequent pulmonary emboli following
knee/hip replacement surgery. Duration
of treatment is 35 days for patients with
hip replacement and 12 days for patients
with knee replacement surgery.
CLASSIFICATION: SELECTIVE FACTOR
Xa INHIBITOR
GENERIC NAME: Fondaparinux
BRAND NAME: Arixtra
RECOMMENDED DOSAGE, ROUTE, AND
FREQUENCY:
Treatment of DVT/PE
Subcut (Adults):_50 kg—5mg once daily
for at least 5 days warfarin may be
started within 72 hr of fondaparinux (has
been used for up to 26 days); 50–100 kg
—7.5 mg once daily for at least 5 days
until therapeutic anticoagulation with
warfarin is achieved (INR_2 for 2
consecutive days);_100 kg—10 mg once
daily for at least 5 days until therapeutic
anticoagulation with warfarin is achieved
(INR _2 for 2 consecutive days); warfarin
may be started within 72 hr of
fondaparinux.
Prevention of DVT/PE
Subcut (Adults): 2.5 mg once daily,
starting 6–8 hr after surgery, continuing
for
5–9 days (up to 11 days) following
abdominal surgery or knee/hip
replacement or continuing for 24 days
following hip fracture surgery (up to 32
days).
DRUG ACTION:
Binds selectively to antithrombin III (AT III).
This binding potentiates the neutralization
(inactivation) of active factor X (Xa).
Therapeutic Effects: Interruption of the
coagulation cascade resulting in inhibition of
thrombus formation. Prevention of thrombus
formation decreases the risk of pulmonary
emboli.
Pharmacokinetics
A: 100% absorbed following
subcutaneous administration.
D: Distributes mainly throughout the
intravascular space.
M: Half-life: 17–21 hr.
E: Eliminatedmainly unchanged in urine.
Pharmacodynamics:
O: rapid
P: 3hr
D: 24hr
DRUG-DRUG DRUG-FOOD
INTERACTIONS:
Drug-Drug: Risk of bleeding may beqby
concurrent use of warfarin or drugs that
affect platelet function, including aspirin,
NSAIDs, dipyridamole, some
cephalosporins, valproates, clopidogrel,
Page | 11
ticlopidine, abciximab, eptifibatide, Assessment
tirofiban, and dextran. ● Assess for signs of bleeding and
Drug-Natural Products: increase risk of hemorrhage (bleeding gums; nosebleed;
bleeding with arnica, chamomile, clove, unusual bruising; black, tarry stools;
dong quai, feverfew, garlic, ginger, hematuria; fall in hematocrit; sudden
gingko, Panax ginseng, and others. drop in BP; guaiac positive stools);
bleeding from surgical site. Notify health
INDICATIONS: care professional if these occur.
Prevention and treatment of deep vein ● Assess for evidence of additional or
thrombosis and pulmonary embolism. increased thrombosis. Symptoms will
Unlabeled depend on area of involvement. Monitor
Use: Systemic anticoagulation for other neurological status frequently for signs
diagnoses of impairment, especially in patients with
indwelling epidural catheters for
CONTRAINDCIATIONS: administration
Increase risk of bleeding); Body weight of analgesia or with concomitant use of
_50 kg (for prophylaxis) (markedly drugs affecting hemostasis (NSAIDs,
increase risk of bleeding); Active major platelet inhibitors, other anticoagulants).
bleeding; Bacterial endocarditis; Risk is increased by traumatic or
Thrombocytopenia due to fondaparinux repeated epidural or spinal puncture.May
antibodies. require urgent treatment.
Use Cautiously in: Mild-to-moderate renal ● Lab Test Considerations: Monitor
impairment (CCr 30–50 mL/min); platelet count closely; may cause
Untreated hypertension; Recent history thrombocytopenia. If platelet count
of ulcer disease; Body weight _50 kg (for is_100,000/mm3, discontinue
treatment of DVT or PE) (may increase fondaparinux.
risk of bleeding); Geri: Patients _65 yr ● Fondaparinux is not accurately
(increased risk of bleeding); Malignancy; measured by prothrombin time (PT),
History of heparin-induced activated thromboplastin time (aPTT), or
thrombocytopenia; OB, Lactation, international standards of heparin or low
Pedi: Safety not established; use during molecular weight heparins. If unexpected
pregnancy only if clearly needed. changes in coagulation parameters or
Exercise Extreme Caution in: History of major bleeding occurs, discontinue
congenital or acquired bleeding disorder; fondaparinux.
Severe uncontrolled hypertension; ● Monitor CBC, serum creatinine levels,
Hemorrhagic stroke; Recent CNS or and stool occult blood tests routinely
ophthalmologic surgery; Active GI during therapy.
bleeding/ulceration; Retinopathy ● May cause asymptomaticqin AST and
(hypertensive or diabetic); ALT. Elevations are fully reversible and
Spinal/epidural anesthesia or spinal not associated withqin bilirubin.
puncture (qrisk of spinal/epidural ● May causeqaPTT temporally associated
hematoma that may lead to long-termor with bleeding with or without
permanent paralysis). concomitant administration of other
anticoagulants and thrombocytopenia
with thrombosis similar to heparin-
SIDE EFFECTS induced thrombocytopenia, with or
Skin: injection site reactions (mild without exposure to heparin or low
bleeding, rash, itching, pain bruising, molecular-weight heparin.
redness, and swelling), Potential NursingDiagnoses
CNS: sleep problems, headache, Ineffective tissue perfusion (Indications)
(insomnia), dizziness, Risk for injury (Side Effects)
GI: nausea, vomiting Implementation
● Fondaparinux cannot be used
ADVERSE REACTIONS: interchangeably with heparin, low-
CNS: confusion, dizziness, headache, molecularweight heparins, or
insomnia. CV: edema, hypotension. GI: heparinoids as they differ in
constipation, diarrhea, manufacturing process, anti-Xa and anti-
dyspepsia,increase liver enzymes, IIa activity, units, and dose. Each of these
nausea, vomiting. GU: urinary retention. medications has its own instructions for
Derm: bullous eruption, hematoma, use.
purpura, rash. Hemat: bleeding, ● Initial dose should be administered 6-8
thrombocytopenia. hr after surgery. Administration before 6
F and E: hypokalemia. Misc: hr after surgery has been associated with
hypersensitivity reactions including risk of major bleeding.
ANGIOEDEMA, fever,qwound drainage. ● Subcut: Administer subcut only into
fatty tissue, alternating sites between
NURSING RESPONSIBILITIES: right and left anterolateral or
posterolateral abdominal wall. Inject

Page | 12
entire length of needle at a 45_ or 90_
angle into a skin fold held between
thumb and forefinger; hold skin fold
throughout injection. Do not aspirate or
massage. Rotate sites frequently. Do not
administer IM because of danger of
hematoma formation. Solution should be
clear; do not inject solution containing
particulate matter. Do not mix with other
injections.
● Fondaparinux is provided in a single-
dose prefilled syringe with an automatic
needle protection system. Do not expel
air bubble from prefilled syringe before
injection to prevent loss of drug.
Patient/Family Teaching
● Advise patient to report any symptoms
of unusual bleeding or bruising,
dizziness, itching, rash, fever, swelling,
or difficulty breathing to health care
professional immediately.
● Instruct patient not to take aspirin or
NSAIDs without consulting health care
professional during therapy.
Evaluation/Desired Outcomes
● Prevention and treatment of deep vein
thrombosis and pulmonary embolism.
B. ANTIPLATELET DRUGS
CLASSIFICATION: CYCLOOXYGENASE
INHIBITOR
GENERIC NAME: Aspirin
BRAND NAME: acetylsalicylic acid,
Acuprin, ASA, Asaphen, Aspergum, Aspir-
Low, Aspirtab,
Bayer Aspirin, Bayer Timed-Release
Arthritic Pain Formula, Easprin, Ecotrin, 8-
Hour Bayer Timed-Release, Empirin,
Entrophen, Halfprin, Healthprin,
Lowprin, Norwich Aspirin, Novasen, Rivasa,
Sloprin, St. Joseph Adult
Chewable Aspirin, Therapy Bayer,
ZORprin
PO (Adults): 80–325 mgonce daily
Suspected acute MI-160 mg as soon as
MI is suspected.
PO (Children): 3–10 mg/kg/day given
once daily (round dose to a convenient
amount).
Kawasaki Disease
PO (Children): 80–100 mg/kg/day in 4
divided doses until fever resolves; may
be followed by maintenance dose of 3–
5mg/kg/day as a single dose for up to 8
wk.
DRUG ACTION:
Produce analgesia and reduce inflammation
and fever by inhibiting the production of
prostaglandins. Decreases platelet
aggregation. Therapeutic Effects:
Analgesia. Reduction of inflammation.
Reduction of fever. Decreased incidence of
transient ischemic attacks and MI.
Pharmacokinetics
A: Well absorbed from the upper small
intestine; absorption from enteric-coated
preparations may be unreliable; rectal
absorption is slow and variable.
D: Rapidly and widely distributed;
crosses the placenta and enters breast
milk.
Metabolism and Excretion: Extensively
metabolized by the liver; inactive
metabolites excreted by the kidneys.
Amount excreted unchanged by the
kidneys depends on urine pH; as pH
increases, amount excreted unchanged
increases from 2–
3% up to 80%.
Half-life: 2–3 hr for low doses; up to 15–
30 hr with larger doses because of
saturation
of liver metabolism.
Pharmacodynamics:
O: PO, 50-30 min
P: 1-3hr
D: 3-6hr

RECOMMENDED DOSAGE, ROUTE, AND DRUG-DRUG DRUG-FOOD

FREQUENCY: INTERACTIONS:
Pain/Fever Drug-Drug: Mayqthe risk of bleeding with
PO, Rect (Adults): 325–1000 mg q 4–6 hr warfarin, heparin, heparin-like
(not to exceed 4 g/day). Extendedrelease agents, thrombolytic agents,
tablets—650 mg q 8 hr or 800 mg q 12 hr. dipyridamole, ticlopidine, clopidogrel,
PO, Rect (Children 2–11 yr): 10–15 tirofiban,
mg/kg/dose q 4–6 hr; maximum dose: 4 or eptifibatide, although these agents are
g/ day. frequently used safely in combination
Inflammation and in sequence. Ibuprofen: may negate
PO (Adults): 2.4 g/day initially; increased the cardioprotective antiplatelet effects
to maintenance dose of 3.6–5.4 g/day in of low-dose aspirin. Mayqrisk of bleeding
divided doses (up to 7.8 g/day for acute with cefoperazone, cefotetan, and
rheumatic fever). valproic acid. Mayqactivity of penicillins,
PO (Children): 60–100 mg/kg/day in phenytoin, methotrexate, valproic
divided doses (up to 130 mg/kg/day for acid, oral hypoglycemic agents, and
acute rheumatic fever). sulfonamides. Urinary acidificationq
Prevention of Transient Ischemic Attacks reabsorption and mayqserum salicylate
PO (Adults): 50–325 mg once daily. levels. Alkalinization of the urine or the
Prevention ofMyocardial ingestion of large amounts of
Infarction/Antiplatelet effects antacidsqexcretion andpserum salicylate
levels.May blunt the therapeutic

Page | 13
response to diuretics and ACE tartrazine are at an increased risk for
inhibitors.qrisk of GI irritation with developing hypersensitivity reactions.
NSAIDs. ● Pain: Assess pain and limitation of
Drug-Natural Products:qanticoagulant movement; note type, location, and
effect and bleeding risk with arnica, intensity before and at the peak (see
chamomile, clove, feverfew, garlic, Time/Action Profile) after administration.
ginger, ginkgo, Panax ginseng, and ● Fever: Assess fever and note
others. associated signs (diaphoresis,
Drug-Food: Foods capable of acidifying tachycardia, malaise, chills).
the urine mayqserum salicylate levels. ● Lab Test Considerations: Monitor
hepatic function before antirheumatic
INDICATIONS: therapy and if symptoms of
Inflammatory disorders including: hepatotoxicity occur; more likely in
Rheumatoid arthritis, Osteoarthritis. Mild patients, especially children, with
tomoderate pain. Fever. Prophylaxis of rheumatic fever, systemic lupus
transient ischemic attacks and MI. erythematosus, juvenile arthritis, or pre-
Unlabeled existing hepatic disease. May
Use: Adjunctive treatment of Kawasaki causeqserum AST, ALT, and alkaline
disease. phosphatase, especially when plasma
concentrations exceed 25 mg/100 mL.
CONTRAINDCIATIONS: May return to normal despite continued
Contraindicated in: Hypersensitivity to use or dose reduction. If severe
aspirin or other salicylates; Cross- abnormalities or active liver disease
sensitivity occurs, discontinue and use with caution
with other NSAIDs may exist (less with in future.
nonaspirin salicylates); Bleeding ● Monitor serum salicylate levels
disorders periodically with prolonged high-dose
or thrombocytopenia; Pedi: May increase therapy to determine dose, safety, and
risk of Reye’s syndrome in children efficacy, especially in children with
or adolescents with viral infections. Kawasaki disease.
Use Cautiously in: History of GI bleeding ● May alter results of serum uric acid,
or ulcer disease; Chronic alcohol use/ urine vanillylmandelic acid (VMA),
abuse; Severe hepatic or renal disease; protirelin- induced thyroid-stimulating
OB: Salicylates may have adverse effects hormone (TSH), urine
on hydroxyindoleacetic acid
fetus and mother and should be avoided (5-HIAA) determinations, and
during pregnancy, especially during the radionuclide thyroid imaging.
3rd ● Prolongs bleeding time for 4–7 days
trimester; Lactation: Safety not and, in large doses, may cause
established; Geri:qrisk of adverse prolonged prothrombin time. Monitor
reactions especially hematocrit periodically in prolonged
GI bleeding; more sensitive to toxic high-dose therapy to assess for GI blood
levels. loss.
● Toxicity and Overdose: Monitor for the
onset of tinnitus, headache,
SIDE EFFECTS/ hyperventilation, agitation, mental
SKIN: rash, confusion, lethargy, diarrhea, and
GI gastrointestinal ulcerations, sweating. If thesen symptoms appear,
abdominal pain,upset withhold medication and notify health
stomach,heartburn, drowsiness, care professional immediately.
headache, cramping, nausea, gastritis,
and bleeding Potential NursingDiagnoses
Acute pain (Indications)
ADVERSE REACTIONS:. Impaired physical mobility (Indications)
EENT: tinnitus. GI: GI BLEEDING, Implementation
dyspepsia, epigastric distress, nausea, ● Use lowest effective dose for shortest
abdominal period of time.
pain, anorexia, hepatotoxicity, vomiting. ● PO: Administer after meals or with food
Hemat: anemia, hemolysis. Derm: rash, or an antacid to minimize gastric
urticaria. Misc: allergic reactions irritation. Food slows but does not alter
including ANAPHYLAXIS and the total amount absorbed.
LARYNGEAL EDEMA. ● Do not crush or chew enteric-coated
tablets. Do not take antacids within 1–2
NURSING RESPONSIBILITIES: hr of enteric-coated tablets. Chewable
tablets may be chewed, dissolved in
Assessment liquid, or swallowed whole. Some
● Patients who have asthma, allergies, extended-release tablets may be broken
and nasal polyps or who are allergic to or crumbled but must not be ground up

Page | 14
before swallowing. See manufacturer’s Half-life: 6 hr (activemetabolite 30 min).
prescribing information for individual Pharmacodynamics:
products. O: PO, within 24hr
Patient/Family Teaching P: 3-7days
● Instruct patient to take salicylates with D: 5 days
a full glass of water and to remain in an
upright position for 15–30min after DRUG-DRUG DRUG-FOOD
administration. INTERACTIONS:
● Advise patient to report tinnitus; Drug-Drug: Concurrent abciximab,
unusual bleeding of gums; bruising; eptifibatide, tirofiban, aspirin, NSAIDs,
black, tarry stools; or fever lasting longer heparin, LMWHs, thrombolytic agents,
than 3 days. ticlopidine, or warfarin mayqrisk of
Evaluation/Desired Outcomes bleeding. Maypmetabolism andqeffects
● Relief of mild tomoderate discomfort. of phenytoin, tolbutamide, tamoxifen,
● Increased ease of jointmovement. May torsemide, fluvastatin, and many NSAIDs.
take 2–3 wk for maximumeffectiveness. Concurrent use with the CYP2C19
● Reduction of fever. inhibitors, omeprazole or esomeprazole
● Prevention of transient ischemic maypantiplatelet effects; avoid
attacks. concurrent
● Prevention of MI. use; may consider using H2 antagonist
or another proton pump inhibitor
(e.g. dexlansoprazole, lansoprazole, or
CLASSIFICATION: P2Y12 ADP pantoprazole).
RECEPTOR ANTAGONIST Drug-Natural Products: increase bleeding
GENERIC NAME: Dipyridamole risk with anise, arnica, chamomile, clove,
BRAND NAME: Persantine fenugreek, feverfew, garlic, ginger,
ginkgo, Panax ginseng, and others
RECOMMENDED DOSAGE, ROUTE, AND
FREQUENCY: INDICATIONS:
Recent MI, Stroke, or Peripheral Vascular Reduction of atherosclerotic events (MI,
Disease stroke, vascular death) in patients at risk
PO (Adults): 75 mg once daily. for
Acute Coronary Syndrome such events including recent MI, acute
PO (Adults): 300 mg initially, then 75 mg coronary syndrome (unstable
once daily; aspirin 75–325 mg once daily angina/non–
should be given concurrently Q-wave MI), stroke, or peripheral
vascular disease.
DRUG ACTION:
Dipyridamole likely inhibits CONTRAINDCIATIONS:
both adenosine Hypersensitivity; Pathologic bleeding
deaminase and phosphodiesterase, (peptic ulcer, intracranial
preventing the degradation of cAMP, an hemorrhage); Concurrent use of
inhibitor of platelet function. This omeprazole or esomeprazole; Impaired
elevation in cAMP blocks the release of CYP2C19 function due to genetic
arachidonic acid from membrane variation; Lactation: Lactation.
phospholipids and reduces thromboxane Use Cautiously in: Patients at risk for
A2 activity. bleeding (trauma, surgery, or other
pathologic
Pharmacokinetics conditions); History of GI bleeding/ulcer
Absorption: Well absorbed following oral disease; Severe hepatic impairment;
administration; rapidly metabolized to Hypersensitivity to another
an active antiplatelet compound. Parent thienopyridine (ticlopidine, prasugrel);
drug has no antiplatelet activity. OB: Use only if clearly indicated; Pedi:
Distribution: Unknown. Safety and effectiveness not established.
Protein Binding: Clopidogrel—98%;
activemetabolite—94%. SIDE EFFECTS/ADVERSE REACTIONS:.
Metabolism and Excretion: Rapidly and CNS: depression, dizziness, fatigue,
extensively converted by the liver headache. EENT: epistaxis. Resp: cough,
(CYP2C19) to its active metabolite, which dyspnea, eosinophilic pneumonia.
is then eliminated 50% in urine and 45% CV: chest pain, edema, hypertension. GI:
in GI BLEEDING, abdominal pain, diarrhea,
feces; 2% of Whites, 4% of Blacks, and dyspepsia, gastritis. Derm: DRUG RASH
14% of Asians have CYP2C19 genotype WITH EOSINOPHILIA AND SYSTEMIC
that SYMPTOMS,
results in reduced metabolism of pruritus, purpura, rash. Hemat:
clopidogrel (poor metabolizers) into its BLEEDING, NEUTROPENIA,
active metabolite THROMBOTIC
(may result inpantiplatelet effects).

Page | 15
THROMBOCYTOPENIC PURPURA. ● Instruct patient to notify health care
Metab: hypercholesterolemia. MS: professional of all Rx or OTC
arthralgia, back medications, vitamins,
pain. Misc: fever, hypersensitivity or herbal products being taken and to
reactions consult health care professional before
taking any other Rx, OTC, or herbal
NURSING RESPONSIBILITIES: products, especially those containing
aspirin or NSAIDs or proton pump
Assessment inhibitors.
● Assess patient for symptoms of stroke, ● Advise female patient to notify health
peripheral vascular disease, or MI care professional if pregnancy is planned
periodically during therapy. or suspected, or if breast feeding.
● Monitor patient for signs of thrombotic
thrombocytic purpura Evaluation/Desired Outcomes
(thrombocytopenia, microangiopathic ● Prevention of stroke, MI, and vascular
hemolytic anemia, neurologic findings, death in patients at risk.
renal dysfunction, fever). May rarely
occur, even after short exposure
( 2 wk). Requires prompt treatment. CLASSIFICATION:
● Lab Test Considerations: Monitor GLYCOPROTEIN IIb/IIIa
bleeding time during therapy. Prolonged
bleeding time, which is time- and dose- RECEPTOR ANTAGONIST
dependent, is expected. GENERIC NAME: Abciximab
● Monitor CBC with differential and BRAND NAME: ReoPro
platelet count periodically during
therapy. Neutropenia and RECOMMENDED DOSAGE, ROUTE, AND
thrombocytopenia may rarely occur. FREQUENCY:
● May causeqserum bilirubin, hepatic IV (Adults): 250 mcg (0.25 mg)/kg bolus
enzymes, total cholesterol, nonprotein 10–60 min prior to PCI, followed by
nitrogen (NPN), and uric acid 0.125 mcg/kg/min (up to 10 mcg/min)
concentrations. continuous infusion for 12 hr; patients
with
unstable angina not responding to
conventional therapy and who are
Potential Nursing Diagnoses planned to undergo PCI within 24 hours
Risk for injury (Indications) (Side Effects) —250 mcg (0.25 mg)/kg bolus followed
by 10 mcg/
Implementation min continuous infusion for 18–24 hr,
● Do not confuse Plavix with Paxil. ending 1 hr after PCI.
● Discontinue clopidogrel 5–7 days
before planned surgical procedures. If DRUG ACTION:
clopidogrel must be temporarily Binds to glycoprotein (GP) receptors on
discontinued, restart as soon as platelet surfaces (GP IIb/IIIa), resulting in
possible. Premature discontinuation of decreased platelet aggregation.
therapy may increase risk of Therapeutic Effects: Decreased incidence
cardiovascular events. of restenosis of coronary arteries and
● PO: Administer once daily without improvedmyocardial perfusion.
regard to food. Pharmacokinetics
Absorption: IV administration results in
Patient/Family Teaching complete bioavailability.
● Instruct patient to take medication Distribution: Unknown.
exactly as directed. Take missed doses Metabolism and Excretion: Remains bound
as soon as possible unless almost time to platelet receptor sites for up to 10
for next dose; do not double doses. Do days.
not discontinue clopidogrel without Half-life: 30 min
consulting health care professional; may Pharmacodynamics:
increase risk of cardiovascular events. O: IV, within min
Advise patient to read the Medication P: 1 hr
Guide before starting clopidogrel and D:24-28 day
with each Rx refill in case of changes.
● Advise patient to notify health care DRUG-DRUG DRUG-FOOD
professional promptly if fever, chills, INTERACTIONS:
sore throat, rash, or unusual bleeding or Drug-Drug: Risk of bleeding may be
bruising occurs. increased by concurrent thrombolytics,
● Advise patient to notify health care warfarin, NSAIDs, cefoperazone, cefotetan,
professional of medication regimen prior dipyridamole, dextran, clopidogrel,
to treatment or surgery. heparin, heparin-like drugs, valproates, or
ticlopidine, although

Page | 16
concurrent use with heparin and aspirin is edema. Hemat: BLEEDING,
recommended. thrombocytopenia. Misc: allergic
Drug-Natural Products: Increased bleeding reactions including ANAPHYLAXIS.
risk with anise, arnica, chamomile,
clove, feverfew, garlic, ginger, ginkgo, NURSING RESPONSIBILITIES:
Panax ginseng, and others.
Assessment
INDICATIONS: ● Monitor ECG and vital signs closely
Used with heparin and aspirin to throughout therapy.
decrease cardiac ischemic complications ● Assess patient for bleeding at all
before or potential bleeding sites (catheter
after percutaneous coronary intervention insertion; arterial and venous puncture;
(PCI), including percutaneous cutdown; needle puncture; GI, GU, and
transluminal retroperitoneal sites) frequently
coronary angioplasty (PTCA). Unlabeled throughout therapy. If serious
Use: In combination with heparin uncontrollable bleeding occurs, stop
and and/or low-dose alteplase or abciximab and concurrent heparin
reteplase to enhance coronary perfusion therapy.
in patients ● Check the sheath insertion site and
with acute coronary syndromes (ACS) distal pulses of affected leg(s) frequently
while femoral artery sheath is in place
CONTRAINDCIATIONS: and for 6 hr after femoral artery sheath is
Hypersensitivity to abciximab or murine removed. Measure any hematoma and
(mouse) protein; monitor for signs of enlargement.
Active internal bleeding; Recent ● Monitor for signs of hypersensitivity
significant GI or GU bleeding (within 6 reaction or anaphylaxis (rash, pruritus,
wk); History laryngeal edema, wheezing) throughout
of CVA (within 2 yr) or CVA with therapy. If reactions occur, stop
neurologic sequelae; History of bleeding abciximab immediately and initiate
disorder; treatment of anaphylaxis. Epinephrine,
Recent (within 7 days) oral anticoagulant dopamine, theophylline, antihistamines,
therapy (PT _1.2 times control); Platelet and corticosteroids should be readily
count_100,000 cells/mm3; Recent trauma available.
or major surgery (within 6 wk); ● Observe patient for mental status
Intracranial changes, asses nose and mouth mucous
neoplasm; Aneurysm or AV membranes, and examine urine, stool
malformation; Severe uncontrolled and emesis for presence of blood. Use
hypertension; carewhenremoving dressings.
History of vasculitis; Concurrent use of ● Lab Test Considerations: Measure
another parenteral GP IIb/IIIa inhibitor; platelet count, PT, and aPTT before
Recent or concurrent dextran therapy. infusion of abciximab to identify pre-
Use Cautiously in: Patients weighing _75 existing hemostatic abnormalities.
kg or _65 yr (increased risk of bleeding); ● Monitor platelet count prior to therapy,
History of previous GI pathology; 2–4 hr following bolus administration,
Concurrent thrombolytic or heparin and at 24 hr or before discharge,
therapy; whichever is first. If platelet count
PCI within 12 hr of onset of MI symptoms decreases to_100,000/mm3 or 25% of
or PCI procedure lasting _70 min; OB, pretreatment levels, verify true
Lactation, Pedi: Safety not established. thrombocytopenia by additional platelet
counts drawn in separate tubes
SIDE EFFECTS:. containing EDTA, citrate, or heparin. If
GI: nausea, vomiting, true thrombocytopenia is verified,
SKIN: injection site reactions, bleeding, immediately discontinue abciximab.
irritation, or ● If serious uncontrolled bleeding occurs
MS: pain, back pain, or surgery is required (especially
CNS: changes in vision, mood changes. majorprocedures) within 48–72 hr of
headache abciximab therapy, determine bleeding
CV: heartburn, low blood pressure, slow time. Platelet transfusions may partially
heart rate, chest pain restore platelet function.
GI: stomach upset, abdominal pain, Potential NursingDiagnoses
SKIN: swelling of the extremities Ineffective tissue perfusion (Indications)
Risk for injury (Side Effects) Assessment
ADVERSE REACTIONS ● Monitor ECG and vital signs closely
CNS: abnormal thinking, dizziness, throughout therapy.
headache. CV: hypotension, atrial ● Assess patient for bleeding at all
fibrillation/flutter, bradycardia, complete potential bleeding sites (catheter
AV block, supraventricular tachycardia, insertion; arterial and venous puncture;
vascular disorder, chest pain, peripheral cutdown; needle puncture; GI, GU, and

Page | 17
retroperitoneal sites) frequently
throughout therapy. If serious
uncontrollable bleeding occurs, stop
abciximab and concurrent heparin
therapy.
● Check the sheath insertion site and
distal pulses of affected leg(s) frequently
while femoral artery sheath is in place
and for 6 hr after femoral artery sheath is
removed. Measure any hematoma and
monitor for signs of enlargement.
● Monitor for signs of hypersensitivity
reaction or anaphylaxis (rash, pruritus,
laryngeal edema, wheezing) throughout
therapy. If reactions occur, stop
abciximab immediately and initiate
treatment of anaphylaxis. Epinephrine,
dopamine, theophylline, antihistamines,
and corticosteroids should be readily
available.
● Observe patient for mental status
changes, asses nose and mouth mucous
membranes, and examine urine, stool
and emesis for presence of blood. Use
carewhenremoving dressings.
● Lab Test Considerations: Measure
platelet count, PT, and aPTT before
infusion of abciximab to identify pre-
existing hemostatic abnormalities.
● Monitor platelet count prior to therapy,
2–4 hr following bolus administration,
and at 24 hr or before discharge,
whichever is first. If platelet count
decreases to_100,000/mm3 or 25% of
pretreatment levels, verify true
thrombocytopenia by additional platelet
counts drawn in separate tubes
containing EDTA, citrate, or heparin. If
true thrombocytopenia is verified,
immediately discontinue abciximab.
● If serious uncontrolled bleeding occurs
or surgery is required (especially
majorprocedures) within 48–72 hr of
abciximab therapy, determine bleeding
time. Platelet transfusions may partially
restore platelet function.
Potential NursingDiagnoses
Ineffective tissue perfusion (Indications)
Risk for injury (Side Effects)
Implementation
● High Alert: Accidental overdosage of
antiplatelet medications has resulted in
patient harm and/or death from internal
hemorrhage or intracranial bleeding.
Have second practitioner independently
check original order, dosage
calculations, and infusion pump settings.
● Do not use preparations of abciximab
containing opaque particles.
● Avoid nonessential use of arterial and
venous punctures, IM injections, urinary
catheters, NG intubation, NG tubes, and
automated BP cuffs during therapy.
Avoid use of noncompressible sites
(subclavian or jugular veins) for IV
access. Use heparin locks for drawing
blood. Use a chemical tape remover
when removing dressings.
● Restrain affected limb in a neutral
position and maintain complete bedrest
withthe head of bed elevated to at least
30_ while the femoral artery sheath is in
place.
● Heparin should be discontinued at
least 4 hr prior to removal of the femoral
artery sheath.
● Apply pressure to the femoral artery for
at least 30 min with manual compression
or a mechanical device for hemostasis
following sheath removal. Apply a
pressure dressing following hemostasis.
Maintain bedrest for 6–8 hr following
sheath removal or discontinuation of
abciximab, whichever is later.
IV Administration
● Direct IV: Do not shake the vial.
Withdraw the amount of abciximab
needed for bolus through a sterile,
nonpyrogenic, low-protein-binding 0.2- or
0.22-micron filter into a syringe. Rate:
Administer as a bolus injection 10–60
min before the start of PCI or in patients
for which PCI is planned within the next
24 hr.
Patient/Family Teaching
● Explain the purpose of the medication
to patient and family. Instruct patient to
report hypersensitivity reactions (rash,
dyspnea), bleeding, or bruising.
● Explain need for bedrest, leg
immobilization, and minimal handling
during therapy to avoid injury.
Evaluation/Desired Outcomes
● Prevention of acute cardiac ischemic
complications following PCI.
● Enhanced coronary perfusion in
patients with acute coronary syndromes.
CLASSIFICATION: COMINED
ANTIPLATELETS
GENERIC NAME: Dipyridamole
BRAND NAME: Apo-Dipyridamole,
Dipridacot, Novodipiradol, Persantine,
Persantine IV
RECOMMENDED DOSAGE, ROUTE, AND
FREQUENCY:
Prevention of Thromboembolism in Cardiac
Valve Replacement
Adult: PO 75–100 mg q.i.d.
Child: PO 1–2 mg t.i.d.
Thromboembolic Disorders
Adult: PO 150–400 mg/d in divided doses
Thallium Stress Test
Page | 18
Adult: IV 0.142 mg/kg/min for 4 min
Assessment
● PO: Monitor BP and pulse before
DRUG ACTION: instituting therapy and regularly during
PO: Decreases platelet aggregation by period of dosage adjustment. Geri:
inhibiting the enzyme phosphodiesterase. Assess geriatric patients for orthostatic
IV: Produces coronary vasodilation by hypotension.
inhibiting adenosine uptake. Therapeutic ● IV: Monitor vital signs during and for 10–
Effects: PO: Inhibition of platelet 15 min after infusion. Obtainn ECG in at
aggregation and subsequent least 1 lead. If severe chest pain or
thromboembolic events. IV: In diagnostic bronchospasm occurs, administer IV
thallium imaging, dipyridamole dilates aminophylline 50–250 mg at a rate of 50–
normal coronary arteries, reducing flow to 100 mg over 30– 60 sec. If hypotension is
vessels that are narrowed and causing severe, place patient in a supine position
abnormal thallium distribution. with head tilting down. If chest pain is
A: Readily absorbed from GI tract. .  unrelieved with aminophylline 250
D: Small amount crosses placenta mg, administer nitroglycerin SL. If chest pain
M: Half-Life: 10–12 h Metabolized in liver.  is still unrelieved, treat as myocardial
E: Mainly excreted in feces. . infarction.
Pharmacodynamics: ● Lab Test Considerations: Bleeding time
O: UNKNOWN should be monitored periodically
P: UNKNOWN throughout therapy.
IV, 6.5min  Potential NursingDiagnoses
D: PO, UNKNOWN Decreased cardiac output (Indications)
IV, 30min Acute pain (Indications)
Implementation
DRUG-DRUG DRUG-FOOD ● PO: Administer with a full glass of
INTERACTIONS: water at least 1 hr before or 2 hr after
Drug-Drug: Additive effects with aspirin on meals for faster absorption. If GI irritation
platelet aggregation. Risk of bleeding occurs, may be administered with or
may beqwhen used with anticoagulants, immediately after meals. Tablets may be
thrombolytic agents, NSAIDs, cefoperazone, crushed and mixed with food if patient
cefotetan, or valproic acid.qrisk of has difficulty swallowing. Pharmacistmay
hypotension with alcohol. Theophylline make a suspension.
may negate the effects of dipyridamole IV Administration
during diagnostic thallium imaging ● pH: 2.2–3.2.
● Intermittent Infusion: Diluent: Dilute in at
least a 1:2 ratio of 0.45% NaCl, 0.9%
INDICATIONS: NaCl, or D5W for a total volume of 20–50
To prevent postoperative mL. Undiluted dipyridamole may cause
thromboembolic complications venous irritation. Rate: Infuse over 4 min.
associated with prosthetic heart valves ● Y-Site Compatibility: No information
and as adjunct for thallium stress testing. available

CONTRAINDCIATIONS: Patient/Family Teaching

Pregnancy (category C), lactation. ● PO: Instruct patient to take medication
Cautious Use at evenly spaced intervals as directed.
Hypotension, anticoagulant therapy. Take missed doses as soon as
remembered unless the next scheduled
SIDE EFFECTS dose is within 4 hr. Do not double doses.
GI : nausea, vomiting, constipation, Benefit of medication may not be
stomach or abdominal pain, loss of apparent to patient; encourage patient to
appetite, gas, diarrhea, continue takingmedication as directed.
CNS: headache, dizziness, skin rash, ● Caution patient to change positions
weakness, fatigue, slowly to minimize orthostatic
MS: muscle cramps, hypotension.
CV: cough, ● Advise patient to avoid the use of
Respi: shortness of breath, Repro: alcohol, as it may potentiate the
impotence. hypotensive effects. Tobacco products
should also be avoided because nicotine
ADVERSE REACTIONS:. causes vasoconstriction.
CNS: Headache, dizziness, faintness, ● Advise patient to consult health care
syncope, weakness. CV: Peripheral professional before taking OTC
vasodilation, flushing. GI: Nausea, medications concurrently with this
vomiting, diarrhea, abdominal medication. Aspirin should be taken only
distress. Skin: Skin rash, pruritus. if directed and only in dose prescribed.
Advise patient to discuss alternatives for
NURSING RESPONSIBILITIES: pain relief or fever.

Page | 19
● Instruct patient to notify health care and activity of cilostazol (use lower
professional if unusual bleeding or doses). Concurrent use with aspirin has
bruising occurs. Concurrent use of additive
aspirin or warfarin may increase risk of effects on platelet function.
bleeding but is commonly used with Drug-Food: Grapefruit juice inhibits
specific indications. metabolism and increases effects;
● Advise patient to notify health care concurrent
professional of medication regimen and use should be avoided.
whether using concurrent aspirin or
warfarin therapy. INDICATIONS:
● IV: Instruct patient to notify health care Reduction of the symptoms of
professional immediately if dyspnea or intermittent claudication as measured by
chest pain occurs. increased
Evaluation/Desired Outcomes walking distance
● Prevention of postoperative
thromboembolic complications CONTRAINDCIATIONS:
associated with prosthetic heart valves. Hypersensitivity; HF; OB: Potential for
● Maintenance of patency after surgical congenital defects,
graft procedures. stillbirth, and low birth weight; Lactation:
● Coronary vasodilation in thallium Potential risk to nursing infants;
myocardial perfusion imaging discontinue
or bottle feed.
Use Cautiously in: Pedi: Safety not
established.
CLASSIFICATION: ANTIPLATELET-
VASODILATOR SIDE EFFECTS/ADVERSE REACTIONS:.
CNS: headache, dizziness. CV:
GENERIC NAME: palpitations, tachycardia. GI: diarrhea.
BRAND NAME:

RECOMMENDED DOSAGE, ROUTE, AND NURSING RESPONSIBILITIES:

FREQUENCY: Assessment
PO (Adults): 100 mg twice daily (50 mg ● Assess patient for intermittent
twice daily if receiving inhibitors of claudication before and periodically
cilostazol during therapy.
metabolism). ● Lab Test Considerations: May
occasionally cause anemia,
hyperlipemia, hyperuricemia,
DRUG ACTION: and albuminuria.May prolong bleeding
Pharmacokinetics time.
Absorption: Slowly absorbed after oral Potential NursingDiagnoses
administration. Activity intolerance (Indications)
Distribution: Unknown. Implementation
Protein Binding: 95–98% bound to plasma ● PO: Administer on an empty stomach, 1
proteins; one active metabolite is hr before or 2 hr after meals.
97.4% bound, the other is 66% bound. ● Do not administer with grapefruit juice.
Metabolism and Excretion: Extensively May increase cilostazol levels
metabolized by the liver, two metabolites Patient/Family Teaching
have platelet aggregation inhibitory ● Instruct patient to take cilostazol on an
activity; metabolites are mostly excreted empty stomach, exactly as directed.
by ● May cause dizziness. Caution patient to
the kidneys. avoid driving or other activities requiring
Half-life: Cilostazol and its alertness until response to medication is
activemetabolites—11–13 hr. known.
Pharmacodynamics: ● Advise patient to avoid smoking;
O: PO, 2-4wk nicotine constricts blood vessels.
P: upto 12wk Evaluation/Desired Outcomes
D:unknown ● Relief fromcramping in calfmuscles,
buttocks, thighs, and feet during
DRUG-DRUG DRUG-FOOD exercise.
INTERACTIONS: ● Improvement in walking endurance.
Drug-Drug: Concurrent administration of Therapeutic effects may be seen in 2–4 wk.
ketoconazole, itraconazole, erythromycin,
diltiazem, fluconazole, miconazole,
fluvoxamine, fluoxetine, nefazodone,
sertraline, or omeprazole decreases
metabolism and increases levels

Page | 20
C. THROMBOLYTIC OR concurrent useqrisk of bleeding,
FIBRINOLYTIC DRUGS although these agents are frequently
used together or in sequence. Effects
CLASSIFICATION: TISSUE may bepby antifibrinolytic agents,
PLASMINOGEN ACTIVATORS including
GENERIC NAME: aminocaproic acid or tranexamic acid.
BRAND NAME: Drug-Natural Products:qanticoagulant
effect and bleeding risk with anise,
RECOMMENDED DOSAGE, ROUTE, AND arnica,
FREQUENCY: chamomile, clove, dong quai, fenugreek,
IV (Adults): 15 mg bolus, then 0.75 mg/kg feverfew, garlic, ginger,
(up to 50 mg) over 30 min, then 0.5 mg/ ginkgo, Panax ginseng, licorice, and
kg (up to 35 mg) over next 60 min; others
usually accompanied by heparin therapy.
Myocardial Infarction (Standard Regimen) INDICATIONS:
IV (Adults 65 kg): 60 mg over 1st hr (6–10 Acute myocardial infarction (MI). Acute
mg given as a bolus over first 1–2 ischemic stroke. Pulmonary embolism
min), 20 mg over the 2nd hr, and 20 mg (PE). Occluded central venous access
over the 3rd hr for a total dose of 100 mg. devices. Unlabeled Use: Deep venous
IV (Adults 65 kg): 0.75 mg/kg over 1st hr thrombosis (DVT). Acute peripheral
(0.075–0.125 mg/kg given as a bolus arterial thrombosis.
over first 1–2 min), 0.25 mg/kg over the
2nd hr, and 0.25 mg/kg over the 3rd hr for CONTRAINDCIATIONS:
a Active internal bleeding; History of
total dose of 1.25 mg/kg (not to exceed cerebrovascular accident
100 mg total). (for MI and PE only); Recent (within 3 mo)
Acute Ischemic Stroke intracranial or intraspinal injury or
IV (Adults): 0.9 mg/kg (not to exceed 90 trauma; Intracranial neoplasm,
mg), given as an infusion over 1 hr, with arteriovenous malformation, or
10% of the dose given as a bolus over aneurysm; Known
the 1st min. bleeding diathesis; Severe uncontrolled
PulmonaryEmbolism hypertension (systolic BP_185 mmHgor
IV (Adults): 100mg over 2 hr; follow with diastolic
heparin. BP _110 mmHg specifically for stroke
Occluded Venous Access Devices indication); Evidence or suspicion of
IV (Adults and Children 30 kg): 2 mg/2 mL intracranial hemorrhage on pretreatment
instilled into occluded catheter; if evaluation (for stroke indication only);
unsuccessful, may repeat once after 2 hr. Recent
IV (Adults and Children 30 kg): 110% of the (within 3 mo) stroke (for stroke indication
lumen volume (not to exceed 2mg only); History of intracranial hemorrhage
in 2mL) instilled into occluded catheter; if (for stroke indication only); Seizure at the
unsuccessful, may repeat once after 2 hr. onset of stroke (for stroke indication
only); Current use of oral anticoagulants
or an INR _1.7 or a prothrombin time
DRUG ACTION: _15 sec (for stroke indication only);
Pharmacokinetics Administration of heparin 48 hr before
Absorption: Complete after IV the onset
administration. Intracoronary of stroke with an elevated aPTT at
administration or presentation (for stroke indication only);
administration into occluded catheters or Platelet
cannulae has amore localized effect. count _100,000/mm3 (for stroke
Distribution: Unknown. indication only); Hypersensitivity (for
Metabolismand Excretion: Rapidly central
metabolized by the liver. venous access device occlusion
Half-life: 35 min. indication only).
Pharmacodynamics:
O: 30min SIDE EFFECTS/ADVERSE REACTIONS:.
P: 60min CNS: INTRACRANIAL HEMORRHAGE.
D:unknown EENT: epistaxis, gingival bleeding.
Resp: bronchospasm,
DRUG-DRUG DRUG-FOOD hemoptysis.
INTERACTIONS: CV: reperfusion arrhythmias,
Drug-Drug: Aspirin, other NSAIDs, hypotension, RECURRENT ISCHEMIA/
warfarin, heparin and heparin-like THROMBOEMBOLISM. GI: GI BLEEDING,
agents, abciximab, eptifibatide, tirofiban, nausea, RETROPERITONEAL BLEEDING,
clopidogrel, ticlopidine, or dipyridamole vomiting. GU: GU TRACT BLEEDING.
— Derm: ecchymoses, flushing, urticaria.
Hemat:

Page | 21
BLEEDING. Local: hemorrhage
injection site, phlebitis at injection site.
MS: musculoskeletal
pain.
Misc: allergic reactions including
ANAPHYLAXIS, fever.
NURSING RESPONSIBILITIES:
Assessment
● Begin therapy as soon as possible after
the onset of symptoms.
● Monitor vital signs, including
temperature, continuously for myocardial
infarction and at least every 4 hr during
therapy for other indications. Do not use
lower extremities to monitor BP. Notify
health care professional if systolic
BP_180mmHg or diastolic BP _110 mm
Hg. Thrombolytic therapy should not be
given if hypertension is uncontrolled.
Inform health care professional if
hypotension occurs. Hypotension may
result from the drug, hemorrhage, or
cardiogenic shock.
● Assess patient carefully for bleeding
every 15 min during the 1st hr of therapy,
every 15–30 min during the next 8 hr, and
at least every 4 hr for the duration of
therapy. Frank bleeding may occur from
sites of invasive procedures or from
body orifices. Internal bleeding may also
occur (decreased neurologic status;
abdominal pain with coffee-grounds
emesis or black, tarry stools; hematuria;
joint pain). If uncontrolled bleeding
occurs, stop medication and notify health
care professional immediately.
● Assess patient for hypersensitivity
reaction (rash, dyspnea, fever,changes in
facial color, swelling around the eyes,
wheezing). If these occur, inform health
care professional promptly. Keep
epinephrine, an antihistamine, and
resuscitation equipment close by in the
event of an anaphylactic reaction.
● Assess neurologic status throughout
therapy. Altered sensorium or neurologic
changes may be indicative of intracranial
bleeding.
● Assess intensity, character, location,
and radiation of chest pain. Note
presence of associated symptoms
(nausea, vomiting, diaphoresis).
Administer analgesics as directed. Notify
health care professional if chest pain is
unrelieved or recurs.
● Monitor heart sounds and breath
sounds frequently. Inform health care
professional if signs of HF occur
(rales/crackles, dyspnea, S3 heart sound,
jugular venous distention, relieved CVP).
● Lab Test Considerations: Hematocrit,
hemoglobin, platelet count, fibrin/fibrin
degradation product (FDP/fdp) titer,
fibrinogen concentration, prothrombin
time, thrombin time, and activated partial
thromboplastin time may be evaluated
before and frequently during therapy.
at Bleeding time may be assessed before
therapy if patient has received platelet
aggregation inhibitors.
● Obtain type and crossmatch and have
blood available at all times in case of
hemorrhage.
● Stools should be tested for occult
blood loss and urine for hematuria
periodically during therapy
POTENTIAL DIAGNOSES
Ineffective tissue perfusion (Indications)
Risk for injury (Side Effects)
Implementation
● High Alert: Overdose and under-dosage
of thrombolytic medications have
resulted in patient harm or death. Have
second practitioner independently check
original order, dose calculations, and
infusion pump settings. Clarify orders
that contain any of these abbreviations.
● Do not confuse the abbreviation t-PA for
alteplase (Activase) with the
abbreviations TNK t-PA for tenecteplase
(TNKase) and r-PA for reteplase
(Retevase). Do not confuse Activase with
Cathflo Activase or TNKase.
● Thrombolytic agents should be used
only in settings in which hematologic
function and clinical response can be
adequatelymonitored.
● Starting two IV lines before therapy is
recommended: one for the thrombolytic
agent, the other for any additional
infusions.
● Avoid invasive procedures, such as IM
injections or arterial punctures, with this
therapy. If such procedures must be
performed, apply pressure to all arterial
and venous puncture sites for at least 30
min. Avoid venipunctures at
noncompressible sites (jugular vein,
subclavian site).
● Acetaminophen may be ordered to
control fever.
IV Administration
● pH: 7.3.
● Intermittent Infusion: Vials are packaged
with sterile water for injection (without
preservatives) to be used as diluent. Do
not use bacteriostatic water for injection.
Reconstitute 50-mg vials with 50 mL and
100–mg with 100 mL using an 18- gauge
needle. Avoid excess agitation during
dilution; swirl or invert gently to mix.
Solution may foam upon reconstitution.
Bubbles will resolve upon standing a few
min. Solution will be clear to pale yellow.
Stable for 8 hr at room temperature.
Concentration: May be administered as
reconstituted (1 mg/mL). Diluent: May be
further diluted immediately before use in
an equal amount of 0.9% NaCl or D5W.
Rate: Flush line with 20–30 mL of saline
at completion of infusion to ensure entire
dose is received. See Route and Dosage
section for specific rates.
Page | 22
 Drug-Drug: Aspirin, other NSAIDs,
Patient/Family Teaching warfarin, heparin and heparin-like
● Explain purpose of medication and the agents, abciximab, eptifibatide, tirofiban,
need for close monitoring to patient and clopidogrel, ticlopidine, or dipyridamole
family. Instruct patient to report —
hypersensitivity reactions (rash, concurrent useqrisk of bleeding,
dyspnea) and bleeding or bruising. although these agents are frequently
● Explain need for bedrest and minimal used together or in sequence. Effects
handling during therapy to avoid injury. may bepby antifibrinolytic agents,
Avoid all unnecessary procedures such including
as shaving and vigorous tooth brushing. aminocaproic acid or tranexamic acid.
Drug-Natural Products:qanticoagulant
effect and bleeding risk with anise,
Evaluation/Desired Outcomes arnica,
● Lysis of thrombi and restoration of chamomile, clove, dong quai, fenugreek,
blood flow. feverfew, garlic, ginger,
● Prevention of neurologic sequelae in ginkgo, Panax ginseng, licorice, and
acute ischemic stroke. others.
● Cannula or catheter patency.
INDICATIONS:
Acute myocardial infarction (MI).
CLASSIFICATION: STREPTOKINASE Pulmonary embolism (PE). Deep vein
GENERIC NAME: thrombosis
BRAND NAME: (DVT). Acute peripheral arterial
thrombosis. Occluded arteriovenus
RECOMMENDED DOSAGE, ROUTE, AND cannulae
FREQUENCY:
Myocardial Infarction CONTRAINDCIATIONS:
IV (Adults): 1.5million IU given as a Recent (within 2 mo) intracranial or
continuous infusion over up to intraspinal injury or trauma; Intracranial
60minutes. neoplasm, arteriovenous malformation,
Intracoronary (Adults): 20,000 IU bolus or aneurysm; Severe uncontrolled
followed by 2000 IU/min infusion for 60 hypertension;
min. Known bleeding tendencies;
Deep Venous Thrombosis, Pulmonary Hypersensitivity; cross-sensitivity with
Emboli, ArterialEmboli, or anistreplase
Other Thromboses and streptokinasemay occur.
IV (Adults): 250,000 IU loading dose,
followed by 100,000 IU/hr for 24 hr for
pulmonary SIDE EFFECTS/ADVERSE REACTIONS:.
emboli, 72 hr for recurrent pulmonary CNS: INTRACRANIAL HEMORRHAGE.
emboli or deep vein thrombosis. EENT: epistaxis, gingival bleeding.
Occluded Arteriovenous Cannulae Resp: bronchospasm, hemoptysis.
IV (Adults): 250,000 IU/2 mL instilled into CV: reperfusion arrhythmias,
occluded catheter. hypotension, RECURRENT ISCHEMIA/
THROMBOEMBOLISM. GI: GI BLEEDING,
DRUG ACTION: hepatotoxicity, nausea,
Pharmacokinetics RETROPERITONEAL
A: Complete after IV administration. BLEEDING, vomiting. GU: GU TRACT
Administration into occluded cannulae BLEEDING.
has amore localized effect. Derm: ecchymoses, flushing, urticaria.
D: Streptokinase appears to cross the Hemat: BLEEDING. Local: hemorrhage at
placenta minimally, if at all. Remainder of injection site, phlebitis at injection site.
distribution for streptokinase is not MS: musculoskeletal pain.
known. Misc: allergic reactions including
M: t ½ : Initial half–life (due to clearance ANAPHYLAXIS,
by antibodies)–18 min, then 83 min Fever

E: Rapidly cleared from circulation by NURSING RESPONSIBILITIES:

antibodies and Assessment
other unknown mechanisms. ● Begin therapy as soon as possible after
Pharmacodynamics: the onset of symptoms.
O: immediate ● Monitor vital signs, including
P: rapid temperature, continuously for myocardial
D: 4hr (upt o 12 hr) infarction. Do not use lower extremities
to monitor BP. Notify health care
DRUG-DRUG DRUG-FOOD professional if systolic BP _180 mm Hg
INTERACTIONS: or diastolic BP _110 mm Hg.

Page | 23
Thrombolytic therapy should not be
given if hypertension is uncontrolled.
Inform health care professional if
hypotension occurs. Hypotension may
result from the drug, hemorrhage, or
cardiogenic shock.
● Assess patient carefully for bleeding
every 15 min during the 1st hr of therapy,
every 15–30 min during the next 8 hr, and
at least every 4 hr for the duration of
therapy. Frank bleeding may occur from
sites of invasive procedures or from
body orifices. Internal bleeding may also
occur (decreased neurologic status;
abdominal pain with coffee-grounds
emesis or black, tarry stools; hematuria;
joint pain). If uncontrolled bleeding
occurs, stop medication and notify health
care professional immediately.
● Inquire about previous reaction to
streptokinase therapy. Assess patient for
hypersensitivity reaction (rash, dyspnea,
fever, changes in facial color, swelling
around the eyes, wheezing). If these
occur, inform health care professional
promptly. Keep epinephrine, an
antihistamine, and resuscitation
equipment close by in the event of an
anaphylactic reaction.
● Inquire about recent streptococcal
infection. Streptokinase may be less
effective if administered between 5 days
and 12mo of a streptococcal infection.
● Assess neurologic status throughout
therapy. Altered sensorium or neurologic
changes may be indicative of intracranial
bleeding.
● Lab Test Considerations: Hematocrit,
hemoglobin, platelet count, fibrin/fibrin
degradation product (FDP/fdp) titer,
fibrinogen concentration, prothrombin
time, thrombin time, and activated partial
thromboplastin time may be evaluated
before and frequently during therapy.
Bleeding time may be assessed before
therapy if patient has received platelet
aggregation inhibitors.
● Obtain type and crossmatch and have
blood available at all times in case of
hemorrhage.
● Stools should be tested for occult
blood loss and urine for hematuria
periodically during therapy.
POTENTIAL DIAGNOSES
Ineffective tissue perfusion (Indications)
Risk for injury (Side Effects)
Implementation
● High Alert: Overdosage and under-
dosage of thrombolytic medications have
resulted in patient harm or death. Have
second practitioner independently check
original order, dosage calculations, and
infusion pump settings.
● Thrombolytic agents should be used
only in settings in which hematologic
function and clinical response can be
adequatelymonitored.
● Starting two IV lines before therapy is
recommended: one for the thrombolytic
agent, the other for any additional
infusions.
● Avoid invasive procedures, such as IM
injections or arterial punctures, with this
therapy. If such procedures must be
performed, apply pressure to all arterial
and venous puncture sites for at least 30
min. Avoid venipunctures at
noncompressible sites (jugular vein,
subclavian site).
● Acetaminophen may be ordered to
control fever.
● Intracoronary: Dilute 250,000 IU vial to
a total volume of 125 mL with 0.9% NaCl
or D5W. Administer 20,000 IU (10mL) via
bolus injection.
● Rate: Intracoronary bolus is
administered over 15 sec–2 min.
IV Administration
● pH: 6.5.
● Intermittent Infusion: Diluent:
Reconstitute with 5 mL of 0.9% NaCl or
D5W (direct to sides of vial) and swirl
gently; do not shake. Dilute further with
0.9% NaCl for a total volume of 45–500
mL (45 mL for MI, 90 mL for deep vein
thrombosis or pulmonary embolism).
Solution is slightly yellow in color.
Administer through 0.8-micron pore–size
filter. Use reconstituted solution within
24 hr.
Rate: Administer dose for MI within 60
min.
● Intracoronary bolus should be followed
by an intracoronary maintenance
infusion of 2000 IU/min for 60 min.
● Loading dose for deep vein thrombosis
or pulmonary embolismis administered
over 30 min, followed by an infusion of
100,000 IU/hr.
● Use infusion pump to ensure accurate
dose.
Patient/Family Teaching
● Explain purpose of medication and the
need for close monitoring to patient and
family. Instruct patient to report
hypersensitivity reactions (rash,
dyspnea) and bleeding or bruising.
● Explain need for bedrest and minimal
handling during therapy to avoid injury.
Avoid all unnecessary procedures such
as shaving and vigorous tooth brushing.
Evaluation/Desired Outcomes
● Lysis of thrombi and restoration of
blood flow.
● Cannula patency.
Page | 24
CLASSIFICATION: UROKINASE secondary angle-closure glaucoma, a
GENERIC NAME: Urokinase type of eye disorder, decreased blood
BRAND NAME: volume, basal cell carcinoma of the skin,
cessation of urine production, Acid Base
RECOMMENDED DOSAGE, ROUTE, AND Problem with Low Chloride and Basic pH
FREQUENCY: Blood, cancer of the squamous cells in
Initial dose: 4400 international units/kg IV the skin
at a rate of 90 mL/hr over 10 minutes Allergies: Thiazides, Potassium Sparing
Diuretics, Amiloride
Maintenance dose: 4400 international
units/kg/hr IV at a rate of 15 mL for 12
hours SIDE EFFECTS/ADVERSE REACTIONS:.
CNS: INTRACRANIAL HEMORRHAGE. 
DRUG ACTION: EENT: epistaxis, gingival bleeding. 
Directly converts plasminogen to Resp: bronchospasm, hemoptysis. 
plasmin, which then degrades clot-bound CV: reperfusion arrhythmias,
fibrin. Therapeutic Effects: Lysis of hypotension, RECURRENT
pulmonary emboli. Lysis of thrombi in ISCHEMIA/THROMBOEMBOLISM. GI: GI
coronary arteries, with improvement of BLEEDING, nausea, RETROPERITONEAL
ventricular function, and reduced risk of BLEEDING, vomiting. GU: GU TRACT
heart failure or death. Lysis of thrombi BLEEDING. Derm: ecchymoses, flushing,
causing ischemic stroke, reducing risk of urticaria. 
neurologic sequelae. Restoration of Hemat: BLEEDING. 
cannula or catheter function. Local: hemorrhage at injection site,
phlebitis at injection site. 
DRUG-DRUG DRUG-FOOD MS: musculoskeletal pain. 
INTERACTIONS: Misc: ALLERGIC REACTIONS,
A blood thinner (heparin, warfarin, INCLUDING ANAPHYLAXIS, fever.
Coumadin, Jantoven);
NSAIDs (nonsteroidal anti-inflammatory NURSING RESPONSIBILITIES:
drugs)--aspirin, ibuprofen (Advil, Motrin), Examination and Evaluation
naproxen (Aleve), celecoxib, diclofenac,  Assess for signs of bleeding and
indomethacin, meloxicam, and others; or hemorrhage, including bleeding
medication used to prevent blood clots-- gums, nosebleeds, unusual
abciximab, eptifibatide, tirofiban, bruising, coughing up blood,
vorapaxar. black/tarry stools, hematuria, or a
fall in hematocrit or blood
INDICATIONS: pressure. Be especially alert for
Pulmonary embolism (PE). Unlabeled signs of intracranial bleeds,
Use: Deep venous thrombosis (DVT). including sudden severe
Acute peripheral arterial thrombosis. headache, confusion, nausea,
Acute ischemic stroke. Acute myocardial vomiting, paralysis, numbness,
infarction (MI). Occluded central venous speech problems, visual
access devices. disturbances. Notify physician or
nursing staff immediately if these
signs occur.
CONTRAINDCIATIONS:
 Monitor signs of recurrent
Conditions: kidney disease from
thromboembolism and PE,
diabetes, diabetes, low amount of
including shortness of breath,
sodium in the blood
chest pain, cough, and bloody
acidosis a high level of acid in the blood
sputum. Notify physician
high levels of potassium in the blood,
immediately, and request
liver problems, kidney disease with
objective tests (Doppler
reduction in kidney function, decreased
ultrasound, lung scan, others) if
urine production
PE is suspected. and chest,
sympathectomy, increased activity of the
bronchospasm, wheezing, cough,
parathyroid gland, high cholesterol, a
dyspnea) or skin reactions (rash,
type of joint disorder due to excess uric
pruritus, urticaria). Notify
acid in the blood called gout, low amount
physician or nursing staff
of magnesium in the blood, high amount
immediately if these reactions
of calcium in the blood, dehydration, low
occur
amount of potassium in the blood, liver
failure, acute inflammation of the  Assess blood pressure,
pancreas, systemic lupus especially for the first few days
erythematosus, an autoimmune disease, after infusion. Report low blood
yellowing of the skin in a newborn child, pressure (hypotension),
high amount of uric acid in the blood, especially if patient experiences
abnormally high levels of nitrogen- dizziness or syncope.
containing compounds in your blood,

Page | 25
  Be alert for signs of recurrent (unlabeled). Dalteparin overdose—1
cardiac ischemia (chest pain, mg/100 anti-Xa IU of dalteparin. If
pain radiating into the arm or jaw, required,
shortness of breath, dizziness, a second dose of 0.5 mg/100 anti-Xa IU of
sweating, anxiety), cerebral dalteparin may be given 2–4 hr
ischemia (sudden dizziness, later if laboratory assessment indicates
vertigo, slurred speech, need (unlabeled).
incoordination, numbness), or
peripheral arterial thrombosis
(pain, cramping, coldness, and DRUG ACTION:
cyanosis in the affected limb). Pharmacokinetics
Notify physician or nursing staff A: Administered IV only, resulting in
immediately if these signs occur. complete bioavailability.
 Monitor signs of allergic D: Unknown.
reactions or anaphylaxis, M: t 1/2: Unknown.
including pulmonary symptoms E: Metabolic fate not known. Protamine-
(tightness in the throat heparin complex eventually degrades.
 Assess any muscle of joint pain Pharmacodynamics:
to rule out musculoskeletal O: immediate
pathology or hemorrhage; that is, P: rapid
try to determine if pain is drug D: 4hr (upt o 12 hr
induced rather than caused by
anatomic or biomechanical DRUG-DRUG DRUG-FOOD
problems. Be especially INTERACTIONS:
concerned about back pain that Drug-Drug: None significant
could indicate retroperitoneal
bleeding. INDICATIONS:
 Assess injection site during and Acute management of severe heparin
after IV administration, and report overdosage. Used to neutralize heparin
signs of bleeding or phlebitis received
 Assess heart rate, EcG, and heart during dialysis, cardiopulmonary bypass,
sounds when cardiac perfusion is and other procedures. Unlabeled
restored. Report any rhythm Use: Management of overdose of
disturbances or symptoms of heparin-like compounds
increased arrhythmias, including
palpitations, chest discomfort, CONTRAINDCIATIONS:
shortness of breath, fainting, and Contraindicated in: Hypersensitivity to
fatigue/weakness. protamine or fish.
Use Cautiously in: Patients who have
received previous protamine-containing
D. ANTICOAGULANT insulin
ANTAGONISTS or vasectomized men (qrisk of
hypersensitivity reactions); OB, Lactation,
CLASSIFICATION: ANTICOAGULANT Pedi: Safety not established.
ANTAGONISTS
GENERIC NAME: SIDE EFFECTS/ADVERSE REACTIONS:.
BRAND NAME: Resp: dyspnea. CV: bradycardia,
hypertension, hypotension, pulmonary
RECOMMENDED DOSAGE, ROUTE, AND hypertension.
FREQUENCY: GI: nausea, vomiting. Derm: flushing,
IV (Adults and Children): Heparin overdose warmth. Hemat: bleeding. MS: back
—1 mg/100 units of heparin. If pain. Misc: hypersensitivity reactions,
given _30 min after heparin, give 0.5 including ANAPHYLAXIS,
mg/100 units of heparin (not to exceed ANGIOEDEMA , and PULMONARY
100 EDEMA.
mg/2 hr). Further doses should be
determined by coagulation tests. If NURSING RESPONSIBILITIES:
heparin was
administered subcutaneously, use 1–1.5 Assessment
mg protamine per 100 units of heparin, ● Assess for bleeding and hemorrhage
give 25–50 mg of the protamine dose throughout therapy. Hemorrhage may
slowly followed by a continuous infusion recur 8–9 hr after therapy because of
over rebound effects of heparin. Rebound may
8–16 hours. Enoxaparin overdose—1 occur as late as 18 hr after therapy in
mg/each mg of enoxaparin to be patients heparinized for cardiopulmonary
neutralized bypass.
● Assess for allergy to fish (salmon),
previous reaction to or use of protamine

Page | 26
insulin or protamine sulfate. Vasectomized
and infertile menalso have higher risk of
hypersensitivity reaction.
● Observe patient for signs and symptoms
of hypersensitivity reaction (hives, edema,
coughing, wheezing). Keep epinephrine, an
antihistamine, and resuscitative equipment
close by in the event of anaphylaxis.
● Assess for hypovolemia before
initiation of therapy. Failure to correct
hypovolemia may result in
cardiovascular collapse from peripheral
vasodilating effects of protamine sulfate.
● Lab Test Considerations: Monitor
clotting factors, activated clotting time
(ACT), activated partial thromboplastin
time (aPTT), and thrombin time (TT) 5– 15
min after therapy and again as
necessary.
Potential NursingDiagnoses
Risk for injury (Indications)
Ineffective tissue perfusion (Indications)
Implementation
● Do not confuse protaminewith Protonix
(pantoprazole).
● Discontinue heparin infusion. In milder
cases, overdosage may be treated by
heparin withdrawal alone
● In severe cases, fresh frozen plasma or
whole blood may also be required to
control bleeding.
● Dose varies with type of heparin, route
of heparin therapy, and amount of time
elapsed since discontinuation of heparin.
● Do not administer _100 m g in 2 hr
without rechecking clotting studies, as
protamine sulfate has its own
anticoagulant properties.
IV Administration
● pH: 6.0–7.0.
● Direct IV: Diluent: May be administered
undiluted. If further dilution is desired,
D5W or 0.9% NaCl may be used.
Concentration: 10 mg/mL. Rate:
Administer by slow IV push over 1–3 min.
Rapid infusion rate may result in
hypotension, bradycardia, flushing, or
feeling of warmth. If these symptoms
occur, stop infusion and notify physician.
No more than 50 mg should be
administered within a 10–min period.
Patient/Family Teaching
● Explain purpose of the medication to
patient. Instruct patient to report
recurrent bleeding immediately.
● Advise patient to avoid activities that
may result in bleeding (shaving, brushing
teeth, receiving injections or rectal
temperatures, or ambulating) until risk of
hemorrhage has passed.
Evaluation/Desired Outcomes
● Control of bleeding.
● Normalization of clotting factors in
heparinized patients
I. DRUGS FOR HEMOPHILIA
A. FACTOR VIII
CONCENTRATES
1. RECOMBINANT-DERIVED
Generic Name: antihemophilic factor
(recombinant) (ant ee hee moe FIL ik FAK
tor (ree KOM bin ant))
Brand Name: Advate, Adynovate, Afstyla,
Eloctate with Fc Fusion Protein, Helixate
FS, Kogenate FS, Kovaltry, Novoeight,
Nuwiq, Recombinate, Xyntha
Recommended Route, Dosage and
Frequency:
single-dose vials, which contain nominally
250, 500 and 1000 International Units per
vial. When reconstituted with the appropriate
volume of diluent, the product contains the
following stabilizers in maximum amounts:
For 5 mL reconstitution volume: 25 mg/mL
Albumin (Human), 0.40 mg/mL calcium, 3
mg/mL polyethylene glycol (3350), 360
mEq/L sodium, 110 mM histidine, 1.5
µg/Factor VIII International Unit (IU)
polysorbate-80. 
Drug Action:
Factor VIII is the specific clotting factor
deficient in patients with hemophilia A
(classical hemophilia). Hemophilia A is a
genetic bleeding disorder characterized by
hemorrhages, which may occur
spontaneously or after minor trauma. The
administration of Recombinate provides an
increase in plasma levels of Factor VIII and
can temporarily correct the coagulation
defect in these patients. 
Indication: treat or prevent bleeding
episodes in adults and children with
hemophilia A. It is also used to control
bleeding related to surgery or dentistry in a
person with hemophilia, and to prevent joint
damage in people age 16 or older with
severe hemophilia A and no prior joint
damage.
Contraindication:
Contraindicated in patients who have
manifested life-threatening immediate
hypersensitivity reactions, including
anaphylaxis, to the product or its
components, including bovine, mouse or
hamster proteins.
Page | 27
Interaction: over-the-counter Recommended Route, Dosage and
medicines, vitamins, and herbal product Frequency:
The following general formula may be
used: Human-derived products—Dose
Side effects: (units) body weight (kg) 1 unit/kg desired
GI: nausea, vomiting, diarrhea; factor IX increase (% of normal).
CNS: headache, dizziness, weakness, Recombinant DNA product—Dose (units)
feeling tired, fever body weight (kg) 1.2 units/kg desired
MS: joint pain factor IX increase (% of normal).
SKIN: rash; Hemophilia B
RESPI: sore throat, cough, stuffy nose IV (Adults and Children): Major bleeding
SKIN: pain, swelling, itching, or irritation —50– 100% activity q 12– 24 hr for 7– 10
where the injection was given. days; moderate bleeding—25– 50%
activity q 12– 24 hr until bleeding stops
Adverse Reactions and healing begins (2– 7 days); minor
Blood And Lymphatic System bleeding—20– 30% activity q 12– 24 hr
Disorders: Factor VIII inhibition for 1– 2 days. Factor VII
Cardiac Disorders: Tachycardia, Deficiency (Proplex Tonly)
Cyanosis IV (Adults and Children): 75 units/kg.
Gastrointestinal Disorders: Vomiting,
Abdominal pain Drug Action:
General Disorders And Administration -Factor IX complex preparations
Site Conditions: Malaise, Injection site (Bebulin VH, Profilnine SD, Proplex T)
reactions. Chest pain, Chest discomfort contain blood coagulation factors II, VII,
Immune System Disorders: Anaphylactic IX, and X. Purified protein preparations
reaction, Hypersensitivity (AlphaNine SD, Benefix, Mononine)
Nervous System Disorders: Loss of contain factor IX activity only. Benefix is
consciousness, Headache, Paresthesia made via recombinant DNA technology.
Respiratory, Thoracic And Mediastinal
Disorders: Dyspnea, Cough, Laryngeal Absorption: Administered IV only,
edema resulting in complete bioavailability.
Skin And Subcutaneous Tissue Distribution: Unknown.
Disorders: Angioedema, Urticaria, Metabolism and Excretion: Rapidly
Erythema cleared from plasma by utilization in
clotting process. Half-life: Factor IX—24–
32 hr; factor VII—3– 6 hr.
Nursing Implications
Indications:
Assessment & Drug Effects -Treatment of active or impending
bleeding due to factor IX deficiency
(hemophilia B, Christmas disease).
 Note: The ACIP recommends
Treatment of bleeding in patients with
serologic confirmation of
factor VIII inhibitors (Proplex T only).
postvaccination immunity in patients
Prevention and treatment of bleeding in
undergoing dialysis and in
patients with factor VII deficiency
immunodeficient patients.
 Monitor temperature. Some patients
Drug Interactions:
develop a temperature elevation of
Drug-Drug
38.3° C (101° F) following
-Use with aminocaproic acid may
vaccination that may last 1 or 2 d.
increase risk of thrombosis.

Patient & Family Education Contraindications:

-Factor VII deficiency (except Proplex
 Learn potential adverse reaction. T); Intravascular coagulation or
 Do not breast feed while taking this fibrinolysis associated with liver disease;
drug without consulting physician. Allergy to mouse protein (Mononine).

Side Effects:
CNS: drowsiness, headache, dizziness
B. FACTOR IX CONCENTRATES GI: nausea, vomiting.
Derm: flushing, urticaria.
Misc: chills, fever
Generic Name: Factor IX (human) Local: injection site reactions (pain,
Brand Name: AlphaNine SD redness, or swelling)
Classification: Plasma-Derived, Neuro: tingling.
Recombinant-Derived
Adverse Reactions:
CNS: lethargy.

Page | 28
CV: changes in BP, changes in heart rate.
Hemat: disseminated intravascular
coagulation, thrombosis.
Resp: dyspnea.
Misc: risk of transmission of viral
hepatitis, risk of transmission of HI
Nursing Responsibilities (ADPIE):
ASSESSMENT
-Monitor BP, pulse, and respirations
frequently.
-Obtain history of current trauma;
estimate amount of blood loss.
Monitor for renewed or increased
bleeding every 15– 30 min. Immobilize
and apply ice to the affected joints.
-If hypersensitivity reaction (fever,
chills, tingling, headache, urticaria,
changes in BP or pulse, nausea and
vomiting, lethargy) occurs, slow infusion
and notify physician. Pyrogenic reactions
(fever, chills) may also occur and are
more common with high doses.
NURSING DIAGNOSES:
-Ineffective tissue perfusion
(Indications)
-Risk for injury (Indications)
-Deficient knowledge, related to
medication regimen (Patient/Family
Teaching)
PLANNING:
-Patient will prevent spontaneous
bleeding or cessation of bleeding in
patients with factor IX deficiency
IMPLEMENTATION
-Obtain type and crossmatch of blood in
case a transfusion is necessary.
-Hepatitis B vaccine may be given prior
to therapy to prevent hepatitis.
Inform all personnel of patient’s bleeding
tendency, to prevent further trauma.
Apply pressure to all venipuncture sites
for at least 5 min; avoid all IM injections.
-Instruct patient to notify health care
professional immediately if bleeding
recurs.
EVALUATION:
-Patient demonstrate prevention of
spontaneous bleeding or cessation of
bleeding in patients with factor IX
deficiency (hemophilia B, Christmas
disease), factor VIII inhibitors, factor VII
deficiency, or anticoagulant overdose
C. DESMOPRESSIN
Brand Name: DDAVP, Stimate
Generic Name: Desmopressin
Classification: Desmopressin
Recommended Route, Dosage and
Frequency:
Primary Nocturnal Enuresis
PO: CHILDREN 6 YRS AND OLDER: 0.2–
0.6 mg once before bedtime. Limit fluid
intake 1 hr prior and at least 8 hrs after
dose.
Central Cranial Diabetes Insipidus (Fluid
restriction should be observed)
PO: ADULTS, ELDERLY, CHILDREN 4
YRS AND OLDER: Initially, 0.05 mg twice
daily. Titrate to desired response. Range:
0.1–1.2 mg/day in 2–3 divided doses.
Hemophilia A, Von Willebrand’s Disease
(Type I)
IV Infusion: ADULTS, ELDERLY,
CHILDREN: 0.3 mcg/kg as a slow
infusion.
Intranasal: (Use 1.5 mg/mL Concentration
Providing 150 mcg/Spray):ADULTS,
ELDERLY, CHILDREN WEIGHING MORE
THAN 50 KG: 300 mcg; use 1 spray in
each nostril. ADULTS, ELDERLY,
CHILDREN WEIGHING 50 KG OR LESS:
150 mcg as a single spray. Repeat use
based on clinical conditions/laboratory
work.
Drug Action:
-Increases cAMP in renal tubular cells,
which increases water permeability,
decreasing urine volume. Increases
levels of von Willebrand factor, factor
VIII, tissue plasminogen activator (tPA).
Absorption: 1% absorbed following oral
administration; nasal solution 10– 20%
absorbed; nasal spray 3– 4% absorbed.
Distribution: Distribution not fully known.
Enters breast milk.
Metabolism and Excretion: Unknown.
Half-life: PO– 1.5– 2.5 hr; IV— 75 min
(increase in renal impairment); Intranasal
— 3.3– 3.5 hr
Indications:
-DDAVP Nasal: (DDAVP Rhinal Tube):
Antidiuretic replacement therapy in
managing central cranial diabetes
insipidus. Management of temporary
polyuria and polydipsia following head
trauma or surgery in the pituitary region.
Parenteral: Antidiuretic replacement
therapy in managing central cranial
diabetes insipidus. Manage polyuria and
polydipsia following head trauma or
surgery in pituitary region. Maintain
hemostasis and control bleeding in
hemophilia A, von Willebrand’s disease
(type I). Stimate intranasal: Maintain
hemostasis and control bleeding due to
spontaneous or trauma-induced injuries
in hemophilia A, von Willebrand’s
disease (type I)
Drug Interactions:
Drug-drug
Page | 29
 -CarBAMazepine, lamoTRIgine, NSAIDs
(e.g., ibuprofen, ketorolac, naproxen),
SSRIs (e.g., citalopram, sertraline),
tricyclic antidepressants (e.g.,
amitriptyline, doxepin, nortriptyline) may
increase effect. Demeclocycline, lithium
may decrease effect.
Contraindications:
-Hypersensitivity to desmopressin.
Hyponatremia, history of hyponatremia,
moderate to severe renal impairment.
Recommended Route, Dosage and
Frequency:
IV (Adults and Children): 10 mg/kg just
prior to surgery with appropriate
replacement therapy, then 10 mg/kg 3– 4
times daily for 2– 8 days.
Renal Impairment
IV (Adults and Children): SCr 1.36– 2.83
mg/dL—10 mg/kg twice daily; SCr 2.83–
5.66 mg/dL—10 mg/kg daily;SCr 5.66
mg/dL—10 mg/kg every 48 hrs or 5 mg/kg
once daily.
PO (Adults): 1300 mg 3 times daily for a
maximum of 5 days during menstruation.

Side Effects: Drug Action:

Derm: flushed skin, pain, redness, -Inhibits activation of plasminogen,
swelling at the injection site thereby preventing the conversion of
CNS: headache plasminogen to plasmin.
GI: nausea with high dosages, abdominal
cramps Absorption: 100% bioavailable with IV
EENT: Rhinorrhea, nasal congestion, administration; 45% bioavailability after
CV: slight B/P elevation. oral administration.
Distribution: Penetrates readily into joint
Adverse Reactions: fluid and synovial membranes.
CNS: SEIZURES, drowsiness, Metabolism and Excretion: 95% excreted
listlessness. unchanged in urine.
Resp: dyspnea. Half-life: 2 hr (IV) (qin renal impairment);
CV: hypertension, hypotension, 11 hr (PO).
tachycardia (large IV doses only).
Indications
Nursing Responsibilities (ADPIE): -Treatment and control of excessive
ASSESSMENT bleeding in various surgical and medical
-Establish baselines for B/P, pulse, conditions.
weight, serum electrolytes, urine specific
gravity. Drug Interactions:
-Check lab values for factor VIII Drug-Drug
coagulant concentration for hemophilia -Concurrent use of hormonal
A, von Willebrand’s disease. contraceptives may increase risk of
thrombosis (PO); concurrent use
NURSING DIAGNOSES: contraindicated. Concurrent use of
-Deficient fluid volume (Indications) clotting factor complexes may increase
-Excess fluid volume (Adverse the risk of thrombotic complications
Reactions) (give tranexamic acid 8 hr following
clotting factor replacement therapy). May
PLANNING: increase the procoagulant effects of all-
-Patient will reduce the risk of stroke trans retinoic acid. Decreased
and systemic embolism. effectiveness with thrombolytic agents.

IMPLEMENTATION Contraindications:
-IV desmopressin has 10 times the -Hypersensitivity; Thromboembolic
antidiuretic effect of intranasal disorders (current, history of, or at risk
desmopressin. for); Acquired defective color vision (IV);
-PO: Begin oral doses 12 hr after last Subarachnoid hemorrhage; Concurrent
intranasal dose. Monitor response use of combination hormonal
closely contraception (PO).
-Check B/P, pulse with IV infusion.
Side Effects:
EVALUATION: Gl: frequently included nausea, vomiting,
-Patient reported decreased frequency and diarrhea.
of nocturnal enuresis. Nervo: giddiness, dizziness, headache,
-Patient manifested a decrease in urine tension headache, and migraine
volume. Hem: thromboembolic events (e.g., deep
vein thrombosis, pulmonary embolism
Brand Name: Hemostan MS: back pain, musculoskeletal pain
Generic Name: Tranexamic Acid
Classification: Antifibrinolytics

Page | 30
Respi: nasal and sinus symptoms PO (Adults): 4 g 1– 2 times daily (initially,
including nasal, respiratory tract and may be increased as needed/tolerated up
sinus congestion to 24 g/day in 6 divided doses).
PO (Children): 240 mg/kg/day in 2– 3
Adverse Reactions: divided doses (not >8 g/day).
CNS: seizures, headache, dizziness
EENT: visual abnormalities.
CV: hypotension, thromboembolism, Drug Action:
thrombosis. -Bind bile acids in the GI tract, forming
GI: diarrhea, nausea, vomiting. an insoluble complex. Result is
MS: pain increased clearance of cholesterol.
Misc: PO—anaphylaxis.
Absorption: Action takes place in the GI
Nursing Responsibilities (ADPIE): tract.
ASSESSMENT No absorption occurs.
-Prevention of post-surgical Distribution: No distribution.
hemorrhage: Observe site of surgery for Metabolism and Excretion: After binding
excessive bleeding. bile acids, insoluble complex is
-Heavy menstrual bleeding: Monitor eliminated in the feces.
menstrual flow prior to and during Half-life: Unknown
therapy.
-Patients taking tranexamic acid for Indications
more than several days should have -Management of primary
ophthalmologic examinations to detect hypercholesterolemia. Pruritus
visual abnormalities prior to and at associated with elevated levels of bile
regular intervals during and after acids.
therapy. Discontinue therapy if visual
changes occur. Drug Interactions:
Drug-Drug
NURSING DIAGNOSIS: -May decrease absorption/effects of
-Risk for injury (Indications) orally administered acetaminophen,
-Deficient knowledge, related to amiodarone,clindamycin,clofibrate,
medication regimen (Patient/Family digoxin, diuretics, gemfibrozil, glipizide,
Teaching) corticosteroids, imipramine,
mycophenolate, methotrexate,
PLANNING: methyldopa, niacin, NSAIDs, penicillin,
-Patient will be able to report reduction phenytoin, phosphates, propranolol,
of blood loss. tetracyclines, tolbutamide, thyroid
preparations, ursodiol, warfarin, and fat-
IMPLEMENTATION soluble vitamins (A, D, E, and K).
-PO: Administer 3 times daily without
regard to food. Swallow the tablets Contraindications:
whole; do not crush, break, or chew. -Hypersensitivity; Complete biliary
Intermittent Infusion: Diluent: May be obstruction; Some products contain
diluted with most solutions, such as aspartame and should be avoided in
electrolyte, carbohydrate, amino acid, patients with phenylketonuria.
and dextran solutions. Prepare mixture
on day of infusion. Rate: Infuse at a rate Side Effects:
not to exceed 100 mg (1 mL)/min. More EENT: irritation of the tongue
rapid administration has resulted in GI: abdominal discomfort, constipation,
hypotension. nausea, fecal impaction, flatulence,
hemorrhoids, perianal irritation,
EVALUATION: steatorrhea, vomiting
-Patient reported reduced menstrual Derm: irritation, rashes
blood loss.
Adverse Reactions :
EENT: irritation of the tongue
J. ANTIHYPERLIPIDEMICS GI: fecal impaction, flatulence,
hemorrhoids, perianal irritation,
Brand Name: Questran steatorrhea
Generic Name: cholestyramine F and E: hyperchloremic acidosis
Classification: bile acid sequestrants Metab: vitamin A, D, and K deficiency

Nursing Responsibilities (ADPIE):

Recommended Route, Dosage and ASSESSMENT
Frequency: -Hypercholesterolemia: Obtain a diet
history, especially in regard to fat
consumption.

Page | 31
 -Pruritus: Assess severity of itching and
skin integrity. Dose may be decreased Drug Interactions:
when relief of pruritus occurs. Drug-drug
-Diarrhea: Assess frequency, amount, -Statins (e.g., atorvastatin, simvastatin)
and consistency of stools may increase risk for
myopathy/rhabdomyolysis. May increase
NURSING DIAGNOSES: effects of repaglinide, warfarin. Bile acid–
-Constipation (Side Effects) binding resins (e.g., colestipol) may
-Noncompliance (Patient/Family decrease concentration.
Teaching) HERBAL: None significant.
FOOD: None known.
PLANNING: LAB VALUES: May increase serum
-patient will be a decrease in serum low- alkaline phosphatase, bilirubin, creatine
density lipoprotein cholesterol levels. kinase, LDH, ALT, AST.

IMPLEMENTATION Contraindications:
-Parenteral or water-miscible forms of -Hypersensitivity to gemfibrozil. Hepatic
fat-soluble vitamins (A, D, and K) and impairment (including primary biliary
folic acid may be ordered for patients on cirrhosis), preexisting gallbladder
chronic therapy. disease, severe renal impairment,
-PO: Administer before meals. concurrent use with dasabuvir,
Scoops for powdered preparations may repaglinide or simvastatin.
not be exchangeable between products.
Administer other medications 1 hr before Side Effects:
or 4– 6 hr after the administration of this CNS: fatigue, vertigo, headache,
medication. EENT: altered taste
GI: dyspepsia, abdominal pain, diarrhea,
EVALUATION: nausea, vomiting, constipation, acute
-patient had decrease in serum low- appendicitis
density lipoprotein cholesterol levels. Derm: rash, pruritus

Adverse Reactions:
Generic Name: Gemfibrozil CNS: dizziness, headache
Brand Name: Lopid EENT: blurred vision
Classification: Fibrates (Fibric acid) GI: diarrhea, epigastric pain, flatulence,
gallstones, heartburn
Recommended Route, Dosage and Derm: alopecia, rashes, urticaria.
Frequency: Hemat: anemia, leukopenia.
Hyperlipidemia/Hypertriglyceridemia MS: myositis
PO: ADULTS, ELDERLY: 600 mg twice
daily 30 min before breakfast and dinner. Nursing Responsibilities (ADPIE):
ASSESSMENT
Drug Action: -Obtain diet history, esp. fat/alcohol
Inhibits peripheral lipolysis. Decreases consumption.
triglyceride production by the liver. -Obtain serum glucose, triglyceride,
Decreases production of the triglyceride cholesterol, LFT.
carrier protein.Increases HDL. -Question history of hepatic/renal
impairment, cholecystectomy.
Absorption: Well absorbed from the GI Receive full medication history and
tract after oral administration. screen for contraindications.
Distribution: Unknown.
Metabolism: Some metabolism by the NURSING DIAGNOSIS:
liver -Noncompliance (Patient/Family
Excretion: 70% excreted by the kidneys Teaching)
(mostly unchanged), 6% excreted in
feces. PLANNING:
Half-life: 1.3– 1.5 hr -Patient will be able to decrease in
serum triglyceride and cholesterol levels
Indications and improved HDL to total cholesterol
-Treatment of hypertriglyceridemia in ratios
types IV and V hyperlipidemia in pts who
are at greater risk for pancreatitis and IMPLEMENTATION
those who have not responded to dietary -Monitor LDL, VLDL, serum
intervention. Reduce risk of coronary triglycerides, cholesterol lab results for
heart disease (CHD) development in pts therapeutic response.
without symptoms who have decreased -Monitor daily pattern of bowel activity,
HDL, increased LDL, increased stool consistency.
triglycerides.

Page | 32
 -Assess for rash, pruritus. Question for -Alcohol may increase the risk of side
headache, dizziness. effects. May increase effect of
-Monitor serum glucose in pts receiving antihypertensives (e.g., amlodipine,
insulin, oral antihyperglycemics. lisinopril, valsartan). Lovastatin,
-Take before meals. pravastatin, simvastatin may increase
risk of acute renal failure,
EVALUATION: rhabdomyolysis. Vasoactive drugs (e.g.,
-Patient manifested n decrease in serum calcium channel blockers, nitrates) may
triglyceride and cholesterol levels and increase hypotension.
improved HDL to total cholesterol ratios.
Contraindications:
Brand Name: Niaspan -Hypersensitivity to niacin, nicotinic
Generic Name: Niacin acid. Active peptic ulcer disease, arterial
Classification: Antihyperlipidemic: hemorrhage, significant or unexplained
Nicotinic Acid persistent elevations in hepatic
transaminases, active hepatic disease.
Recommended Route, Dosage and
Frequency: Side Effects:
Hyperlipidemia Derm: Flushing, rash,
PO (Immediate-Release): ADULTS, hyperpigmentation, dry skin
ELDERLY: Initially, 250 mg once daily GI: GI upset, flatulence, nausea,
(with evening meal). May increase dose vomiting, diarrhea
q4–7days up to 1.5–2 g/day in 2–3 CNS: Dizziness, hypotension, headache,
divided doses. After 2 mos may increase EENT: blurred vision
at 2- to 4-wk intervals to 3 g/day in 3 Metab: Hyperglycemia, glycosuria
divided doses. Maximum: 6 g/day in 3
divided doses. Usual daily dose: 1.5–3 Adverse Reactions:
g/day. CV: orthostatic hypotension.
PO (Extended-Release): ADULTS, GI: hepatotoxicity
ELDERLY: Initially, 500 mg/day at Metab: glycosuria, hyperglycemia,
bedtime for 4 wks, then 1 g at bedtime for hyperuricemia.
4 wks. May increase by no more than 500 MS: myalgia.
mg q4wks up to a maximum of 2 g/day.
Usual daily dose: 1–2 g/day. Nursing Responsibilities (ADPIE):
Dosage for Hepatic Toxicity ASSESSMENT
Transaminases more than 3 times ULN: -Obtain diet history, especially fat
Discontinue therapy. consumption.
-Question for history of hypersensitivity
Drug Action: to niacin, tartrazine, aspirin.
-Component of two coenzymes needed -Obtain baseline serum cholesterol,
for tissue respiration, lipid metabolism, triglyceride, glucose, LFT.
glycogenolysis. May inhibit release of
free fatty acids from adipose tissue, NURSING DIAGNOSIS:
increase lipoprotein lipase activity. -Imbalanced nutrition: less than body
requirements (Indications)
Absorption: Readily absorbed from the -Noncompliance (Patient/Family
GI tract. Teaching)
Distribution: Widely distributed following
conversion to niacinamide. Enters breast PLANNING:
milk. Protein binding: 20%. -Patient will be able to show a decrease
Metabolism: Metabolized in liver. in serum cholesterol and triglyceride
Amounts required for metabolic levels.
processes are converted to niacinamide.
Excretion: Large doses of niacin are IMPLEMENTATION
excreted unchanged in the urine -Evaluate flushing, degree of GI
Half-life: 45 min. discomfort. Check for headache,
dizziness, blurred vision. Monitor daily
Indications pattern of bowel activity, stool
-Treatment of dyslipidemias, lowers risk consistency.
of recurrent MI (pts with history of -Monitor LFT, serum cholesterol,
MI/hyperlipidemia), slow progression of triglycerides.
CAD, treatment of hypertriglyceridemia in -Check serum glucose carefully in pts
pts at risk for pancreatitis, dietary on insulin, oral antihyperglycemics.
supplement. Assess skin rashes, dryness. Monitor
serum uric acid.
Drug Interactions: -Report nausea, vomiting, loss of
Drug-drug appetite, yellowing of skin, dark urine,
feeling of weakness.

Page | 33
 Drug-Food: Grapefruit juice inhibits
EVALUATION: metabolism
-Patient manifested prevention and
treatment of niacin deficiency. andqeffects; concurrent use should be
avoided.

K. PERIPHERAL VASODILATORS INDICATIONS: Reduction of the symptoms

of intermittent claudication
as measured by increased walking distance.

HEMORRHEOLOGIC
CONTRAINDICATIONS
Hypersensitivity; HF; OB: Potential for
congenital defects, stillbirth, and low birth
BRAND NAME: Pletal
weight; Lactation: Potential risk to nursing
GENERIC NAME: Cilostazol
infants; discontinue or bottle feed.
CLASSIFICATION: platelet aggregation
inhibitors
SIDE EFFECTS
RECOMMENDED DOSAGE, ROUTE, AND CNS: headache, dizziness.
FREQUENCY
PO (Adults): 100 mg twice daily (50 mg CV: hypotension, left ventricular outflow
twice daily if receiving inhibitors of cilostazol obstruction, palpitations, tachycardia.
metabolism).
GI: diarrhea.

DRUG ACTION ADVERSE REACTION

Inhibits the enzyme cyclic adenosine
monophosphate (cAMP) phosphodiesterase
III (PDE III), which results in increased
cAMP in platelets and blood vessels,
producing inhibition of platelet aggregation
and vasodilation.
CNS: headache, dizziness.
CV: hypotension, left ventricular outflow
obstruction, palpitations, tachycardia.
GI: diarrhea.

Therapeutic Effects: Reduced symptoms NURSING RESPONSIBILITIES

of
ASSESSMENT
intermittent claudication with improved
walking distance. ● Assess patient for intermittent claudication
ABSORPTION before and periodically during therapy.
Slowly absorbed after oral administration.
DISTRIBUTION: Unknown. ● Lab Test Considerations: May
METABOLISM: Extensively metabolized by occasionally cause anemia, hyperlipemia,
the liver, two metabolites have platelet hyperuricemia, and albuminuria. May
aggregation prolong bleeding time.
inhibitory activity
EXCRETION: metabolites are mostly DIAGNOSES
excreted
by the kidneys. Activity intolerance (Indications)
ONSET
2–4 wk PLANNING
PEAK
up to 12 wk Within the shift the nurse will be able to:
DURATION
Unknown ● Instruct patient to take cilostazol on an
empty stomach, exactly as directed.
DRUG-DRUG AND DRUG-FOOD
INTERACTIONS ● Advise patient to avoid grapefruit juice
Drug-Drug: Concurrent administration of during therapy.
ketoconazole, itraconazole, erythromycin,
diltiazem, fluconazole, miconazole, ● May cause dizziness. Caution patient to
fluvoxamine, fluoxetine, nefazodone, avoid driving or other activities requiring
sertraline, or omeprazole decrease alertness until response to medication is
metabolism and increase levels and activity known.
of cilostazol (use lower
● Advise patient to avoid smoking; nicotine
doses). Concurrent use with aspirin has constricts blood vessels.
additive effects on platelet function.
IMPLEMENTATION

Page | 34
● PO: Administer on an empty stomach, 1 hr MAO inhibitors: intensified and prolonged
before or anticholinergic effects

2 hr after meals. Other CNS depressants (such as

EVALUATION
● Relief from cramping in calf muscles,
buttocks, thighs, and feet during exercise.
antihistamines, opioids, sedative-hypnotics):
additive CNS depression Ototoxic drugs
(such as aminoglycosides, ethacrynic acid):
masking of signs or symptoms of ototoxicity

● Improvement in walking endurance. Drug-diagnostic tests. Allergy skin

Therapeutic effects may be seen in 2–4 wk.
tests: false-negative results

Drug-behaviors. Alcohol use: increased

XII. Gastrointestinal Agents
Antiemetics
Nonprescription
Antiemetics
BRAND NAME: Dramamine
GENERIC NAME: Dimenhydrinate
CLASSIFICATION: Anticholinergic
CNS depression
INDICATIONS
➣Prevention and treatment of nausea,
vomiting, dizziness, and vertigo
Antihistamine
CONTRAINDICATIONS
● Hypersensitivity to drug or tartrazine
● Alcohol intolerance

Pregnancy risk category B
RECOMMENDED DOSAGE, ROUTE, AND
FREQUENCY
Adults and children ages 12 and older:
50 to 100 mg P.O. q 4 hours (not to exceed
400 mg/day), or 50 mg I.M. or
SIDE EFFECTS
CNS: drowsiness, dizziness, headache,
paradoxical stimulation (in children)
CV: hypotension, palpitations
EENT: blurred vision, tinnitus
GI: diarrhea, constipation, dry mouth

I.V. q 4 hours p.r.n. GU: dysuria, urinary frequency

Children ages 6 to 12: 25 to 50 mg P.O. q Skin: photosensitivity

6 to 8 hours (not to exceed 150 mg/day), or
1.25 mg/kg I.M. (37.5 mg/m2) q 6 hours Other: decreased appetite, pain at I.M. site
p.r.n.
ADVERSE REACTION
Children ages 2 to 6: 12.5 to 25 mg CNS: drowsiness, dizziness, headache,
paradoxical stimulation (in children)
P.O. q 6 to 8 hours (not to exceed
CV: hypotension, palpitations
75 mg/day)
EENT: blurred vision, tinnitus
DRUG ACTION
Prevents nausea and vomiting by inhibiting GI: diarrhea, constipation, dry mouth

vestibular stimulation of chemoreceptor GU: dysuria, urinary frequency

trigger zone and inhibiting stimulation of Skin: photosensitivity

vomiting center in brain 15-60 min
Other: decreased appetite, pain at I.M. site
PEAK
1-2 hr NURSING RESPONSIBILITIES
DURATION
3-6 hr ASSESSMENT

DRUG-DRUG AND DRUG-FOOD ● Assess for lethargy and drowsiness.

INTERACTIONS
Drug-drug. Disopyramide, quinidine, ● Monitor for dizziness, nausea, and
vomiting (possible indicators of drug
tricyclic antidepressants: increased toxicity).
anticholinergic effects
DIAGNOSES

Page | 35
Risk for injury related to nausea and
vomiting
Knowledge deficit related to drug therapy
PLANNING
Within the shift the nurse will be able to:
● Caution patient to avoid alcohol and
sedative-hypnotics during therapy.
● As appropriate, review all other significant
adverse reactions and interactions,
especially those related to the drugs, tests,
and behaviors mentioned above.
IMPLEMENTATION
● To prevent motion sickness, advise patient
to take drug 30 minutes before traveling and
to repeat dose before meals and at bedtime.
● Instruct patient to avoid driving and other
hazardous activities until he knows how drug
affects concentration and alertness.
EVALUATION
 The patient verbalized
understanding of drug treatment.
 The patient did not suffer any
drug adverse reactions.
Miscellaneous OTC Antiemetic
BRAND NAME
Pepto-Bismol
GENERIC NAME
Bismuth Subsalicylate
CLASSIFICATION: Adsorbent
Pregnancy risk category C
RECOMMENDED DOSAGE, ROUTE, AND
FREQUENCY
Adults: Two tablets or 30 ml P.O.
(15 ml of maximum strength) q 30
minutes, or two tablets or 60 ml
(30 ml of extra/maximum strength)
q 60 minutes as needed. Don’t exceed
4.2 g in 24 hours.
Children ages 9 to 12: One tablet or 15
ml P.O. (7.5 ml of maximum strength)
q 30 to 60 minutes. Don’t exceed 2.1 g
in 24 hours.
Children ages 6 to 9: 10 ml (5 ml of
maximum strength) P.O. q 30 to 60
minutes. Don’t exceed 1.4 g in 24 hours.
Children ages 3 to 6: 5 ml (2.5 ml of
maximum strength) P.O. q 30 to 60 minutes.
Don’t exceed 704 mg in 24 hours.
DRUG ACTION
Promotes intestinal adsorption of fluids and
electrolytes and decreases
synthesis of intestinal prostaglandins.
Adsorbent action removes irritants
from stomach and soothes irritated
bowel lining. Also shows antibacterial
activity to eradicate Helicobacter pylori.
DRUG-DRUG AND DRUG-FOOD
INTERACTIONS
Drug-drug. Aspirin, other salicylates:
salicylate toxicity
Corticosteroids, probenecid (large doses),
sulfinpyrazone: decreased bismuth
efficacy
Enoxacin: decreased enoxacin
bioavailability
Methotrexate: increased risk of bismuth
toxicity
Tetracycline: decreased tetracycline
absorption
Drug-diagnostic tests. Radiologic GI
tract examination: test interference
INDICATIONS
➣Adjunctive therapy for mild to
moderate diarrhea, nausea, abdominal
cramping, heartburn, and indigestion
accompanying diarrheal illnesses
➣Ulcer disease caused by H. pylori
CONTRAINDICATIONS
● Hypersensitivity to aspirin
● Elderly patients with fecal impaction
● Children or adolescents during or after
recovery from chickenpox or flulike illness
Page | 36

SIDE EFFECTS
EENT: tinnitus, tongue discoloration
GI: nausea, vomiting, diarrhea, constipation,
gray-black stools, fecal impaction
Respiratory: tachypnea
Other: salicylate toxicity
ADVERSE REACTION
EENT: tinnitus, tongue discoloration
Prescription Antihistamines
BRAND NAME: Vistaril
GENERIC NAME: Hydroxyzine
CLASSIFICATION: Piperazine derivative
Pregnancy risk category NR
RECOMMENDED DOSAGE, ROUTE, AND
FREQUENCY
Adults: 25 to 100 mg I.M. q 4 to
6 hours
Children: 1.1 mg/kg I.M. q 4 to 6 hours

GI: nausea, vomiting, diarrhea, constipation,

DRUG ACTION
gray-black stools, fecalmimpaction Unknown. Anxiolytic and sedative effects
may stem from suppression of activity in
Respiratory: tachypnea subcortical levels of CNS. Antihistamine
effects may result from histamine
Other: salicylate toxicity
suppression at cellular receptor sites.
NURSING RESPONSIBILITIES
DRUG-DRUG AND DRUG-FOOD
ASSESSMENT INTERACTIONS
Drug-drug. Anticholinergics,
● Monitor fluid intake and electrolyte levels. antidepressants,
● Monitor stool frequency and appearance. antihistamines, phenothiazines, quinidine:
additive effects of these drugs
● Assess infants and debilitated patients for
fecal impaction. Antidepressants, antihistamines, opioids,
sedative-hypnotics, other CNS depressants:
DIAGNOSES
additive CNS depression
 Pain related to ulcer Drug-diagnostic tests. Skin tests using
 Risk for injury related to ulcer
disease allergen extracts: false-negative results

PLANNING Drug-herbs. Angel’s trumpet, jimsonweed,

scopolia: increased anticholinergic effects

Within the shift the nurse will be able to:
● Instruct patient to chew tablets or dissolve
them in mouth before swallowing.
● Inform patient that drug may turn stools
gray-black temporarily.
IMPLEMENTATION
● Tell patient to notify prescriber if he has
diarrhea with fever for more than 48 hours.
Chamomile, hops, kava, skullcap, valerian:
increased CNS depression
Drug-behaviors. Alcohol use: increased
CNS depression
INDICATIONS
➣Psychiatric emergencies; acute or
chronic alcoholism
➣Nausea and vomiting; adjunct in

● As appropriate, review all other significant pre- and postoperative sedation

adverse reactions and interactions, ➣Anxiety

especially those related to the drugs and
tests mentioned above. ➣Pruritus

EVALUATION
CONTRAINDICATIONS
The patient verbalized understanding of ● Hypersensitivity to drug or cetirizine
medical treatment
● Early pregnancy
The patient describes pain as five out of ten
SIDE EFFECTS

Page | 37
CNS: drowsiness, agitation, dizziness, ● Instruct patient to avoid alcoholwhile
taking drug.
headache, asthenia, ataxia
● As appropriate, review all other significant
GI: nausea, constipation, dry mouth adverse reactions and interactions,
especially those related to the drugs, tests,
GU: urinary retention herbs, and behaviors mentioned above.
Respiratory: wheezing

Skin: flushing EVALUATION

Other: bitter taste, hypersensitivity
The patient verbalized understanding of
reaction, pain or abscess at I.M. injection medical treatment
site
The patient did not suffer any adverse
ADVERSE REACTION reactions
CNS: drowsiness, agitation, dizziness,
headache, asthenia, ataxia Anticholinergics
GI: nausea, constipation, dry mouth BRAND NAME
Transderm-Scop
GU: urinary retention
GENERIC NAME
Respiratory: wheezing Scopolamine
CLASSIFICATION: anticholinergics
Skin: flushing

Other: bitter taste, hypersensitivity

RECOMMENDED DOSAGE, ROUTE, AND
reaction, pain or abscess at I.M. injection FREQUENCY
site Transdermal (Adults): Motion sickness—
Apply 1 patch 4 hr prior to travel and then
every 3 days (as needed); Preoperative—
NURSING RESPONSIBILITIES Apply 1 patch the evening before surgery or
1 hr prior to cesarean section (remove 24 hr
ASSESSMENT after surgery).

● Monitor closely for CNS depression and
oversedation, especially if patient is
receiving other CNS depressants.
● Assess for adverse effects, especially in
elderly patients.
PO (Adults): 0.4–0.8 mg; may repeat every
8–12 hr as needed (dose may beqin
parkinsonism and spastic states); for motion
sickness, give at least 1 hr before exposure
to motion.

● Monitor liver function test results in DRUG ACTION

patients with hepatic impairment. Inhibits the muscarinic activity of
acetylcholine. Corrects,the imbalance of
DIAGNOSES acetylcholine and norepinephrine,in the
CNS, which may be responsible for motion
Imbalanced nutrition: less than body sickness. Therapeutic Effects: Reduction
requirements related to nausea and vomiting of postoperative nausea and vomiting.
Reduction of spasms.
Risk for fluid imbalance related to nausea
ABSORPTION
and vomiting Well absorbed following transdermal
administration.
PLANNING
DISTRIBUTION
Within the shift the nurse will be able to: Crosses the placenta and blood-brain
barrier.
● Tell patient to contact prescriber if he
experiences wheezing,muscle spasms, or METABOLISM
incoordination. Mostly metabolized by the liver.

● Caution patient to avoid driving and other EXCRETION

hazardous activities until he knows how drug Half-life: 8 hr.
affects concentration and alertness. ONSET
30 min
IMPLEMENTATION PEAK

Page | 38
1 hr Derm:psweating.
DURATION
4–6 hr
NURSING RESPONSIBILITIES
DRUG-DRUG AND DRUG-FOOD
INTERACTIONS ASSESSMENT
Drug-Drug: increase anticholinergic effects
with antihistamines, antidepressants, ● Assess patient for signs of urinary
quinidine, or disopyramide. Increase CNS retention periodically during therapy.
depression with alcohol, antidepressants,
antihistamines, opioid analgesics, or ● Monitor heart rate periodically during
sedative/hypnotics. May alter the absorption parenteral therapy.
of other orally administered drugs by
slowing motility of the GI tract. May increase ● Assess patient for pain prior to
GI mucosal lesions in patients taking oral administration. Scopolamine may act as a
wax-matrix potassium chloride preparations. stimulant in the presence of pain, producing
delirium if used without opioid analgesics.
Drug-Natural Products: increase
anticholinergic effects with jimson weed and ● Antiemetic: Assess patient for nausea
scopolia. and vomitingperiodically during therapy.

INDICATIONS
Transdermal: Prevention of motion DIAGNOSES
sickness. Preventionof postoperative
nausea and vomiting. PO: Symptomatic  Risk for injury related to drug
treatment of postencephalitis parkinsonism adverse reaction
and paralysis agitans. Treatment of  Knowledge deficit related to drug
spasticity. Inhibits excessive motility and therapy
hypertonus of GI tract in irritable colon PLANNING
syndrome, mild dysentery, diverticulitis, and
pylorospasm. Prevention of motion sickness. Within the shift the nurse will be able to:

● Instruct patient to take medication as

CONTRAINDICATIONS
Hypersensitivity; Angle-closure glaucoma;
Acute hemorrhage; Prostatic hyperplasia
(oral only); Pyloric obstruction (oral only);
Tachycardia secondary to cardiac
insufficiency or thyrotoxicosis.
directed. Take missed doses as soon as
remembered. Do not double doses.
● May cause drowsiness or blurred vision.
Caution patient to avoid driving or other
activities requiring alertness until response
to medication is known.

SIDE EFFECTS
CNS: drowsiness, confusion.
EENT: blurred vision,
photophobia.
CV: tachycardia, palpitations.
GI: dry mouth, constipation.
GU: urinary hesitancy, urinary retention.
Derm: decrease sweating.
ADVERSE REACTION
CNS: drowsiness, confusion.
EENT: blurred vision,
mydriasis, photophobia.
CV: tachycardia, palpitations.
IMPLEMENTATION
● PO: Administer at least 1 hr prior to
exposure to travel for motion sickness.
mydriasis, Tablets may be crushed or dissolved in
water to decrease onset.
● Transdermal: Instruct patient on
application of transdermal patches. Apply at
least 4 hr (US product) before exposure to
travel to prevent motion sickness. Wash
hands and dry thoroughly before and after
application. Apply to hairless, clean, dry
area behind ear; avoid areas with cuts or
irritation. Apply pressure over system to
ensure contact with skin.
System is effective for 3 days. If system
becomes dislodged, replace with a new
system on another site behind the ear.
System is waterproof and not affected by
bathing or showering.

GI: dry mouth, constipation.

EVALUATION
GU: urinary hesitancy, urinary retention.

Page | 39
● Prevention of motion sickness.
● Prevention of postoperative nausea and
vomiting.
● Reduction in spasms.
● Reduction in excessive GI motility.
CNS depressants, including alcohol,
antidepressants, antihistamines, opioid
analgesics, sedative/hypnotics, or general
anesthetics. Additive anticholinergic effects
with other drugs possessing anticholinergic
properties, including antihistamines, some
antidepressants, atropine, haloperidol, and
other phenothiazines. Lithiumqrisk of
extrapyramidal

reactions. May mask early signs of lithium

Dopamine Antagonists toxicity. Increse risk of agranulocytosis with
antithyroid agents. Decrease beneficial
Phenothiazines
effects of levodopa. Antacids may decrease
BRAND NAME: Compazine absorption.
GENERIC NAME: Prochlorperazine Maleate
Drug-Natural Products: Concomitant use of
CLASSIFICATION: phenothiazines
kava-kava, valerian, chamomile, or hops
canq
RECOMMENDED DOSAGE, ROUTE, AND
FREQUENCY CNS depression.qanticholinergic effects with
PO (Adults and Children _12 yr): 5–10 mg angel’s trumpet, jimson weed, and scopolia.
3–4

times daily (not to exceed 40 mg/day). INDICATIONS

Management of nausea and vomiting.
DRUG ACTION Treatment of psychoses.
Alters the effects of dopamine in the CNS.
Possesses significant anticholinergic and Treatment of anxiety.
alpha-adrenergic blocking activity.
Depresses the chemoreceptor trigger zone CONTRAINDICATIONS
(CTZ) in the CNS. Therapeutic Effects: Hypersensitivity; Cross-sensitivity with other
Diminished nausea and vomiting. phenothiazines may exist; Angle-closure
Diminished signs and symptoms of
psychoses or anxiety. glaucoma; Bone marrow depression; Severe
liver or cardiovascular disease;
ABSORPTION Hypersensitivity to bisulfites or benzyl
Absorption from tablet is variable; may be alcohol (some parenteral products); Pedi:
better with oral liquid formulations. Well Children <2 yr or <9.1 kg.
absorbed after IM administration.

DISTRIBUTION SIDE EFFECTS

Widely distributed, high concentrations in CNS: NEUROLEPTIC MALIGNANT
the CNS. Crosses the placenta and probably SYNDROME, extrapyramidal
enters breast milk.
reactions, sedation, tardive dyskinesia.
Protein Binding: _90%. EENT: blurred vision, dry eyes, lens
opacities.
METABOLISM
Highly metabolized by the liver and GI CV: ECG changes, hypotension,
mucosa. Converted to some compounds tachycardia. GI: constipation, dry mouth,
with antipsychotic activity. anorexia, drug-induced hepatitis, ileus.
EXCRETION
Urine GU: pink or reddish-brown discoloration of
Half-life: Unknown. urine, urinary retention.

ONSET Derm: photosensitivity, pigment

30–40 min
PEAK changes, rashes.
Unknown
DURATION Endo: galactorrhea.
3–4 hr
Hemat:
DRUG-DRUG AND DRUG-FOOD
INTERACTIONS AGRANULOCYTOSIS, leukopenia.
Drug-Drug: Additive hypotension with
Metab: hyperthermia.
antihypertensives, nitrates, or acute
ingestion of alcohol. Misc: allergic reactions.
Additive CNS depression with other
ADVERSE REACTION

Page | 40
CNS: NEUROLEPTIC MALIGNANT
SYNDROME, extrapyramidal reactions,
sedation, tardive dyskinesia. EENT: blurred
vision, dry eyes, lens opacities. CV: ECG
changes, hypotension, tachycardia. GI:
constipation, dry mouth, anorexia, drug-
induced hepatitis, ileus.
GU: pink or reddish-brown discoloration of
urine, urinary retention. Derm:
photosensitivity, pigment changes, rashes.
Endo: galactorrhea. Hemat:
AGRANULOCYTOSIS, leukopenia.
Metab: hyperthermia.
Misc: allergic reactions.
NURSING RESPONSIBILITIES
ASSESSMENT
● Monitor BP (sitting, standing, lying down),
ECG, pulse, and respiratory rate before and
frequently during the period of dosage
adjustment. May cause Q-wave and T-wave
changes in ECG.
● Assess patient for level of sedation after
administration.
DIAGNOSES
 Deficient fluid volume
(Indications)
 Disturbed thought process
(Indications)
PLANNING
Within the shift the nurse will be able to:
● Instruct patient to take medication as
directed, not to skip doses or double up on
missed doses. Take missed doses as soon
as remembered unless almost time for next
dose. If more than 2 doses are scheduled
each day, missed dose should be taken
within about 1 hr of the ordered time. Abrupt
withdrawal may lead to gastritis, nausea,
vomiting, dizziness, headache, tachycardia,
and insomnia.
● Inform patient of possibility of
extrapyramidal symptoms and tardive
dyskinesia. Instruct patient to report these
symptoms immediately to health care
professional.
IMPLEMENTATION
● To prevent contact dermatitis, avoid
getting solution on hands.
● Phenothiazines should be discontinued 48
hr before and not resumed for 24 hr after
myelography; they lower seizure threshold.
● PO: Administer with food, milk, or a full
glass of water to minimize gastric irritation.
EVALUATION
● Relief of nausea and vomiting.
● Decrease in excitable, paranoic, or
withdrawn behavior when used as an
antipsychotic.
● Decrease in feelings of anxiety.
Butyrophenones
BRAND NAME: Inapsine
GENERIC NAME: Droperidol
CLASSIFICATION: Butyrophenone
Pregnancy risk category C
RECOMMENDED DOSAGE, ROUTE, AND
FREQUENCY
Adults: Initially, 2.5 mg I.M. or I.V.
Additional doses of 1.25 mg may be given.
Dosages are highly individualized according
to patient’s age, weight, physical status, and
underlying pathologic condition.
Children ages 2 to 12: Initially, 0.1 mg/kg
I.M. or I.V. Additional doses up to a total of
2.5 mg may be given. Dosages are highly
individualized according to patient’s age,
weight, physical status, and underlying
clinical condition.
DRUG ACTION
Produces marked sedation by directly
blocking subcortical receptors. Produces
antiemetic effect by blocking CNS receptors
in chemoreceptor trigger
zone.
3-10 min
PEAK
30 min
DURATION
2-4 hr
DRUG-DRUG AND DRUG-FOOD
INTERACTIONS
Drug-drug. Antihypertensives, nitrates:
additive hypertension CNS depressants
(including antidepressants, antihistamines,
opioids): additive
CNS depression
Drugs that induce hypokalemia or
hypomagnesemia (such as diuretics and
laxatives and supraphysiologic use of
Page | 41
steroid hormones with mineralocorticoid Other: toothache, weight loss, hot flashes,
activity): possible precipitation, QT interval influenza, chills
prolongation

Drugs that prolong QTc interval (such as ADVERSE REACTION

antidepressants, class I or III CNS: weakness, dysarthria, dysphonia,
antiarrhythmics, dizziness, extrapyramidal reactions,
headache, postoperative hallucinatory
antimalarials, calcium channel episodes with transient depression, tremor,
irritability, paresthesia, aggression, vertigo,
blockers, some antihistamines, some ataxia, loss of consciousness, seizures,
neuroleptics): increased risk of conduction neuroleptic malignant syndrome
abnormalities
CV: chest pain, hypertension, hypotension,
Drug-herbs. Chamomile, hops, kava, vasodilation, arrhythmias, atrial fibrillation
skullcap, valerian: increased CNS EENT: cataracts, blurred vision, eye
irritation, sore throat
depression
GI: nausea, vomiting, diarrhea, abdominal
Drug-behaviors. Alcohol use: additive cramps, bloating, epigastric pain, fecal
incontinence, increased salivation,
CNS depression
dysphagia
INDICATIONS GU: urinary frequency, increased libido
➣Perioperative nausea and vomiting
Hepatic: cholestatic jaundice

Metabolic: dehydration
CONTRAINDICATIONS
● Hypersensitivity to drug Musculoskeletal: muscle cramps, arthritis,
bone fractures
● Known or suspected QT-interval
prolongation (more than 440 millisec,in Respiratory: bronchitis, dyspnea
males or 450 millisec in females)
Skin: bruising, rash, urticaria, facial
sweating, diaphoresis, pruritus, flushing
SIDE EFFECTS
CNS: weakness, dysarthria, Other: toothache, weight loss, hot flashes,
dysphonia,dizziness, extrapyramidal influenza, chills
reactions, headache, postoperative
hallucinatory episodes with transient
depression, tremor, irritability, paresthesia, NURSING RESPONSIBILITIES
aggression, vertigo, ataxia, loss of
consciousness, seizures, neuroleptic ASSESSMENT
malignant syndrome
● Avoid abrupt position changes.
CV: chest pain, hypertension, hypotension,
vasodilation, arrhythmias, atrial fibrillation ● Observe for signs and symptoms of

EENT: cataracts, blurred vision, eye respiratory compromise if drug is used

irritation, sore throat concurrently with narcotics.

GI: nausea, vomiting, diarrhea, abdominal ● Assess vital signs frequently. Stay
cramps, bloating, epigastric pain, fecal
incontinence, increased salivation, alert for orthostatic hypotension and
dysphagia tachycardia. Keep I.V. fluids and
vasopressors
GU: urinary frequency, increased libido
on hand to treat pronounced hypotension.
Hepatic: cholestatic jaundice
DIAGNOSES
Metabolic: dehydration
Risk for injury related to drug adverse
Musculoskeletal: muscle cramps, arthritis, reactions
bone fractures
Imbalanced nutrition: less than body
Respiratory: bronchitis, dyspnea
requirements related to nausea and vomiting
Skin: bruising, rash, urticaria, facial
sweating, diaphoresis, pruritus, flushing PLANNING

Page | 42
Within the shift the nurse will be able to: and fluids. Crosses blood-brain barrier and
placenta.
● Tell patient drug may cause extreme
drowsiness for several days after Enters breast milk in concentrations greater
administration. than

● Caution patient not to drive or perform plasma.

METABOLISM
other activities requiring mental alertness. Partially metabolized by the liver;

● Instruct patient to change positions slowly. EXCRETION

25% eliminated unchanged in the urine.
IMPLEMENTATION
Half-life: 2.5–6 hr.
● Instruct patient to change positions slowly. ONSET
30–60 min
● As appropriate, review all other significant PEAK
Unknown
and life-threatening adverse reactions and DURATION
interactions, especially those related to the 1–2 hr
drugs, herbs, and behaviors mentioned
above. DRUG-DRUG AND DRUG-FOOD
INTERACTIONS
EVALUATION Drug-Drug: Additive CNS depression with
other CNS depressants, including alcohol,
The patient did not experience any drug antidepressants, antihistamines,
adverse reactions
opioid analgesics, and sedative/hypnotics.
The patient verbalized understanding of
drug therapy May decrease absorption and risk of toxicity
from cyclosporine.

May affect the GI absorption of other orally

Prokinetic administered drugs as a result of effect on
GI motility.
BRAND NAME
May exaggerate hypotension during general
Reglan
anesthesia.
GENERIC NAME: Metoclopramide
Increase risk of extrapyramidal reactions
CLASSIFICATION : antiemetics with agents such as haloperidol or
phenothiazines. Opioids and anticholinergics
RECOMMENDED DOSAGE, ROUTE, AND may antagonize the GI effects of
FREQUENCY metoclopramide.
PO, IV (Adults and Children): 1–2 mg/kg
Use cautiously with MAO inhibitors (causes
30 min before chemotherapy. Additional
release of catecholamines).
doses of 1–2 mg/kg may be given q 2–4 hr,
Mayqneuromuscular blockade from
pretreatment with diphenhydramine will
succinylcholine. Maypeffectiveness of
decrease the risk of extrapyramidal
levodopa.
reactions to this dose.
May increase tacrolimus serum levels.
DRUG ACTION
INDICATIONS
Blocks dopamine receptors in
Prevention of chemotherapy-induced
chemoreceptor trigger zone of the CNS.
emesis. Treatmentof postsurgical and
Stimulates motility of the upper GI tract and
diabetic gastric stasis. Facilitationmof small
accelerates gastric emptying. Therapeutic
bowel intubation in radiographic procedures.
Effects:
Management of gastroesophageal reflux.
Decreased nausea and vomiting. Decreased
symptoms of gastric stasis. Easier passage Treatment and prevention of postoperative
of nasogastricmtube into small bowel. nausea and vomiting when nasogastric
suctioning is undesirable.
ABSORPTION
Well absorbed from the GI tract, from rectal Unlabeled Use: Treatment of hiccups.
mucosa, and from IM sites. Adjunct managementof migraine
headaches.
DISTRIBUTION
Widely distributed into body tissues

Page | 43
CONTRAINDICATIONS
Contraindicated in: Hypersensitivity;
Possible GI obstruction or hemorrhage;
History of seizure disorders;
Pheochromocytoma; Parkinson’s disease.
Use Cautiously in: History of depression;
Diabetes (may alter response to insulin);
Renal impairment (decrease dose in CCr
_50 mL/min); Chronic use _3 mo (increase
risk for tardive dyskinesia); OB, Lactation:
Safety not established;
Pedi: Prolonged clearance in neonates can
result in high serum concentrations andqthe
risk for methemoglobinemia. Side effects are
more common in children, especially
extrapyramidal reactions; Geri: More
susceptible to oversedation, extrapyramidal
reactions, and tardive dyskinesia.
SIDE EFFECTS
CNS: drowsiness, extrapyramidal reactions,
restlessness,
NEUROLEPTIC MALIGNANT SYNDROME,
anxiety, depression, irritability, tardive
dyskinesia.
CV: arrhythmias (supraventricular
tachycardia, bradycardia), hypertension,
hypotension. GI: constipation, diarrhea, dry
mouth, nausea. Endo: gynecomastia.
Hemat:
methemoglobinemia, neutropenia,
leukopenia, agranulocytosis.
ADVERSE REACTION
CNS: drowsiness, extrapyramidal reactions,
restlessness,
NEUROLEPTIC MALIGNANT SYNDROME,
anxiety, depression, irritability, tardive
dyskinesia.
CV: arrhythmias
(supraventricular tachycardia, bradycardia),
hypertension, hypotension.
GI: constipation, diarrhea,
dry mouth, nausea.
Endo: gynecomastia.
Hemat:
methemoglobinemia, neutropenia,
leukopenia, agranulocytosis.
NURSING RESPONSIBILITIES
ASSESSMENT
● Assess for nausea, vomiting, abdominal
distention, and bowel sounds before and
after administration.
● Assess for extrapyramidal side effects
(parkinsonian— difficulty speaking or
swallowing, loss of balance control, pill
rolling, mask-like face, shuffling gait, rigidity,
tremors; and dystonic—muscle spasms,
twisting motions, twitching, inability to move
eyes, weakness of arms or legs) periodically
throughout course of therapy. May occur wk
to mo after initiation of therapy and are
reversible on discontinuation.
Dystonic reactions may occur within minutes
of IV infusion and stop within 24 hr of
discontinuation of metoclopramide. May be
treated with 50 mg of IM diphenhydramine
or diphenhydramine
1 mg/kg IV may be administered
prophylactically
15 min before metoclopramide IV infusion.
DIAGNOSES
 Imbalanced nutrition: less than
body requirements (Indications)
 Risk for injury (Side Effects)
PLANNING
Within the shift the nurse will be able to:
● May cause drowsiness. Caution patient to
avoid driving
or other activities requiring alertness until
response to medication is known.
● Advise patient to avoid concurrent use of
alcohol and other CNS depressants while
taking this medication.
● Inform patient of risk of extrapyramidal
symptoms, tardive dyskinesia, and
neuroleptic malignant syndrome.
Advise patient to notify health care
professional immediately if involuntary or
repetitive movements of eyes, face, or limbs
occur.
● Advise female patient to notify health care
professional if pregnancy is planned or
suspected or if breast feeding.
IMPLEMENTATION
● PO: Administer doses 30 min before
meals and at bedtime.
● Do not to remove orally disintegrating
tablets from the bottle until just prior to
dosing. Remove tablet from bottle with dry
hands and immediately place on tongue to
Page | 44
disintegrate and swallow with saliva. Tablet 15–60 min
typically disintegrates in 1–1.5 minutes. PEAK
Administration with liquid is not necessary. 1–6 hr
DURATION
● IM: For prevention of postoperative 8–12 hr
nausea and vomiting, inject IM near the end
of surgery. DRUG-DRUG AND DRUG-FOOD
INTERACTIONS
Drug-Drug: Use with opioids or other CNS
depressants, including
EVALUATION otherbenzodiazepines, nonbenzodiazepine
sedative/hypnotics, anxiolytics, general
● Prevention or relief of nausea and anesthetics, muscle relaxants,
vomiting. antipsychotics, and alcohol may cause
profound sedation, respiratory depression,
● Decreased symptoms of gastric stasis. coma, and death; reserve concurrent use for
when alternative treatment options are
● Facilitation of small bowel intubation.
inadequate. Maypthe efficacy of levodopa.
● Decreased symptoms of esophageal Smoking may increase metabolism
reflux. andpeffectiveness. Valproate and
probenecid canqlevels;pdose by 50%. Oral
● Metoclopramide should not be used for contraceptives
more than
May decrease levels.
12 wk due to risk of tardive dyskinesia.
Drug-Natural Products: Concomitant use
of

Benzodiazepines kava-kava, valerian, or chamomile can

increase CNS depression.
BRAND NAME: Ativan
GENERIC NAME: Lorazepam INDICATIONS
CLASSIFICATION: benzodiazepines PO: Anxiety disorder. IM, IV Status
epilepticus, Preanestheticto produce
sedation, decrease preoperative anxiety and
RECOMMENDED DOSAGE, ROUTE, AND induce amnesia.
FREQUENCY
IV, IM (Adults): 4 mg; may be repeated
after 10–15 min. CONTRAINDICATIONS
Hypersensitivity; Cross-sensitivity

DRUG ACTION with other benzodiazepines may exist;

Depresses the CNS, probably by Comatose patients or those with pre-existing
potentiating GABA, an inhibitory CNS depression; Uncontrolled severe pain;
neurotransmitter. Therapeutic Effects: Angle-closure glaucoma; Severe
hypotension; Sleep apnea; OB, Lactation:
Sedation. Decreased anxiety. Decreased Use in pregnancy and lactation may cause
seizures. CNS depression, flaccidity, feeding
ABSORPTION difficulties, hypothermia, seizures, and
Well absorbed following oral administration. respiratory problems in the neonate;
discontinue drug or bottle-feed; IV use may
Rapidly and completely absorbed following affect child’s brain development when used
IM during 3rd trimester.

administration. Sublingual absorption is

more rapid SIDE EFFECTS
CNS: dizziness drowsiness, lethargy,
than oral and is similar to IM. hangover, headache, ataxia, slurred speech,
DISTRIBUTION forgetfulness, confusion, mental depression,
Widely distributed. Crosses the bloodbrain rhythmic myoclonic jerking in preterm
infants, paradoxical excitation.
barrier. Crosses the placenta; enters breast
milk. EENT: blurred vision.

METABOLISM Resp: respiratory depression.

Highly metabolized by the liver.
CV: rapid IV use only—APNEA, CARDIAC
EXCRETION ARREST, bradycardia, hypotension.
Urine
ONSET

Page | 45
GI: constipation, diarrhea, nausea, vomiting,
weight gain (unusual). Derm: rashes. Misc:
physical dependence, psychological
dependence, tolerance.
ADVERSE REACTION
CNS: dizziness drowsiness, lethargy,
hangover, headache, ataxia, slurred speech,
forgetfulness, confusion, mental depression,
rhythmic myoclonic jerking in preterm
infants, paradoxical excitation.
EENT: blurred vision.
Resp: respiratory depression.
CV: rapid IV use only—APNEA, CARDIAC
ARREST, bradycardia, hypotension.
GI: constipation, diarrhea, nausea, vomiting,
weight gain (unusual).
Derm: rashes.
Misc: physical dependence, psychological
dependence, tolerance.
NURSING RESPONSIBILITIES
ASSESSMENT
● Conduct regular assessment of continued
need for treatment.
● Pedi: Assess neonates for prolonged CNS
depression related to inability to metabolize
lorazepam.
● Geri: Assess geriatric patients carefully for
CNS reactions as they are more sensitive to
these effects. Assess falls risk.
DIAGNOSES
 Anxiety (Indications)
 Risk for injury (Indications, Side
Effects)
PLANNING
Within the shift the nurse will be able to:
● Instruct patient to take medication exactly
as directed and not to skip or double up on
missed
doses. If medication is less effective after a
few weeks, check with health care
professional; do not increase dose.
● Advise patient that lorazepam is usually
prescribed for short-term use and does not
cure underlying problem.
● Advise patient to decrease lorazepam
dose gradually to minimize withdrawal
symptoms; abrupt withdrawal may cause
tremors, nausea, vomiting, and abdominal
and muscle cramps.
IMPLEMENTATION
● Do not confuse lorazepam with alprazolam
or clonazepam.
● Following parenteral administration, keep
patient supine for at least 8 hr and observe
closely.
● PO: Tablet may also be given sublingually
(unlabeled) for more rapid onset.
● Take concentrated liquid solution with
water, soda, pudding, or applesauce.
● IM: Administer IM doses deep into muscle
mass at least 2 hr before surgery for
optimum effect.
EVALUATION
● Increase in sense of well-being.
● Decrease in subjective feelings of anxiety
without excessive sedation.
● Reduction of preoperative anxiety.
● Postoperative amnesia.
● Improvement in sleep patterns.
Serotonin Antagonists
BRAND NAME: Anzemet
GENERIC NAME: Dolasetron Mesylate
CLASSIFICATION: 5-HT3 antagonists
RECOMMENDED DOSAGE, ROUTE, AND
FREQUENCY
PO (Adults): 100 mg given within 1 hr
before chemotherapy.
PO (Children 2–16 yr): 1.8 mg/kg given
within 1 hr before chemotherapy (not to
exceed 100 mg).
DRUG ACTION
Blocks the effects of serotonin at receptor
sites (selective antagonist) located in vagal
nerve terminals and in the chemoreceptor
trigger zone in the CNS. Therapeutic
Effects: Decreased incidence and severity
of nausea/vomiting associated with
emetogenic chemotherapy
or surgery.
DRUG-DRUG AND DRUG-FOOD
INTERACTIONS
Drug-Drug: Concurrent diuretic or
antiarrhythmic therapy or cumulative high-
dose anthracycline therapy may increase
Page | 46
risk of conduction abnormalities. Blood
levels and effects of hydrodolasteron are
increase by atenolol and cimetidine. Blood
levels and effects of hydrodolasetron arepby
rifampin.qrisk of QT interval prolongation
with other agents causing QT interval
prolongation. Drugs that affect serotonergic
neurotransmitter
systems, including SSRIs, SNRIs, tricyclic
antidepressants, MAOIs, fentanyl,
lithium,
buspirone, tramadol, methylene blue, and
triptans increase risk of serotonin
syndrome.
INDICATIONS
PO: Prevention of nausea and vomiting
associated with emetogenic chemotherapy.
Misc: SEROTONIN SYNDROME,
chills, fever, pain.
NURSING RESPONSIBILITIES
ASSESSMENT
● Assess patient for nausea, vomiting,
abdominal distention, and bowel sounds
before and after administration.
● Monitor ECG in patients with HF,
bradycardia, underlying heart disease, renal
impairment, and elderly patients.
● Lab Test Considerations: Monitor serum
potassium and magnesium prior to and
periodically during therapy.

DIAGNOSES
CONTRAINDICATIONS
Hypersensitivity; Congenital long QT  Imbalanced nutrition: less than
syndrome; Complete heart block (unless body requirements (Indications)
pacemaker present).
PLANNING
SIDE EFFECTS
Within the shift the nurse will be able to:
CNS: headache (increased in cancer
patients), dizziness, fatigue, syncope.
● Explain purpose of dolasetron to patient.
CV: CARDIAC ARREST, TORSADE DE
● Advise patient to notify health care
POINTES, VENTRICULAR professional if nausea or vomiting occurs.
ARRHYTHMIAS, bradycardia, heart
● Advise patient to notify health care
block, hypertension, hypotension, PR professional symptoms of abnormal heart
interval prolongation, QRS interval rate or rhythm (racing heart beat, shortness
prolongation, QT interval prolongation, of breath, dizziness, fainting) occur.
tachycardia.

GI: diarrhea, dyspepsia.

IMPLEMENTATION
GU: oliguria.
● PO: Administer within 1 hr before
Derm: pruritus. chemotherapy.

Misc: SEROTONIN SYNDROME, chills, EVALUATION

fever, pain.
● Prevention of nausea and vomiting
associated with
ADVERSE REACTION
CNS: headache (increased in cancer emetogenic cancer chemotherapy.
patients), dizziness, fatigue, syncope.

CV: CARDIAC ARREST, TORSADE DE

Glucocorticoids
POINTES, VENTRICULAR
ARRHYTHMIAS, bradycardia, heart block, BRAND NAME: Decadron
hypertension, hypotension, PR interval GENERIC NAME: Dexamethasone
prolongation, CLASSIFICATION
Pharmacologic class: Glucocorticoid
QRS interval prolongation, QT interval
prolongation, tachycardia. GI: diarrhea, Pregnancy risk category C
dyspepsia.
RECOMMENDED DOSAGE, ROUTE, AND
GU: oliguria. FREQUENCY
Adults: 0.75 to 9 mg/day (dexamethasone)
Derm: pruritus.

Page | 47
P.O. as a single dose or in divided Drug-behaviors. Alcohol use: increased
risk of gastric irritation and GI ulcers
doses; in severe cases,much higher

dosages may be needed. Dosage INDICATIONS

➣Macular edema following branch retinal
350 dexamethasone vein occlusion or central retinal vein
occlusion; noninfectious uveitis affecting
posterior segment of eye
DRUG ACTION
Unclear. Reduces inflammation by ➣Allergic and inflammatory conditions
suppressing
➣Cerebral edema
polymorphonuclear leukocyte migration,
reversing increased capillary permeability, ➣Suppression test for Cushing’s syndrome
and stabilizing leukocyte lysosomal
membranes. Also suppresses immune
response (by reducing lymphatic activity), CONTRAINDICATIONS
stimulates bone marrow, and promotes ● Hypersensitivity to drug, benzyl alcohol,
protein, fat, and carbohydrate metabolism. bisulfites, EDTA, creatinine, polysorbate 80,
or methylparaben
Unknown
PEAK ● Systemic fungal infections
1-2 hr
DURATION ● Active or suspected ocular or periocular
2.75 days infections, advanced glaucoma (intravitreal
implant)
DRUG-DRUG AND DRUG-FOOD
INTERACTIONS
Drug-drug. Barbiturates, phenytoin, SIDE EFFECTS
rifampin: decreased dexamethasone effects CNS: headache, malaise, vertigo,
psychiatric disturbances, increased
Digoxin: increased risk of digoxin toxicity intracranial pressure, seizures

Ephedrine: increased dexamethasone CV: hypotension, thrombophlebitis,

clearance myocardial rupture after recent myocardial
infarction, thromboembolism
Estrogen, hormonal contraceptives: blocking
of dexamethasone metabolism EENT: cataracts; elevated intraocular
Fluoroquinolones: increased risk of tendon pressure (IOP), conjunctival hemorrhage
(with intravitreal implant)
Rupture Itraconazole, ketoconazole:
increased dexamethasone blood level and GI: nausea, vomiting, abdominal distention,
effects dry mouth, anorexia, peptic ulcer, bowel
perforation, pancreatitis, ulcerative
Live-virus vaccines: decreased antibody esophagitis
response to vaccine, increased risk of
adverse reactions Metabolic: decreased carbohydrate
tolerance, hyperglycemia, cushingoid
Loop and thiazide diuretics: additive appearance (moon face, buffalo hump),
hypokalemia decreased growth (in children), latent
diabetes mellitus, sodium and fluid retention,
Nonsteroidal anti-inflammatory negative nitrogen balance, adrenal
drugs:increased risk of GI adverse effects suppression, hypokalemic alkalosis

Somatrem, somatropin: decreased response Musculoskeletal: muscle wasting,

to these drugs
muscle pain, osteoporosis, aseptic joint
Drug-diagnostic tests. Calcium, necrosis, tendon rupture, long bone
potassium: decreased levels fractures

Cholesterol, glucose: increased levels Skin: diaphoresis, angioedema, erythema,

rash, pruritus, urticaria, contact dermatitis,
Nitroblue tetrazolium test: falsenegative acne, decreased wound healing, bruising,
result skin fragility, petechiae
Drug-herbs. Echinacea: increased immune- Other: facial edema, weight gain or loss,
stimulating effect increased susceptibility to infection,
hypersensitivity reactions
Ginseng: potentiation of immunemodulating
response

Page | 48
ADVERSE REACTION IMPLEMENTATION
CNS: headache, malaise, vertigo,
psychiatric disturbances, increased ● As appropriate, review all other significant
intracranial pressure, seizures and life-threatening adverse reactions and
interactions, especially those related to the
CV: hypotension, thrombophlebitis, drugs, tests, herbs, and behaviors
myocardial rupture after recent myocardial mentioned above.
infarction, thromboembolism
● Monitor patient for increased IOP after
EENT: cataracts; elevated intraocular intravitreal injection.
pressure (IOP), conjunctival hemorrhage
(with intravitreal implant)

GI: nausea, vomiting, abdominal distention, EVALUATION

dry mouth, anorexia, peptic
 The patient verbalized
ulcer, bowel perforation, pancreatitis, understanding of drug therapy
 The patient did not experience
ulcerative esophagitis
drug adverse reactions
Metabolic: decreased carbohydrate
tolerance, hyperglycemia, cushingoid
appearance (moon face, buffalo hump), Cannabinoids
decreased growth (in children), latent
Chemoreceptor
diabetes mellitus, sodium and fluid retention,
negative nitrogen balance, adrenal Trigger Zone Impulse Suppressant
suppression, hypokalemic alkalosis
BRAND NAME: Tigan
Musculoskeletal: muscle wasting, muscle GENERIC NAM: Trimethobenzamide
pain, osteoporosis, aseptic joint necrosis, hydrochloride
tendon rupture, long bone fractures CLASSIFICATION
Pharmacologic class: Anticholinergic
Skin: diaphoresis, angioedema, erythema,
rash, pruritus, urticaria, contact dermatitis, Pregnancy risk category C
acne, decreased wound healing, bruising,
skin fragility, petechiae RECOMMENDED DOSAGE, ROUTE, AND
FREQUENCY
Other: facial edema, weight gain or loss,
Adults: 300 mg P.O. three to four times
increased susceptibility to infection,
hypersensitivity reactions daily or 200 mg I.M. three to four

times daily
NURSING RESPONSIBILITIES DRUG ACTION
Unclear. Thought to block dopamine
ASSESSMENT
receptors and emetic impulses in
● Monitor blood glucose level closely in chemoreceptor
diabetic patients receiving drug orally.
trigger zone, preventing
● Monitor hemoglobin and potassium levels.
nausea and vomiting.
● Assess for occult blood loss. ABSORPTION
Tigan I.M. injection, the time to reach
DIAGNOSES maximum plasma concentration (Tmax) was
about half an hour, about 15 minutes longer
 Risk for injury related to drug for Tigan 300 mg oral capsule than an I.M.
adverse reactions injection.
 Knowledge deficit related to drug DISTRIBUTION
therapy A single dose of Tigan 300 mg oral capsule
PLANNING provided a plasma concentration profile of
trimethobenzamide similar to Tigan 200 mg
Within the shift the nurse will be able to: I.M.
METABOLISM
● Monitor blood glucose level closely in The relative bioavailability of the capsule
diabetic patients receiving drug orally. formulation compared to the solution is
100%.
● Monitor hemoglobin and potassium levels. EXCRETION

● Assess for occult blood loss.

Page | 49
Between 30 – 50% of a single dose in opisthotonos
humans is excreted unchanged in the urine
within 48-72 hours. Skin: rash, urticaria, flushing
ONSET
10-40 min Other: pain and stinging at I.M. injection
PEAK site, hypersensitivity reaction
Unknown
DURATION
3-4 hr NURSING RESPONSIBILITIES

DRUG-DRUG AND DRUG-FOOD ASSESSMENT

INTERACTIONS
Drug-drug. Antidepressants, ● Monitor neurologic status, especially for
antihistamines, parkinsonian symptoms and other serious
adverse reactions.
CNS depressants, opioids, sedative-
● Assess CBC and liver function tests.
hypnotics: additive CNS depression Watch for blood dyscrasias and jaundice.

Drug-behaviors. Alcohol use: additive ● Evaluate injection site for pain and
stinging.
CNS depression
● Closely monitor patient’s nutritional and
INDICATIONS hydration status. Report continuing nausea.

➣Nausea and vomiting

DIAGNOSES
CONTRAINDICATIONS
 Imbalanced nutrition: lesser than
● Hypersensitivity to drug body requirements related to
nausea and vomiting
● Parenteral form in children
 Knowledge deficit related to drug
SIDE EFFECTS therapy

CNS: drowsiness, dizziness, headache, PLANNING

depression, disorientation, parkinsonian
symptoms, coma, seizures Within the shift the nurse will be able to:

CV: hypotension ● Advise patient to take as needed for

nausea and vomiting, but only as
EENT: blurred vision prescribed.

Hematologic: blood dyscrasias ● Tell patient to contact prescriber

Hepatic: jaundice promptly if nausea persists despite therapy.

Musculoskeletal: muscle cramps, ● Instruct patient to minimize nausea and

opisthotonos
Skin: rash, urticaria, flushing
Other: pain and stinging at I.M. injection
site, hypersensitivity reaction
vomiting by eating small, frequent servings
of healthy food and drinking plenty of fluids.
● Advise patient to avoid alcohol.
IMPLEMENTATION

● Caution patient to avoid driving and other

ADVERSE REACTION hazardous activities until drug effects are
CNS: drowsiness, dizziness, headache, known.
depression, disorientation, parkinsonian
symptoms, coma, seizures ● As appropriate, review all other significant
and life-threatening adverse reactions and
CV: hypotension interactions, especially those related to the
drugs and behaviors mentioned above.
EENT: blurred vision

Hematologic: blood dyscrasias

EVALUATION
Hepatic: jaundice

Musculoskeletal: muscle cramps,

Page | 50
  Patient is free from nausea and
vomiting
 Patient verbalized understanding
of drug therapy
peptides. Increases absorption of fluid and
electrolytes
from the GI tract and increases transit time.
Decreases

Emetics/Drugs That Induce Vomiting levels of serotonin metabolites. Also

suppresses
Ipecac Syrup
growth hormone, insulin, and glucagon.
Adsorbent
ABSORPTION
BRAND NAME Well absorbed following subcut
Charcoaid administration

GENERIC NAME and IM administration of depot form.

Charcoal DISTRIBUTION
CLASSIFICATION Unknown.
DRUG ACTION METABOLISM
ABSORPTION Extensive hepatic
DISTRIBUTION
METABOLISM Metabolism.
EXCRETION EXCRETION
ONSET 32% excreted unchanged in urine.
PEAK ONSET
DURATION Unknown
DRUG-DRUG AND DRUG-FOOD PEAK
INTERACTIONS unknown
INDICATIONS DURATION
RECOMMENDED DOSAGE, ROUTE, AND up to 12 hr
FREQUENCY DRUG-DRUG AND DRUG-FOOD
INTERACTIONS
CONTRAINDICATIONS May alter requirements for insulin or
SIDE EFFECTS
ADVERSE REACTION oral hypoglycemic agents. Maypblood
NURSING RESPONSIBILITIES levels of cyclosporine.

Mayqlevels of QTc-prolonging agents.

ASSESSMENT
INDICATIONS
Treatment of severe diarrhea and flushing
DIAGNOSES
episodes in
PLANNING patients with GI endocrine tumors, including
metastatic
Within the shift the nurse will be able to:
carcinoid tumors and vasoactive intestinal
IMPLEMENTATION peptide tumors

EVALUATION (VIPomas). Treatment of acromegaly.

Unlabeled
Antidiarrheals
Use: Management of diarrhea in AIDS
Opiates And Opiate- Related Agents patients,

Diphenoxylate With Atropine (Lomotil) patients with fistulas, chemotherapy-induced

diarrhea,
Somatostatin Analogue
and graft- vs. host–disease-induced
BRAND NAME diarrhea. Treatment
Sandostatin
of hyperinsulinemic hypoglycemia of infancy.
GENERIC NAME
Management of postoperative chylothorax.
OcreotideCLASSIFICATION RECOMMENDED DOSAGE, ROUTE, AND
FREQUENCY
Therapeutic: antidiarrheals, hormones Subcut, IV (Adults): Sandostatin—100–600
DRUG ACTION mcg/
Suppresses secretion of serotonin and
gastroenterohepatic day in 2–4 divided doses during first 2 wk of
therapy

Page | 51
(range 50–1500 mcg/day). DIAGNOSES

IM (Adults): Sandostatin LAR—20 mg q 4 Diarrhea (Indications)

wk for 2
PLANNING
mo; dose may be further adjusted.
CONTRAINDICATIONS Within the shift the nurse will be able to:
Hypersensitivity.
SIDE EFFECTS ● May cause dizziness, drowsiness, or
CNS: dizziness, drowsiness, fatigue, visual disturbances.
headache, weakness.
Caution patient to avoid driving or other
EENT: visual disturbances. CV: activities requiring alertness until response
bradycardia, to medication is known.
edema, orthostatic hypotension, palpitations. ● Advise patient to change positions slowly
GI: ILEUS, to minimize orthostatic hypotension.
abdominal pain, cholelithiasis, diarrhea, fat ● Home Care Issues: Instruct patients
malabsorption, administering octreotide at home on correct
technique for injection, storage, and disposal
nausea, vomiting. Derm: flushing. Endo:
of equipment.
hyperglycemia,
● Instruct patient to administer octreotide
hypoglycemia, hypothyroidism. Local:
exactly as directed. If a dose is missed,
injection-site pain. administer as soon as possible, then return
ADVERSE REACTION to regular schedule. Do not double doses.
CNS: dizziness, drowsiness, fatigue,
headache, weakness.

EENT: visual disturbances. CV: IMPLEMENTATION

bradycardia,
EVALUATION
edema, orthostatic hypotension, palpitations.
GI: ILEUS, ● Decrease in severity of diarrhea and
improvement of electrolyte imbalances in
abdominal pain, cholelithiasis, diarrhea, fat patients with carcinoid or VIP-secreting
malabsorption, tumors.

nausea, vomiting. Derm: flushing. Endo: ● Relief of symptoms and suppressed tumor
hyperglycemia, growth in patients with pituitary tumors
associated with acromegaly.
hypoglycemia, hypothyroidism. Local:
● Management of diarrhea in patients with
injection-site pain. AIDS.
NURSING RESPONSIBILITIES

ASSESSMENT
● Assess frequency and consistency of
stools and bowel sounds throughout
therapy.
● Monitor pulse and BP prior to and
periodically during, therapy.
AdsorbentsKaolin- Pectin (Kapectolin)
Miscellaenous Antidiarrheal
BRAND NAME: Xifaxan
GENERIC NAME: Rifaximin
CLASSIFICATION: rifamycins

● Assess patient’s fluid and electrolyte RECOMMENDED DOSAGE, ROUTE, AND

balance and skin turgor for dehydration. FREQUENCY
PO (Adults): 5–10 mL (540–1080 mg)
● Monitor diabetic patients for signs of between meals and at bedtime.
hypoglycemia.

May require reduction in requirements for DRUG ACTION

insulin and sulfonylureas and treatment with
diazoxide.
● Assess for gallbladder disease; assess for
pain and monitor ultrasound examinations of
gallbladder and bile ducts prior to and
periodically during prolonged therapy.
Inhibits bacterial RNA synthesis by binding
to bacterial
DNA-dependent RNA polymerase.
Therapeutic Effects: Decreased severity of
travelers’ diarrhea. Decreased episodes of
overt hepatic encephalopathy. Decreased

Page | 52
signs/symptoms of IBS. Spectrum: ● Hepatic Encephalopathy: Assess mental
Escherichia coli (enterotoxigenic and status periodically during therapy.
enteroaggregative strains).
● IBS with Diarrhea: Assess frequency and
ABSORPTION consistency of stools and other IBS
Poorly absorbed, action is primarily in GI symptoms (bloating, cramping) daily.
tract.

DISTRIBUTION
80–90% concentrated in gut. DIAGNOSES
METABOLISM
Almost exclusively  Diarrhea (Indications)
 Risk for deficient fluid volume
EXCRETION
(Indications)
Excreted unchanged in feces.
ONSET: unknown
PLANNING
PEAK: unknown
DURATION: unknown
Within the shift the nurse will be able to:
DRUG-DRUG AND DRUG-FOOD
● Monitor bowel function. Diarrhea,
INTERACTIONS
abdominal
Drug-Drug: P-glycoprotein inhibitors,
including cramping, fever, and bloody stools should
cyclosporine, may increase levels. be reported to health care professional
promptly as a sign of Clostridium difficile-
INDICATIONS associated diarrhea (CDAD).
Travelers’ diarrhea due to noninvasive
strains of Escherichia coli. Reduction in risk May begin up to several wk following
of overt hepatic encepha lopathy recurrence. cessation of therapy.
Treatment of irritable bowel syndrome (IBS)
with diarrhea. ● Lab Test Considerations: May cause
lymphocytosis, monocytosis, and
neutropenia.
CONTRAINDICATIONS
Hypersensitivity to rifaximin or other
rifamycins; Diarrhea with fever or bloody
stools; Diarrhea caused by other infectious IMPLEMENTATION
agents; Lactation:
● Instruct patient to take rifaximin as
Potential for adverse effects in the infant. directed and to complete therapy, even if
Switch to formula for duration of treatment. feeling better. Caution patient to stop taking
rifaximin if diarrhea symptoms get worse,
persist more than 24–48 hr, or are
SIDE EFFECTS accompanied by fever or blood in the stool.
Cns: Dizziness. Consult health care professional if these
occur. Advise patient not to treat diarrhea
Cv: Peripheral Edema. Gi: Clostridium
without consulting health care professional.
Difficile-Associated Diarrhea (CDAD). May occur up to several wk after
ADVERSE REACTION discontinuation of medication.
Cns: Dizziness.
● May cause dizziness. Caution patient to
Cv: Peripheral Edema. avoid driving and other activities requiring
alertness until response to medication is
Gi: Clostridium known.

Difficile-Associated Diarrhea (CDAD). ● Do not confuse rifaximin with rifampin.

NURSING RESPONSIBILITIES ● PO: Administer with or without food.

● Advise female patients to notify health

ASSESSMENT
care professional if pregnant or if pregnancy
is suspected, or if breast feeding.
● Traveler’s Diarrhea: Assess frequency
and consistency of stools and bowel sounds
prior to and during therapy.
EVALUATION
● Assess fluid and electrolyte balance and
skin turgor for dehydration.
● Decreased severity of travelers’ diarrhea.

Page | 53
● Reduction in risk of overt hepatic magnesium salts—hypermagnesemia;
encephalopathy recurrence. aluminum salts, hypophosphatemia.

● Reduction in symptoms of IBS with

diarrhea. ADVERSE REACTION
GI: aluminum salts—constipation;
magnesium

Laxatives salts, diarrhea. F and E: magnesium salts—

hypermagnesemia;
Osmotics Or Osmolar Laxatives
aluminum salts, hypophosphatemia.
BRAND NAME: Milk Of Magnesia
GENERIC NAME: Magnesium Hydroxide
NURSING RESPONSIBILITIES
CLASSIFICATION: antacids
ASSESSMENT
DRUG ACTION
Neutralize gastric acid following dissolution
● Antacid: Assess for heartburn and
in gastric contents. Inactivate pepsin if pH is
indigestion as
raised to _4.
well as location, duration, character, and
ABSORPTION
precipitating
During routine use, antacids are
nonabsorbable. factors of gastric pain.
With chronic use, 15–30% of magnesium ● Lab Test Considerations: Monitor serum
and smaller amounts of aluminum may be phosphate,
absorbed.
potassium, and calcium levels periodically
DISTRIBUTION
Small amounts absorbed are widely during chronic use. May causeqserum
distributed, cross the placenta, and appear calcium and
in breast
pserum phosphate concentrations.
milk. Aluminum concentrates in the CNS
METABOLISM DIAGNOSES
Excreted by the kidneys.
EXCRETION Acute pain (Indications)
Excreted by the kidneys.
ONSET: slightly delayed PLANNING

PEAK Within the shift the nurse will be able to:

30 min
● Caution patient to consult health care
DURATION: 30 min–1 hr (empty stomach); professional before taking antacids for more
3 than 2 wk if problem is recurring, if relief is
hr (after meals) not obtained, or if symptoms of gastric
bleeding (black, tarry stools; coffeeground
emesis) occur.
DRUG-DRUG AND DRUG-FOOD
INTERACTIONS ● Advise patient not to take this medication
Absorption of tetracyclines, phenothiazines, within 2 hr of taking other medications.
ketoconazole, itraconazole, iron salts, ● Pedi: Aluminum- or magnesium-containing
medicines can cause serious side effects in
fluoroquinolones, and isoniazid may
children, especially when given to children
bep(separate by at least 2 hr).
with renal disease or dehydration. Advise
parents or caregivers not to administer OTC
INDICATIONS antacids to children without consulting
Useful in a variety of GI complaints, health care professional.
including: Hyperacidity,

Indigestion, GERD, Heartburn.

IMPLEMENTATION
SIDE EFFECTS
GI: aluminum salts—constipation; ● Magnesium and aluminum are combined
magnesium salts, diarrhea. F and E: as antacids to balance the constipating
effects of aluminum with the laxative effects
of magnesium.

Page | 54
● PO: To prevent tablets from entering small PEAK: unknown
intestine DURATION: unknown

in undissolved form, they must be chewed DRUG-DRUG AND DRUG-FOOD

thoroughly INTERACTIONS
Antacids, histamine H2-receptor
before swallowing. Follow with at least 1⁄2 antagonists, and gastric acid–pump
inhibitors may remove enteric coating of
glass of water. tablets resulting in gastric
irritation/dyspepsia. May decrease the
● Shake suspensions well before
absorption of other orally administered drugs
administration.
because of increase motility and decrease
● For an antacid effect, administer 1–3 hr transit time
after meals and at bedtime.

EVALUATION INDICATIONS
Treatment of constipation. Evacuation of the
● Relief of gastric pain and irritation bowel before radiologic studies or surgery.
Part of a bowel regimen in spinal cord injury
patients.

Stimulants

BRAND NAME: Dulcolax CONTRAINDICATIONS

GENERIC NAME: Bisacodyl
CLASSIFICATION: stimulant laxatives
RECOMMENDED DOSAGE, ROUTE, AND
FREQUENCY
PO (Adults and Children _12 yr): 5–15
mg/day
(up to 30 mg/day) as a single dose.
PO (Children 3–11 yr): 5–10 mg/day (0.3
mg/kg) as a single dose.
Rect (Adults and Children _12 yr): 10
mg/day single dose.
Hypersensitivity; Abdominal pain;
Obstruction; Nausea or vomiting (especially
with fever or other signs of an acute
abdomen).
Use Cautiously in: Severe cardiovascular
disease; Anal or rectal fissures; Excess or
prolonged use (may result in dependence);
OB, Lactation: May be used during
pregnancy and lactation.
SIDE EFFECTS
GI: abdominal cramps, nausea, diarrhea,
rectal burning.

Rect (Children 2–11 yr): 5–10 mg/day F and E: hypokalemia (with chronic use).
single dose.
MS: muscle weakness (with chronic use).
Rect (Children _2 yr): 5 mg/day single
dose. Misc: proteinlosing

DRUG ACTION enteropathy, tetany (with chronic use).

Stimulates peristalsis. Alters fluid and
electrolyte transport, producing fluid ADVERSE REACTION
accumulation in the colon. GI: abdominal cramps, nausea, diarrhea,
rectal burning.
ABSORPTION
Variable absorption follows oral F and E: hypokalemia (with chronic use).
administration; rectal absorption is minimal;
MS: muscle weakness (with chronic use).
action is local in the colon.
Misc: proteinlosing
DISTRIBUTION
Small amounts of metabolites excreted in enteropathy, tetany (with chronic use).
breast milk

METABOLISM
NURSING RESPONSIBILITIES
Small amounts absorbed are metabolized by
the liver.
ASSESSMENT
EXCRETION ● Assess patient for abdominal distention,
Small amounts absorbed are metabolized by presence of bowel sounds, and usual
the liver. pattern of bowel function.
● Assess color, consistency, and amount of
ONSET stool produced.
6–12 hr DIAGNOSES

Page | 55
Constipation (Indications)
PLANNING
Within the shift the nurse will be able to:
● Advise patients, other than those with
spinal cord injuries, that laxatives should be
used only for shortterm therapy. Prolonged
therapy may cause electrolyte imbalance
and dependence.
● Advise patient to increase fluid intake to at
least
1500–2000 mL/day during therapy to
prevent dehydration.
● Encourage patients to use other forms of
bowel regulation (increasing bulk in the diet,
increasing fluid intake, or increasing
mobility). Normal bowel habits may vary
from 3 times/day to 3 times/wk.
IMPLEMENTATION
● Do not confuse Dulcolax (bisacodyl)
with Dulcolax (docusate sodium).
● May be administered at bedtime for
morning results.
● PO: Taking on an empty stomach will
produce more rapid results.
● Do not crush or chew enteric-coated
tablets. Take with a full glass of water or
juice.
EVALUATION
● Soft, formed bowel movement when used
for constipation.
● Evacuation of colon before surgery or
radiologic studies, or for patients with spinal
cord injuries.
Drug classification: OPHTHALMIC
IMMUNOSUPPRESSANTS
Generic name: Dexamethasone
Brand name:
Recommended Dosage, Route, And
Frequency:PO, IM, IV (Adults): Anti-
inflammatory—0.75–9 mg daily in divided
doses q 6–12 hr. Airwayedema or
extubation—0.5–2 mg/kg/day dividedq 6 hr;
begin 24 hr prior to extubation and continue
for 24 hr post-extubation. Cerebral edema—
10 mg IV, then 4 mg IM or IV q 6 hr until
maximal response achieved, then switch to
PO regimen and taperover 5–7 days. PO,
IM, IV (Children): Airway edema or
extubation—0.5–2 mg/kg/day divided q 6 hr;
begin 24hr prior to extubation and continue
for 24 hrpostextubation. Anti-inflammatory—
0.08–0.3 mg/kg/day or 2.5–10 mg/m2/day
divided q 6–12 hr. Physiologic replacement
—0.03–0.15 mg/kg/dayor 0.6–0.75
mg/m2/day divided q 6–12 hr.PO (Adults):
Suppression test—1mg at 11PM or 0.5 mg q
6 hr for 48 hr.
Action: In pharmacologic doses, all agents
suppress inflammationand the normal
immune response. All agentshave numerous
intense metabolic effects .
Suppress adrenal function at chronic doses
of dexamethasone—0.75 mg/day.
Drug-Drug & Drug-Food
Interactions:Drug-Drug:risk of
hypokalemia with thiazide and loop diuretics,
amphotericin B, piperacillin, orticarcillin.
Hypokalemia may risk of digoxin toxicity.
May requirement for insulin or oral
hypoglycemic agents. May levels
ofphenytoin and isoniazid. Levels may be 
with oral contraceptives. risk of adverse GI
effects with NSAIDs(including
aspirin),alcohol land caffeine. At chronic
doses that suppress adrenal function, may 
the antibody response to and risk of
adverse reactions fromlive-virus vaccines.
May or the effects ofwarfarin. Levels may
bepwhen used with phenytoin,
phenobarbital, or rifampin. May risk of
tendon rupture when used with
fluoroquinolones.
Indications: Used systemically and locally
in a wide variety of chronic diseases
including: Inflammatory, Allergic,
Hematologic, Neoplastic, Autoimmune
disorders. Management of cerebral edema:
Diagnostic agent in adrenal disorders.
Treatment of airway edemaprior to
extubation.Facilitation of ventilator weaning
in neonates with
bronchopulmonarydysplasia.
Contraindications: Active untreated
infections(may be used in patients being
treated for someforms of meningitis);
Lactation: Avoid chronic use;Known alcohol,
bisulfite, or tartrazinehypersensitivityor
intolerance (some products contain these
andshould be avoided in susceptible
patients); Administrationof live virus
vaccines.
Side effects: CNS: depression, euphoria,
headache, ↑ intracranial pressure (children
only), personality changes,psychoses,
restlessness. EENT: cataracts, ↑ intraocular
pressure. GI: peptic ulceration,
anorexia, nausea, vomiting. Hemat:
thromboembolism, thrombophlebitis.
Derm: acne, ↓ wound healing, ecchymoses,
fragility, hirsutism, petechiae.
Adverse effects: CV: hypertension. Endo:
adrenal suppression, hyperglycemia.
F and E: fluid retention (long-term high
doses), hypokalemia, hypokalemic
alkalosis.Metab: weight gain. MS: muscle
wasting, osteoporosis,avascular necrosis of
joints, muscle pain. Misc: cushingoid
appearance (moon face, buffalo hump),
↑susceptibility to infection.
Responsibilities in the Nursing Process
Page | 56
Assessment: Indications:Treatment of eyelash
● Monitor intake and output ratios and daily hypotrichosis.
weights. Observe patient for peripheral
edema, steady weight gain, rales/crackles, Contraindications:Hypersensitivity.
or dyspnea. Notify health care professional if
these occur. Side effects:EENT: conjunctival hyperemia,
● Lab Test Considerations: Monitor serum
eye pruritus, hyperpigmentation of eyelids,
electrolytes and glucose. May cause
hyperglycemia, especially in persons with macular edema, permanent pigmentation of
diabetes.May cause hypokalemia. Patients the iris.
on prolonged therapy should routinely have
CBC, serum electrolytes, and serum and Responsibilities in the Nursing Process
urine glucose evaluated. May ↓ WBCs. May
↓ serum potassium and calcium Assessment
and ↓ serum sodium concentrations.
Potential Nursing Diagnoses ● Monitor intraocular pressure in patients
Risk for infection (Side Effects) with a history of increased intraocular
Disturbed body image (Side Effects) pressure or who are using prostaglandin
Patient/Family Teaching analogs for intraocular pressure reduction
● Instruct patient on correct technique of
concurrently.
medication administration.Advise patient to
take medication as directed. Take missed
Potential Nursing Diagnoses
doses as soon as remembered unless
almost time for next dose. Do not double
Disturbed body image (Indications)
doses.
Implementation
Evaluation/Desired Outcomes
● Suppression of the inflammatory and
immune responses in autoimmune ● Topical: Apply once each night using the
disorders, allergic reactions, and neoplasms. accompanying sterile applicators. Additional
● Decrease in intracranial pressure. applications will not increase the growth of
● Management of symptoms in adrenal eyelashes.
insufficiency.
Patient/Family Teaching

● Instruct patient on correct application of

Drug classification: Prostaglandin
bimatoprost. If a dose is missed, omit and
Analogues
apply next evening; do not double dose.
Generic name: Bimatoprost
Patient should wash face and remove all
Brand name:Latisse makeup and contact lenses prior to
Recommended Dosage, Route, And application. Contact lenses may be
Frequency: Adults: Route/Dosage Topical reinserted 15 min following administration.
(Adults): Apply to upper eyelid margin Place one drop of medication on the
nightly. disposable sterile applicator and brush
cautiously along the skin of the upper eyelid
Action:Increases the percent of hair in margin at the base of the eyelashes. Use
eyelashes and prolongs the duration of only the applicator supplied with the product.
growth phase. Therapeutic Effects: Use each applicator for one eye then
Increases eyelash growth, improving length, discard; reuse may result in contamination
thickness, and darkness. and infection. If solution gets into the eye, it
is not harmful and does not need to be
Absorption: Minimal systemic absorption.
Distribution: Small amounts absorbed are rinsed. Do not apply to lower lash line. Blot
widely distributed. any excess solution outside upper eyelid
Metabolism and Excretion: Highly margin with a tissue or other absorbent
metabolized; 67% excreted in urine, 25% in material. Do not allow tip of bottle or
feces mostly as metabolites. applicator to come in contact with
Half-life: 45 min. surrounding structures, fingers, or any other
Route:Topical
unintended surface to avoid contamination.
Onset: 2 mos
Peak: 4 mos Instruct patient to read the Patient
Duration: 4 wk or more Information guide prior to use and with each
Rx refill, in case of new information.
Drug-Drug & Drug-Food Interactions:
Drug-Drug: May  the intraocular pressure ● Inform patient that eyelid skin may darken
lowering effect of prostaglandin analogs. with use of bimatoprost; may be reversible

Page | 57
with discontinuation of medication.
Instillation directly into eye may result in
increased brown iris pigmentation; usually
permanent.
● Inform patient of potential for hair growth
occurring outside target treatment area if
medication repeatedly touched same area of
skin
● Advise patient to notify health care
professional immediately if eye trauma or
infection, sudden decrease in visual acuity,
conjunctivitis, or eyelid reactions occur or if
having ocular surgery.
● Instruct patient to notify health care
professional of bimatoprost use prior to
intraocular pressure examinations.
● Advise female patients to notify health
care professional if pregnancy is planned or
suspected or if breast feeding.
Evaluation/Desired Outcomes
● Increased length, thickness, and darkness
of eyelashes. Onset is gradual and may not
be noticed for 2 mos. Length, thickness,
number of eyelashes, and/or direction of
eyelash growth may vary between eyes.
Upon discontinuation, eyelashes usually
return to pretreatment level within 4 wk to
mos.
Drug classification:
CHOLINERGIC AGONISTS
OR DIRECT-ACTING
CHOLINERGICS
Generic name: Pilocarpine
Brand name:IsoptoCarpine
Recommended Dosage, Route, And
Frequency: Head and Neck Cancer
PatientsPO (Adults): 5 mg three times daily
initially, thentitrated to need/response, usual
range 15–30 mg/day (no single should
exceed 10 mg).
Patients with Sjo¨gren’s Syndrome
PO (Adults): 5 mg four times daily
Action: Stimulates cholinergic receptors,
resulting in primarilymuscarinic action,
including stimulation ofexocrine glands.
Other effects include: Increased
sweating, gastric secretions, Increased
bronchial secretions, Increased tone and
motility of the urinarytract, gallbladder, and
biliary duct smooth muscle.
Drug-Drug & Drug-Food Interactions:
Drug-Drug: Concurrent use of
anticholinergics will the effectiveness of
pilocarpine. Concurrentuse of bethanechol
or ophthalmic cholinergics may result in 
cholinergic effects. Concurrent use
withbeta blockers may  the risk of adverse
cardiovascular reactions (conduction
disturbances).
Indications: Management of xerostomia,
which may occur as aconsequence of
radiation therapy for cancer of thehead and
neck. Treatment of dry mouth in patients
with Sjogren’s syndrome.
Contraindications:Hypersensitivity;
Uncontrolledasthma; Angle-closure
glaucoma; Iritis.
Side effects: CNS: dizziness, headache,
weakness. EENT: amblyopia, epistaxis,
rhinitis.G I: nausea, vomiting, dyspepsia,
dysphagia. GU: urinary frequency.
Derm: flushing,sweating.
Adverse effects: CV: edema, hypertension,
tachycardia. Neuro: tremors. Misc: chills,
voicechange.
Responsibilities in the Nursing Process
Assessment
● Assess oral mucosa for dryness and
ulcerationperiodically during therapy.
Potential Nursing Diagnoses
Impaired oral mucous membrane
(Indications)
Implementation
● Do not confuse Salagen (pilocarpine) with
selegiline.
● PO: Use lowest dose that is tolerated and
effectivefor maintenance.
Patient/Family Teaching
● Instruct patient to take medication as
directed.
● Caution patient that pilocarpine may cause
visualchanges, especially at night; avoid
driving orother activities requiring alertness
until effects ofmedication are known.
● Advise patient to drink adequate daily
fluids(1500–2000 mL/day), especially if
sweating occurs.Less than adequate fluid
intake may lead todehydration.
Evaluation/Desired Outcomes
● Increased salivary gland secretion in
patients with
xerostomia.
● Decrease in dry mouth in patients with
Sjo¨ gren’s
syndrome. Full effects in cancer patients
may not
be seen for up to 12 weeks or 6 weeks in
patients
with Sjo¨ gren’s syndrome.
Page | 58
Drug Classification: Contraindications: Hypersensitivity to
CHOLINESTERASE pyridostigmineor bromides; Mechanical
obstruction of theGI or GU tract; Known
INHIBITORS OR INDIRECT alcohol intolerance (syruponly).
ACTING CHOLINERGICS
Generic name: Pyridostigmine Side effects: CNS: seizures, dizziness,
Brand name: weakness. EENT: lacrimation, miosis. GI:
abdominalcramps, diarrhea, excessive
Recommended Dosage, Route, And salivation,nausea, vomiting. Derm:
Frequency: Myasthenia Gravis sweating, rashes.
PO (Adults): Tablets/syrup—30–60 mg q 3–
4hr initially; then adjusted as required; usual Adverse effects: Resp: bronchospasm,
maintenancedose is 600 mg/day in divided excessive secretions.
doses (range60–1500 mg/day). Extended- CV: bradycardia, hypotension.
release tablets—180–540 mg 1–2 times
daily (dosing intervalshould be at least 6 hr; Responsibilities in the Nursing Process
may be associated with increasedrisk of
cholinergic crisis; concurrent immediate- Assessment
release products may be required). ● Assess pulse, respiratory rate, and BP
PO (Children): 7 mg/kg (200 mg/m2)/day in before administration.Report significant
5–6divided doses. changes in heartrate.
IM, IV (Adults): 2 mg (1/30 of oral dose); ● Myasthenia Gravis: Assess
may berepeated q 2–3 hr. During neuromuscularstatus, including vital
labor/delivery—1 mgbefore second stage of capacity, ptosis, diplopia,chewing,
labor is complete. swallowing, hand grasp, and gait before
IM (Neonates Born to Myasthenic administering and at peak effect. Patients
Mothers):50–150 mcg/kg q 4–6 hr. withmyasthenia gravis may be advised to
Antidote for Nondepolarizing keep a dailyrecord of their condition and the
NeuromuscularBlocking Agents effects of thismedication.
IV (Adults): 10–20 mg; pretreat with 0.6–1.2 ● Toxicity and Overdose: Atropine is the
mgatropine IV. antidote.
Potential Nursing Diagnoses
Action: Inhibits the breakdown of Impaired physical mobility (Indications)
acetylcholine and prolongsits effects Ineffective breathing pattern (Indications)
(anticholinesterase). Effects include: Implementation
Miosis, Increased intestinal and skeletal ● For patients who have difficulty chewing,
muscletone, bronchial and ureteral pyridostigminemay be administered 30 min
constriction, bradycardia,increased beforemeals.
salivation, lacrimation, sweating. ● Oral dose is not interchangeable with IV
Therapeutic Effects: Improved muscular dose.Parenteral form is 30 times more
functionin patients with myasthenia gravis. potent.
Reversal ofparalysis from nondepolarizing ● When used as an antidote to
neuromuscularblocking agents. Prevention nondepolarizingneuromuscular blocking
of Soman nerve gas toxicity. agents, atropine may beordered before or
currently with large doses ofpyridostigmine
Drug-Drug & Drug-Food Interactions: to prevent or to treat bradycardiaand other
Drug-Drug: Cholinergic effects may be side effects.
● PO: Administer with food or milk to
antagonizedby other drugs possessing
minimizeside effects. Extended-release
anticholinergicproperties, including tablets should beswallowed whole; do not
antihistamines, antidepressants,atropine, crush, break, or chew.
haloperidol, phenothiazines,procainamide,
quinidine , or disopyramide.Prolongs the Patient/Family Teaching
action of depolarizingmuscle-relaxing agents Advise patient to carry identification
and cholinesterase describingdisease and medication regimen
at all times.
inhibitors(succinylcholine, ● Instruct patient to space activities to avoid
decamethonium).toxicity with other fatigue.
cholinesterase inhibitors,including Evaluation/Desired Outcomes
echothiophate. ● Relief of ptosis and diplopia; improved
chewing,swallowing, extremity strength, and
Indications: Used to increase muscle breathingwithout the appearance of
strength in the symptomatictreatment of cholinergic symptoms.
myasthenia gravis. Reversal of ● Reversal of nondepolarizing
nondepolarizingneuromuscular blocking neuromuscularblocking agents in general
agents.Prophylaxisof lethal effects of anesthesia.
poisoning with the nerveagent soman.

Page | 59
Drug classification: BETA- arrhythmias/tachycardia.Migraine
ADRENERGIC BLOCKERS prophylaxis.Tremors.Aggressive
behavior.Drug-induced akathisia.Anxiety.
Generic name: Metoprolol
Brand name: Contraindications:Uncompensated HF;
Pulmonaryedema; Cardiogenic shock;
Recommended Dosage, Route, And Bradycardia, heartblock, or sick sinus
Frequency: PO (Adults): syndrome (in absence of apacemaker).
Antihypertensive/antianginal—25–100
mg/day as a single dose initially or 2 divided Side effects:CNS: fatigue, weakness,
doses; may be  q 7 days as needed up to anxiety, depression, dizziness, drowsiness,
450mg/day (immediate-release) or 400 insomnia, memory loss, mental status
mg/day (extended-release) (for angina, give changes, nervousness, nightmares.
in divided doses).Extended-release products GI: constipation, diarrhea, drug-induced
are given once daily. hepatitis, dry mouth, flatulence, gastric pain,
MI—25–50 mg (starting 15 min after last IV heartburn, ↑ liver enzymes, nausea,
dose)q 6 hr for 48 hr, then 100 mg twice vomiting GU: erectile dysfunction, ↓ libido,
daily. Heartfailure—12.5–25 mg once daily urinary frequency. Derm: rash
(of extended-release can be doubled every EENT: blurred vision, stuffy nose.
2 wk up to 200 mg/day. Migraine prevention
—50–100 mg 2–4 Adverse effects: Resp: bronchospasm,
times daily (unlabeled). wheezing. CV: bradycardia, hf, pulmonary
IV (Adults): MI—5 mg q 2 min for 3 doses, edema,hypotension, peripheral
followedby oral dosing. vasoconstriction. Endo: hyperglycemia,
hypoglycemia. Ms: arthralgia,
Action: Blocks stimulation of back pain, joint pain. Misc: drug-induced
beta1(myocardial)-adrenergic lupussyndrome.
receptors. Does not usually affect
beta2(pulmonary,vascular, uterine)- Responsibilities in the Nursing Process
adrenergic receptor sites. Therapeutic
Effects: Decreased BP and heart rate. Assessment
Decreased frequency of attacks of angina ● Monitor BP, ECG, and pulse frequently
pectoris.Decreased rate of cardiovascular duringdose adjustment and periodically
mortality and hospitalization in patients with during therapy.
heart failure. ● Monitor intake and output ratios and daily
weights. Assess routinely for signs and
Drug-Drug & Drug-Food symptomsof HF (dyspnea, rales/crackles,
Interactions:General anesthesia, IV weight gain, peripheraledema, jugular
phenytoin, venous distention)..
andverapamilmay causemyocardial ● Lab Test Considerations: May
depression.Qrisk of bradycardia when causeBUN,serum lipoprotein, potassium,
used with digoxin,verapamil, diltiazem, or triglyceride, anduric acid levels.
clonidine.qhypotensionmay occur with other ● May causeANA titers.
antihypertensives,acute ingestion of alcohol, ● May causein blood glucose levels.
or nitrates. Concurrentuse with ● May causeserum alkaline phosphatase,
amphetamines, cocaine, ephedrine, LDH,AST, and ALT levels.
epinephrine, norepinephrine, phenylephrine, Potential Nursing Diagnoses
orpseudoephedrinemay result in unopposed Decreased cardiac output (Side Effects)
alpha-adrenergic stimulation (excessive Noncompliance (Patient/Family Teaching)
hypertension, Implementation
bradycardia). Concurrent administration of ● PO: Take apical pulse before
thyroidadministration mayeffectiveness. administering. If<50 bpm or if arrhythmia
May alter the effectiveness occurs, withhold medicationand notify health
ofinsulinsororal hypoglycemic care professional
agents(dose adjustments may be Patient/Family Teaching
necessary). Maythe effectiveness of Abrupt withdrawal may precipitate
theophylline. May the beneficial beta1- life-threatening arrhythmias, hypertension,
cardiovascular effects of dopamine ormyocardial ischemia. Advise patient to
ordobutamine notify health care professional ifslow pulse,
difficulty breathing, wheezing, coldhands
Indications: Hypertension. Angina pectoris. and feet, dizziness, light-headedness,
Prevention of MI anddecreased mortality in confusion,depression, rash, fever, sore
patients with recent MI. Management throat, unusualbleeding, or bruising occurs.
of stable, symptomatic (class II or III) Evaluation/Desired Outcomes
heart failure due to ischemic, hypertensive ● Decrease in BP.
or cardiomyopathcorigin (may be used with ● Reduction in frequency of anginal attacks.
ACE inhibitors,diuretics and/or digoxin; ● Increase in activity tolerance.
Toprol XL only). UnlabeledUse: Ventricular ● Prevention of MI.

Page | 60
Drug classification: ALPHA-
ADRENERGIC AGONISTS
Generic name: Epinephrine
Brand name:
Recommended Dosage, Route, And
Frequency: IV (Adults): Severe
anaphylaxis—0.1–0.25 mgq 5–15 min; may
be followed by 1–4 mcg/min continuous
infusion; cardiopulmonary resuscitation
(ACLS guidelines)—1 mg q 3–5 min;
bradycardia(ACLS guidelines)—2–10
mcg/min).IV (Children): Severe anaphylaxis
—0.1 mg (lessin younger children); may be
followed by 0.1 mcg/
kg/min continuous infusion (may bequp to
1.5mcg/kg/min); symptomatic
bradycardia/pulselessarrest (PALS
guidelines)—0.01 mg/kg, may be repeated
3–5 min higher doses (up to 0.1–0.2 mg/
kg) may be considered; may also be given
by the intraosseousroute.
several positive pressure ventilations.
Action:Results in the accumulation of cyclic
adenosinemonophosphate (cAMP) at beta-
adrenergic receptors.Affects both
beta1(cardiac)-adrenergic receptors
and beta2(pulmonary)-adrenergic receptor
sites. Produces bronchodilation. Also has
alpha-adrenergicagonist properties, which
result in vasoconstriction.Inhibits the release
of mediators of immediate
hypersensitivity reactions from mast cells.
Drug-Drug & Drug-Food
Interactions:Drug-Drug: Concurrent use
with other adrenergic agents will have
additive adrenergic side effects.Use with
MAO inhibitors may lead to hypertensive
crisis. Beta blockers may negate therapeutic
effect. Tricyclic antidepressants enhance
pressor response
to epinephrine.
Indications:Subcut, IV, Inhaln:
Management of reversible airway
disease due to asthma or COPD. Subcut,
IM,IV: Management of severe allergic
reactions. IV, Intracardiac,Intratracheal,
Intraosseous (partof advanced cardiac life
support [ACLS] andpediatric advanced life
support [PALS] guidelines):Management of
cardiac arrest (unlabeled).Inhaln:
Management of upper airway obstruction
and croup (racemic epinephrine).
Local/Spinal:Adjunct in the
localization/prolongation of anesthesia.
Contraindications:Hypersensitivity to
adrenergicamines; Some products may
contain bisulfites orfluorocarbons (in some
inhalers) and should beavoided in patients
with known hypersensitivity orintolerance.
Side effects: CNS: nervousness,
restlessness, tremor, headache,
insomnia. GI: nausea, vomiting.
Adverse effects: Resp: paradoxical
bronchospasm (excessive use of inhalers).
CV: angina, arrhythmias, hypertension,
tachycardia. Endo: hyperglycemia.
Responsibilities in the Nursing Process
Assessment
● Bronchodilator: Assess lung sounds,
respiratorypattern, pulse, and BP before
administrationduring peak of medication.
Note amount,color, and character of sputum
produced, andnotify health care professional
of abnormal findings.
● Monitor pulmonary function tests before
and periodicallyduring therapy.
● Observe for paradoxical bronchospasm
(wheezing).If condition occurs, withhold
medicationand notify health care
professional immediately.
● Vasopressor: Monitor BP, pulse, ECG,
and respiratoryrate frequently during IV
administration.Continuous ECG,
hemodynamic parameters, and
urine output should be monitored
continuouslyduring IV administration.
● Shock: Assess volume status. Correct
hypovolemiaprior to administering
epinephrine IV.
● Nasal Decongestant: Assess patient for
nasaland sinus congestion prior to and
periodicallyduring therapy.
● Lab Test Considerations: May cause
transientpin serum potassium
concentrations with nebulization
or at higher than recommended doses.
● May cause anqin blood glucose and
serum lacticacid concentrations.
Potential Nursing Diagnoses
Ineffective airway clearance (Indications)
Ineffective tissue perfusion (Indications)
Implementation
● Do not confuse epinephrine with
ephedrine.
● Use a tuberculin syringe with a 26-gauge
1⁄2-in.
needle for subcut injection to ensure that
correctamount of medication is
administered.
Patient/Family Teaching
● Autoinjector: Instruct patients using auto-
injectorfor anaphylactic reactions to remove
graysafety cap, placing black tip on thigh at
right angleto leg. Press hard into thigh until
auto-injectorfunctions, hold in place for 10
seconds, remove,and discard properly.
Massage injected area for10 sec.
Evaluation/Desired Outcomes
● Prevention or relief of bronchospasm.
● Increase in ease of breathing.
● Prevention of bronchospasm or reduction
of frequencyof acute asthma attacks in
patients withchronic asthma.
● Prevention of exercise-induced asthma.
Page | 61
Drug classification: CARBONIC
ANHYDRASE INHIBITORS (CAIs)
Generic name: Acetazolamide
Brand name:
Recommended Dosage, Route, And
Frequency: PO (Adults): Glaucoma (open
angle)—250–1000 mg/day in 1–4 divided
doses (up to 250 mg q4 hr) or 500-mg
extended-release capsules twicedaily.
Epilepsy—4–16 mg/kg/day in 1–4 divided
doses (maximum 30 mg/kg/day or 1 g/day).
Altitudesickness—250 mg 2–4 times daily
started24–48 hr before ascent, continued for
48 hr orlonger to control symptoms.
Antiurolithic—250
mg at bedtime. Edema—250–375
mg/day.Urinealkalinization—5 mg/kg/dose
repeated 2–3times over 24 hr.
PO (Children): Glaucoma—8–30 mg/kg
(300–900 mg/m2/day) in 3 divided doses
(usual range10–15 mg/kg/day). Edema—5
mg/kg/dose oncedaily.Epilepsy—4–16
mg/kg/day in 1–4 divideddoses (maximum
30 mg/kg/day or 1 g/day).
PO (Neonates): Hydrocephalus—5
mg/kg/dose q6 hrqby 25 mg/kg/day up to a
maximum of 100mg/kg/day.
Action: Inhibition of carbonic anhydrase in
the eye results indecreased secretion of
aqueous humor. Inhibitionof renal carbonic
anhydrase, resulting in self-limiting
urinary excretion of sodium, potassium,
bicarbonate,and water. CNS inhibition of
carbonic anhydraseand resultant diuresis
mayabnormalneuronal firing. Alkaline
diuresis prevents precipitation
of uric acid or cystine in the urinary tract.
Drug-Drug & Drug-Food Interactions:
Drug-Drug: Excretion of barbiturates,
aspirin,and lithium isand may lead
toeffectiveness.Excretion of amphetamine,
quinidine, procainamide,and possibly
tricyclic antidepressants isand may lead to
toxicity. Maycyclosporinelevels.
Indications: Lowering of intraocular
pressure in the treatment of
glaucoma. Management of acute altitude
sickness. Edema due to HF. Adjunct to the
treatment of refractory
seizures.
Contraindications: Hypersensitivity or
crosssensitivitywith sulfonamides may
occur; Hepatic diseaseor insufficiency;
Concurrent use with ophthalmic
carbonic anhydrase inhibitors (brinzolamide,
dorzolamide) is not recommended; OB:
Avoid duringfirst trimester of pregnancy.
Side effects: CNS: depression, fatigue,
weakness, drowsiness.EENT: transient
nearsightedness. GI: anorexia, metallictaste,
nausea, vomiting, melena. GU:
crystalluria,renal calculi. Derm: STEVENS-
JOHNSON SYNDROME,rashes.
Adverse effects:Endo: hyperglycemia.
F and E: hyperchloremic acidosis,
hypokalemia, growth retardation (in children
receiving chronic therapy).
Hemat: aplastic anemia, hemolytic anemia,
leukopenia.Metab: weight loss,
hyperuricemia. Neuro:paresthesias. Misc:
allergic reactions including anaphylaxis.
Responsibilities in the Nursing Process
Assessment
● Observe for signs of hypokalemia (muscle
weakness,malaise, fatigue, ECG changes,
vomiting).
● Assess for allergy to sulfonamides.
● Lab Test Considerations: Serum
electrolytes,complete blood counts, and
platelet countsshould be evaluated initially
and periodically duringprolonged therapy.
May causepotassium,
bicarbonate, WBCs, and RBCs. May
causeserumchloride.
● May causein serum and urine glucose;
monitorserum and urine glucose carefully in
diabetic patients.
● May cause false-positive results for urine
proteinand 17-hydroxysteroid tests.
● May causeblood ammonia, bilirubin, uric
acid,urine urobilinogen, and calcium.
Mayurine citrate.
Potential Nursing Diagnoses
Disturbed sensory perception (Indications)
Implementation
● Encourage fluids to 2000–3000 mL/day,
unlesscontraindicated, to prevent crystalluria
and stoneformation.
Patient/Family Teaching.
● Advise patient to report numbness or
tingling ofextremities, weakness, rash, sore
throat, unusualbleeding or bruising, fever, or
signs/symptoms ofa sulfonamide adverse
reaction (Stevens-Johnsonsyndrome [flu-like
symptoms, spreading redrash, or
skin/mucous membrane blistering],
toxic epidermal necrolysis [widespread
peeling/blistering of skin]) to health care
professional. Ifhematopoietic reactions,
fever, rash, hepatic, orrenal problems occur,
acetazolamide should bediscontinued.
Evaluation/Desired Outcomes
● Decrease in intraocular pressure when
used forglaucoma. If therapy is not effective
or patient isunable to tolerate one carbonic
anhydrase inhibitor,using another may be
effective and more tolerable.
● Decrease in the frequency of seizures.
● Reduction of edema.
● Prevention of altitude sickness.
● Prevention of uric acid or cystine stones in
theurinary tract.
Page | 62
Drug classification:OSMOTICS
Generic name: Mannitol
Brand name:Osmitrol
Recommended Dosage, Route, And
Frequency: IV (Adults): Edema, oliguric
renal failure—50–100 g as a 5–25%
solution; may precede with a testdose of 0.2
g/kg over 3–5 min. Reduction of intracranial/
intraocular pressure—0.25–2 g/kg as
15–25% solution over 30–60 min (500mg/kg
maybe sufficient in small or debilitated
patients). Diuresisin drug intoxications—50–
200 g as a 5–25%solution titrated to
maintain urine flow of 100–500mL/hr.
IV (Children): Initial—0.5–1 g/kg as a 15–
20%solution; may precede with a test dose
of 0.2 g/kgover 3–5 min. Maintenance—
0.25–0.5 g/kg q4–6 hrs. Reduction of
intracranial/intraocularpressure—1–2 g/kg
(30–60 g/m2) as a 15–20%solution over 30–
60 min (500 mg/kg may be sufficient
in small or debilitated patients). Diuresis in
drug intoxications—up to 2 g/kg (60 g/m2)
as a5–10% solution.
IV (Neonates): Acute renal failure—0.5–1
g/kg/dose.
Action: Increases the osmotic pressure of
the glomerular filtrate,thereby inhibiting
reabsorption of water andelectrolytes.
Causes excretion of: Water, Sodium,
Potassium,Chloride, Calcium, Phosphorus,
Magnesium,Urea, Uric acid.
Therapeutic Effects: Mobilization
of excess fluid in oliguric renal failure or
edema. Reduction of intraocular or
intracranialpressure.Increased urinary
excretion of toxic materials.Decreased
hemolysis when used as an irrigant
after transurethral prostatic resection.
Drug-Drug & Drug-Food Interactions:
Drug-Drug: Hypokalemiathe risk of
digoxintoxicity.
Indications: IV: Adjunct in the treatment of:
Acute oliguric renal failure, Edema,
Increased intracranial or intraocular
pressure, Toxic overdose. GU irrigant:
During transurethral procedures (2.5–5%
solution only).
Contraindications:Hypersensitivity; Anuria;
Dehydration;Active intracranial bleeding;
Severe pulmonaryedema or congestion.
Side effects:CNS: confusion, headache.
EENT: blurred vision, rhinitis. GI: nausea,
thirst, vomiting. GU: renal failure, urinary
retention.
Adverse effects:CV: transient volume
expansion, chest pain, HF, pulmonary
edema, tachycardia. F and E: dehydration,
hyperkalemia, hypernatremia, hypokalemia,
hyponatremia. Local: phlebitisat IV site.
Responsibilities in the Nursing Process
Assessment
● Monitor vital signs, urine output, CVP, and
pulmonaryartery pressures (PAP) before
and hourlythroughout administration. Assess
patient forsigns and symptoms of
dehydration (decreasedskin turgor, fever,
dry skin and mucous mem branes, thirst) or
signs of fluid overload (increasedCVP,
dyspnea, rales/crackles, edema).
● Increased Intracranial Pressure: Monitor
neurologic status and intracranial pressure
readingsin patients receiving this medication
to decreasecerebral edema.
● Lab Test Considerations: Renal function
andserum electrolytes should be monitored
routinelythroughout course of therapy.
Potential Nursing Diagnoses
Excess fluid volume (Indications)
Risk for deficient fluid volume (Side Effects)
Implementation
● Observe infusion site frequently for
infiltration.Extravasation may cause tissue
irritation and necrosis.
● Do not administer electrolyte-free mannitol
solutionwith blood. If blood must be
administeredsimultaneously with mannitol,
add at least 20mEq NaCl to each liter of
mannitol.
● Confer with physician regarding placement
of anindwelling Foley catheter (except when
used todecrease intraocular pressure).
● IV: Administer by IV infusion undiluted. If
solutioncontains crystals, warm bottle in hot
waterand shake vigorously. Do not
administer solutionin which crystals remain
undissolved. Cool tobody temperature. Use
an in-line filter for 15%,20%, and 25%
infusions.
● Test Dose: Administer over 3–5 min to
producea urine output of 30–50 mL/hr. If
urine flowdoes not increase, administer 2nd
test dose. Ifurine output is not at least 30–50
mL/hr for 2–3hr after 2nd test dose, patient
should be re-evaluated.
● Increased Intracranial Pressure: Infuse
doseover 30–60 min in adults and children.
● Intraocular Pressure: Administer dose
over 30min. When used preoperatively,
administer 60–90 min before surgery.
Patient/Family Teaching
● Explain purpose of therapy to patient.
Evaluation/Desired Outcomes
● Urine output of at least 30–50 mL/hr or an
increasein urine output in accordance with
parametersset by physician.
● Reduction in intracranial pressure.
● Reduction of intraocular pressure.
● Excretion of certain toxic substances.
● Irrigation during transurethral prostate
resection.
Page | 63
Drug Classification:
ANTICHOLINERGIC MYDRIATICS
& CYCLOPEGICS
Generic name: Atropine
Brand name:Atro-Pen
Recommended Dosage, Route, And
Frequency:Bradycardia
IV (Adults): 0.5–1 mg; may repeat as
needed q 5min, not to exceed a total of 2 mg
(q 3–5 min in AdvancedCardiac Life Support
guidelines) or 0.04 mg/
kg (total vagolytic dose).IV (Children): 0.02
mg/kg (maximum single dose
is 0.5 mg in children and 1 mg in
adolescents); mayrepeat q 5 min up to a
total dose of 1 mg in children
(2 mg in adolescents).
Endotracheal (Children): use the IV dose
and dilutebefore administration.
Reversal of Adverse Muscarinic Effects
of Anticholinesterases
IV (Adults): 0.6–12 mg for each 0.5–2.5 mg
ofneostigmine methylsulfate or 10–20 mg of
pyridostigminebromide concurrently with
anticholinesterase.
Bronchospasm
Inhaln (Adults): 0.025–0.05 mg/kg/dose q
4–6hr as needed; maximum 2.5 mg/dose.
Inhaln (Children): 0.03–0.05 mg/kg/dose
3–4times/day; maximum 2.5 mg/dose.
Action: Inhibits the action of acetylcholine at
postganglionicsites located in: Smooth
muscle, Secretory glands,CNS
(antimuscarinic activity). Low doses
decrease:Sweating, Salivation, Respiratory
secretions. Intermediatedoses result in:
Mydriasis (pupillary dilation),Cycloplegia
(loss of visual accommodation),
Increased heart rate. GI and GU tract
motility are decreasedat larger doses.
Drug-Drug & Drug-Food
Interactions:Drug-Drug:anticholinergic
effects with otheranticholinergics, including
antihistamines, tricyclicantidepressants,
quinidine, and disopyramide.
Anticholinergics may alter the absorption
ofother orally administered drugs by slowing
motilityof the GI tract. Antacidsabsorption
of anticholinergics.MayGI mucosal lesions
in patientstaking oral potassium chloride
tablets. May alter
response to beta-blockers.
Indications: IM: Given preoperatively to
decrease oral and respiratory secretions. IV:
Treatment of sinus bradycardia and heart
block. PO: Adjunctive therapy in the
management of peptic ulcer and irritable
bowel syndrome.
IV: Reversal of adverse muscarinic effects
ofanticholinesterase agents (neostigmine,
physostigmine,or pyridostigmine). IM, IV:
Treatment of
anticholinesterase(organophosphate
pesticide) poisoning.
Inhaln: Treatment of exercise-induced
bronchospasm.
Contraindications:Hypersensitivity; Angle-
closureglaucoma; Acute hemorrhage;
Tachycardia secondaryto cardiac
insufficiency or thyrotoxicosis;
Obstructive disease of the GI tract.
Side effects:CNS: drowsiness, confusion,
hyperpyrexia. EENT:blurred vision,
cycloplegia, photophobia, dry eyes,
mydriasis. GI: dry mouth, constipation,
impaired GI motility.
GU: urinary hesitancy, retention, impotency.
Adverse effects:CV: tachycardia,
palpitations, arrhythmias Resp: tachypnea,
pulmonary edema. Misc: flushing,
decreased sweating.
Responsibilities in the Nursing Process
Assessment
● Assess vital signs and ECG tracings
frequently duringIV drug therapy. Report any
significantchanges in heart rate or BP, or
increased ventricularectopy or angina to
physician promptly.
● Monitor intake and output ratios in elderly
orsurgical patients because atropine may
cause urinaryretention.
● Assess patients routinely for abdominal
distentionand auscultate for bowel sounds. If
constipationbecomes a problem, increasing
fluids and addingbulk to the diet may help
alleviate constipation.
● Toxicity and Overdose: If overdose
occurs,physostigmine is the antidote.
Potential Nursing Diagnoses
Decreased cardiac output (Indications)
Impaired oral mucous membrane
Constipation (Side Effects)
Implementation
● PO: Oral doses of atropine may be given
withoutregard to food.
● IM: Intense flushing of the face and trunk
mayoccur 15–20 min following IM
administration. Inchildren, this response is
called “atropine flush”and is not harmful.
Patient/Family Teaching A
● Pedi: Instruct parents or caregivers that
medicationmay cause fever and to notify
health careprofessional before administering
to a febrilechild.
● Geri: Inform male patients with benign
prostatichyperplasia that atropine may
cause urinary hesitancyand retention.
Changes in urinary streamshould be
reported to health care professional.
Evaluation/Desired Outcomes
● Increase in heart rate.
● Dryness of mouth.
● Reversal of muscarinic effects.
Page | 64
Page | 65
Page | 66
Drug classification:OTIC
ANTIINFECTIVES
Generic name: Ciprofloxacin
Brand name: Cipro
Recommended Dosage, Route, And
Frequency: PO (Adults): Most infections—
500–750 mg q 12 hr. Complicated urinary
tract infections—500 mg q 12 hr for 7–14
days (immediate-release);or 1000 mg q 24
hr for 7–14 days (extended-release).
Uncomplicated urinary tract infections— 250
mg every 12 hr for 3 days (immediate-
release) or 500 mg every 24 hr for 3 days
(extended-release).Gonorrhea—250-mg
single dose.Inhalationalanthrax (post
exposure) or cutaneous anthrax—
500 mg every 12 hr for 60 days.
PO (Children 1–17 yr): Complicated urinary
tract infections—10–15 mg/kg q 12 hr (not to
exceed 750 mg/dose) for 10–21 days.
Inhalational anthrax (post-exposure) or
cutaneous anthrax—10–15 mg/kg q 12 hr
(not to exceed 500mg/dose) for 60 days.
Action:Inhibit bacterial DNA synthesis by
inhibiting DNA gyrase. Therapeutic Effects:
Death of susceptiblebacteria.
Drug-Drug & Drug-Food Interactions:
Drug-Drug: Concurrent use ofamiodarone,
disopyramide,erythromycin, procainamide,
dofetilide,quinidine, some antipsychotics,
sotalol,or tricyclic antidepressantsqrisk of
torsade de pointes in susceptible individuals
(avoidconcurrent use). Ciprofloxacin
maylevels and effectiveness of phenytoin.
Levelsof fluoroquinolones may beby
antineoplastics. Beneficial effects of
ciprofloxacin maybe antagonized by
nitrofurantoin. Probenecid
renal elimination of fluoroquinolones.
Mayrisk ofnephrotoxicity from cyclosporine.
Concurrent useof ciprofloxacin with
foscarnet mayrisk of seizures.
Indications: PO, IV: Treatment of the
following bacterial infections: urinary tract
infections including cystitis and
Prostatitis.Gonorrhea (may not be
considered firstlineagents due to increasing
resistance), Gynecologicinfections
(ciprofloxacin, norfloxacin, ofloxacin), Bone
and joint infections.Infectious diarrhea.
Intra-abdominal infections.
Febrile neutropenia Post-exposure
treatment of inhalational anthrax
(ciprofloxacin, levofloxacin).
Contraindications: Hypersensitivity. Cross-
sensitivityamong agents within class may
occur; Historyof myasthenia gravis (may
worsen symptoms including
muscle weakness and breathing problems).
Side effects: CNS: elevated intracranial
pressure (includingpseudotumor cerebri),
seizures, dizziness, headache,nsomnia,
acute psychoses, agitation, confusion,
depression, drowsiness, hallucinations,
nightmares,paranoia, tremor. GI:
pseudomembranouscolitis, diarrhea,
nausea, abdominal pain,liver
enzymes (ciprofloxacin, moxifloxacin),
vomiting.GU: vaginitis. Derm:
photosensitivity, rash.
Adverse effects:
Endo:hyperglycemia, hypoglycemia. Local:
phlebitis at IVsite. MS: tendinitis, tendon
rupture. Misc: hypersensitivityreactions
including ANAPHYLAXIS,
STEVENSJOHNSON
Responsibilities in the Nursing Process
Assessment● Assess forinfection (vital
signs; appearance of wound, sputum, urine,
and stool; WBC; urinalysis; frequency and
urgency of urination; cloudy or foul-smelling
urine) at beginning of and throughout
therapy.● Obtain specimens for culture and
sensitivity before initiating therapy.
● Observe for signs and symptoms of
anaphylaxis (rash, pruritus, laryngeal
edema, wheezing). ● Monitor bowel
function. Diarrhea, abdominal cramping,
fever, and bloody stools should be reported
to health care professional promptly as a
sign of pseudomembranous colitis.
● Lab Test Considerations:May
causeserum AST, ALT, LDH, bilirubin, and
alkaline phosphatase. May also
causeorserum glucose
● Moxifloxacin may cause hyperglycemia,
hyperlipidemia,and altered prothrombin time.
It may also causeWBC;serum calcium,
chloride, albumin, and globulin;
andglucose, hemoglobin,RBCs,
neutrophils, eosinophils, and basophils.
Potential Nursing Diagnoses
Risk for infection (Patient/Family Teaching)
Implementation
If gastric irritation occurs, ciprofloxacin may
beadministered with meals.
● Ciprofloxacin 5% and 10% oral
suspensionshould not be administered
through a feeding tube (mayabsorption).
Patient/Family Teaching
● Advise patient to notify health care
professional ofany personal or family history
of QTc prolongationor proarrhythmic
conditions such as recenthypokalemia,
significant bradycardia, or recent
Myocardial ischemia or if fainting spells or
palpitationsoccur.
Evaluation/Desired Outcomes
● Resolution of the signs and symptoms of
infection.Time for complete resolution depends
onorganism and site of infection.
● Post exposure treatment of inhalational
anthraxor cutaneous anthrax (ciprofloxacin and
levofloxacin).
Page | 67
Drug classification: OTIC in children). EENT: blurred vision, tinnitus.
ANTIHISTAMINES GI: anorexia, dry mouth, constipation,
nausea. GU: dysuria,
Generic name: Diphenhydramine frequency, urinary retention. Derm:
Brand name: Benadryl photosensitivity.

Recommended Dosage, Route, And Adverse effects: CV: hypotension,

Frequency: PO (Adults and Children _12 palpitations.Resp: chest tightness,
yr): Antihistaminic/antiemetic/antivertiginic— thickened bronchialsecretions,
25–50 mg q4–6 hr, not to exceed 300 wheezing.Local: pain at IM site.
mg/day. Antitussive—25 mg q 4 hr as
needed, not to exceed Responsibilities in the Nursing Process
150mg/day.Antidyskinetic—25–50 mg q 4 hr
(not to exceed400 Assessment
mg/day).Sedative/hypnotic—50 mg 20– ● Prevention and Treatment of
30min before bedtime. Anaphylaxis:Assess for urticaria and for
PO (Children 6–12 yr): patency of airway.
Antihistaminic/antiemetic/antivertiginic— ● Allergic Rhinitis: Assess degree of nasal
12.5–25 mg q 4–6 hr(not to exceed 150 stuffiness,rhinorrhea, and sneezing.
mg/day).Antidyskinetic—1–1.5 mg/kg q 6–8 ● Lab Test Considerations: Mayskin
hr as needed (not to exceed 300mg/day). responseto allergy tests. Discontinue 4 days
Antitussive—12.5 mg q 4 hr (not to beforeskin testing.
exceed75 mg/day).Sedative/hypnotic—1
mg/kg/dose 20–30 min before bedtime (not Potential Nursing Diagnoses
to exceed 50mg). Insomnia (Indications)
PO (Children 2–6 yr): Risk for deficient fluid volume (Indications)
Antihistaminic/antiemetic/antivertiginic— Risk for injury (Side Effects)
6.25–12.5 mg q 4–6 hr(not to exceed 37.5
mg/day). Antidyskinetic—1–1.5 mg/kg q 4–6 Implementation
hr as needed (not to exceed 300mg/day). ● Do not confuse Benadryl with benazepril.
Antitussive—6.25 mg q 4 hr (not to exceed ● When used for insomnia, administer 20
37.5 mg/24 hr).Sedative/hypnotic—1 mg/ min beforebedtime and schedule activities to
kg/dose 20–30 min before bedtime (not to minimizeinterruption of sleep.
exceed50 mg). ● When used for prophylaxis of motion
sickness,administer at least 30 min and
Action:Antagonizes the effects of histamine preferably 1–2 hrbefore exposure to
at H1-receptorsites; does not bind to or conditions that may precipitatemotion
inactivate histamine. Significant sickness.
CNS depressant and anticholinergic
properties. Patient/Family Teaching
● Pedi: Can cause excitation in children.
Drug-Drug & Drug-Food Cautionparents or caregivers about proper
Interactions:Drug-Drug:risk of CNS dose calculation;overdose, especially in
depression with otherantihistamines, infants and children,can cause
alcohol, opioid analgesics, hallucinations, seizures, or death. Caution
andsedative/hypnotics.qanticholinergic parents to avoid OTC cough and cold
effects with productswhile breastfeeding or to children
tricyclic antidepressants, quinidine, or <4 yr.
disopyramide.MAO inhibitors intensify and ● Geri: Instruct older adults to avoid OTC
prolongthe anticholinergic effects of productsthat contain diphenhydramine due
antihistamines. to increasedsensitivity to anticholinergic
effects and potentialfor adverse reactions
Indications:Relief of allergic symptoms related to these effects.
caused by histamine releaseincluding:
Anaphylaxis, Seasonal and perennial Evaluation/Desired Outcomes
allergic rhinitis, Allergic dermatoses. ● Prevention of, or decreased urticaria in,
Parkinson’sdisease and dystonic reactions anaphylaxis
from medications.Mild nighttime or other allergic reactions.
sedation.Prevention of motion sickness. ● Decreased dyskinesia in parkinsonism
Antitussive (syrup only). and extrapyramidal
reactions.
Contraindications:Hypersensitivity; Acute ● Sedation when used as a
attacksof asthma; Lactation: Lactation; sedative/hypnotic.
Known alcoholintolerance (some liquid ● Prevention of or decrease in nausea and
products). vomitingcaused by motion sickness.
● Decrease in frequency and intensity of
Side effects: CNS: drowsiness, dizziness, coughwithout eliminating cough reflex.
headache, paradoxical excitation (increased

Page | 68
Drug classification: OTIC
DECONGESTANTS
Generic name:Pseudoephedrine
Brand name:Sudafed
Recommended Dosage, Route, And
Frequency:PO (Adults and Children >12
yr): 60 mg q 6 hr as needed (not to exceed
240 mg/ day) or 120 mg extended-release
preparation q 12 hr or 240 mg extended-
release preparation q 24 hr.
PO (Children 6–12 yr): 30 mg q 6 hr as
needed (not to exceed 120 mg/day).
PO (Children 4–5 yr): 15 mg q 6 hr (not to
exceed 60 mg/day).
Action:Stimulates alpha- and beta-
adrenergic receptors. Produces
vasoconstriction in the respiratory tract
mucosa (alpha-adrenergic stimulation) and
possibly bronchodilation (beta2-adrenergic
stimulation). Therapeutic Effects: Reduction
of nasal congestion, hyperemia, and
swelling in nasal passages.
Drug-Drug & Drug-Food
Interactions:Drug-Drug: Concurrent use
with MAO inhibitors may cause hypertensive
crisis. Additive adrenergic effects with other
adrenergics. Concurrent use with beta
blockers may result in hypertension or
bradycardia. Drugs that acidify the
urinemaypeffectiveness. Phenothiazinesand
tricyclic antidepressants potentiate pressor
effects. Drugs that alkalinize the urine
(sodium bicarbonate, high-dose antacid
therapy)may intensify effectiveness. Drug-
Food: Foods that acidify the
urinemayeffectiveness. Foods that
alkalinize the urinemay intensify
effectiveness.
Indications:Symptomatic management of
nasal congestion associated with acute viral
upper respiratory tract infections. Used in
combination with antihistamines in the
management of allergic conditions.Used to
open obstructed eustachian tubes in chronic
otic inflammation or infection.
Contraindications:Hypersensitivity to
sympathomimetic amines; Hypertension,
severe coronary artery disease; Concurrent
MAO inhibitor therapy; Known alcohol
intolerance (some liquid products).
Side effects:CNS: seizures, anxiety,
nervousness, dizziness, drowsiness,
excitability, fear, hallucinations, headache,
insomnia, restlessness, weakness.GI:
anorexia, dry mouth.GU: dysuria.
Adverse effects:Resp: respiratory difficulty.
CV: cardiovascular collapse, palpitations,
hypertension, tachycardia. Misc:
diaphoresis.
Responsibilities in the Nursing Process
Assessment
● Assess congestion (nasal, sinus,
eustachian tube) before and periodically
during therapy.
● Monitor pulse and BP before beginning
therapy and periodically during therapy.
● Assess lung sounds and character of
bronchial secretions. Maintain fluid intake of
1500– 2000 mL/day to decrease viscosity of
secretions.
Potential Nursing Diagnoses
Ineffective airway clearance (Indications)
Implementation
● Do not confuse Sudafed with sotalol or
Sudafed PE.
● Administer pseudoephedrine at least 2 hr
before bedtime to minimize insomnia.
● PO: Extended-release tablets and
capsules should be swallowed whole; do not
crush, break, or chew. Contents of the
capsule can be mixed with jam or jelly and
swallowed without chewing for patients with
difficulty swallowing.
Patient/Family Teaching
● Instruct patient to take medication as
directed and not to take more than
recommended. Take missed doses within 1
hr; if remembered later, omit. Do not double
doses. Caution parents to avoid OTC cough
and cold products while breast feeding or to
children 4 yr.
● Instruct patient to notify health care
professional if nervousness, slow or fast
heart rate, breathing difficulties,
hallucinations, or seizures occur, because
these symptoms may indicate overdose.
● Instruct patient to contact health care
professional if symptoms do not improve
within 7 days or if fever is present.
Evaluation/Desired Outcomes
● Decreased nasal, sinus, or eustachian
tube congestion.
Drug classification:
CERUMINOLYTICS
Generic name:Carbamide
peroxide
Brand name:Debrox
Recommended Dosage, Route, And
Frequency:Adult: 5–10 drops in ear canal.
Keep drops in ear several minutes. Use
twice daily for up to 4 days.May irrigate with
warm water. Children: Not recommended.
Action: It helps to soften, loosen, and
remove the earwax. Too much earwax can
block the ear canal and reduce hearing. This
Page | 69
medication releases oxygen and starts to
foam when it comes in contact with the skin.
The foaming helps break up and remove the
earwax.
Drug-Drug & Drug-Food
Interactions:Unknown
Indications: This medication is used to treat
earwax buildup.Cerumen removal.
Contraindications:Hypersensitivity.
Perforated tympanic membrane, discharge
or pain, irritation or rash in the ear,
Dizziness.
Side effects:CNS:dizziness. EENT:foaming
or crackling sound in the ear. Temporary
decrease in hearing.Derm:Irritation or
itchiness.
Adverse effects: CV: may cause
anaphylaxis.
Responsibilities in the Nursing Process
Assessment
Assess for allergic reaction.
It should be not use if the patient have a
hole in ear drum (ruptured ear drum), or if
have any signs of ear infection or injury,
such as pain, warmth, swelling, drainage, or
bleeding.
Implementation
Patient may complain of foaming.
Patient/Family Teaching
Contact physician if dizziness or otic
redness, rash, irritation, tenderness, pain,
drainage, or discharge develop; do not drink
or rinse mouth for 5 minutes after oral use of
gel.
Before using this medication, tell your doctor
or pharmacist if you are allergic to it; or if
you have any other allergies. This product
may contain inactive ingredients, which can
cause allergic reactions or other problems.
Talk to your pharmacist for more details.If
you have any of the following health
problems, consult your doctor or pharmacist
before using this product: other ear
problems (e.g., ear drainage, infection, pain,
rash, injury, recent ear surgery,
hole/perforation in the eardrum),
dizziness.Tell your doctor if you are
pregnant or breast-feeding before using this
medication.
Drug classification: OTIC
IRRIGATION
Generic name:Sodium chloride
Brand name:Slo-salt
Recommended Dosage, Route, And
Frequency:IV (Adults): 0.9% NaCl (isotonic)
—1 L (contains 150 mEq sodium/L), rate
and amount determined by condition being
treated. 0.45% NaCl (hypotonic)—1–2 L
(contains 75 mEq sodium/L), rate and
amount determined by condition being
treated. 3%, 5% NaCl (hypertonic)—100 mL
over 1 hr (3% contains 50 mEq sodium per
100 mL; 5% contains 83.3 mEq sodium per
100 mL). PO (Adults): 1– 2 g 3 times daily.
PO, IV (Children and Infants): Maintenance
sodium requirements—3–4 mEq/kg/day
(maximum: 150 mEq/day). PO, IV
(Neonates):Maintenance sodium
requirements—1– 4 mEq/kg/day.
Action:Sodium is a major cation in
extracellular fluid and helps maintain water
distribution, fluid and electrolyte balance,
acid-base equilibrium, and osmotic
pressure. Chloride is the major anion in
extracellular fluid and is involved in
maintaining acid-base balance. Solutions of
NaCl resemble extracellular fluid. Reduces
corneal edema by an osmotic effect.
Therapeutic Effects: IV, PO: Replacement in
deficiency states and maintenance of
homeostasis.
Drug-Drug & Drug-Food
Interactions:Drug-Drug: Excessive
amounts of NaCl may partially antagonize
the effects of antihypertensives. Use with
corticosteroidsmay result in excess sodium
retention.
Indications: IV: Hydration and provision of
NaCl in deficiency states. Maintenance of
fluid and electrolyte status in situations in
which losses may be excessive (excess
diuresis or severe salt restriction). 0.45%
(“half-normal saline”) solution is most
commonly used for hydration and the
treatment of hyperosmolar diabetes
(hypotonic). 0.9% (“normal saline”) solution
is used for: Replacement, Treatment of
metabolic alkalosis, A priming fluid for
hemodialysis, To begin and end blood
transfusions. Small volumes of 0.9% NaCl
(preservative-free or bacteriostatic) are used
to reconstitute or dilute other medications.
Hypertonic solution (3%, 5%) may be
required in situations in which rapid
replacement of sodium is necessary:
Hyponatremia, Hypochloremia, Renal
failure, Heart failure. PO: Prevention of or
management of volume depletion due to salt
Page | 70
restriction or heat prostration when
excessive sweating occurs during exposures
to high temperatures.Irrigating Solutions:
0.9% and 0.45%may be used as irrigating
solutions. Concentrated sodium chloride:
Used as an additive to parenteral fluid
therapy in very specific situations.
Contraindications:Hypertonic (3%, 5%)
solutions should not be used in patients with
elevated, slightly decreased, or normal
serum sodium; Fluid retention or
hypernatremia.
Adverse effects:CV: HF, PULMONARY
EDEMA, edema. F and E: hypernatremia,
hypervolemia, hypokalemia. Local: IV—
extravasation, irritation at IV site.
Responsibilities in the Nursing Process
Assessment
● Assess fluid balance (intake and output,
daily weight, edema, lung sounds)
throughout therapy.
● Assess patient for symptoms of
hyponatremia (headache, tachycardia,
lassitude, dry mucous membranes, nausea,
vomiting, muscle cramps) or hypernatremia
(edema, weight gain, hypertension,
tachycardia, fever, flushed skin, mental
irritability) throughout therapy.
● Lab Test Considerations: Monitor serum
sodium, potassium, bicarbonate, and
chloride concentrations and acid-base
balance periodically for patients receiving
prolonged therapy with sodium chloride.
● Monitor serum osmolarity in patients
receiving hypertonic saline
solutions.Potential Nursing Diagnoses
Deficient fluid volume (Indications) Excess
fluid volume (Side Effects)
Implementation
● High Alert: Accidental administration of
hypertonic sodium chloride solutions
(greater than 0.9%) have resulted in serious
electrolyte imbalances. Do not confuse vials
of concentrated sodium chloride (23.4%)
with vials of sodium chloride flush solution
(0.9%).
● Dose of NaCl depends on patient’s age,
weight, condition, fluid and electrolyte
balance, and acid-base balance.
● Do not administer bacteriostatic NaCl
containing benzyl alcohol as a preservative
to neonates.
● Infusion of 0.45% NaCl is hypotonic, 0.9%
NaCl is isotonic, and 3% and 5% NaCl are
hypertonic.
Patient/Family Teaching
● Explain to patient the purpose of the
infusion.
● Advise patients at risk for dehydration due
to exposure to extreme temperatures when
and how to take NaCL
tablets.Evaluation/Desired Outcomes
● Prevention or correction of dehydration.
● Normalization of serum sodium and
chloride levels.
● Prevention of heat prostration during
exposure to high temperatures.
Drug classification: TOPICAL
KERATOLYTICAGENTS
Generic name: Hydrocortisone
Brand name:Solu-CORTEF
Recommended Dosage, Route, And
Frequency:Topical (Adults and Children):
Apply to affected area(s) 1– 4 times daily
(depends on product, preparation, and
condition being treated). Rect (Adults):
Aerosol foam—90 mg 1– 2 times/day for 2–
3wk; then adjusted.
Action: Suppress normal immune response
and inflammation. Therapeutic Effects:
Suppression of dermatologic inflammation
and immune processes.
Absorption: Minimal. Prolonged use on
large surface areas, application of large
amounts, or use of occlusive dressings may
systemic absorption.
Distribution: Remain primarily at site of
action.
Metabolism and Excretion: Usually
metabolized in skin; some have been
modified to resist local metabolism and have
a prolonged local effect.
Half-life: 1.5– 2 hr (plasma), 8– 12 hr
(tissue).
Route:Topical
Onset:mins–hrs
Peak:hrs–days
Duration: hrs–days
Drug-Drug & Drug-Food
Interactions:Drug-Drug: None significant
Indications: Management of inflammation
and pruritis associated with various
allergic/immunologic skin problems.
Contraindications: Hypersensitivity or
known intolerance to glucocorticoid or
components of vehicles (ointment or cream
base, preservative, alcohol); Untreated
bacterial or viral infections.
Side effects: Derm:allergic contact
dermatitis, atrophy, burning, dryness,
edema, folliculitis, hypersensitivity reactions,
hypertrichosis, hypopigmentation, irritation,
maceration, miliaria, perioral dermatitis,
secondary infection, striae.
Adverse effects: Misc: adrenal
suppression (use of occlusive dressings,
long-term therapy).
Responsibilities in the Nursing Process
Assessment
Page | 71
● Assess affected skin before and daily
during therapy. Note degree of inflammation
and pruritus. Notify health care professional
if symptoms of infection (increased pain,
erythema, purulent exudate) develop.
● Lab Test Considerations: Periodic
adrenal function tests may be ordered to
assess degree of hypothalamic-pituitary-
adrenal (HPA) axis suppression in chronic
topical therapy if suspected. Children and
patients with dose applied to a large area,
using an occlusive dressing, or using high-
potency products are at highest risk for HPA
suppression.
● May cause increased serum and urine
glucose concentrations if significant
absorption occurs.
Potential Nursing Diagnoses
Risk for impaired skin integrity (Indications)
Risk for infection (Side Effects) Deficient
knowledge, related to medication regimen
(Patient/Family Teaching)
Implementation
● Choice of vehicle depends on site and
type of lesion. Ointments are more occlusive
and preferred for dry, scaly lesions. ● Apply
ointments, creams, or gels sparingly as a
thin film to clean, slightly moist skin. Wash
hands immediately after application.
● Apply lotion, solution, orgel to hair by
parting hair and applying a small amount to
affected area. Rub in gently. Protect area
from washing, clothing, or rubbing until
medication has dried.
● Use aerosols by shaking well and spraying
on affected area, holding container 3– 6 in.
away. Spray for about 2 sec to cover an
area the size of a hand. Do not inhale. If
spraying near face, cover eyes.
Patient/Family Teaching
● Instruct patient on correct technique of
medication administration. Emphasize
importance of avoiding the eyes. If a dose is
missed, it should be applied as soon as
remembered unless almost time for next
dose.
● Caution patient to use only as directed.
Avoid using cosmetics, bandages,
dressings, or other skin products over the
treated area unless directed by health care
professional.
● Advise parents of pediatric patients not to
apply tight-fitting diapers or plastic pants on
a child treated in the diaper area; these
garments work like an occlusive dressing
and may cause more of the drug to be
absorbed.
● Instruct patient to inform health care
professional if symptoms of underlying
disease return or worsen or if symptoms of
infection develop.
Evaluation/Desired Outcomes
● Resolution of skin inflammation, pruritus,
or other dermatologic conditions.
Drug classification: TOPICAL
ANTIBIOTICS
Generic name: Erythromycin
Brand name:
Recommended Dosage, Route, And
Frequency:
250 mg of erythromycin base or stearate
400 mg of erythromycin ethylsuccinate.
Most Infections PO (Adults): Base,
stearate—250 mg q 6 hr, or 333 mg q 8 hr,
or 500 mg q 12 hr. Ethylsuccinate—400 mg
q 6 hr or 800 mg q 12 hr. PO (Children
1 mo): Base and ethylsuccinate—30– 50
mg/kg/day divided q 6– 8 hr (maximum 2
g/day as base or 3.2 g/day as
ethylsuccinate).Stearate—30– 50 mg/kg/day
divided q 6 hr (maximum 2 g/day). PO
(Neonates ): Ethylsuccinate—20– 50
mg/kg/day divided q 6– 12 hr. IV (Adults):
250– 500 mg (up to 1 g) q 6 hr. IV (Children
1 mo): 15– 50 mg/kg/day divided q 6 hr,
maximum 4 g/day. Acne Topical (Adults and
Children 12 yr): 2% ointment, gel, solution,
or pledgets twice daily.
Action:Suppresses protein synthesis at the
level of the 50S bacterial ribosome.
Therapeutic Effects: Bacteriostatic action
against susceptible bacteria. Spectrum:
Active against many gram-positive cocci,
including: Streptococci, Staphylococci.
Gram-positive bacilli, including: Clostridium,
Corynebacterium. Several gram-negative
pathogens, notably: Neisseria, Legionella
pneumophila. Mycoplasma and Chlamydia
are also usually susceptible.
Absorption:Variable absorption from the
duodenum after oral administration (dependent
on salt form). Absorption of enteric-coated
products is delayed. Minimal absorption may
follow topical or ophthalmic use.
Distribution:Widely distributed. Minimal
CNS penetration. Crosses placenta; enters
breast milk.
Protein binding: 70-80%
Metabolism and Excretion: Partially
metabolized by the liver, excreted mainly
unchanged in the bile; small amounts
excreted unchanged in the urine.
Half-life:Neonates: 2.1 hr; Adults: 1.4– 2 hr.
Route:PO, IV
Onset: 1hr, Rapid
Peak: 1-4 Hr, End Of Infusion
Duration: 6-12 Hr
Drug-Drug & Drug-Food
Interactions:Drug-Drug: Concurrent use
with pimozide may levels and the risk for
serious arrhythmias (concurrent use
contraindicated); similar effects may occur
with diltiazem, verapamil, ketoconazole,
itraconazole, nefazodone, and protease
inhibitors; avoid concurrent use. May levels
of ergotamine and dihydroergotamine and
Page | 72
risk for acute ergot toxicity; concurrent use
contraindicated. Concurrent use with
amiodarone, dofetilide, orsotalol may risk
of torsades de pointe; avoide concurrent
use. May verapamil levels and the risk for
hypotension, bradycardia, and lactic
acidosis.qblood levels and effects
ofsildenafil, tadalafiland vardenafil ; use
lower doses. Concurrentrifabutin
orrifampinmay  effect of erythromycin and
 risk of adverse GI reactions.levels and
risk of toxicity from alfentanil, alprazolam,
bromocriptine, carbamazepine,
cyclosporine, cilostazol diazepam
disopyramide, ergot alkaloids, felodipine,
methylprednisolone, midazolam, quinidine,
rifabutin, tacrolimus, triazolam, or
vinblastine. May levels of lovastatin, and
simvastatin and the risk of
myopathy/rhabdomyolysis.May
serumdigoxin
levels.Theophyllinemayblood
levels.Maycolchicine levels and the risk for
toxicity; use lower starting and maximum
dose of colchicine. Maytheophylline levels
and the risk for toxicity;theophylline dose.
Maywarfarin levels and the risk for
bleeding.
Indications:IV, PO: Infections caused by
susceptible organisms including: Upper and
lower respiratory tract infections, Otitis
media (with sulfonamides), Skin and skin
structure infections, Pertussis, Diphtheria,
Erythrasma, Intestinal amebiasis, Pelvic
inflammatory disease, Nongonococcal
urethritis, Syphilis, Legionnaires’ disease,
Rheumatic fever. Useful when penicillin is
the most appropriate drug but cannot be
used because of hypersensitivity, including:
Streptococcal infections, Treatment of
syphilis or gonorrhea. Topical: Treatment of
acne.
Contraindications:Hypersensitivity;
Concurrent use of pimozide, ergotamine,
dihydroergotamine, procainamide, quinidine,
dofetilide, amiodarone, or sotalol; Long QT
syndrome; Hypokalemia; Hypomagnesemia;
Heart rate 50 bpm; Known alcohol
intolerance (most topicals); Tartrazine
sensitivity (some products contain tartrazine
— FDC yellow dye #5); Products containing
benzyl alcohol should be avoided in
neonates.
Side effects:CNS: seizures (rare). EENT:
ototoxicity. GI: pseudomembranous colitis,
nausea, vomiting, abdominal pain,
cramping, diarrhea, hepatitis, infantile
hypertrophic pyloric stenosis, pancreatitis
(rare). GU: interstitial nephritis.Derm: rash.
Adverse effects:CV: Torsade De Pointes,
Ventricular Arrhythmias, QT Interval
Prolongation. Local: phlebitisat IV
site.Misc:allergic reactions, superinfection.
Responsibilities in the Nursing Process
Assessment
● Assess for infection (vital signs;
appearance of wound, sputum, urine, and
stool; WBC) at beginning of and during
therapy.
● Obtain specimens for culture and
sensitivity before initiating therapy. First
dose may be given before receiving results.
● Monitor bowel function. Diarrhea,
abdominal cramping, fever, and bloody
stools should be reported to health care
professional promptly as a sign of
pseudomembranous colitis. May begin up to
several weeks following cessation of
therapy.
● Lab Test Considerations: Monitor liver
function tests periodically on patients
receiving high-dose, long-term therapy.
● May causeqserum bilirubin, AST, ALT,
and alkaline phosphatase concentrations.
● May cause falseqof urinary
catecholamines.
Potential Nursing Diagnoses
Risk for infection (Indications) (Side Effects)
Noncompliance (Patient/Family Teaching)
Implementation
● PO: Administer around the clock.
Erythromycin film-coated tablets (base and
stearate) are absorbed better on an empty
stomach, at least 1 hr before or 2 hr after
meals; may be taken with food if GI irritation
occurs. Enteric-coated erythromycin (base)
may be taken without regard to meals.
Erythromycin ethylsuccinateis best absorbed
when taken with meals. Take each dose
with a full glass of water.
● Use calibrated measuring device for liquid
preparations. Shake well before using.
● Chewable tablets should be crushed or
chewed and not swallowed whole.
● Do not crush or chew delayed-release
capsules or tablets; swallow whole.
Erythromycin base delayed-release
capsules may be opened and sprinkled on
applesauce, jelly, or ice cream immediately
before ingestion. Entire contents of the
capsule should be taken.
IV Administration
● IV: Add 10 mL of sterile water for injection
without preservatives to 250- or 500- mg
vials and 20 mL to 1-g vial. Solution is stable
for 7 days after reconstitution if refrigerated.
● Intermittent Infusion: Diluent: Dilute in
0.9% NaCl or D5W. Concentration: 1– 5
mg/mL. Rate: Administer slowly over 20– 60
min to avoid phlebitis. Assess for pain along
Page | 73
vein; slow rate if pain occurs; apply ice and Distribution: Appears to be widely
notify health care professional if unable to distributed; crosses the placenta.
relieve pain. ● Continuous Infusion: May Protein binding:99.9%
also be administered as an infusion over 4 Metabolism and Excretion: Metabolized by
hr. Diluent: 0.9% NaCl, D5W, or LR. the liver and excreted in the urine and feces.
Concentration: 1 g/L. Half-life: 10– 20 hr
Route: PO
Patient/Family Teaching Onset: unknown
● Instruct patient to take medication around Peak: up to 8 wk
the clock and to finish the drug completely Duration: unknown
as directed, even if feeling better. Take
missed doses as soon as remembered, with Drug-Drug & Drug-Food
remaining doses evenly spaced throughout Interactions:Drug-Drug: Additive toxicity
day. Advise patient that sharing of this with vitamin A and drugs having
medication may be dangerous. anticholinergic properties.qrisk of
● May cause nausea, vomiting, diarrhea, or pseudotumor cerebri with tetracycline or
stomach cramps; notify health care minocycline. Concurrent use with
professional if these effects persist or if alcoholqrisk of hypertriglyceridemia. Drying
severe abdominal pain, yellow discoloration effectsqby concurrent use of benzoyl
of the skin or eyes, darkened urine, pale peroxide,sulfur, tretinoin, and other topical
stools, or unusual tiredness develops. May agents.
cause infantile hypertrophic pyloric stenosis
in infants; notify health care professional if Indications:Management of severe nodular
vomiting and irritability occur. acne resistant to more conventional therapy,
● Caution patient to notify health care including topical therapy and systemic
professional if fever and diarrhea occur, antibiotics. Not to be used under any
especially if stool contains blood, pus, or circumstances in pregnant patients.
mucus. Advise patient not to treat diarrhea
without consulting health care professional. Contraindications:Hypersensitivity to
May occur up to several weeks after retinoids, glycerin, soybean oil, or parabens;
discontinuation of medication. OB, Lactation: Pregnancy and lactation;
● Advise patient to report signs of Women of childbearing age who may
superinfection (black, furry overgrowth on become or who intend to become pregnant;
the tongue; vaginal itching or discharge; Patients planning to donate blood.
loose or foul-smelling stools).
● Instruct patient to notify health care
professional if symptoms do not improve. Side effects: CNS:suicide attempt, behavior
changes, depression, pseudotumor cerebri,
Evaluation/Desired Outcomes psychosis, suicidal ideation.
● Resolution of the signs and symptoms of EENT:conjunctivitis, epistaxis, blurred
infection. Length of time for complete vision, contact lens intolerance, corneal
resolution depends on the organism and site opacities,pnight vision, dry eyes. GI:cheilitis,
of infection. dry mouth, nausea, vomiting, abdominal
● Improvement of acne lesions. pain, anorexia, hepatitis,
pancreatitis,qappetite. Derm:stevens-
johnson syndrome, toxic epidermal
necrolysis, pruritus, palmar desquamation,
Drug Classification:TOPICAL photosensitivity, skin infections, thinning of
RETINOIDS OR VITAMIN A hair.
DERIVATIVES
Generic name:Isotretinoin Adverse effects: CV:edema. Hemat:
Brand name:Sotret anemia. Metab: p high-density lipoprotein
cholesterol, hypercholesterolemia,
hypertriglyceridemia, hyperglycemia,
Recommended Dosage, Route, And hyperuricemia. MS: arthralgia, back pain,
Frequency: muscle/bone pain (qin adolescents),
PO (Adults and Children 12 yr): 0.5– 1 hyperostosis. Misc: severe birth defects,q
mg/kg/day (up to 2 mg/kg/day) in 2 divided thirst.
doses for 15– 20 wk. Once discontinued, if
relapse occurs, therapy may be reinstituted Responsibilities in the Nursing Process
after an 8-wk rest period.
Assessment
Action:A metabolite of vitamin A (retinol); ● Monitor patient for behavioral changes
reduces sebaceous gland size and throughout therapy.May cause depression,
differentiation. psychosis, and suicide ideation. If behavioral
Absorption:Rapidly absorbed following changes occur, they usually resolve with
(23– 25%) oral administration; discontinuation of therapy.
absorptionwhen taken with a high-fat meal.

Page | 74
● Lab Test Considerations: Obtain 2
negative sequential serum or urine
pregnancy tests with a sensitivity 25 mIU/mL
before receiving initial prescription and
monthly before each new Rx. ● Monitor liver
function (AST, ALT, and LDH) prior to
therapy, after 1 mo of therapy, and
periodically thereafter. Inform health care
professional if these values becomeq;
therapy may need to be discontinued.
● Monitor blood lipids (cholesterol, HDL,
triglycerides) under fasting conditions prior
to beginning therapy, at 1– 2 wk intervals
until lipid response to isotretinoin is
established (usually within 1 mo), and
periodically thereafter.
Potential Nursing Diagnoses
Risk for impaired skin integrity (Indications)
(Side Effects) Disturbed body image
(Indications)
Implementation
● PO: Administer with meals. Do not crush
or open capsules.
Patient/Family Teaching
● Instruct patient that oral rinses, good oral
hygiene, and sugarless gum or candy may
help minimize dry mouth. Notify health care
professional if dry mouth persists for more
than 2 wk.
● Inform diabetic patients that difficulty
controlling blood glucose may occur.
● Inform patient of need for medical follow-
up. Periodic lab tests may be required.
● Advise patient not to donate blood while
receiving this medication. After discontinuing
isotretinoin, wait at least 1 mo before
donating blood to prevent the possibility of a
pregnant patient receiving the blood.
Evaluation/Desired Outcomes
● Decrease in the number and severity of
cysts in severe acne. Therapy may take 4–
5 mo before full effects are seen. Therapy is
discontinued when the number ofcysts is
reduced by 70% or after 5 mo.
Drug Classification:ORAL
CONTRACEPTIVES
Generic name:Ortho Tri-Cyclen
Brand name:
Recommended Dosage, Route, And
Frequency:PO (Adults):PO (Adults):
Ortho Tri-Cyclen—Take daily for 21
days, off for 7 days.
Action:COCs lower the risk of becoming
pregnant primarily by suppressing ovulation.
Other possible mechanisms may include
cervical mucus changes that inhibit sperm
penetration and endometrial changes that
reduce the likelihood of implantation.Acne is
a skin condition with a multifactorial etiology,
including androgen stimulation of sebum
production. While the combination of ethinyl
estradiol and norgestimate increases sex
hormone-binding globulin (SHBG) and
decreases free testosterone, the relationship
between these changes and a decrease in
the severity of facial acne in otherwise
healthy women with this skin condition has
not been established.
Absorption:Rapidly absorbed
Distribution: Unknown.
Metabolism and Excretion: Undergo
extensive first-pass hepatic metabolism.
Half-life:12– 20 hr
Route:PO
Onset:1 mo
Peak:1 mo
Duration:1 mo
Drug-Drug & Drug-Food Interactions:Oral
contraceptive efficacy may beby
penicillins,chloramphenicol, barbiturates,
chronic alcohol use,carbamazepine,
oxcarbazepine, bosentan, felbamate,
systemic corticosteroids, phenytoin,
topiramate, primidone, modafinil, rifampin,
rifabutin, some protease inhibitors (including
ritonavir), non-nucleoside reverse
transcriptase inhibitors. or tetracyclines.
May effects/risk of toxicity of some
benzodiazepines, beta blockers,
corticosteroids, cyclosporine, and
theophylline.
Indications:Ortho-Cyclen and Ortho Tri-
Cyclen Tablets are indicated for use by
females of reproductive potential to prevent
pregnancy. Ortho Tri-Cyclen is indicated for
the treatment of moderate acne vulgaris in
females at least 15 years of age, who have
no known contraindications to oral
contraceptive therapy and have achieved
menarche. Ortho Tri-Cyclen should be used
for the treatment of acne only if the patient
desires an oral contraceptive for birth
control.
Contraindications:A high risk of arterial or
venous thrombotic diseases; Liver tumors,
benign or malignant, or liver disease;
Undiagnosed abnormal uterine bleeding ;
Pregnancy, because there is no reason to
use COCs during pregnancy; Breast cancer
or other estrogen- or progestin-sensitive
cancer, now or in the past; Use of Hepatitis
C drug combinations containing
ombitasvir/paritaprevir/ritonavir, with
orwithout dasabuvir, due to the potential for
ALT elevations.
Side effects:CNS: depression, headache.
EENT: contact lens intolerance, optic
neuritis, retinal thrombosis. Derm:melasma,
rash. GI: pancreatitis, abdominal cramps,
bloating, gallbladder disease, liver tumor,
nausea, vomiting.
Adverse effects:CV: thromboembolism
(risk is greatest during first 6 mo of therapy
Page | 75
or after restarting the same or different
therapy), edema, hypertension, Raynaud’s
phenomenon, thrombophlebitis. GU:
amenorrhea, breakthrough bleeding,
dysmenorrhea, spotting.Misc: weight
change.
Responsibilities in the Nursing Process
Assessment
● Assess BP before and periodically during
therapy.
● Acne: Assess skin lesion before and
periodically during therapy.
● Lab Test Considerations: Monitor
hepatic function periodically during therapy.
Potential Nursing Diagnoses
Noncompliance (Patient/Family Teaching)
Implementation
● Do not confuse Ortho Tri-Cyclen with
Ortho Tri-Cyclen Lo. Do not confuse Yasmin
with Yaz.
● PO: Oral doses may be administered with
or immediately after food to reduce nausea.
Chewable tablets may be swallowed whole
or chewed; if chewed follow with 8 ounces of
liquid.
Patient/Family Teaching
● Instruct patient to take oral medication as
directed at the same time each day. Pills
should be taken in proper sequence and
kept in the original container. Advise patient
not to skip pills even if not having sex very
often.
● Caution patients to use sunscreen and
protective clothing to prevent increased
pigmentation.
Evaluation/Desired Outcomes
● Prevention of pregnancy.
● Regulation of the menstrual cycle.
● Decrease in menstrual blood loss.
● Decrease in acne.
● Decrease in symptoms of premenstrual
dysphoric disorder.
Drug classification: ANDROGEN
RECEPTOR BLOCKER
Generic name:Losartan
Brand name:Cozaar
Recommended Dosage, Route, And
Frequency:PO (Adults): Hypertension— 50
mg once daily initially (range 25– 100
mg/day as a single daily dose or 2 divided
doses) (initiate therapy at 25 mg once daily
in patients who are receiving diuretics or are
volume depleted). Prevention of stroke in
patients with hypertension and left
ventricular hypertrophy—50 mg once daily
initially; hydrochlorothiazide 12.5 mg once
daily should be added and/or dose of
losartanqto 100 mg once daily followed by
an increase in hydrochlorothiazide to 25 mg
once daily based on BP response;
Nephropathy in patients with type 2 diabetes
— 50 mg once daily, mayqto 100 mg once
daily depending on BP response. Hepatic
Impairment
PO (Adults): Hypertension— 25 mg once
daily initially; may beqas tolerated. PO
(Children 6 yr): Hypertension— 0.7 mg/kg
once daily (up to 50 mg/day), may be titrated
up to 1.4 mg/kg/day (or 100 mg/day).
Action:Blocks the vasoconstrictor and
aldosterone-secreting effects of angiotensin
II at various receptor sites, including
vascular smooth muscle and the adrenal
glands. Therapeutic Effects: Lowering of BP
in hypertensive patients. Decreased
progression of diabetic nephropathy.
Decreased incidence of stroke in patients
with hypertension and left ventricular
hypertrophy (effect may be less in black
patients).
Absorption: Well absorbed but undergoes
extensive first-pass hepatic metabolism,
resulting in 33% bioavailability.
Distribution: Crosses the placenta.
Metabolism and Excretion: Undergoes
extensive first-pass hepatic metabolism;
14% is converted to an active metabolite.
4% excreted unchanged in urine; 6%
excreted in urine as active metabolite; some
biliary elimination also occurs.
Half-life: 2 hr (6– 9 hr for metabolite).
Route: PO
Onset: 6 hr
Peak: 3–6 wks
Duration: 24 hr
Drug-Drug & Drug-Food Interactions:
Drug-Drug: Additive hypotension with other
antihypertensives. Excessive hypotension
may occur with concurrent use of
diuretics.qrisk of hyperkalemia with
concurrent use of potassium supplements,
potassium-containing salt substitutes, or
potassium-sparing diuretics.qrisk of
hyperkalemia, renal dysfunction,
hypotension, and syncope with concurrent
use of ACE inhibitors. Rifampin mayp
antihypertensive effects. NSAIDsand
selective COX-2 inhibitorsmay blunt the
antihypertensive effect andqthe risk of renal
dysfunction.
Indications:Alone or with other agents in
the management of hypertension. Treatment
of diabetic nephropathy in patients with type
2 diabetes.Prevention of stroke in patients
with hypertension and left ventricular
hypertrophy.
Contraindications:Hypersensitivity;
Bilateral renal artery stenosis; OB: Can
cause injury or death of fetus – if pregnancy
occurs, discontinue immediately;
Lactation:Discontinue drug or use formula.
Page | 76
Side effects:CNS: dizziness, fatigue,
headache, insomnia, weakness. EENT:
nasal congestion. GI: diarrhea, abdominal
pain, dyspepsia, nausea. GU: impaired renal
function.
Adverse effects:CV: chest pain, edema,
hypotension. Endo: hypoglycemia, weight
gain. F and E: hyperkalemia.MS: back pain,
myalgia.Misc: angioedema, fever.
Responsibilities in the Nursing Process
Assessment
● Assess BP (lying, sitting, standing) and
pulse frequently during initial dose
adjustment and periodically during therapy.
Notify health care professional of significant
changes.
● Monitor frequency of prescription refills to
determine compliance.
● Assess patient for signs of angioedema
(dyspnea, facial swelling).May rarely cause
angioedema.
● Lab Test Considerations: Monitor renal
function. May causeqBUN and serum
creatinine.
● May causeqAST, ALT, and serum
bilirubin.
● May cause hyperkalemia. ● May cause
slightphemoglobin and hematocrit.
Potential Nursing Diagnoses
Risk for injury (Adverse Reactions)
Noncompliance (Patient/Family Teaching)
Implementation
● Correct volume depletion, if possible,
before initiation of therapy.
● PO: For patients with difficulty swallowing
tablets, pharmacist can compound an oral
suspension; stable for 4 wk if refrigerated.
Shake suspension before each use.
Patient/Family Teaching
● Instruct patient to notify health care
professional if swelling of face, eyes, lips, or
tongue or if difficulty swallowing or breathing
occur.
Evaluation/Desired Outcomes
● Decrease in BP without appearance of
excessive side effects.
● Decreased incidence of stroke in patients
with hypertension and left ventricular
hypertrophy.
Drug classification: ORAL
ANTIBIOTICS
Generic name:Erythromycin
Brand name:
Recommended Dosage, Route, And
Frequency:250 mg of erythromycin base or
stearate 400 mg of erythromycin
ethylsuccinate.
Most Infections PO (Adults): Base, stearate
—250 mg q 6 hr, or 333 mg q 8 hr, or 500
mg q 12 hr. Ethylsuccinate—400 mg q 6 hr
or 800 mg q 12 hr. PO (Children 1 mo):
Base and ethylsuccinate—30– 50 mg/kg/day
divided q 6– 8 hr (maximum 2 g/day as base
or 3.2 g/day as ethylsuccinate).Stearate—
30– 50 mg/kg/day divided q 6 hr (maximum
2 g/day). PO (Neonates ): Ethylsuccinate—
20– 50 mg/kg/day divided q 6– 12 hr. IV
(Adults): 250– 500 mg (up to 1 g) q 6 hr. IV
(Children 1 mo): 15– 50 mg/kg/day divided q
6 hr, maximum 4 g/day.
Acne Topical (Adults and Children 12 yr):
2% ointment, gel, solution, or pledgets twice
daily.
Action:Suppresses protein synthesis at the
level of the 50S bacterial ribosome.
Therapeutic Effects: Bacteriostatic action
against susceptible bacteria. Spectrum:
Active against many gram-positive cocci,
including: Streptococci, Staphylococci.
Gram-positive bacilli, including: Clostridium,
Corynebacterium. Several gram-negative
pathogens, notably: Neisseria, Legionella
pneumophila. Mycoplasma and Chlamydia
are also usually susceptible.
Absorption:Variable absorption from the
duodenum after oral administration (dependent
on salt form). Absorption of enteric-coated
products is delayed. Minimal absorption may
follow topical or ophthalmic use.
Distribution:Widely distributed. Minimal
CNS penetration. Crosses placenta; enters
breast milk.
Protein binding: 70-80%
Metabolism and Excretion: Partially
metabolized by the liver, excreted mainly
unchanged in the bile; small amounts
excreted unchanged in the urine.
Half-life:Neonates: 2.1 hr; Adults: 1.4– 2 hr.
Route:PO, IV
Onset: 1hr, Rapid
Peak: 1-4 Hr, End Of Infusion
Duration: 6-12 Hr
Drug-Drug & Drug-Food
Interactions:Drug-Drug: Concurrent use
with pimozide may levels and the risk for
serious arrhythmias (concurrent use
contraindicated); similar effects may occur
with diltiazem, verapamil, ketoconazole,
itraconazole, nefazodone, and protease
inhibitors; avoid concurrent use. May levels
of ergotamine and dihydroergotamine and
risk for acute ergot toxicity; concurrent use
contraindicated. Concurrent use with
amiodarone, dofetilide, orsotalol may risk
of torsades de pointe; avoide concurrent
use. May verapamil levels and the risk for
hypotension, bradycardia, and lactic
acidosis.blood levels and effects
ofsildenafil, tadalafiland vardenafil ; use
lower doses. Concurrentrifabutin
orrifampinmay  effect of erythromycin and
 risk of adverse GI reactions.levels and
risk of toxicity from alfentanil, alprazolam,
bromocriptine, carbamazepine,
cyclosporine, cilostazol diazepam
disopyramide, ergot alkaloids, felodipine,
methylprednisolone, midazolam, quinidine,
rifabutin, tacrolimus, triazolam, or
Page | 77
vinblastine. May levels of lovastatin, and
simvastatin and the risk of
myopathy/rhabdomyolysis.May
serumdigoxin
levels.Theophyllinemayblood
levels.Maycolchicine levels and the risk for
toxicity; use lower starting and maximum
dose of colchicine. Maytheophylline levels
and the risk for toxicity;theophylline dose.
Maywarfarin levels and the risk for
bleeding.
Indications:IV, PO: Infections caused by
susceptible organisms including: Upper and
lower respiratory tract infections, Otitis
media (with sulfonamides), Skin and skin
structure infections, Pertussis, Diphtheria,
Erythrasma, Intestinal amebiasis, Pelvic
inflammatory disease, Nongonococcal
urethritis, Syphilis, Legionnaires’ disease,
Rheumatic fever. Useful when penicillin is
the most appropriate drug but cannot be
used because of hypersensitivity, including:
Streptococcal infections, Treatment of
syphilis or gonorrhea. Topical: Treatment of
acne.
Contraindications:Hypersensitivity;
Concurrent use of pimozide, ergotamine,
dihydroergotamine, procainamide, quinidine,
dofetilide, amiodarone, or sotalol; Long QT
syndrome; Hypokalemia; Hypomagnesemia;
Heart rate 50 bpm; Known alcohol
intolerance (most topicals); Tartrazine
sensitivity (some products contain tartrazine
— FDC yellow dye #5); Products containing
benzyl alcohol should be avoided in
neonates.
Side effects:CNS: seizures (rare). EENT:
ototoxicity. GI: pseudomembranous colitis,
nausea, vomiting, abdominal pain,
cramping, diarrhea, hepatitis, infantile
hypertrophic pyloric stenosis, pancreatitis
(rare). GU: interstitial nephritis.Derm: rash.
Adverse effects:CV: Torsade De Pointes,
Ventricular Arrhythmias, QT Interval
Prolongation. Local: phlebitisat IV
site.Misc:allergic reactions, superinfection.
Responsibilities in the Nursing Process
Assessment
● Assess for infection (vital signs;
appearance of wound, sputum, urine, and
stool; WBC) at beginning of and during
therapy.
● Obtain specimens for culture and
sensitivity before initiating therapy. First
dose may be given before receiving results.
● Monitor bowel function. Diarrhea,
abdominal cramping, fever, and bloody
stools should be reported to health care
professional promptly as a sign of
pseudomembranous colitis. May begin up to
several weeks following cessation of
therapy.
● Lab Test Considerations: Monitor liver
function tests periodically on patients
receiving high-dose, long-term therapy.
● May causeserum bilirubin, AST, ALT,
and alkaline phosphatase concentrations.
● May cause falseof urinary
catecholamines.
Potential Nursing Diagnoses
Risk for infection (Indications) (Side Effects)
Noncompliance (Patient/Family Teaching)
Implementation
● PO: Administer around the clock.
Erythromycin film-coated tablets (base and
stearate) are absorbed better on an empty
stomach, at least 1 hr before or 2 hr after
meals; may be taken with food if GI irritation
occurs. Enteric-coated erythromycin (base)
may be taken without regard to meals.
Erythromycin ethylsuccinateis best absorbed
when taken with meals. Take each dose
with a full glass of water.
● Use calibrated measuring device for liquid
preparations. Shake well before using.
● Chewable tablets should be crushed or
chewed and not swallowed whole.
● Do not crush or chew delayed-release
capsules or tablets; swallow whole.
Erythromycin base delayed-release
capsules may be opened and sprinkled on
applesauce, jelly, or ice cream immediately
before ingestion. Entire contents of the
capsule should be taken.
IV Administration
● IV: Add 10 mL of sterile water for injection
without preservatives to 250- or 500- mg
vials and 20 mL to 1-g vial. Solution is stable
for 7 days after reconstitution if refrigerated.
● Intermittent Infusion: Diluent: Dilute in
0.9% NaCl or D5W. Concentration: 1– 5
mg/mL. Rate: Administer slowly over 20– 60
min to avoid phlebitis. Assess for pain along
vein; slow rate if pain occurs; apply ice and
notify health care professional if unable to
relieve pain.
● Continuous Infusion: May also be
administered as an infusion over 4 hr.
Diluent: 0.9% NaCl, D5W, or LR.
Concentration: 1 g/L.
Patient/Family Teaching
● Instruct patient to take medication around
the clock and to finish the drug completely
as directed, even if feeling better. Take
missed doses as soon as remembered, with
remaining doses evenly spaced throughout
day. Advise patient that sharing of this
medication may be dangerous.
Page | 78
 ● May cause nausea, vomiting, diarrhea, or
stomach cramps; notify health care
professional if these effects persist or if
severe abdominal pain, yellow discoloration
of the skin or eyes, darkened urine, pale
stools, or unusual tiredness develops. May
cause infantile hypertrophic pyloric stenosis
in infants; notify health care professional if
vomiting and irritability occur.
● Caution patient to notify health care
professional if fever and diarrhea occur,
especially if stool contains blood, pus, or
mucus. Advise patient not to treat diarrhea
without consulting health care professional.
May occur up to several weeks after
discontinuation of medication.
● Advise patient to report signs of
superinfection (black, furry overgrowth on
the tongue; vaginal itching or discharge;
loose or foul-smelling stools).
● Instruct patient to notify health care
professional if symptoms do not improve.
Evaluation/Desired Outcomes
● Resolution of the signs and symptoms of
infection. Length of time for complete
resolution depends on the organism and site
of infection.
● Improvement of acne lesions.
Drug classification:ALPHA2-
ADRENERGIC AGONIST
Generic name:Clonidine
Brand name:Catapres
Recommended Dosage, Route, And
Frequency:PO (Adults and Adolescents
12 yrs): Hypertension (immediate release)
— 100 mcg (0.1 mg) BID,by 100– 200 mcg
(0.1– 0.2 mg)/day q 2– 4 days; usual
maintenance dose is 200– 600 mcg (0.2–
0.6 mg)/day in 2– 3 divided doses (up to 2.4
mg/day). Urgent treatment of hypertension
(immediate-release)—200 mcg (0.2 mg)
loading dose, then 100 mcg (0.1 mg) q hr
until BP is controlled or 800 mcg (0.8 mg)
total has been administered; follow with
maintenance dosing; Opioid withdrawal
(immediate-release)—300 mcg (0.3 mg)–
1.2 mg/day, may be by 50%/ day for 3
days, then discontinued or by 100– 200
mcg (0.1– 0.2 mg)/day. PO (Geriatric
Patients): Hypertension (immediate–
release)—100 mcg (0.1 mg) at bedtime
initially,asneeded.PO (Children):
Hypertension (immediate-release)—Initial 5–
10 mcg/kg/day divided BID-TID, then
gradually to 5– 25 mcg/kg/day in divided
doses q 6 hr; maximum dose: 0.9 mg/day.
ADHD (Kapvay-extended release) (children
6 yr)—0.1 mg once daily at bedtime; after 1
wk,dose to 0.1 mg in AM and at bedtime;
after 1 wk,dose to 0.1 mg in AM and 0.2
mg at bedtime; after 1 wk,dose to 0.2 mg in
AM and at bedtime (max dose 0.4 mg/day).
ADHD (Immediate release) (children 6 yr, 45
kg)—0.05 mg once daily at bedtime; then q
3– 7 days to 0.05 mg BID; then 0.05 mg
TID; then 0.05 mg QID. Neuropathic pain
(immediate-release)—2 mcg/kg/dose q 4– 6
hr then gradually over days up to 4
mcg/kg/dose q 4– 6 hr. PO (Neonates):
Neonatal abstinence syndrome—0.5– 1
mcg/kg/dose q 4– 6 hr. Once stabilized
taper by 0.25 mcg/kg/dose q 6 hr.
Transdermal (Adults): Hypertension—
Transdermal system delivering 100– 300
mcg (0.1– 0.3 mg)/24 hr applied every 7
days. Initiate with 100 mcg (0.1 mg)/ 24 hr
system; dosage increments may be made q
1– 2 wk when system is changed.
Transdermal (Children): Once stable oral
dose is reached, children may be switched
to a transdermal system equivalent closest
to the total daily oral dose.
Epidural (Adults):30 mcg/hr initially; titrated
according to need.
Epidural (Children): 0.5 mcg/kg/hr initially;
titrated according to need up to 2 mcg/kg/hr.
Action:Stimulates alpha-adrenergic
receptors in the CNS, which results in
decreased sympathetic outflow inhibiting
cardioacceleration and vasoconstriction
centers. Prevents pain signal transmission
to the CNS by stimulating alpha-adrenergic
receptors in the spinal cord.Therapeutic
Effects: Decreased BP. Decreased pain.
Improvement in ADHD symptoms.
Absorption: Well absorbed from the GI
tract and skin. Enters systemic circulation
following epidural use. Some absorption
follows sublingual administration.
Distribution: : Widely distributed; enters
CNS. Crosses the placenta readily; enters
breast milk in high concentrations
Metabolism and Excretion:Mostly
metabolized by the liver; 40– 60%
eliminated unchanged in urine.
Half-life:Neonates—44– 72 hr; Children—
8– 12 hr; Adults: Plasma—12– 16 hr (qin
renal impairment); CNS—1.3 hr.
Route: PO;Transdermal; Epidural
Onset: 30–60 min;2–3 days;
Peak: 1–3 hr; unknown; unknown
Duration:8–12 hr; unknown; unknown
Drug-Drug & Drug-Food
Interactions:Drug-Drug: Additive sedation
with CNS depressants, including alcohol,
antihistamines, opioid analgesics, and
sedative/hypnotics. Additive hypotension
with other antihypertensivesand nitrates.
Additive bradycardia with beta blockers,
diltiazem,verapamil, or digoxin.MAO
inhibitors, amphetamines, ortricyclic
antidepressants may antihypertensive
effect. Withdrawal phenomenon may be by
discontinuation of beta blockers. Epidural
clonidine prolongs the effects of epidurally
administered local anesthetics. May
effectiveness of levodopa.
Page | 79
Indications: PO, Transdermal:Mild to
moderate hypertension. PO: Attention-deficit
hyperactivity disorder (ADHD) (as
monotherapy or as adjunctive to stimulants)
(Kapvay only). Epidural: Management of
cancer pain unresponsive to opioids alone.
Unlabeled Use:Management of opioid
withdrawal. Adjunctive treatment of
neuropathic pain.
Contraindications:Hypersensitivity;
Epidural—injection site infection,
anticoagulant therapy, or bleeding problems.
Side effects:CNS: drowsiness, depression,
dizziness, hallucinations, nervousness,
nightmares. EENT: dry eyes. GI: dry mouth,
constipation, nausea, vomiting. GU: erectile
dysfunction. Derm: rash, sweating.
Adverse effects: CV: AV block,
bradycardia, hypotension ( with epidural),
palpitations. F and E: sodium retention.
Metab: weight gain. Neuro:
paresthesia.Misc: withdrawal phenomenon.
Responsibilities in the Nursing Process
Assessment
● Hypertension: Monitor intake and output
ratios and daily weight, and assess for
edema daily, especially at beginning of
therapy.
● Monitor BP and pulse prior to starting,
frequently during initial dose adjustment and
dose increases and periodically throughout
therapy. Titrate slowly in patients with
cardiac conditions or those taking other
sympatholytic drugs. ● Pain: Assess
location, character, and intensity of pain
prior to, frequently during first few days, and
routinely throughout administration.
● Monitor for fever as potential sign of
catheter infection.
● Opioid Withdrawal: Monitor patient for
signs and symptoms of opioid withdrawal
(tachycardia, fever, runny nose, diarrhea,
sweating, nausea, vomiting, irritability,
stomach cramps, shivering, unusually large
pupils, weakness, difficulty sleeping,
gooseflesh).
● ADHD: Assess attention span, impulse
control, and interactions with others.
● Lab Test Considerations: May cause
transient in blood glucose levels.
● May causepurinary catecholamine and
vanillylmandelic acid (VMA) concentrations;
these may on abrupt withdrawal.
● May cause weakly positive Coombs’ test
result.
Potential Nursing Diagnoses
Chronic pain (Indications)
Impaired social interaction (Indications)
Risk for injury (Side Effects)
Implementation
● In the peri-operative setting, continue
clonidine up to 4 hr prior to surgery and
resume as soon as possible thereafter. Do
not interrupt transdermal clonidine during
surgery. Monitor BP carefully.
PO: Administer last dose of the day at
bedtime. May be taken without regard for
food.
● Swallow extended-release tablets whole;
do not crush, break, or chew.
● Transdermal: Transdermal system
should be applied once every 7 days. May
be applied to any hairless site; avoid cuts or
calluses. Absorption is greater when placed
on chest or upper arm and decreased when
placed on thigh. Rotate sites. Wash area
with soap and water; dry thoroughly before
application. Apply firm pressure over patch
to ensure contact with skin, especially
around edges. ● Epidural: Dilute 500
mcg/mL with 0.9% NaCl for a concentration
of 100 mcg/mL. Do not administer solutions
that are discolored or contain a precipitate.
Discard unused portion.
Patient/Family Teaching
● Instruct patient to take clonidine at the
same time each day, even if feeling well. Do
not take more than the prescribed daily dose
in any 24 hr. If more than 1 oral dose in a
row is missed or if transdermal system is
late in being changed by 3 or more days,
consult health care professional.
● May cause drowsiness, which usually
diminishes with continued use. Advise
patient to avoid driving or other activities
requiring alertness until response to
medication is known.
● Caution patient to avoid sudden changes
in position to decrease orthostatic
hypotension.Use of alcohol, standing for
long periods, exercising, and hot weather
may increase orthostatic hypotension.
● If dry mouth occurs, frequent mouth
rinses, good oral hygiene, and sugarless
gum or candy may decrease effect. If dry
mouth continues for more than 2 wk, consult
health care professional.
● Caution patients with contact lenses that
clonidine may cause dryness of eyes.
Instruct patient to notify health care
professional of all Rx or OTC medications,
vitamins, or herbal products being taken and
to consult health care professional before
taking any other Rx, OTC, or herbal
products, especially cough, cold, or allergy
remedies.
● Advise patient to notify health care
professional if itching or redness of skin
(with transdermal patch), mental depression,
swelling of feet and lower legs, paleness or
Page | 80
cold feeling in fingertips or toes, or vivid
dreams or nightmares occur.
● Hypertension: Encourage patient to
comply with additional interventions for
hypertension (weight reduction, low-sodium
diet, discontinuation of smoking,moderation
of alcohol consumption, regular exercise,
and stress management). Medication helps
control but does not cure hypertension
● Instruct patient and family on proper
technique for BP monitoring. Advise them to
check BP at least weekly and report
significant changes.
● Transdermal: Instruct patient on proper
application of transdermal system.
Transdermal system can remain in place
during bathing or swimming. ● Advise
patient referred for MRI test to discuss patch
with referring health care professional and
MRI facility to determine if removal of patch
is necessary prior to test and for directions
for replacing patch.
Evaluation/Desired Outcomes
● Decrease in BP.
● Decrease in severity of pain.
Decrease in the signs and symptoms of
opioid withdrawal.
● Improved attention span and social
interactions in ADHD.
Drug
Classification:ORAL/SYSTEMIC
ANTIMETABOLITES
Generic name: Diphenhydramine
Brand name:Benadryl
Recommended Dosage, Route, And
Frequency:PO (Adults and Children >12
yr): Antihistaminic/antiemetic/antivertiginic—
25– 50 mg q 4– 6 hr, not to exceed 300
mg/day. Antitussive—25 mg q 4 hr as
needed, not to exceed 150 mg/day.
Antidyskinetic—25– 50 mg q 4 hr(not to
exceed 400 mg/day).Sedative/hypnotic—50
mg 20– 30 min before bedtime.
PO (Children 6– 12 yr):
Antihistaminic/antiemetic/antivertiginic—
12.5– 25 mg q 4– 6 hr (not to exceed 150
mg/day). Antidyskinetic—1– 1.5 mg/kg q 6–
8 hr as needed (not to exceed 300 mg/day).
Antitussive—12.5 mg q 4 hr(not to exceed
75 mg/day).Sedative/hypnotic—1
mg/kg/dose 20– 30 min before bedtime (not
to exceed 50 mg).
PO (Children 2– 6 yr):
Antihistaminic/antiemetic/antivertiginic—
6.25– 12.5 mg q 4– 6 hr (not to exceed 37.5
mg/day). Antidyskinetic—1– 1.5 mg/kg q 4–
6 hr as needed (not to exceed 300 mg/day).
Antitussive—6.25 mg q 4 hr(not to exceed
37.5 mg/24 hr).
Action:Antagonizes the effects of histamine
at H1-receptor sites; does not bind to or
inactivate histamine. Significant CNS
depressant and anticholinergic properties.
Absorption: Well absorbed after oral or IM
administration but 40– 60% of an oral dose
reaches systemic circulation due to first-
pass metabolism.
Distribution: Widely distributed. Crosses
the placenta; enters breast milk.
Metabolism and Excretion: 95%
metabolized by the liver.
Half-life:2.4– 7 hr;
Route: PO; IM ; IV
Onset: 15–60 min; 20–30 min; rapid
Peak: 2–4 hr; 2–4 hr; unknown
Duration: 4–8 hr; 4–8 hr; 4–8 hr
Drug-Drug & Drug-Food Interactions:
Drug-Drug: risk of CNS depression with
other antihistamines, alcohol, opioid
analgesics, and
sedative/hypnotics.anticholinergic effects
with tricyclic antidepressants, quinidine, or
disopyramide. MAO inhibitorsintensify and
prolong the anticholinergic effects of
antihistamines. Drug-Natural Products:
Concomitant use of kava-kava,valerian,
orchamomile can CNS depression.
Indications:Relief of allergic symptoms
caused by histamine release including:
Anaphylaxis, Seasonal and perennial
allergic rhinitis, Allergic dermatoses.
Parkinson’s disease and dystonic reactions
from medications.Mild nighttime
sedation.Prevention of motion sickness.
Contraindications:Hypersensitivity; Acute
attacks of asthma; Lactation:Lactation;
Known alcohol intolerance (some liquid
products).
Side effects: CNS: drowsiness, dizziness,
headache, paradoxical excitation (increased
in children). EENT: blurred vision, tinnitus.
GI:anorexia, dry mouth, constipation,
nausea. GU: dysuria, frequency, urinary
retention. Derm: photosensitivity.
Adverse effects:CV: hypotension,
palpitations. Resp: chest tightness,
thickened bronchial secretions, wheezing.
Local: pain at IM site.
Responsibilities in the Nursing Process
Assessment
● Allergic Rhinitis: Assess degree of nasal
stuffiness, rhinorrhea, and sneezing.
● Parkinsonism and Extrapyramidal
Reactions: Assess movement disorder
before and after administration.
● Cough Suppressant: Assess frequency
and nature of cough, lung sounds, and
amount and type of sputum produced.
Unless contraindicated, maintain fluid intake
of 1500– 2000 mL daily to decrease
viscosity of bronchial secretions.
● Pruritus: Assess degree of itching, skin
rash, and inflammation.
Page | 81
● Lab Test Considerations: May skin
response to allergy tests. Discontinue 4
days before skin testing.
Potential Nursing Diagnoses
Insomnia (Indications) Risk for deficient
fluid volume (Indications) Risk for injury
(Side Effects) Implementation
● When used for insomnia, administer 20
min before bedtime and schedule activities
to minimize interruption of sleep.
Patient/Family Teaching
● May cause dry mouth.Inform patient that
frequent oral rinses, good oral hygiene, and
sugarless gum or candy may minimize this
effect. Notify health care professional if dry
mouth persists for more than 2 wk.
● Teach sleep hygiene techniques (dark
room, quiet, bedtime ritual, limit daytime
napping, avoidance of nicotine and caffeine)
to patients taking diphenhydramine to aid
sleep.
Evaluation/Desired Outcomes
● Prevention of, or decreased urticaria in,
anaphylaxis or other allergic reactions.
● Decreased dyskinesia in parkinsonism
and extrapyramidal reactions.
● Sedation when used as a
sedative/hypnotic.
● Prevention of or decrease in nausea and
vomiting caused by motion sickness.
● Decrease in frequency and intensity of
cough without eliminating cough reflex.
Drug Classification:ORAL TUMOR
NECROSIS FACTOR ANTAGONISTS
Generic Name: Infliximab
Brand Name:Remicade
Recommended Dosage, Route, And
Frequency:Crohn’s Disease IV (Adults): 5
mg/kg initially, then repeat at 2 and 6 wk
after initial infusion, then maintenance dose
of 5 mg/kg q 8 wk; dose may be adjustedup
to 10 mg/kg in patients who initially respond
and then lose their response. IV (Children):
5 mg/kg initially, then repeat at 2 and 6 wk
after initial infusion, then maintenance dose
of 5 mg/kg q 8 wk.
Ankylosing Spondylitis IV (Adults): 5
mg/kg initially, then repeat at 2 and 6 wk
after initial infusion, then maintenance dose
of 5 mg/kg q 6 wk. Psoriatic Arthritis IV
(Adults): 5 mg/kg initially, then repeat at 2
and 6 wk after initial infusion, then
maintenance dose of 5 mg/kg q 8 wk (to be
used with or without methotrexate).
Plaque Psoriasis IV (Adults): 5 mg/kg
initially, then repeat at 2 and 6 wk after initial
infusion, then maintenance dose of 5 mg/kg
q 8 wk.
Action:Neutralizes and prevents the activity
of tumor necrosis factor-alpha (TNF-alpha),
resulting in anti-inflammatory and
antiproliferative activity.
Absorption: IV administration results in
complete bioavailability
Distribution: Predominantly distributed
within the vascular compartment
Metabolism and Excretion: Unknown.
Half-life: 9.5 days.
Route: IV
Onset: 1–2 wk
Peak: unknown
Duration: 12–48 wk†
Drug-Drug & Drug-Food
Interactions:Concurrent use with anakinra
or abatacept risk of serious infections (not
recommended). Concurrent use with
azathioprine and/or methotrexate may risk
of HSTCL.
Indications:Active rheumatoid arthritis
(moderate to severe, with methotrexate).
Active Crohn’s disease (moderate to
severe).Active psoriatic arthritis.Active
ankylosing spondylitis. Active ulcerative
colitis (moderate to severe) with inadequate
response to conventional therapy: reducing
signs and symptoms, and inducing and
maintaining clinical remission and mucosal
healing, and eliminating corticosteroid use.
Plaque psoriasis (chronic severe).
Contraindicated in: Hypersensitivity to
infliximab, murine (mouse) proteins, or other
components in the formulation; HF;
Concurrent anakinra or abatacept;
Lactation:Lactation.
Side effects: CNS: fatigue, headache,
anxiety, depression, dizziness, insomnia.
EENT:conjunctivitis. GI: abdominal pain,
nausea, vomiting, constipation, diarrhea,
dyspepsia, flatulence, hepatotoxicity,
intestinal obstruction, oral pain, tooth pain,
ulcerative stomatitis. GU: dysuria, urinary
frequency, urinary tract infection. Derm:
acne, alopecia, dry skin, ecchymosis,
eczema, erythema, flushing, hematoma, hot
flashes, pruritus, psoriasis, rash, sweating,
urticaria.
Adverse effects:Resp: upper respiratory
tract infection, bronchitis, cough, dyspnea,
laryngitis, pharyngitis, respiratory tract
allergic reaction, rhinitis, sinusitis. CV: chest
pain, hypertension, hypotension, pericardial
effusion, tachycardia, HF. Hemat:
neutropenia. MS: arthralgia, arthritis, back
pain, involuntary muscle contractions,
myalgia. Neuro: paresthesia.
Responsibilities in the Nursing Process
Assessment
● Assess for infusion-related reactions
(fever, chills, urticaria, pruritus) during and
for 2 hr after infusion. Symptoms usually
resolve when infusion is discontinued.
● Crohn’s Disease and Ulcerative Colitis:
Assess for signs and symptoms before,
during, and after therapy. ● Psoriasis:
Assess lesions periodically during therapy.
Page | 82
● Lab Test Considerations: May causein
positive ANA. Frequency may be decreased
with baseline immunosuppressant therapy.
● Monitor liver function tests periodically
during therapy. May cause mild to moderate
AST and ALT without progressing to liver
dysfunction. If patient develops jaundice or
liver enzyme elevations 5 times the upper
limits of normal, discontinue infliximab
Potential Nursing Diagnoses
Chronic pain (Indications)
Diarrhea (Indications)
Patient/Family Teaching
● Advise patient of risk of malignancies such
as hepatosplenic T-cell lymphoma.
● Advise patient to examine skin periodically
during therapy and notify health care
professional of any changes in appearance
of skin or growths on skin.
Evaluation/Desired Outcomes
● Decreased pain and swelling with
decreased rate of joint destruction and
improved physical function in patients with
ankylosing spondylitis, psoriatic, or
rheumatoid arthritis.
● Decrease in the signs and symptoms of
Crohn’s disease and a decrease in the
number of draining enterocutaneous fistulas.
● Decrease in induration, scaling and
erythema of psoriatic lesions.
Drug Classification:INTERLEUKIN
ANTAGONIST
Generic name: Ustekinumab
Brand name: Stelara
Recommended Dosage, Route, And
Frequency:Psoriasis Subcut (Adults 100
kg): 45 mg initially and 4 wk later, then 45
mg q 12 wk. Subcut (Adults>100 kg): 90
mg initially and 4 wk later, then 90 mg q 12
wk. Psoriatic Arthritis Subcut (Adults): 45
mg initially and 4 wk later, then 45 mg q 12
wk. Subcut (Adults >100 kg with
concomitant moderate-severe plaque
psoriasis): 90 mg initially and 4 wk later,
then 90 mg q 12 wk.
Action:Binds to the p40 protein subunit
used by both the interleukin (IL)-12 and IL-
23 cytokines. These cytokines that are
involved in inflammatory and immune
responses, including natural killer cell
activation and CD4 T-cell differentiation and
activation. Binding to interleukins
antagonizes their effects, disrupting IL-12
and IL-23 mediated signaling and cytokine
cascades.
Absorption: Well absorbed following
subcutaneous administration.
Distribution: Unknown
Metabolism and Excretion: Broken down
by catabolic processes into peptides and
amino acids.
Half-life: 15– 46 days;
Route: 45 mg subcut; 90 mg subcut
Onset: unknown; unknown
Peak: 13.5 days; 7 days
Duration: 12 wk; 12 wk
Drug-Drug & Drug-Food Interactions:May
 antibody response to and risk of adverse
reactions from live vaccines. May desired
antibody response to non-live vaccines. May
affect the activity of CYP450 drug-
metabolizing enzymes; when treatment is
started during concurrent CYP450
substrates, especially those with a narrow
therapeutic indices, including warfarin and
cyclosporine; appropriate monitoring and
dose adjustment should be carried out.
Indications:Moderate to severe plaque
psoriasis in patients who are candidates for
phototherapy or systemic therapy. Active
psoriatic arthritis (as monotherapy or with
methotrexate).
Contraindicated in: Hypersensitivity; Active
untreated infection.
Side effects:CNS: Reversible Posterior
Leukoencephalopathy Syndrome, Fatigue,
Headache
Adverse effects:Local:erythema.
Misc: anaphylaxis, angioedema,
infection,malignancy.
Responsibilities in the Nursing Process
Assessment
● Assess for signs of infection (fever,
dyspnea, flu-like symptoms, frequent or
painful urination, redness or swelling at the
site of a wound), including tuberculosis, prior
to injection.New infections should be
monitored closely; most common are upper
respiratory tract infections, bronchitis, and
urinary tract infections. Patients genetically
deficient in IL-12/IL-23 are particularly
vulnerable to disseminated infections;
diagnostic testing should be considered.
● Assess patient for latent tuberculosis with
a tuberculin skin test prior to initiation of
therapy.
● Monitor for signs and symptoms of
hypersensitivity reaction and anaphylaxis
(rash, chest tightness, feeling faint, difficulty
breathing, throat tightness, swelling of face,
eyelids, tongue, or throat) during therapy.
Potential Nursing Diagnoses
Impaired skin integrity (Indications)
Implementation
● Administer a tuberculin skin test prior to
administration of ustekinumab. Patients with
active latent TB should be treated for TB
prior to therapy.
● Immunizations should be current prior to
initiating therapy. Patients on ustekinumab
may receive concurrent vaccinations, except
for live vaccines.
Page | 83
● Subcut: Administer using a 27 gauge, 1/2
inch needle in upper arm, gluteal region,
thigh, or abdomen; rotate site.
Patient/Family Teaching
● Instruct patient on correct technique for
self-injection, care and disposal of
equipment.
● Inform patient that ustekinumab may lower
ability to fight and increase risk for
infections. Advise patient to notify health
care professional immediately if signs of
anaphylaxis or infection (fever, sweats,
chills, muscle aches, cough, shortness of
breath, blood in phlegm, weight loss, warm,
red, or painful sores, diarrhea or stomach
pain, burning or urination or urinary
frequency, tiredness) occur.
● Inform patient that ustekinumab may
increase for cancer.
● Advise patient to notify health care
professional if signs of reversible posterior
leukiencephalopathy syndrome (headache,
seizures, confusion, visual problems) occur.
● Advise female patient to notify health care
professional if pregnancy is planned or
suspected or if breast feeding.
Evaluation/Desired Outcomes
● Decrease in extent and severity of
psoriatic lesions.
● Decreased progression of psoriatic
arthritis.
Drug Classification:
GLUCOCORTICOIDS
Generic name: Prednisone
Brand name:
Recommended Dosage, Route, And
Frequency:
PO (Adults): Most uses—5– 60 mg/day as
a single dose or in divided doses (delayed-
release tablets should be administered once
daily). Multiple sclerosis—200 mg/day for 1
wk, then 80 mg every other day for 1 mo.
Adjunctive therapy of Pneumocystis jirovecii
pneumonia in AIDS patients—40 mg twice
daily for 5 days, then 40 mg once daily for 5
days, then 20 mg once daily for 10 days.
PO (Children): Nephrotic syndrome—2
mg/kg/day initially given in 1– 3 divided
doses (maximum 80 mg/day; delayed-
release tablets should be administered once
daily) until urine is protein free for 4– 6
weeks. Maintenance dose of 2 mg/kg/day
every other day in the morning, gradually
taper off after 4– 6 weeks. Asthma
exacerbation—1 mg/kg q 6 hr for 48 hr, then
1– 2 mg/kg/day (maximum 60 mg/day) in
divided doses twice daily.
Action:In pharmacologic doses, suppresses
inflammation and the normal immune
response. Suppresses adrenal function at
chronic doses of 5 mg/day.Replaces
endogenous cortisol in deficiency states.
Has minimal mineralocorticoid activity.
Absorption: Well absorbed after oral
administration.
Distribution: Widely distributed; crosses the
placenta and probably enters breast milk.
Metabolism and Excretion: Converted by
the liver to prednisolone, which is then
metabolized by the liver.
Half-life: 3.4– 3.8 hr (plasma), 18– 36 hr
(tissue); adrenal suppression lasts 1.25– 1.5
days.
Route: PO
Onset: hrs
Peak: unknown
Duration: 1.25–1.5 days
Drug-Drug & Drug-Food
Interactions:Drug-Drug: Additive
hypokalemia withthiazide and loop diuretics,
amphotericin B, piperacillin, or ticarcillin.
Hypokalemia may  risk of digoxin toxicity.
May requirement for insulins ororal
hypoglycemic agents. Phenytoin,
phenobarbital, and rifampin stimulate
metabolism; may effectiveness. Oral
contraceptives may metabolism.risk of
adverse GI effects with NSAIDs(including
aspirin). At chronic doses that suppress
adrenal function, may  antibody response
to and the risk of adverse reactions from
live virus vaccines. May risk of tendon
rupture fromfluoroquinolones.
Indications:Used systemically and locally in
a wide variety of chronic diseases including:
Inflammatory, Allergic, Hematologic,
Neoplastic, Autoimmune disorders. Suitable
for alternate-day dosing in the management
of chronic illness.
Contraindicated in: Active untreated
infections (may be used in patients being
treated for tuberculous meningitis); Some
products contain alcohol and should be
avoided in patients with known intolerance;
Lactation: Avoid chronic use.
Side effects:CNS: depression, euphoria,
headache,intracranial pressure (children
only), personality changes, psychoses,
restlessness. EENT: cataracts,intraocular
pressure.GI: PEPTIC ULCERATION,
anorexia, nausea, vomiting. Derm:
acne,wound healing, ecchymoses, fragility,
hirsutism, petechiae.
Adverse effects:CV: hypertension. Endo:
adrenal suppression, hyperglycemia.
F and E: fluid retention (long-term high
doses), hypokalemia, hypokalemic alkalosis.
Hemat: thromboembolism, thrombophlebitis.
Metab: weight gain, weight loss. MS:
muscle wasting, osteoporosis, avascular
necrosis of joints, muscle
pain.Misc:cushingoid appearance (moon
face, buffalo hump), susceptibility to
infection.
Page | 84

Responsibilities in the Nursing Process
Assessment
● Pedi: Children should have periodic
evaluations of growth.
● Lab Test Considerations: Monitor serum
electrolytes and glucose. May decrease
WBC counts.May  serum potassium and
calcium and serum sodium concentrations.
● Guaiac-test stools. Promptly report
presence of guaiac-positive stools.
● May serum cholesterol and lipid
values.May uptake of thyroid 123I or 131I.
Potential Nursing Diagnoses
Risk for infection (Side Effects
Deficient knowledge, related to medication
regimen (Patient/Family Teaching)
Patient/Family Teaching
● Instruct patient on correct technique of
medication administration.Advise patient to
take medication as directed. Take missed
doses as soon as remembered unless
almost time for next dose.
Evaluation/Desired Outcomes
● Decrease in presenting symptoms with
minimal systemic side effects.
● Suppression of the inflammatory and
immune responses in autoimmune
disorders, allergic reactions, and
neoplasms.● Management of symptoms in
adrenal insufficiency.
Drug Classification:VITAMIN A hair.
DERIVATIVE
Generic name: Isotretinoin
Brand name: Sotret
Recommended Dosage, Route, And
Frequency:
PO (Adults and Children 12 yr): 0.5– 1
mg/kg/day (up to 2 mg/kg/day) in 2 divided
doses for 15– 20 wk. Once discontinued, if
relapse occurs, therapy may be reinstituted
after an 8-wk rest period.
Action:A metabolite of vitamin A (retinol);
reduces sebaceous gland size and
differentiation.
Absorption:Rapidly absorbed following
(23– 25%) oral administration;
absorptionwhen taken with a high-fat meal.
Distribution: Appears to be widely
distributed; crosses the placenta.
Protein binding: 99.9%
Metabolism and Excretion: Metabolized by
the liver and excreted in the urine and feces.
Half-life: 10– 20 hr
Route: PO
Onset: unknown
Peak: up to 8 wk
Duration: unknown
Drug-Drug & Drug-Food
Interactions:Drug-Drug: Additive toxicity
with vitamin A and drugs having
anticholinergic properties.qrisk of
pseudotumor cerebri with tetracycline or
minocycline. Concurrent use with
alcoholqrisk of hypertriglyceridemia. Drying
effectsqby concurrent use of benzoyl
peroxide,sulfur, tretinoin, and other topical
agents.
Indications:Management of severe nodular
acne resistant to more conventional therapy,
including topical therapy and systemic
antibiotics. Not to be used under any
circumstances in pregnant patients.
Contraindications:Hypersensitivity to
retinoids, glycerin, soybean oil, or parabens;
OB, Lactation: Pregnancy and lactation;
Women of childbearing age who may
become or who intend to become pregnant;
Patients planning to donate blood.
Side effects: CNS: suicide attempt,
behavior changes, depression, pseudotumor
cerebri, psychosis, suicidal ideation.
EENT:conjunctivitis, epistaxis, blurred
vision, contact lens intolerance, corneal
opacities,pnight vision, dry eyes. GI:cheilitis,
dry mouth, nausea, vomiting, abdominal
pain, anorexia, hepatitis,
pancreatitis,appetite. Derm:stevens-
johnson syndrome, toxic epidermal
necrolysis, pruritus, palmar desquamation,
photosensitivity, skin infections, thinning of
Adverse effects: CV:edema. Hemat:
anemia. Metab: p high-density lipoprotein
cholesterol, hypercholesterolemia,
hypertriglyceridemia, hyperglycemia,
hyperuricemia. MS: arthralgia, back pain,
muscle/bone pain (qin adolescents),
hyperostosis. Misc: severe birth defects,q
thirst.
Responsibilities in the Nursing Process
Assessment
● Monitor patient for behavioral changes
throughout therapy.May cause depression,
psychosis, and suicide ideation. If behavioral
changes occur, they usually resolve with
discontinuation of therapy.
● Lab Test Considerations: Obtain 2
negative sequential serum or urine
pregnancy tests with a sensitivity 25 mIU/mL
before receiving initial prescription and
monthly before each new Rx. ● Monitor liver
function (AST, ALT, and LDH) prior to
therapy, after 1 mo of therapy, and
periodically thereafter. Inform health care
professional if these values becomeq;
therapy may need to be discontinued.
● Monitor blood lipids (cholesterol, HDL,
triglycerides) under fasting conditions prior
Page | 85
to beginning therapy, at 1– 2 wk intervals
until lipid response to isotretinoin is
established (usually within 1 mo), and
periodically thereafter.
Potential Nursing Diagnoses
Risk for impaired skin integrity (Indications)
(Side Effects) Disturbed body image
(Indications)
Implementation
● PO: Administer with meals. Do not crush
or open capsules.
Patient/Family Teaching
● Instruct patient that oral rinses, good oral
hygiene, and sugarless gum or candy may
help minimize dry mouth. Notify health care
professional if dry mouth persists for more
than 2 wk.
● Inform diabetic patients that difficulty
controlling blood glucose may occur.
● Inform patient of need for medical follow-
up. Periodic lab tests may be required.
● Advise patient not to donate blood while
receiving this medication. After discontinuing
isotretinoin, wait at least 1 mo before
donating blood to prevent the possibility of a
pregnant patient receiving the blood.
Evaluation/Desired Outcomes
● Decrease in the number and severity of
cysts in severe acne. Therapy may take 4–
5 mo before full effects are seen. Therapy is
discontinued when the number ofcysts is
reduced by 70% or after 5 mo.
Drug Classification: DNA
SYNTHESIS SUPPRESSANTS
Generic name: Methotrexate
Brand Name:
Recommended Dosage, Route, And
Frequency:Trophoblastic Neoplasms PO,
IM (Adults): 15– 30 mg/day for 5 days;
repeat after 1 or more weeks for 3– 5
courses.
Osteosarcoma IV (Adults): 12 g/m2 as a 4-
hr infusion followed by leucovorin rescue,
usually as part of a combination
chemotherapeutic regimen (or increase
dose until peak serum methotrexate level is
10-3 M/L but not to exceed 15 g/m2 ; 12
courses are given starting 4 wk after surgery
and repeated at scheduled intervals.
Psoriasis Therapy may be preceded by a 5-
– 10-mg test dose. PO, IM, Subcut, IV
(Adults): 10– 25 mg/weekly (not to exceed
30 mg/wk); Otrexup may be used when
dose is 10– 25 mg/wk.
Action:Interferes with folic acid metabolism.
Result is inhibition of DNA synthesis and cell
reproduction (cell-cycle S-phase– specific).
Also has immunosuppressive activity.
Absorption:Small doses are well absorbed
from the GI tract. Larger doses incompletely
absorbed.
Distribution: Actively transported across
cell membranes, widely distributed. Does
not reach therapeutic concentrations in the
CSF. Crosses placenta; enters breast milk in
low concentrations. Absorption in children is
variable (23– 95%) and dosedependent.
Metabolism and Excretion: Excreted
mostly unchanged by the kidneys.
Half-life: Low dose—3– 10 hr; high dose—
8– 15 hr (in renal impairment).
Route:PO, IM, IV
Onset:4–7 days
Peak: 7–14 days
Duration:21 days
Drug-Drug & Drug-Food Interactions:
The following drugs may hematologic
toxicity of methotrexate: highdosesalicylates,
NSAIDs, oral hypoglycemic agents
(sulfonylureas), phenytoin, tetracyclines,
probenecid, trimethoprim/sulfamethoxazole,
pyrimethamine, proton pump inhibitors and
chloramphenicol.hepatotoxicity with other
hepatotoxic drugs including
azathioprine,sulfasalazine, and retinoids.
nephrotoxicity with other nephrotoxic
drugs.bone marrow depression with other
antineoplastics orradiation therapy.
Radiation therapy risk of soft tissue
necrosis and osteonecrosis.May antibody
response to live-virus vaccines and  risk of
adverse reactions.risk of neurologic
reactions with acyclovir (IT methotrexate
only). Asparaginase may effects of
methotrexate.
Indications:Alone or with other treatment
modalities in the treatment of: Trophoblastic
neoplasms (choriocarcinoma,
chorioadenoma destruens, hydatidiform
mole), Leukemias, Breast carcinoma, Head
carcinoma, Neck carcinoma, Lung
carcinoma. Severe psoriasis, rheumatoid
arthritis, and polyarticular juvenile idiopathic
arthritis unresponsive to conventional
therapy.Treatment of mycosis fungoides
(cutaneous T-cell lymphoma).
Contraindicated in: Hypersensitivity;
Alcoholism or hepatic impairment;
Immunosuppresion; bone marrow reserve;
OB, Lactation: Pregnancy or lactation; Pedi:
Products containing benzyl alcohol should
not be used in neonates.
Side effects: CNS: arachnoiditis (IT use
only), dizziness, drowsiness, headache,
malaise, seizures. EENT: blurred vision,
dysarthriatransient blindness.GI:
hepatotoxicity, anorexia, diarrhea, nausea,
stomatitis, vomiting. GU: acute renal failure,
infertility. Derm: erythema multiforme,
stevens-johnson syndrome, toxic epidermal
necrolysis, alopecia, painful plaque erosions
Page | 86
(during psoriasis treatment),
photosensitivity, pruritus, rashes, skin
ulceration, urticaria.
Adverse effects: Resp: pulmonary fibrosis,
interstitial pneumonitis.Hemat: aplastic
anemia, anemia, leukopenia,
thrombocytopenia. Metab: hyperuricemia.
MS: osteonecrosis, stress fracture. Misc:
nephropathy, chills, fever, soft tissue
necrosis.
Responsibilities in the Nursing Process
Assessment
● Monitor vital signs periodically during
administration. Report significant changes.
● Monitor for abdominal pain, diarrhea, or
stomatitis; therapy may need to be
discontinued.
● Monitor for bone marrow depression.
Assess for bleeding (bleeding gums,
bruising, petechiae, guaiac stools, urine, and
emesis) and avoid IM injections and taking
rectal temperatures if platelet count is low.
Apply pressure to venipuncture sites for 10
min. Assess for signs of infection during
neutropenia. Anemia may occur. Monitor for
increased fatigue, dyspnea, and orthostatic
hypotension.
● Monitor intake and output ratios and daily
weights.Report significant changes in totals.
● Monitor for symptoms of pulmonary
toxicity, which may manifest early as a dry,
nonproductive cough.
● Monitor for symptoms of gout (increased
uric acid, joint pain, edema). Encourage
patient to drink at least 2 L of fluid each day.
Allopurinol and alkalinization of urine may be
used to decrease uric acid levels.
● Assess nutritional status. Administering
an antiemetic prior to and periodically during
therapy and adjusting diet as tolerated may
help maintain fluid and electrolyte balance
and nutritional status.
● Assess for rash periodically during
therapy.May cause Stevens-Johnson
syndrome. Discontinue therapy if severe or if
accompanied with fever, general malaise,
fatigue, muscle or joint aches, blisters, oral
lesions, conjunctivitis, hepatitis and/or
eosinophilia.
● IT: Assess for development of nuchal
rigidity, headache, fever, confusion,
drowsiness, dizziness, weakness, or
seizures.
● Rheumatoid Arthritis: Assess patient for
pain and range of motion prior to and
periodically during therapy. ● Psoriasis:
Assess skin lesions prior to and periodically
during therapy.
● Lab Test Considerations:Monitor CBC
and differential prior to and frequently during
therapy. The nadir of leukopenia and
thrombocytopenia occurs in 7– 14 days.
Leukocyte and thrombocyte counts usually
recover 7 days after the nadirs. Notify health
care professional of any sudden drop in
values.
● Monitor renal (BUN and creatinine) and
hepatic function (AST, ALT, bilirubin, and
LDH) prior to and every 1– 2 months during
therapy. Urine pH should be monitored prior
to high-dose methotrexate therapy and
every 6 hr during leucovorin rescue. Urine
pH should be kept above 7.0 to prevent
renal damage.
● May cause serum uric acid
concentrations, especially during initial
treatment of leukemia and lymphoma.
● Toxicity and Overdose: Monitor serum
methotrexate levels every 12– 24 hr during
high-dose therapy until levels are< 5 X 10
M. This monitoring is essential to plan
correct leucovorin dose and determine
duration of rescue therapy.
Potential Nursing Diagnoses
Risk for infection (Adverse Reactions)
Imbalanced nutrition: less than body
requirements (Adverse Reactions)
Implementation
● High Alert: Fatalities have occurred with
chemotherapeutic agents. Before
administering, clarify all ambiguous orders;
double check single, daily, and courseof-
therapy dose limits; have second practitioner
independently double check original order,
calculations and infusion pump settings.
Methotrexate for non-oncologic use is given
at a much lower dose and frequency— often
just once a week. Do not confuse non-
oncologic dosing regimens with dosing
regimens for cancer patients.
● Solutions for injection should be prepared
in a biologic cabinet. Wear gloves, gown,
and mask while handling medication.
Discard equipment in specially designated
containers.
● Otrexup is not indicated for treatment of
neoplastic diseases. Not for patients
requiring oral, IM, IV, intra-arterial, or IT
dosing, doses< 10 mg/week, doses <25
mg/week, high-dose regimens, or dose
adjustments of less than 5 mg increments.
● Subcut: Otrexupis a single-dose auto-
injector. Inject once weekly in abdomen or
upper thigh. Avoid areas where skin is
tender, bruised, red, scaly, hard, or has
scars or stretch marks. Solution is clear and
yellow; do not inject solutions that are
discolored or contain particulate matter.
Patient/Family Teaching
● Instruct patient to take medication as
directed. If a dose is missed, it should be
omitted. Consult health care professional if
vomiting occurs shortly after a dose is taken.
● Instruct patient to inspect oral mucosa for
erythema and ulceration. If ulceration
occurs, advise patient to use sponge brush
and to rinse mouth with water after eating
and drinking. Topical therapy may be used if
mouth pain interferes with eating.
● Advise patient to tell health care
professional what medications they are
Page | 87
taking and to avoid taking new Rx, OTC,
vitamins, or herbal products without
consulting health care professional.
● Discuss the possibility of hair loss with
patient. Explore methods of coping.
● Instruct patient not to receive any
vaccinations without advice of health care
professional.
● Caution patient to use sunscreen and
protective clothing to prevent
photosensitivity reactions.
● Advise patient that this medication may
have teratogenic effects.Contraception
should be used during therapy and for at
least 3 mo for men and 1 ovulatory cycle for
women after completion of therapy.
● Subcut: Instruct patient on correct
technique for injection and care and disposal
of equipment.
Evaluation/Desired Outcomes
● Improvement of hematopoietic values in
leukemia.
● Decrease in symptoms of meningeal
involvement in leukemia.
● Decrease in size and spread of non-
Hodgkin’s lymphomas and other solid
cancers.
● Resolution of skin lesions in severe
psoriasis.
● Decreased joint pain and swelling.
● Improved mobility in patients with
rheumatoid arthritis.● Regression of lesions
in mycosis fungoides.
Drug classification:
KERATOLYTICS
Generic name: Clindamycin
Brand Name: Dalacin C
Recommended Dosage, Route, And
Frequency: PO (Children 1 mo): 10– 30
mg/kg/day divided q 6– 8 hr; maximum dose
1.8 g/ day. Bacterial endocarditis
prophylaxis—20 mg/kg 1 hr before
procedure. IM, IV (Adults):Most infections—
300– 600 mg q 6– 8 hr or 900 mg q 8 hr (up
to 4.8 g/day IV has been used; single IM
doses of 600 mg are not recommended). P.
carinii pneumonia—2400– 2700 mg/day in
divided doses with Primaquine (unlabeled).
Toxoplasmosis—1200– 4800 mg/day in
divided doses with pyrimethamine. Bacterial
endocarditis prophylaxis—600 mg 30 min
before procedure.
IM, IV (Children 1 mo): 25– 40 mg/kg/day
divided q 6– 8 hr; maximum dose: 4.8 g/day.
Bacterial endocarditis prophylaxis—20
mg/kg 30 min before procedure; maximum
dose: 600 mg. IM, IV (Infants >1 mo and >2
kg): 5 mg/kg q 8– 12 hr 2 kg—20– 30
mg/kg/ day divided q 6– 8 hr. Vag (Adults
and Adolescents): Cleocin, Clindamax—1
applicatorful (5 g) at bedtime for 3 or 7 days
(7 days in pregnant patients); Clindesse—
one applicatorful (5 g) single dose; or 1
suppository (100 mg) at bedtime for 3
nights. Topical (Adults and Adolescents):
Solution—1% solution/suspension applied
twice daily (range 1– 4 times daily).Foam,
gel—1% foam or gel applied once daily.
Action:Inhibits protein synthesis in
susceptible bacteria at the level of the 50S
ribosome.
Absorption:Well absorbed following PO/IM
administration. Minimal absorption following
topical/vaginal use.
Distribution: Widely distributed. Does not
significantly cross blood-brain barrier.
Crosses the placenta; enters breast milk.
Metabolism and Excretion: Mostly
metabolized by the liver.
Half-life:Neonates: 3.6– 8.7 hr; Infants up to
1 yr: 3 hr; Children and adults: 2– 3 hr.
Route:PO
Onset:rapid
Peak:60 min
Duration: 6-8 hr
Drug-Drug & Drug-Food
Interactions:Drug-Drug: Kaolin/pectin
maypGI absorption. May enhance the
neuromuscular blocking action of other
neuromuscular blocking agents. Topical:
Concurrent use with irritants, abrasives, or
desquamating agentsmay result in additive
irritation.
Indications:Drug-Drug: Kaolin/pectin
maypGI absorption. May enhance the
neuromuscular blocking action of other
neuromuscular blocking agents. Topical:
Concurrent use with irritants, abrasives, or
desquamating agentsmay result in additive
irritation.
Contraindications:
-Drug: Kaolin/pectin maypGI absorption.
May enhance the neuromuscular blocking
action of other neuromuscular blocking
agents. Topical: Concurrent use with
irritants, abrasives, or desquamating
agentsmay result in additive irritation.
Side effects:CNS:dizziness, headache,
vertigo. GI: pseudomembranous colitis,
diarrhea, bitter taste (IV only), nausea,
vomiting.
Adverse effects:
CV: arrhythmias, hypotension. Local: local
irritation (topical products), phlebitis at IV
site.
Responsibilities in the Nursing Process
● Assess for infection (vital signs;
appearance of wound, sputum, urine, and
stool; WBC) at beginning of and during
therapy.
Page | 88
● Obtain specimens for culture and
sensitivity prior to initiating therapy. First
dose may be given before receiving results.
● Lab Test Considerations: Monitor CBC;
may cause transientpin leukocytes,
eosinophils, and platelets.
● May causealkaline phosphatase,
bilirubin, CPK, AST, and ALT
concentrations.
Potential Nursing Diagnoses
Risk for infection (Indications) (Side Effects)
Diarrhea (Side Effects)
Patient/Family Teaching
● Instruct patient to take medication around
the clock at evenly spaced times and to
finish the drug completely as directed, even
if feeling better. Take missed doses as soon
as possible unless almost time for next
dose. Do not double doses. Advise patient
that sharing of this medication may be
dangerous.
● Instruct patient to notify health care
professional immediately if diarrhea,
abdominal cramping, fever, or bloody stools
occur and not to treat with antidiarrheals
without consulting health care professional.
Evaluation/Desired Outcomes
● Resolution of the signs and symptoms of
infection. Length of time for complete
resolution depends on the organism and site
of infection. ● Endocarditis prophylaxis.
● Improvement in acne vulgaris lesions.
Improvement should be seen in 6 wk but
may take 8– 12 wk for maximum benefit.
Drug classification: VITAMIN D3
ANALOGS
Generic name: Calcitriol ointment
Brand Name: Vectical ointment
Recommended Dosage, Route, And
Frequency:
Topical (Adults  18 yr): Apply twice
daily,use should not exceed 200 g/wk.
Action:
Exact mechanism is unknown, but may
affect keratinocyte proliferation and
differentiation, and decrease the action of
proinflammatory cytokines.
Therapeutic Effects: Decreased severity of
plaque psoriasis.
Absorption:
Although intended action is skin, some
systemic absorption follows topical use.
Distribution:
Unknown.
Metabolism and Excretion:
Absorbed calcitriol undergoes enterohepatic
recycling and is excreted in bile.
Half-life: 5– 8 hr.
Route: Topical
Onset: unknown
Peak: within 8 wk
Duration: unknown
Drug-Drug & Drug-Food Interactions:
Drug-Drug: Concurrent use with medications
known to serum calcium levels including
thiazide diuretics, calcium supplements, or
high doses of vitamin D may additively
serum calcium levels; use cautiously.
Indications:
Mild to moderate plaque psoriasis.
Contraindicated in:
No contraindications noted.
Side effects:
GU: hypercalcuria.Derm: pruritus, skin
discomfort.
Responsibilities in the Nursing Process
Assessment
● Assess psoriatic lesions periodically
during therapy.
● Lab Test Considerations:May cause
hypercalcemia and hypercalciuria.
Potential Nursing Diagnoses
Impaired skin integrity (Indications)
Implementation
● Topical: Apply ointment to affected areas
twice daily, morning and evening. Rub
gently into skin so no medication remains
visible. Do not apply to eyes, lips, or facial
skin.
Patient/Family Teaching
● Instruct patient to apply calcitriol ointment
as directed. Do not use more than 200 g/wk.
● Caution patient to avoid excessive
exposure of treated areas to natural or
artificial sunlight, including tanning booths
and sun lamps; may increase risk of skin
tumors.
● Advise patient to report any signs of
adverse reactions to health care
professional.
●Advise female patient to notify health care
professional if pregnancy is planned or
suspected or if breast feeding.
Evaluation/Desired Outcomes
● Decrease in color and elevation of
psoriatic lesions.
Drug classification: SALICYLATES
Generic name: Aspirin
Brand Name:
Recommended Dosage, Route, And
Frequency: Inflammation PO (Adults): 2.4
Page | 89
g/day initially; increased to maintenance
dose of 3.6– 5.4 g/day in divided doses (up
to 7.8 g/day for acute rheumatic fever).
PO (Children): 60– 100 mg/kg/day in
divided doses (up to 130 mg/kg/day for
acute rheumatic fever). Prevention of
Transient Ischemic Attacks PO (Adults):
50– 325 mg once daily.
Kawasaki Disease PO (Children): 80– 100
mg/kg/day in 4 divided doses until fever
resolves; may be followed by maintenance
dose of 3– 5 mg/kg/day as a single dose for
up to 8 wk.
Action: Produce analgesia and reduce
inflammation and fever by inhibiting the
production of prostaglandins. Decreases
platelet aggregation.
Absorption: Well absorbed from the upper
small intestine; absorption from enteric-
coated preparations may be unreliable;
rectal absorption is slow and variable.
Distribution: Rapidly and widely distributed;
crosses the placenta and enters breast milk.
Metabolism and Excretion: Extensively
metabolized by the liver; inactive
metabolites excreted by the kidneys.
Amount excreted unchanged by the kidneys
depends on urine pH; as pH increases,
amount excreted unchanged increases from
2– 3% up to 80%.
Half-life: 2– 3 hr for low doses; up to 15– 30
hr with larger doses because of saturation of
liver metabolism.
Route: PO
Onset:5–30 min
Peak: 1–3 hr
Duration: 3–6 hr
Drug-Drug & Drug-Food Interactions:
Drug-Drug: May the risk of bleeding with
warfarin, heparin, heparin-like agents,
thrombolytic agents, dipyridamole,
ticlopidine,clopidogrel, tirofiban, or
eptifibatide, although these agents are
frequently used safely in combination and in
sequence. Ibuprofen: may negate the
cardioprotective antiplatelet effects of low-
dose aspirin. May risk of bleeding with
cefoperazone,cefotetan, and valproic acid.
May activity of penicillins, phenytoin,
methotrexate,valproic acid, oral
hypoglycemic agents, and sulfonamides.
Indications:
Inflammatory disorders including:
Rheumatoid arthritis, Osteoarthritis.Mild
tomoderate pain.Fever.Prophylaxis of
transient ischemic attacks and MI.
Contraindicated in: Hypersensitivity to
aspirin or other salicylates; Cross-sensitivity
with other NSAIDs may exist (less with
nonaspirin salicylates); Bleeding disorders
or thrombocytopenia; Pedi: May increase
risk of Reye’s syndrome in children or
adolescents with viral infections.
Side effects: EENT: tinnitus. GI: gi
bleeding, dyspepsia, epigastric distress,
nausea, abdominal pain, anorexia,
hepatotoxicity, vomiting.Derm: rash,
urticaria.
Adverse effects: Hemat: anemia,
hemolysis. Misc:allergic reactions including
anaphylaxisand laryngeal edema.
Responsibilities in the Nursing Process
Assessment
● Patients who have asthma, allergies, and
nasal polyps or who are allergic to tartrazine
are at an increased risk for developing
hypersensitivity reactions.
● Lab Test Considerations:Monitor hepatic
function before antirheumatic therapy and if
symptoms of hepatotoxicity occur; more
likely in patients, especially children, with
rheumatic fever, systemic lupus
erythematosus, juvenile arthritis, or pre-
existing hepatic disease. May cause serum
AST, ALT, and alkaline phosphatase,
especially when plasma concentrations
exceed 25 mg/100 mL.
● Toxicity and Overdose:Monitor for the
onset of tinnitus, headache, hyperventilation,
agitation, mental confusion, lethargy,
diarrhea, and sweating.
Potential Nursing Diagnoses
Acute pain (Indications)
Impaired physical mobility (Indications)
Implementation
● PO: Administer after meals or with food or
an antacid to minimize gastric irritation.
Food slows but does not alter the total
amount absorbed.
Patient/Family Teaching
● Instruct patient to take salicylates with a
full glass of water and to remain in an
upright position for 15– 30 min after
administration.
● Pedi: Centers for Disease Control and
Prevention warns against giving aspirin to
children or adolescents with varicella
(chickenpox) or influenza-like or viral
illnesses because of a possible association
with Reye’s syndrome.
Evaluation/Desired Outcomes
● Relief of mild to moderate discomfort.
● Increased ease of joint movement. May
take 2– 3 wk for maximum effectiveness.
● Reduction of fever.
● Prevention of transient ischemic attacks.
● Prevention of MI.
Page | 90
Drug classification: ANTIMITOTIC dressing, is applied until the healing
Generic name: podofilox is complete.
 Monitor neurologic status.
Brand Name: condolyx Sensorimotor polyneuropathy, if it
occurs, appears about 2 wk after
Recommended Dosage, Route, And application of drug, worsens for 3
Frequency: mo, and may persist for up to 9 mo.
Condylomata Acuminata Cerebral effects may persist for 7–
Adult: Topical Use 10% solution and repeat 10 d; ataxia, hypotonia, and
1–2 times/wk for up to 4 applications areflexia improve more slowly than
effects on sensorium.
Verruca Vulgaris (Common Wart)
Adult: Topical Apply 0.5% solution q12h for
Patient & Family Education
up to 4 wk

Multiple Superficial Epitheliomatosis,  Learn proper technique of treatment

Keratoses
Adult: Topical Apply 0.5% solution or gel
daily for several days
Action:Potent cytotoxic and keratolytic
agent with caustic action, derived from
rhizomes and roots of Podophyllum
peltatum (mandrake, May apple). Directly
affects epithelial cell metabolism, causing
degeneration and arrest of mitosis.
Therapeutic Effects:
Slow disruption of cells and tissue erosion
as a result of its caustic action. Selectively
affects embryonic and tumor cells more than
adult cells.
Drug-Drug & Drug-Food Interactions:
No clinically significant interactions
established.
if self-administered as treatment of
verruca vulgaris (common wart).
Also be fully aware of the need to
report treatment failure to physician.
 Be aware that as with any STD, the
patient's sex partner should be
examined.
 Systemic toxicity may be severe and
serious and is associated with
application of drug to large areas, to
tissue that is friable, bleeding, or
recently biopsied, or for prolonged
time. Toxicity may occur within
hours of application. There are
significant dangers from overuse or
misuse of this drug.
 Learn symptoms of toxicity and
report any that appear promptly to
physician. Do not breast feed while
taking this drug.

Indications:For the treatment of external

warts (condylomata acuminata) due to Drug classification: IMMUNE
human papillomavirus (HPV) RESPONSE MODIFIERS
infection.Benign
growths including Generic name: Imiquimod cream
external genital and perianal Brand Name:
warts, papillomas, fibroids.
Contraindications: hypersensitivity Recommended Dosage, Route, And
Frequency:External Genital Warts
Side effects:CNS: Inflammation, Burning, Topical (Adults and children 12 yr):
Erosion, Pain, Bleeding.Derm:Itching, Aldara—Apply thin layer to warts at bedtime
scabbing, discoloration, tenderness, every other day (3 times weekly); leave on
for 6– 10 hr, then rinse off with mild soap
dryness, crusting, fissures,
and water. Use until lesions are completely
soreness, ulceration, tingling, rash, and cleared or up to 16 wk. Zyclara— Apply thin
blisters. layer of 3.75% cream to warts at bedtime
every day; leave on for 8 hr, then rinse off
Adverse effects: CV: edema. with mild soap and water. Use until lesions
are completely cleared or up to 8 wk.
Responsibilities in the Nursing Process Actinic Keratoses Topical (Adults): Aldara
—Apply thin layer to clean, dry affected area
twice weekly; leave on for 8 hr, then rinse off
with mild soap and water. Continue for 16
Assessment
wk. Zyclara—Apply thin layer of 2.5% or
3.75% cream to clean, dry affected area
 Warts become blanched, then once daily before bedtime; leave on for 8 hr,
necrotic within 24–48 h. Sloughing then rinse off with mild soap and water.
begins after about 72 h with no Continue for 2 wk, followed by 2 wk without
scarring. Frequently, a mild topical treatment, then begin applying cream again
antiinfective agent, with or without a for another 2 wk. Superficial Basal Cell
Carcinoma Topical (Adults): Apply thin

Page | 91
layer to clean, dry affected area 5 times per
week; leave on for 8 hr, then rinse off with
mild soap and water. Continue for 6 wk.
Action:May induce the formation of
interferons that have antiproliferative and
antiviral properties. Therapeutic Effects:
Regression of external genital or perianal
warts/condylomata, actinic keratoses, or
basal cell carcinoma lesions.
Absorption: Minimal absorption.
Distribution: Action is primarily local.
Metabolism and Excretion: <0.9%
excreted in urine and feces.
Half-life:Unknown.
Route:Topical
Onset:days–wk
Peak:10–16 wk
Duration: unknown
Drug-Drug & Drug-Food Interactions:
Drug-Drug: None known.
Indications:
External genital or perianal
warts/condylomata (condyloma
acuminatum).Typical, nonhyperkeratotic,
nonhypertrophic actinic keratoses on the
face or scalp.Biopsyconfirmed, primary
superficial basal cell carcinoma (Aldara
only).
Contraindications:
None known.
Side effects:
CNS: dizziness, fatigue, headache. GI:
diarrhea, nausea. GU: dysuria, vulvar
swelling.
Adverse effects:
Local: irritation, pain, pruritus, burning,
swelling, fungal infections (women).
Responsibilities in the Nursing Process
Assessment
● Assess affected area(s) prior to and
periodically during therapy.
Potential Nursing Diagnoses
Risk for infection (Indications)
Risk for infection (Patient/FamilyTeaching)
Implementation
● Do not confuse Aldara (imiquimod) with
Alora (estradiol).
● Topical: Apply a thin film to clean and dry
skin as directed prior to bedtime. Rub in well
and leave on skin for time period specified.
Remove by washing with mild soap and
water. Discard unused cream from single-
dose packet. A rest period of several days
may be taken if required for patient comfort
or severity of skin reaction. Resume therapy
when reaction subsides.
● Do not use occlusive dressings. If
covering is needed, use cotton gauze or
cotton underclothes.
Patient/Family Teaching
● Instruct patient on proper application
technique. Emphasize the importance of
washing hands before and after application
and avoiding contact with eyes. Advise
patient not to use more cream than was
prescribed. Missed doses should be applied
as soon as possible; then return to regular
schedule.
● Advise patient to delay next dose for
several days when experiencing discomfort
or severe reactions. Notify health care
professional if severe reactions occur.
● Advise patient to avoid sharing this
medication with others.
● Instruct patient to avoid contact with
affected areas while the cream is on the
skin. Wash cream off of genital areas before
engaging in sexual activities.
● Advise patient to avoid use of other topical
medications on same treatment area unless
recommended by health care professional.
Evaluation/Desired Outcomes
● Healing of genital or perianal warts.
Treatment is continued until wart is healed
or up to 16 wk.
● Healing of actinic keratosis. Treatment is
continued for 16 wk.
● Resolution of superficial basal cell
carcinoma lesions. Treatment is continued
for 6 wk.
Drug classification: CATECHINS
Generic name: Sinecatechins
Brand Name: Veregen
Recommended Dosage, Route, And
Frequency: PO (Adults >18 yr):apply to
warts three times daily for up to 16 wk.
Action:Beneficial effects may be due to
antioxidant properties; made from extract of
green tea.
Therapeutic Effects:Regression of warts.
Absorption:Minimal systemic absorption
(less than that of a cup of green tea).
Distribution: Unknown.
Metabolism and Excretion: Unknown
Half-life:Unknown
Route:TOP
Onset:unknown
Peak:unknown
Duration:unknown
Drug-Drug & Drug-Food Interactions:
Drug-Drug:None noted.
Indications:Treatment of external genital
and perianal warts (Condylomata acuminata
caused by human papillomavirus[HPV]) in
immunocompetent patients 18 years and
Page | 92
older.
Contraindications: Not to be used for
urethral, intra-vaginal, cervical, rectal, or
intra-anal human papilloma viral disease or
on open wounds.
Adverse effects:Local:burning, edema,
erythema, induration, pain/discomfort,
pruritis, erosion/ulceration, vescicular rash,
bleeding, desquamation, discharge,
irritation, phimosis, rash, regional
lymphadenitis, scar.
Responsibilities in the Nursing Process
Assessment
● Assess affected area(s) prior to and
periodically during therapy.
Potential Nursing Diagnoses
Risk for infection (Indications)
Implementation
● Topical: Apply about 0.5 cm strand of
brown ointment to each wart using finger(s),
dabbing it on to ensure complete coverage
and leaving a thin layer of ointment on
warts. Uncircumcised males treating warts
under the foreskin should retract foreskin
and clean area daily. Avoid application to
open wounds, eyes,
vagina, or anus. Ointment does not need to
be washed off prior to next application.
When area is washed or a bath is taken, re-
apply ointment.
Patient/Family Teaching
● Instruct patient to wash hands before and
after application and on how to apply
ointment. Avoid bandages or occlusive
dressings; loose fitting clothing may be
worn. Instruct patient to readPatient
Informationprior to application. Continue
therapy up to 16 wks or until complete
clearance of all warts. Inform patient that
sinecatechins is not a cure. New warts may
develop during 16– wk treatment period and
may be treated with ointment. If warts do not
go away or return after 16
wks, contact health care professional.
● Inform patient that genital warts are
sexually transmitted and may infect
partners.
Advise patient to avoid sharing this
medication with others, even with same
symptoms.
● Inform patient that local skin reactions
(erythema, erosion, edema, itching, burning)
frequently occur. Continue treatment when
severity is acceptable.If severe reactions
occur, wash ointment off with mild soap and
water, withhold further doses
and notify health care professional.
● Advise patient to avoid exposure of
treated areas to sun and UV light.
● Advise patient to avoid sexual contact
while ointment is on skin. Ointment may
weaken condoms and vaginal diaphragms.
Wash prior to sexual contact.
● Advise female patients to insert tampon
prior to applying ointment. If tampon is
changed while ointment is on skin, avoid
accidental application of ointment to the
vagina.
● Inform patient that ointment may stain
clothing and bedding.
● Advise female patients to notify health
care professional if pregnancy is planned or
suspected or if breast feeding.
Evaluation/Desired Outcomes
● Healing of external genital and perianal
warts. Treatment is continued until warts
are healed or up to 16 wks.
Drug classification: ANTIMITOTIC
Generic name: Podophyllin 10%-
25% Topical
Brand Name:
Recommended Dosage, Route, And
Frequency: Condylomata Acuminata
Adult: Topical Use 10% solution and repeat
1–2 times/wk for up to 4 applications.
Verruca Vulgaris (Common Wart)
Adult: Topical Apply 0.5% solution q12h for
up to 4 wk.
Multiple Superficial Epitheliomatosis,
KeratosesAdult: Topical Apply 0.5%
solution or gel daily for several days.
Action:Potent cytotoxic and keratolytic
agent with caustic action, derived from
rhizomes and roots of Podophyllum
peltatum (mandrake, May apple). Directly
affects epithelial cell metabolism, causing
degeneration and arrest of mitosis.
Therapeutic Effects
Slow disruption of cells and tissue erosion
as a result of its caustic action. Selectively
affects embryonic and tumor cells more than
adult cells.
Drug-Drug & Drug-Food Interactions:
No clinically significant interactions
established.
Indications:For the treatment of external
warts (condylomata acuminata) due to
human papillomavirus (HPV)
infection.Benign growths including external
genital and perianal warts, papillomas,
fibroids.
Page | 93
Contraindications:Birthmarks, moles, or
warts with hair growth from them; cervical,
urethral, oral warts; normal skin and mucous
membranes peripheral to treated areas;
pregnancy (category X), lactation; diabetes
mellitus; patient with poor circulation;
irritated, friable, or bleeding skin; application
of drug over large area.
Side effects: CNS: Inflammation, Burning,
Erosion, Pain, Bleeding.Derm:Itching,
scabbing, discoloration, tenderness,
dryness, crusting, fissures,
soreness, ulceration, tingling, rash, and
blisters.
Adverse effects: CV: edema. Sinus
tachycardia.Hemat: Bone marrow
suppressionsimilar to that caused by
antineoplasticdrug toxicity, leukopenia,
thrombocytopenia.
Responsibilities in the Nursing Process
Assessment
 Warts become blanched, then
necrotic within 24–48 h. Sloughing
begins after about 72 h with no
scarring. Frequently, a mild topical
antiinfective agent, with or without a
dressing, is applied until the healing
is complete.
 Monitor neurologic status.
Sensorimotor polyneuropathy, if it
occurs, appears about 2 wk after
application of drug, worsens for 3
mo, and may persist for up to 9 mo.
Cerebral effects may persist for 7–
10 d; ataxia, hypotonia, and
areflexia improve more slowly than
effects on sensorium.
Implementation
Use 10–25% solution for areas <10
cm2 or 5% solution for areas of 10–
20 cm2, anal, or genital warts; apply
drug to dry surface, allowing area to
dry between drops, wash off after 1–
4 h.
Patient/Family Teaching
 Learn proper technique of treatment
if self-administered as treatment of
verruca vulgaris (common wart).
Also be fully aware of the need to
report treatment failure to physician.
 Be aware that as with any STD, the
patient's sex partner should be
examined.
 Systemic toxicity may be severe and
serious and is associated with
application of drug to large areas, to
tissue that is friable, bleeding, or
recently biopsied, or for prolonged
time. Toxicity may occur within
hours of application. There are
significant dangers from overuse or
misuse of this drug.
 Learn symptoms of toxicity and
report any that appear promptly to
physician. Do not breast feed while
taking this drug.
Drug Classification:
BICHLOROACETIC ACID
AND TRICHLOROACETIC
ACID
Generic
name:TRICHLOROACETIC
ACID
Brand Name:
Recommended Dosage, Route,
And Frequency:80% Topical: Apply to
condyloma. Cover with suitable dressing for
5-6 days. Reapply as needed.
Action: Induces desquamation when
applied to cornified epithelium;aid in the
elimination of condylomata.
Debride callous tissue.
Indications:Tri-Chlor is a Trichloroacetic
acid (80%) in clear liquid solution. It is used
as cauterant to treat condyloma, a wartlike
growth of skin, usually seen on external
genitalia or near the anus.
Contraindications:Hypersensitivity
Malignant or premalignant
lesions.Pregnancy.
Side effects: Derm: burning, inflammation,
or tenderness.
Responsibilities in the Nursing Process
Assessment
 Establish baseline data, including
mental status, vital signs and
weight.
 Document and report any existing
lesions( genital, anal or oral).
 Cover the tissue surrounding the
warts with a protective barrier
cream or a paste of baking soda
and water to protect the tissue
from the caustic treatment
solution.
Page | 94
Patient/Family Teaching
 Wash off the treated area
thoroughly within 1 to 4 hours
after the first application;
gradually increase this period to
6-8 hours after the second and
subsequent applications.
 Return for regular treatment until
warts are gone.
 Refer partners for examination
and any necessary treatment.
 Report any adverse effects
(nausea, diarrhea, local irritation,
lethargy, numbness).
 Avoid sexual activity until you
and your partners have been free
of disease for 1 month.
 Use condoms to prevent future
infections.
 Return for annual Pap smear.
Drug classification: DRUGS FOR
CONTACT DERMATITIS
Generic name: Dexamethasone
cream
Brand Name:
Recommended Dosage, Route, And
Frequency:PO, IM, IV (Adults): Anti-
inflammatory—0.75–9 mg daily in divided
doses q 6–12 hr. Airwayedema or
extubation—0.5–2 mg/kg/day dividedq 6 hr;
begin 24 hr prior to extubation and continue
for 24 hr post-extubation. Cerebral edema—
10 mg IV, then 4 mg IM or IV q 6 hr until
maximal response achieved, then switch to
PO regimen and taperover 5–7 days. PO,
IM, IV (Children): Airway edema or
extubation—0.5–2 mg/kg/day divided q 6 hr;
begin 24hr prior to extubation and continue
for 24 hrpostextubation. Anti-inflammatory—
0.08–0.3 mg/kg/day or 2.5–10 mg/m2/day
divided q 6–12 hr. Physiologic replacement
—0.03–0.15 mg/kg/dayor 0.6–0.75
mg/m2/day divided q 6–12 hr.PO (Adults):
Suppression test—1mg at 11PM or 0.5 mg q
6 hr for 48 hr.
Action: In pharmacologic doses, all agents
suppress inflammationand the normal
immune response. All agentshave numerous
intense metabolic effects .
Suppress adrenal function at chronic doses
of dexamethasone—0.75 mg/day.
Drug-Drug & Drug-Food
Interactions:Drug-Drug:risk of
hypokalemia with thiazide and loop diuretics,
amphotericin B, piperacillin, orticarcillin.
Hypokalemia may risk of digoxin toxicity.
May requirement for insulin or oral
hypoglycemic agents. May levels
ofphenytoin and isoniazid. Levels may be 
with oral contraceptives. risk of adverse GI
effects with NSAIDs(including
aspirin),alcohol land caffeine. At chronic
doses that suppress adrenal function, may 
the antibody response to and risk of
adverse reactions fromlive-virus vaccines.
May or the effects ofwarfarin. Levels may
bepwhen used with phenytoin,
phenobarbital, or rifampin. May risk of
tendon rupture when used with
fluoroquinolones.
Indications: Used systemically and locally
in a wide variety of chronic diseases
including: Inflammatory, Allergic,
Hematologic, Neoplastic, Autoimmune
disorders. Management of cerebral edema:
Diagnostic agent in adrenal disorders.
Treatment of airway edemaprior to
extubation.Facilitation of ventilator weaning
in neonates with
bronchopulmonarydysplasia.
Contraindications: Active untreated
infections(may be used in patients being
treated for someforms of meningitis);
Lactation: Avoid chronic use;Known alcohol,
bisulfite, or tartrazinehypersensitivityor
intolerance (some products contain these
andshould be avoided in susceptible
patients); Administrationof live virus
vaccines.
Side effects: CNS: depression, euphoria,
headache, ↑ intracranial pressure (children
only), personality changes,psychoses,
restlessness. EENT: cataracts, ↑ intraocular
pressure. GI: peptic ulceration,
anorexia, nausea, vomiting. Hemat:
thromboembolism, thrombophlebitis.
Derm: acne, ↓ wound healing, ecchymoses,
fragility, hirsutism, petechiae.
Adverse effects: CV: hypertension. Endo:
adrenal suppression, hyperglycemia.
F and E: fluid retention (long-term high
doses), hypokalemia, hypokalemic
alkalosis.Metab: weight gain. MS: muscle
wasting, osteoporosis,avascular necrosis of
joints, muscle pain. Misc: cushingoid
appearance (moon face, buffalo hump),
↑susceptibility to infection.
Responsibilities in the Nursing Process
Assessment:
● Monitor intake and output ratios and daily
weights. Observe patient for peripheral
edema, steady weight gain, rales/crackles,
or dyspnea. Notify health care professional if
these occur.
● Lab Test Considerations: Monitor serum
electrolytes and glucose. May cause
hyperglycemia, especially in persons with
Page | 95
diabetes.May cause hypokalemia. Patients
on prolonged therapy should routinely have
CBC, serum electrolytes, and serum and
urine glucose evaluated. May ↓ WBCs. May
↓ serum potassium and calcium
and ↓ serum sodium concentrations.
Potential Nursing Diagnoses
Risk for infection (Side Effects)
Disturbed body image (Side Effects)
Patient/Family Teaching
● Instruct patient on correct technique of
medication administration.Advise patient to
take medication as directed. Take missed
doses as soon as remembered unless
almost time for next dose. Do not double
doses.
Evaluation/Desired Outcomes
● Suppression of the inflammatory and
immune responses in autoimmune
disorders, allergic reactions, and neoplasms.
● Decrease in intracranial pressure.
●Management of symptoms in adrenal
insufficiency.
Drug Classification:
MOISTURIZERS
Generic name: Topical emollients
Brand Name: Cetaphil
Moisturizing Cream
Recommended Dosage, Route, And
Frequency:Use exactly as directed on the
label, or as prescribed by your doctor. Do
not use in larger or smaller amounts or for
longer than recommended.
Clean the skin where you will apply the
topical emollient. It may help to apply this
product when your skin is wet or damp.
Follow directions on the product label.
Shake the product container if
recommended on the label.
Apply a small amount of topical emollient to
the affected area and rub in gently.
If you are using a stick, pad, or soap form of
topical emollient, follow directions for use on
the product label.
Action:Emollients/moisturizers work by
forming an oily layer on the top of the skin
that traps water in the skin.
Petrolatum, lanolin, mineral
oil and dimethicone are common emollients.
Humectants, including glycerin, lecithin, and
propylene glycol, draw water into the outer
layer of skin. Many products also have
ingredients that soften the horny substance
(keratin) that holds the top layer of skin cells
together (including urea, alpha hydroxy
acids such as lactic/citric/glycolic acid,
and allantoin). This helps the dead skin cells
fall off, helps the skin keep in more water,
and leaves the skin feeling smoother and
softer.
Drug-Drug & Drug-Food Interactions:
Avoid getting topical emollients in your eyes,
nose, or mouth. If this does happen, rinse
with water.
Avoid exposure to sunlight or tanning beds.
Some topical emollients can make your skin
more sensitive to sunlight or UV rays.
It is not likely that other drugs you take orally
or inject will have an effect on topically
applied emollients. But many drugs can
interact with each other. Tell each of your
health care providers about all medicines
you use, including prescription and over-the-
counter medicines, vitamins, and herbal
products.
Indications:This medication is used as a
moisturizer to treat or prevent dry, rough,
scaly, itchy skin and minor skin irritations
(e.g., diaper rash, skin burns from radiatio
therapy). Emollients are substances that
soften and moisturize the skin and
decrease itching and flaking. Some products
(e.g., zinc oxide, white petrolatum) are used
mostly to protect the skin against irritation
(e.g., from wetness).
Contraindications: Known hypersensitivity
to any ingredient, particularly preservatives
in creams is a contraindication for its
use. Emollients should never be dissolved in
boiling water, which could result in scalds.
Burning, stinging, redness, irritation may
occur.
Side effects:burning, stinging, redness, or
irritation where the product was applied.
Adverse effects: hives; difficult breathing;
swelling of your face, lips, tongue, or throat.
Responsibilities in the Nursing Process
Before using this product, tell your
doctor or pharmacist if you are allergic to
any of the ingredients in the product; or if
you have any other allergies. This product
may contain inactive ingredients, which can
cause allergic reactions or other problems.
Talk to your pharmacist for more details.
If you have any of the following health
problems, consult your doctor or pharmacist
before using this
product: skin cuts/infections/sores. Some
products may worsen acne. If your skin is
prone to acne breakouts, look for the word
"non-comedogenic" (will not clog pores) on
Page | 96
the label. Some products may stain/discolor
clothing. Ask your doctor or pharmacist for
more details.
It is not known whether this drug passes
into breast milk. Consult your doctor before
breast-feeding, especially if you are applying
this product to the breast area.
Drug classification:TOPICAL
GLUCOCORTICOIDS
Generic name:Clobetasol
propionate
Brand Name: Dermovate
Recommended Dosage, Route, And
Frequency:
Topical (Adults and Children): Apply to
affected area(s) 1– 3 times daily (depends
on preparation and condition being treated).
Action:Suppresses normal immune
response and inflammation. Therapeutic
Effects:Suppression of dermatologic
inflammation and immune processes.
Absorption:Minimal. Prolonged use on
large surface areas or large amounts
applied or use of occlusive dressings may
increase systemic absorption.
Distribution: Remains primarily at site of
action.
Metabolism and Excretion:Usually
metabolized in skin; may be modified to
resist local metabolism and have a
prolonged local effect.
Half-life:Unknown.
Route:Topical
Onset:min–hrs
Peak:hrs–days
Duration:hrs–days
Drug-Drug & Drug-Food
Interactions:Drug-Drug:None significant.
Indications:Management of inflammation
and pruritis associated with various
allergic/immunologic skin problems.
Contraindications:Hypersensitivity or
known intolerance to corticosteroid or
components of vehicles (ointment or cream
base, preservative, alcohol); Untreated
bacterial or viral infections.
Adverse effects:Derm:allergic contact
dermatitis, atrophy, burning, dryness,
edema, folliculitis, hypersensitivity reactions,
hypertrichosis, hypopigmentation, irritation,
maceration,
miliaria, perioral dermatitis, secondary
infection, striae.Misc:adrenal suppression
(use of occlusive dressings, long-term
therapy).
Responsibilities in the Nursing Process
Assessment
● Assess affected skin before and daily
during therapy. Note degree of inflammation
and pruritus. Notify health care professional
if symptoms of infection (increased
pain, erythema, purulent exudate) develop.
● Lab Test Considerations: Periodic
adrenal function tests may be ordered to
assess degree of hypothalamic-pituitary-
adrenal (HPA) axis suppression in
chronic topical therapy if suspected.
Children and patients with dose applied to a
large area, using an occlusive dressing, or
using high-potency products are at
highest risk for HPA suppression.
● May cause increased serum and urine
glucose concentrations if significant
absorption occurs.
Potential Nursing Diagnoses
Risk for impaired skin integrity (Indications)
Risk for infection (Side Effects)
Deficient knowledge, related to medication
regimen (Patient/Family Teaching)
Implementation
● Choice of vehicle depends on site and
type of lesion. Ointments are more occlusive
and preferred for dry, scaly lesions. Creams
should be used on oozing or intertriginous
areas, where the occlusive action of
ointments might cause folliculitis or
maceration. Creams may be preferred for
aesthetic reasons even though they may
be more drying to skin than ointments.
Solution, spray, and shampoo are useful in
hairy areas.
● Topical: Apply ointment,creams,gel,
orlotion sparingly as a thin film to clean
skin. Wash hands immediately after
application. Apply occlusive dressing only if
specified by health care professional.
● Applysolution and shampoo to hair by
parting hair and applying a small amount
to affected area. Rub in gently. With
solution, protect area from washing,
clothing, or rubbing until medication has
dried.
Patient/Family Teaching
● Instruct patient on correct technique of
medication administration. Emphasize
importance of avoiding the eyes. If a dose is
missed, it should be applied as soon as
remembered unless almost time for the next
dose.
● Caution patient to use only as directed.
Avoid using cosmetics, bandages,
dressings, or other skin products over the
treated area unless directed by health care
professional.
● Advise parents of pediatric patients not to
apply tight-fitting diapers or plastic
pants on a child treated in the diaper area;
these garments work like an occlusive
dressing and may cause more of the drug to
be absorbed.
Page | 97
● Caution women that medication should not
be used extensively, in large amounts,
or for protracted periods if they are pregnant
or planning to become pregnant.
Evaluation/Desired Outcomes
● Resolution of skin inflammation, pruritus,
or other dermatologic conditions.
Drug classification: TOPICAL
IMMUNOSUPPRESSANTS
Generic name:
Brand Name:
Recommended Dosage, Route, And
Frequency:
Topical (Adults and Children
2 yr): Apply thin film twice daily; rub in
gently and completely.
Action:Inhibits T-cell and mast cell
activation by interfering with production of
inflammatory cytokines. Therapeutic
Effects: Decreased severity of atopic
dermatatis.
Absorption:Minimally absorbed through
intact skin.
Distribution: Local distribution after topical
administration.
Metabolism and Excretion: Systemic
metabolism and excretion is negligible with
local application.
Half-life:Not applicable.
Route:topical
Onset:within 6 days
Peak:unknown unknown
Duration:unknown unknown
Drug-Drug & Drug-Food Interactions:
Drug-Drug: None significant as systemic
absorption is negligible.
Indications:
Short-term and intermittent long-term
management of mild to moderate atopic
dermatitis unresponsive to or in patients
intolerant of conventional treatment.
Contraindications:
Hypersensitivity; Should not be applied to
areas of active cutaneous viral infections
(↑ risk of dissemination); Concurrent use of
occlusive dressings; Netherton’s syndrome
(↑ absorption of pimecrolimus); Lactation:
Discontinue breast feeding.
Use Cautiously in: Possible risk of cancer.
Do not use as first-line therapy; Clinical
infection at treatment site (infection should
be treated/cleared prior to use); Skin
papillomas (warts); allow
treatment/resolution prior to use;
Natural/artificial sunlight (minimize
exposure); OB: Use only if clearly needed;
Pedi: Children 2 yr (safety not established);
use only if other treatments have failed.
Adverse effects:
Local: burning. Misc: ↑ risk of
lymphoma/skin cancer.
Responsibilities in the Nursing Process
Assessment
● Assess skin lesions prior to and
periodically during therapy. Discontinue
therapy after signs and symptoms of atopic
dermatitis have resolved. Resume treatment
at the first signs and symptoms of
recurrence.
Potential Nursing Diagnoses
Impaired skin integrity (Indications)
Implementation
● Topical: Apply a thin layer to affected area
twice daily and rub in gently and completely.
May be used on all skin areas including
head, neck, and intertriginous areas. Do not
use with occlusive dressings.
Patient/Family Teaching
● Instruct patient on correct technique for
application. Apply only as directed to
external areas. Wash hands following
application, unless hands are areas of
application. Advise patient to read
Medication Guide before starting and with
each Rx refill in case of changes.
● Caution patient to avoid exposure to
natural or artificial sunlight, including tanning
beds, while using cream.
● Advise patient that pimecrolimus may
cause skin burning. This occurs most
commonly during first few days of
application, is of mild to moderate severity,
and improves within 5 days or as atopic
dermatitis resolves.
● Advise patient to notify health care
provider if no improvement is seen following
6 wk of treatment or at any time if condition
worsens.
Evaluation/Desired Outcomes
● Resolution of signs and symptoms of
atopic dermatitis.
Drug classification: DRUGS FOR
IMPETIGO
Generic name: Mupirocin
Brand Name: Bactroban
Recommended Dosage, Route, And
Frequency:
Topical (Adults and Children
Page | 98
≥ 2 mo): Ointment: Apply 3– 5 times daily
for 5– 14 days.
Topical (Adults and Children ≥3 mo):
Cream: Apply small amount 3 times/day for
10 days.
Intranasal (Adults and Children ≥ 1 yr):
Apply small amount nasal ointment to each
nostril 2– 4 times/day for 5– 14 days.
Action:Inhibits bacterial protein synthesis.
Therapeutic Effects: Inhibition of bacterial
growth and reproduction. Spectrum:
Greatest activity against gram-positive
organisms, including: S. aureus, Beta-
hemolytic streptococci. Resolution of
impetigo.Eradication ofS.aureuscarrier state.
Absorption:Minimal systemic absorption.
Distribution: Remains in the stratum
corneum after topical use for prolonged
periods of time (72 hr).
Metabolism and Excretion: Metabolized in
the skin, removed by desquamation.
Half-life: 17– 36 min
Route:Nasal; Topical
Onset:unknown
Peak:unknown; 3–5 days
Duration:12 hr; 72 hr
Drug-Drug & Drug-Food
Interactions:Drug-Drug: Nasal mupirocin
should not be used concurrently with other
nasal products.
Indications:Topical: Treatment of:
Impetigo, secondarily infected traumatic skin
lesions (up to 10 cm in length or 100 cm2
area) caused byStaphylococcus aureusand
Streptococcus pyogenes. Intranasal
Eradicates nasal colonization with
methicillin-resistantS. aureus.
Contraindications:Contraindicated in:
Hypersensitivity to mupirocin or polyethylene
glycol.
Side effects:CNS: nasal only— headache.
EENT: nasal only— cough, itching,
pharyngitis, rhinitis, upper respiratory tract
congestion. GI: nausea nasal only, altered
taste. Derm: topical only— burning, itching,
pain, stinging.
Responsibilities in the Nursing Process
Assessment
● Assess lesions before and daily during
therapy.
Potential Nursing Diagnoses
Impaired skin integrity (Indications)
Risk for infection (Indications)
(Patient/Family Teaching)
Implementation
● Topical: Wash affected area with soap and
water and dry thoroughly. Apply a small
amount of mupirocin to the affected area 3
times daily and rub in gently. Treated area
may be covered with gauze if desired.
● Nasal: Apply one half of the ointment from
the single-use tube to each nostril twice
daily (morning and evening) for 5 days. After
application, close nostrils by pressing
together and releasing sides of the nose
repeatedly for 1 min.
Patient/Family Teaching
● Instruct patient on the correct application
of mupirocin. Advise patient to apply
medication exactly as directed for the full
course of therapy. If a dose is missed, apply
as soon as possible unless almost time for
next dose. Avoid contact with eyes.
● Topical: Teach patient and family
appropriate hygienic measures to prevent
spread of impetigo.
● Instruct parents to notify school nurse for
screening and prevention of transmission.
● Patient should consult health care
professional if symptoms have not improved
in 3– 5 days.
Evaluation/Desired Outcomes
● Healing of skin lesions. If no clinical
response is seen in 3– 5 days, condition
should be re-evaluated.
● Eradication of methicillin-resistant S.
aureus carrier state in patients and health
care workers during institutional outbreaks.
Drug classification: DRUGS FOR
HAIR LOSS & BALDNESS
Generic name: Finasteride
Brand Name:
Recommended Dosage, Route, And
Frequency:PO (Adults): BPH—5 mg once
daily (Proscar); Androgenetic alopecia—1
mg once daily (Propecia).
Action:Inhibits the enzyme 5-alpha-
reductase, which is responsible for
converting testosterone to its potent
metabolite 5-alpha-dihydrotestosterone in
prostate, liver, and skin; 5-alpha-
dihydrotestosterone is partially responsible
for prostatic hyperplasia and hair loss.
Therapeutic Effects: Reduced prostate
size with associated decrease in urinary
symptoms. Decreases hair loss; promotes
hair regrowth.
Absorption:Well absorbed after oral
administration (63%).
Distribution: Enters prostatic tissue and
crosses the blood-brain barrier. Remainder
of distribution not known.
Metabolism and Excretion: Mostly
metabolized; 39% excreted in urine as
metabolites; 57% excreted in feces.
Half-life:6 hr (range 6– 15 hr; slightly ↑ in
patients 70 yr).
Route:PO
Onset:rapid
Page | 99
Peak:8 hr ● Caution patient that finasteride poses a
Duration: 2 wk potential risk to a male fetus. Women who
are pregnant or may become pregnant
Drug-Drug & Drug-Food should avoid exposure to semen of a partner
Interactions:Drug-Drug: None noted taking finasteride and should not handle
crushed finasteride because of the potential
Indications:Benign prostatic hyperplasia for absorption.
(BPH); can be used with doxazosin. ● Emphasize the importance of periodic
Androgenetic alopecia (male pattern follow-up exams to determine whether a
baldness) in men only. clinical response has occurred.

Contraindications:Contraindicated in: Evaluation/Desired Outcomes

Hypersensitivity; Women. ● Decrease in urinary symptoms of benign
prostatic hyperplasia.
Adverse effects: Endo: gynecomastia. ● Hair regrowth in androgenetic alopecia.
GU: prostate cancer (high-grade), ↓ libido, Evidence of hair growth usually requires 3
↓ volume of ejaculate, erectile dysfunction, mo or longer. Continued use is
infertility.Misc: BREAST CANCER. recommended to sustain benefit. Withdrawal
leads to reversal of effect within 12 mo.
Responsibilities in the Nursing Process

Assessment Drug classification:

● Assess for symptoms of prostatic
hyperplasia (urinary hesitancy, feeling of AMINOBENZOIC ACID
incomplete bladder emptying, interruption of DERIVATIVES
urinary stream, impairment of size and force Generic name:
of urinary stream, terminal urinary dribbling, Para-aminobenzoic acid
straining to start flow, dysuria, urgency) Brand Name:
before and periodically during therapy.
Recommended Dosage, Route, And
● Digital rectal examinations should be
Frequency:
performed before and periodically during
ADULTS
therapy for BPH.
BY MOUTH:
● Lab Test Considerations: Serum
For Peyronie's disease: A specific PABA
prostate-specific antigen (PSA)
concentrations, which are used to screen for product (POTABA, Glenwood LLC.) 12
prostate cancer, may be evaluated before grams daily in four divided doses with meals
and periodically during therapy. Finasteride for 8-24 months has been used.
may cause a ↓ in serum PSA levels.
APPLIED TO THE SKIN:
Potential Nursing Diagnoses For sunburn: Sunscreens with 1% to 15%
Impaired urinary elimination (Indications) PABA have been used.

Implementation
CHILDREN
● Do not confuse Proscar with Provera.
● PO: Administer once daily with or without APPLIED TO THE SKIN:
meals. For sunburn: Sunscreens with 1% to 15%
PABA have been used.
Patient/Family Teaching
● Instruct patient to take finasteride as Action: It will block ultraviolet
directed, even if symptoms improve or are (UV) radiation to the skin.
unchanged. At least 6– 12 mo of therapy
may be necessary to determine whether or
not an individual will respond to finasteride. Drug-Drug & Drug-Food Interactions:
Advise patient to read the Patient Package Antibiotics (Sulfonamide antibiotics)
Insert prior to starting therapy and with each interacts with PARA-AMINOBENZOIC
Rx refill in case of changes. ACID (PABA)
● Inform patient that the volume of ejaculate Para-aminobenzoic acid (PABA) can
may be decreased and erectile dysfunction decrease the effectiveness of certain
and decreased libido may occur during
therapy and after therapy is completed. antibiotics called
Advise patient to notify health care sulfonamides.<br/><br/>Some of these
professional promptly if changes in breasts antibiotics include sulfamethoxazole
(lumps, pain, nipple discharge) occur. (Gantanol), sulfasalazine (Azulfidine),
● Inform patient that there is an increased sulfisoxazole (Gantrisin), and
risk of high grade prostate cancer in men trimethoprim/sulfamethoxazole (Bactrim,
taking this drug.
Septra).

Page | 100
Dapsone (Avlosulfon) interacts with
PARA-AMINOBENZOIC ACID (PABA)
Dapsone (Avlosulfon) is used as an
antibiotic. Para-aminobenzoic acid (PABA)
might decrease the effectiveness of
dapsone (Avlosulfon) for treating infections.
Cortisone (Cortisone Acetate) interacts
with PARA-AMINOBENZOIC ACID (PABA)
The body breaks down cortisone to get rid of
it. Para-aminobenzoic acid (PABA) might
decrease how quickly the body breaks down
cortisone. Taking PABA by mouth and
getting a cortisone shot might increase the
effects and side effects of cortisone.
Indications: Sunburn. PABA is approved by
the U.S. Food and Drug Administration
(FDA) for use as a sunscreen. PABA seems
to be effective during sweating, but not when
skin is submerged in water - during
swimming, for example.Peyronie's disease.  the lip balm form, apply to the lip area only.
Contraindications: hypersensitivity. Kidney
disease: PABA might build up in the kidneys
making kidney disease worse. Do not use it
if you have kidney problems.
Adverse effects: None significant.
Responsibilities in the Nursing Process
Patient/Family Teaching
PABA is possibly safe when taken by mouth
appropriately and when applied to the eyes
as a solution. PABA can cause skin irritation
and might also stain clothing with a yellow
color. Nausea, vomiting, upset stomach,
diarrhea, and loss of appetite might
sometimes occur. 
PABA is possibly unsafe when taken by
mouth in high doses. Taking more than 12
grams per day can cause serious side
effects such as liver, kidney, and blood
problems.
When applied directly to the skin, PABA
is likely safe for children. PABA is possibly
safe for children to take by mouth
appropriately. Dose is important, as serious
side effects can occur. PABA is possibly
unsafe when taken by mouth in high doses.
Some children who took doses of PABA
greater than 220 mg/kg/day died.
Pregnancy and breast-feeding: PABA
is likely safe when applied to the skin during
pregnancy or breast-feeding. However,
there is not enough reliable information
about the safety of taking PABA by mouth if
you are pregnant or breast-feeding. Stay on
the safe side and avoid use.
Consult Health Care Provider if problem
occur.
Drug classification:CINNAMATES
Generic name:Cinoxate
Brand Name:
Recommended Dosage, Route, And
Frequency:Apply sunscreen generously to
all exposed skin30 minutes before sun
exposure. As a general guide, use 1 ounce
(30 grams) to cover your entire body.
Reapply
the sunscreenafter swimming or sweating or
drying off with a towel or if it has rubbed off.
If you are outside for long periods, reapply
sunscreen every 2 hours. If you are using
Action: The active ingredients in
sunscreens work either by absorbing the
sun's ultraviolet (UV)radiation, preventing it
from reaching the deeper layers of the skin,
or by reflecting the radiation.
Drug-Drug & Drug-Food Interactions:
Unknown significant.
Indications: It help to prevent sunburn and
premature aging (such as wrinkles,
leathery skin). Sunscreens also help to
decrease the risk of skin cancer and also of
sunburn-like skin reactions (sun sensitivity)
caused by some medications (including
tetracyclines, sulfa drugs, phenothiazines
such as chlorpromazine).
Contraindications: hypersensitivity
Side effects: Derm: Irritation. Rash, itching.
CNS:dizziness
Adverse effects: CV: swelling inface,
tongue, throat, dyspnea.
Responsibilities in the Nursing Process
Patient/Family Teaching
-The spray form is flammable. If using the
spray, avoid smoking when applying
thismedication and do not use or store it
near heat or open flame.
-When applying sunscreen to the face, be
careful to avoid contact with the eyes. If the
sunscreen gets in your eyes, rinse
thoroughly with water.
Page | 101
Use cautiously or avoid use on irritated skin.
-Do not use sunscreen on infants younger
than 6 months unless the doctor directs you
to do so. It is best for infants to stay out of
the sun and wear protective clothing (e.g.,
hats, long sleeves/pants) when outdoors.
If you develop a serious sunburn, or if you
think you may have a serious medical
problem, seek immediate medical attention.
Before using a sunscreen, tell your doctor
or pharmacist if you are allergic to any of its
ingredients (e.g., aminobenzoic acid/PABA);
or to some types of anesthetic drugs
(e.g.,benzocaine, tetracaine); or to sulfa
drugs; or if you have any other allergies.
This product may contain inactive
ingredients, which can cause allergic
reactions or other problems. Talk to your
pharmacist for more details.
Drug classification:SALICYLATES
Generic name: Homosalate
Brand Name:
Recommended Dosage, Route, And
Frequency: Apply generously & evenly
before sun exposure. Reapply as
needed or after towel drying, swimming or
sweating.
Ask doctor before using on children under 6
months.
Action: The active ingredients in
sunscreens work either by absorbing the
sun's ultraviolet (UV) radiation, preventing it
from reaching the deeper layers of the skin,
or by reflecting the radiation.
Drug-Drug & Drug-Food Interactions:
If you are using this product under your
doctor's direction, your doctor
or pharmacist may already be aware of
possible drug interactions and may be
monitoring you for them. Do not start, stop,
or change the dosage of any medicine
before checking with your doctor or
pharmacist first.
Indications: Sunscreens are used to protect
the skin from the harmful effects of the sun.
They help to prevent sunburn and premature
aging (such as wrinkles, leathery skin).
Sunscreens also help to decrease the risk
of skin cancer and also of sunburn-
like skin reactions (sun sensitivity) caused
by some medications (including
tetracyclines, sulfa drugs, phenothiazines
such as chlorpromazine).
Contraindications: hypersensitivity
Side effects: Derm: Irritation. Rash, itching.
CNS:dizziness
Adverse effects: CV: swelling inface,
tongue, throat, dyspnea.
Nursing Process
Patient/Family Teaching
-The spray form is flammable. If using the
spray, avoid smoking when applying
thismedication and do not use or store it
near heat or open flame.
-When applying sunscreen to the face, be
careful to avoid contact with the eyes. If the
sunscreen gets in your eyes, rinse
thoroughly with water.
Use cautiously or avoid use on irritated skin.
-Do not use sunscreen on infants younger
than 6 months unless the doctor directs you
to do so. It is best for infants to stay out of
the sun and wear protective clothing (e.g.,
hats, long sleeves/pants) when outdoors.
If you develop a serious sunburn, or if you
think you may have a serious medical
problem, seek immediate medical attention.
Before using a sunscreen, tell your doctor
or pharmacist if you are allergic to any of its
ingredients (e.g., aminobenzoic acid/PABA);
or to some types of anesthetic drugs
(e.g.,benzocaine, tetracaine); or to sulfa
drugs; or if you have any other allergies.
This product may contain inactive
ingredients, which can cause allergic
reactions or other problems. Talk to your
pharmacist for more details.
Drug classification:
BENZOPHENONES
Generic name: Sulisobenzone
Brand Name:
Recommended Dosage, Route, And
Frequency: Sunscreen preparations should
be applied uniformly and generously to all
exposed skin surfaces, including lips, before
exposure to UVB radiation. Two applications
of the sunscreen may be needed for
maximum protection. PABA-containing
sunscreens are most effective when applied
1-2 hours before exposure to sunlight.
Sunscreen products that are not water
Page | 102
resistant should be reapplied after
swimming, towel-drying, or profuse sweating
and, because most sunscreens are easily
removed from the skin, reapplication every
1-2 hours or according to the manufacturer's
directions usually is required to provide
adequate protection from UVB light.
Action: A surface coating of
benzophenones decreases the amount of
UV radiation absorbed by the skin by limiting
the total amount of energy that reaches the
skin . Benzophenone sunscreens, applied
topically, protect the skin from these harmful
effects of ultraviolet light by chemically
absorbing light energy (photons). As this
occurs, the benzophenone molecule
becomes activated to higher energy levels.
As the excited molecule returns to its ground
state, the energy is released in the form of
thermal energy. The hydroxyl group in the
ortho position to the carbonyl group is
believed to be a structural requirement for
the benzophenones' absorption of UV light.
This structural arrangement also contributes
to the electronic stability of the molecule.
Benzophenones absorb energy throughout
the UV range, although the maximum UV
absorbance is between 284 and 287 nm for
the 2-hydroxybenzophenones.
Drug-Drug & Drug-Food Interactions:
None significant.
Indications: Sunscreening agents are used
to prevent sunburn, actinic keratosis, and
premature skin aging and to reduce the
incidence of skin cancer.
Contraindications: none
Side effects: Derm: Irritation. Rash, itching.
CNS:dizziness
Adverse effects: CV: swelling inface,
tongue, throat
Nursing Process
Patient/Family Teaching
Sunscreens should not be used as a means
of extending the duration of solar exposure,
such as prolonging sunbathing, and should
not be used as a substitute for clothing on
usually unexposed sites, such as the trunk
and buttocks.
Infants under 6 months of age should be
kept out of the sun and be physically
protected from direct sun exposure.
Sunscreen agents should not be used on
infants under 6 months of age because of
possible irritation and accidental ingestion. 
If skin irritation or a rash occurs during use
of a sunscreen product, use of the
sunscreen should be discontinued and the
sunscreen washed off. If irritation persists, a
physician should be consulted. Contact of
sunscreen agents with the eyes should be
avoided. If the sunscreen comes in contact
with the eyes, the affected eye(s) should be
flushed thoroughly with water.
Drug classification: HIGHLY
PROTECTIVE
Generic name:
Brand Name: Silvadene
Route/Dosage Topical (Adults and
Children >1 mo): Apply 1% cream
1– 2 times daily in layer 1.5-mm
thick.
Action
Splits to produce bactericidal
concentrations of silver and sulfadiazine.
Action is at level of cell membrane and cell
wall. Therapeutic Effects: Bactericidal action
against organisms found in burns.
Spectrum: Broad spectrum includes activity
against many gram-negative and gram-
positive bacteria, anaerobes, and some
yeast.
Absorption: Small amounts of silver are
systemically absorbed following topical
application. Up to 10% of sulfadiazine is
absorbed.
Distribution: Unknown.
Metabolism and Excretion: Absorbed
sulfadiazine is excreted unchanged by the
kidneys
Half-life: Unknown.
Interactions Drug-Drug: Silver may
inactivate concurrently applied topical
proteolytic enzymes (fibrinolysin,
desoxyribonuclease).
Indications
Prevention and treatment of wound sepsis in
patients with 2nd- and 3rd-degree
burns.Unlabeled Use: Management of:
Minor skin infections, Dermal ulcers.
Contraindicated in: Hypersensitivity (cross-
sensitivity with sulfonamidesmayoccur);
Pedi: Infants< 2 mo ( risk of kernicterus);
OB: Pregnancy near term (qrisk of
kernicterus in infant); G6PD deficiency;
Porphyria.
Side Effects
Page | 103
Derm: EXFOLIATIVE DERMATITIS,
STEVENS-JOHNSON SYNDROME,
TOXIC EPIDERMAL NECROLYSIS,
burning, itching, pain, rash, skin
discoloration, skin necrosis. Hemat:
leukopenia.
NURSINGIMPLICATIONS
Assessment
● Assess burned tissue for infection
(purulent discharge, excessive
moisture, odor, and culture results)
and sepsis (WBC, fever, or shock)
prior to and throughout course of
therapy. ● Monitor for
hypersensitivity reaction (rash,
itching, or burning) at and
surrounding sites of application. ●
Assess patient for skin rash
frequently during therapy.
Discontinue silver sulfadiazine at first
sign of rash; may be life-threatening.
StevensJohnson syndrome or toxic
epidermal necrolysis may develop.
Treat symptomatically; may recur
once treatment is stopped. ● Lab
Test Considerations:Monitor renal
function studies and CBC
periodically when applied to large
area; systemic absorption may
cause nephritis and reversible
leukopenia. Decrease in neutrophil
count is greatest 4 days after
initiation of therapy; levels usually
normalize after 2– 3 days. Potential
Nursing Diagnoses Risk for infection
(Indications) Risk for impaired skin
integrity (Indications) Deficient
knowledge, related to medication
regimen (Patient/Family Teaching)
Implementation ● Generally applied
after cleansing and debriding of burn
wound. Premedicate with analgesic.
● Topical: Cream is white; discard if
it becomes dark.
● Use sterile technique to apply.
Cover entire wound at depth of 1.5
mm. Reapply to sites where cream
rubs off as a result of patient
movement; burn should be coated at
all times. Burn may be dressed or
kept open, depending on
recommendation of health care
professional.
Patient/Family Teaching
● Explain purpose of medication to
patient and family. This medication
will not stain skin. ● Advise patient to
promptly notify health care provider if
rash occurs.
Evaluation/Desired Outcomes
● Prevention and treatment of
infection in 2nd- and 3rd-degree
burns. Therapy is continued until
burn is healed or skin graft is
performed.
Drug classification: AGENTS FOR
BURNS
Generic name:Silver sulfadiazine
Brand Name:
Recommended Dosage, Route, And
Frequency:Topical (Adults and Children
>1 mo): Apply 1% cream 1– 2 times daily in
layer 1.5-mm thick.
Action:Splits to produce bactericidal
concentrations of silver and sulfadiazine.
Action is at level of cell membrane and cell
wall. Therapeutic Effects: Bactericidal
action against organisms found in burns.
Spectrum: Broad spectrum includes activity
against many gram-negative and gram-
positive bacteria, anaerobes, and some
yeast.
Absorption:Small amounts of silver are
systemically absorbed following topical
application. Up to 10% of sulfadiazine is
absorbed.
Distribution: Unknown.
Metabolism and Excretion: Absorbed
sulfadiazine is excreted unchanged by
the kidneys.
Half-life:Unknown
Route:Topical
Onset:on contact
Peak:unknown
Duration:as long as applied
Drug-Drug & Drug-Food
Interactions:Drug-Drug: Silver may
inactivate concurrently applied topical
proteolytic enzymes (fibrinolysin,
desoxyribonuclease).
Indications:Prevention and treatment of
wound sepsis in patients with 2nd- and 3rd-
degree burns.Unlabeled Use:Management
of: Minor skin infections, Dermal ulcers.
Contraindications:Hypersensitivity (cross-
sensitivity with sulphonamides
mayoccur);Pedi: Infants <2 mo (↑ risk of
kernicterus);OB: Pregnancy near term (↑ risk
of kernicterus in infant); G6PD deficiency;
Porphyria.
Side effects:Derm: exfoliative dermatitis,
stevens-johnson syndrome, toxic epidermal
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necrolysis, burning, itching, pain, rash, skin
discoloration, skin necrosis.
Adverse effects:Hemat:
leukopenia
Responsibilities in the Nursing Process
Assessment
● Assess burned tissue for infection
(purulent discharge, excessive moisture,
odor, and culture results) and sepsis (WBC,
fever, or shock) prior to and throughout
course of therapy.
● Monitor for hypersensitivity reaction (rash,
itching, or burning) at and surrounding sites
of application.
● Assess patient for skin rash frequently
during therapy. Discontinue silver
sulfadiazine at first sign of rash; may be life-
threatening. StevensJohnson syndrome or
toxic epidermal necrolysis may develop.
Treat symptomatically; may recur once
treatment is stopped.
● Lab Test Considerations:Monitor renal
function studies and CBC periodically
when applied to large area; systemic
absorption may cause nephritis and
reversible leukopenia. Decrease in
neutrophil count is greatest 4 days after
initiation of therapy; levels usually normalize
after 2– 3 days.
Potential Nursing Diagnoses
Risk for infection (Indications)
Risk for impaired skin integrity (Indications)
Deficient knowledge, related to medication
regimen (Patient/Family Teaching)
Implementation
● Generally applied after cleansing and
debriding of burn wound. Premedicate with
analgesic.
● Topical:Cream is white; discard if it
becomes dark.
● Use sterile technique to apply. Cover
entire wound at depth of 1.5 mm. Reapply to
sites where cream rubs off as a result of
patient movement; burn should be coated
at all times. Burn may be dressed or kept
open, depending on recommendation of
health care professional.
Patient/Family Teaching
● Explain purpose of medication to patient
and family. This medication will not stain
skin.
● Advise patient to promptly notify health
care provider if rash occurs.
Evaluation/Desired Outcomes
● Prevention and treatment of infection in
2nd- and 3rd-degree burns. Therapy is
continued until burn is healed or skin graft is
performed.
Drug classification: DRUGS FOR
SEBORRHEIC DERMATITIS AND
DANDRUFF
Generic name: Ketoconazole
Brand Name:
Recommended Dosage, Route, And
Frequency: Topical (Adults and Children
≥12 yr): Apply cream once daily for
cutaneous candidiasis, tinea corporis, tinea
cruris, tinea pedia, and tinea versicolor.
Apply cream twice daily for seborrheic
dermatitis. Patients with cutaneous
candidiasis, tinea cruris, tinea corporis, and
tinea versicolor should be treated for 2 wk.
Patients with tinea pedis should be treated
for 6 wk. Patients with seborrheic dermatitis
should be treated for 4 wk (2 wk with gel).
For dandruff, use shampoo twice weekly
(wait 3– 4 days between treatments) for 4
wk, then intermittently.
Action:Affects the synthesis of the fungal
cell wall.Therapeutic Effects:Decreased
symptoms of fungal infection.
Absorption:Minimal absorption through
intact skin.
Distribution: If absorption occurs, widely
distributed; crosses the placenta; enters
breast milk. Action after topical
administration is primarily local.
Metabolism and Excretion: If absorbed,
partially metabolized by the liver then
excreted in feces via biliary excretion.
Half-life:If absorbed, 8 hr.
Route:Topical
Onset:unknown
Peak:unknown
Duration:unknown
Drug-Drug & Drug-Food
Interactions:Drug-Drug: None significant
since absorption is minimal with topical
therapy.
Indications:Treatment of a variety of
cutaneous fungal infections, including
cutaneous candidiasis, tinea pedis (athlete’s
foot), tinea cruris (jock itch), tinea corporis
(ringworm), dandruff (as a shampoo),
seborrheic dermatitis, and tinea versicolor.
Contraindications:Hypersensitivity to active
ingredients, additives, preservatives, or
bases; Some products contain sulfites and
should be avoided in patients with
known intolerance.
Side effects:Local: burning, itching, local
hypersensitivity reactions, redness,
stinging.Derm: ↑ hair loss (shampoo).
Responsibilities in the Nursing Process
Assessment
● Inspect involved areas of skin and mucous
Page | 105
membranes before and frequently during
therapy. Increased skin irritation may
indicate need to discontinue medication.
Potential Nursing Diagnoses
Risk for impaired skin integrity (Indications)
Risk for infection (Indications)
Deficient knowledge, related to medication
regimen (Patient/Family Teaching)
Implementation
● Consult health care professional for proper
cleansing technique before applying
medication.
● Topical: Apply small amount to cover
affected area completely. Avoid the use of
occlusive wrappings or dressings unless
directed by health care professional.
● Ketoconazole shampoo:Moisten hair
and scalp thoroughly with water. Apply
sufficient shampoo to produce enough lather
to wash scalp and hair and gently
massage it over the entire scalp area for
approximately 1 min. Rinse hair thoroughly
with warm water. Repeat process, leaving
shampoo on hair for an additional 3
min.After the second shampoo, rinse and
dry hair with towel or warm air
flow. Shampoo twice a week for 4 wk with at
least 3 days between each shampooing and
then intermittently as needed to maintain
control.
● Foam:Hold container upright and
dispense foam into cap of can or other
smooth surface; dispensing directly on to
hand is not recommended as the foam
begins to melt immediately on contact with
warm skin. Pick up small amounts with
fingertips and gently massage into affected
areas until absorbed. Move hair to allow
direct application to skin.
Patient/Family Teaching
● Instruct patient to apply medication as
directed for full course of therapy, even if
feeling better. Emphasize the importance of
avoiding the eyes.
● Patients with athlete’s foot should be
taught to wear well-fitting, ventilated shoes
and to change shoes and socks at least
once a day.
● Advise patient to report increased skin
irritation or lack of response to therapy to
health care professional.
Evaluation/Desired Outcomes
● Decrease in skin irritation and resolution of
infection. Early relief of symptoms
may be seen in 2– 3 days. ForCandida,
tinea cruris, and tinea corporis, 2 wk are
needed, and for tinea pedis, therapeutic
response may take 4– 6 wk. Use for
seborrheic for 4 wk (2 wk with gel).
Recurrent fungal infections may be a sign of
systemic illness.
Drug classification: GROWTH
HORMONE
Generic name: Somatropin
Brand Name:
Recommended Dosage, Route, And
Frequency:Subcut, IM (Adults): Initially
0.005 mg/kg/day, may be increased to 0.01
mg/kg/day after 4 wk.
Subcut, IM (Children):0.06 mg (0.18
unit/kg) 3 times weekly.
Action:Produce growth (skeletal and
cellular). Metabolic actions include:
Increased protein synthesis, Increased
carbohydrate metabolism, Lipid mobilization,
Retention of sodium, phosphorus, and
potassium. Somatropin has the same amino
acid sequence as naturally occurring growth
hormone and is produced by recombinant
DNA techniques. Growth hormone
enhances GI tract mucosal transport of
water, electrolytes and nutrients
Absorption:Well absorbed.
Distribution: Localize to highly perfused
organs (liver, kidneys).
Metabolism and Excretion: Broken down
in renal cells to amino acids that are
recirculated; some liver metabolism.
Half-life:Subcut—3.8 hr;IM—4.9 hr
Route:IM, subcut
Onset:within 3 mo
Peak:unknown
Duration:12–48 hr
Drug-Drug & Drug-Food
Interactions:Drug-
Drug:Excessivecorticosteroiduse (equivalent
to 10– 15 mg/m2
/day) may ↓ response to growth hormone.
Indications:Growth failure in children due to
inadequate secretion of growth hormone.
Growthhormone deficiency in adults as a
result of pituitary disease, hypothalamic
disease, surgery, radiation or trauma.
Contraindications: Closure of epiphyses;
Active neoplasia; Hypersensitivity to
growth hormone or benzyl alcohol
preservative; Acute critical illness (therapy
shouldnot be initiated) or respiratory failure;
Diabetic retinopathy; Prader-Willi syndrome
with obesity and respiratory impairment (risk
of fatal complications; can be used
only if growth hormone deficiency is
documented).
Adverse effects:CV: edema of the hands
and feet. Derm: exacerbation of pre-existing
psoriasis. Endo: hyperglycemia,
hypothyroidism, insulin resistance. Local:
pain at injection site, local lipoatrophy or
lipodystrophy with subcutaneous use.
MS:arthralgia, musculoskeletal pain,
swelling, stiffness.
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Responsibilities in the Nursing Process Drug classification:
GROWTH HORMONE
Assessment
● Growth Failure: Monitor bone age annually SUPPRESSANT DRUGS
and growth rate determinations, Generic name:Ocreotide acetate
height, and weight every 3– 6 mo during Brand Name:
therapy.
● Lab Test Considerations:Monitor thyroid
function prior to and during therapy. May Recommended Dosage, Route, And
decrease T4, radioactive iodine uptake, and Frequency:
thyroxine-binding capacity. Carcinoid Tumors
Hypothyroidism necessitates concurrent Subcut, IV (Adults):Sandostatin—100– 600
thyroid replacement for growth hormone to mcg/day in 2– 4 divided doses during first 2
be effective. Serum inorganic phosphorus, wk of therapy (range 50– 1500mcg/day).
alkaline phosphatase, and IM (Adults):Sandostatin LAR—20 mg q 4
parathyroid hormone may ↑ with somatropin wk for 2 mo; dose may be further adjusted.
therapy. bcut, IV (Adults):Sandostatin—200– 300
● Monitor blood glucose periodically during mcg/day in 2– 4 divided doses during first 2
therapy. Diabetic patients may require wk of therapy (range 150– 750 mcg/day).
↑ insulin dose. IM (Adults):Sandostatin LAR—20 mg q 2
● Monitor for development of neutralizing wk for 2 mo; dose may be further adjusted.
antibodies if growth rate does not exceed Suppression of Growth Hormone
2.5 cm/6 mo. (Acromegaly)
● Monitor alkaline phosphatase closely in Subcut, IV (Adults):Sandostatin—50– 100
patients with adult growth hormone mcg 3 times daily; titrate to achieve
deficiency. growth hormone levels <5 ng/mL or IGF-I
levels < 1.9 units/mL (males) or <2.2
Potential Nursing Diagnoses units/mL(females) (usual effective
Disturbed body image (Indications) dose=100– 200 mcg 3 times daily.
IM (Adults):Sandostatin LAR—20 mg q 4
Implementation wk for 3 mo, then adjusted on the basis
● Rotate injection sites with each injection. of growth hormone levels.
● Saizen:Reconstitute each 5-mg vial with Antidiarrheal
1– 3 mL of bacteriostatic water for injection; Subcut, IV (Adults):AIDS-related—100–
use 2– 3 mL for 8.8 mg vial. Aim the liquid 1800 mcg/day (unlabeled).
against glass vial wall. Do not Subcut, IV (Children): 1– 10 mcg/kg q 12
shake; swirl gently to dissolve. Solution is hr or 1 mcg/kg IV bolus followed by a
clear; do not use solutions that are continuous infusion of 1 mcg/kg/hr.
cloudy or contain a precipitate. Persistent Hyperinsulinemic
● Subcut:Injection volume should not Hypoglycemia of Infancy
exceed 1 mL. IV (Infants): Initially 2– 10 mcg/kg/day
divided q 12 hr up to 40 mcg/kg/day divided
Patient/Family Teaching q 6– 8 hr. Chylothorax
● Instruct patient and parents on correct Subcut (Adults):50– 100 mcg q 8 hr.
procedure for reconstituting medication, Subcut (Children):40 mcg/kg/day.
site selection, technique for subcut injection, IV (Children):0.3– 10 mcg/kg/hr continuous
and disposal of needles and syringes. infusion.
Review dosage schedule. Parents should
report persistent pain or edema at Action:Suppresses secretion of serotonin
injection site. and gastroenterohepatic peptides.
● Emphasize need for regular follow-up with Decreases levels of serotonin metabolites.
endocrinologist to ensure appropriate Also suppresses growth hormone, insulin,
growth rate, to evaluate lab work, and to and glucagon.
determine bone age by x-ray exam. Absorption:Well absorbed following subcut
● Assure parents and child that these dose administration andIM administration
forms are synthetic and therefore not of depot form.
capable of transmitting Creutzfeldt-Jakob Distribution:Unknown.
disease, as was the original somatropin, Metabolism and Excretion:Extensive
which was extracted from human cadavers. hepatic metabolism; 32% excreted
unchanged in urine.
Evaluation/Desired Outcomes Half-life:1.5 hr.
● Child’s attainment of adult height in growth Route:Subcut, IV
failure secondary to pituitary growth Onset:unknown
hormone deficiency. Therapy is limited to Peak:2 wk
period before closure of epiphyseal Duration:up to 12 hr; up to 4 wk
plates (approximately up to 14– 15 yr in Drug-Drug & Drug-Food
girls, 15– 16 yr in boys). Interactions:Drug-Drug: May alter

Page | 107
requirements forinsulin or oral hypoglycemic
agents.
May↓blood levels ofcyclosporine.
May↑levels of QTc-prolonging agents.
Indications:Treatment of severe diarrhea
and flushing episodes in patients with GI
endocrine tumors, including metastatic
carcinoid tumors and vasoactive intestinal
peptide tumors (VIPomas). Treatment of
acromegaly.
Contraindications:Hypersensitivity
Side effects:CNS: dizziness, drowsiness,
fatigue, headache, weakness. EENT: visual
disturbances.GI: ileus, abdominal pain,
cholelithiasis, diarrhea, fat malabsorption,
nausea, vomiting. Derm: flushing.
Adverse effects:CV: bradycardia, edema,
orthostatic hypotension, palpitations.Endo:
hyperglycemia, hypoglycemia,
hypothyroidism.Local:injection-site pain.
Responsibilities in the Nursing Process
Assessment
● Assess patient’s fluid and electrolyte
balance and skin turgor for dehydration.
● Monitor diabetic patients for signs of
hypoglycemia. May require reduction in
requirements for insulin and sulfonylureas
and treatment with diazoxide.
● Lab Test Considerations: Monitor 5-
HIAA (urinary 5-hydroxyindoleacetic
acid), plasma serotonin, and plasma
substance P in patients with carcinoid;
plasma vasoactive intestinal peptide (VIP) in
patients with VIPoma; and free T4
andserum glucose concentrations prior to
and periodically during therapy in all patients
taking octreotide.
Potential Nursing Diagnoses
Diarrhea (Indications)
Implementation
● IM:Mix IM solution by adding diluent
included in kit. Administer immediately after
mixing into the gluteal muscle. Avoid using
deltoid site due to pain of injection.
Patient/Family Teaching
● May cause dizziness, drowsiness, or
visual disturbances. Caution patient to avoid
driving or other activities requiring alertness
until response to medication is
known.
● Advise patient to change positions slowly
to minimize orthostatic hypotension.
Evaluation/Desired Outcomes
● Decrease in severity of diarrhea and
improvement of electrolyte imbalances in
patients with carcinoid or VIP-secreting
tumors.
Drug classification:THYROID-
STIMULATING HORMONE
Generic name:Levothyroxine
Brand Name:
Recommended Dosage, Route, And
Frequency:
PO (Adults): Hypothyroidism—50 mcg as
a single dose initially; may be↑q 2–3
wk by 25 mcg/day; usual maintenance dose
is 75– 125 mcg/day (1.5 mcg/kg/day).
PO (Geriatric Patients and Patients with
Increased Sensitivity to Thyroid
Hormones): 12.5– 25 mcg as a single dose
initially; may be ↑q 6– 8 wk; usual
maintenance dose is 75 mcg/day.
PO (Children>12 yr): 2– 3 mcg/kg/day
(≥150 mcg/day).
PO (Children 6– 12 yr):4– 5 mcg/kg/day
(100– 125 mcg/day).
PO (Children 1– 5 yr):5– 6 mcg/kg/day
(75– 100 mcg/day).
PO (Children 6– 12 mo):6– 8 mcg/kg/day
(50– 75 mcg/day).
PO (Infants 3– 6 mo):8– 10 mcg/kg/day
(25– 50 mcg/day).
PO (Infants 0– 3 mo or Infants at Risk for
Cardiac Failure): 10– 15 mcg/kg/
day or 25 mcg/day; may be↑ after 4– 6 wk to
50 mcg.
IM, IV (Adults):Hypothyroidism—50– 100
mcg/day as a single dose.Myxedema
coma/stupor—300– 500 mcg IV; additional
100– 300 mcg may be given on 2nd
day, followed by daily administration of
smaller doses.
IM, IV (Children):Hypothyroidism—50– 80%
of the oral dose.
Action:Replacement of or supplementation
to endogenous thyroid hormones. Principal
effect is increasing metabolic rate of body
tissues: Promote gluconeogenesis, Increase
utilization and mobilization of glycogen
stores, Stimulate protein synthesis, Promote
cell growth and differentiation, Aid in the
development of the brain and CNS.
Absorption:Levothyroxine is variably (40–
80%) absorbed from the GI tract.
Distribution: Distributed into most body
tissues. Thyroid hormones do not readily
cross the placenta; minimal amounts enter
breast milk.
Metabolism and Excretion: Metabolized by
the liver and other tissues to active
T3. Thyroid hormone undergoes
enterohepatic recirculation and is excreted
in the feces via the bile.
Half-life:6– 7 days
Route:Levothyroxine PO;Levothyroxine IV
Onset:unknown;6–8 hr
Peak:1–3 wk;24 hr
Duration:1–3 wk; unknown
Drug-Drug & Drug-Food
Interactions:Drug-Drug:Bile acid
Page | 108
sequestrantsandorlistatpabsorption of orally
administered thyroid preparations. May↑ the
effects ofwarfarin.May↑ requirement
forinsulin or oral hypoglycemic agents in
diabetics. Concurrent estrogen therapy
may↑ thyroid replacement requirements. ↑
cardiovascular effects withadrenergics
(sympathomimetics).
Indications:Thyroid supplementation in
hypothyroidism. Treatment or suppression of
euthyroid goiters.Adjunctive treatment for
thyrotropin-dependent thyroid cancer.
Contraindications:Hypersensitivity; Recent
MI; Hyperthyroidism.
Side effects:CNS:
headache, insomnia, irritability.
GI: abdominal cramps, diarrhea,
vomiting.Derm:sweating
Adverse effects:CV:angina pectoris,
arrhythmias, tachycardia. Endo:
hyperthyroidism, menstrual irregularities.
Metab: heat intolerance, weight loss. MS:
accelerated bone maturation in children.
Responsibilities in the Nursing Process
Assessment
● Assess apical pulse and BP prior to and
periodically during therapy. Assess for
tachyarrhythmias and chest pain.
● Children:Monitor height, weight, and
psychomotor development.
● Lab Test Considerations:Monitor thyroid
function studies prior to and during
therapy. Monitor thyroid-stimulating
hormone serum levels in adults 8– 12 wks
after changing from one brand to another.
● Monitor blood and urine glucose in
diabetic patients. Insulin or oral
hypoglycemic dose may need to be
increased.
Potential Nursing Diagnoses
Deficient knowledge, related to medication
regimen (Patient/Family Teaching)
Patient/Family Teaching
● Instruct patient to take medication as
directed at the same time each day. Take
missed doses as soon as remembered
unless almost time for next dose. If more
than 2– 3 doses are missed, notify health
care professional. Do not discontinue
without consulting health care professional.
● Explain to patient that medication does not
cure hypothyroidism; it provides a thyroid
hormone supplement. Therapy is lifelong.
● Pedi: Discuss with parents the need for
routine follow-up studies to ensure correct
development. Inform patient that partial hair
loss may be experienced by children on
thyroid therapy. This is usually temporary.
Evaluation/Desired Outcomes
● Resolution of symptoms of hypothyroidism
and normalization of hormone levels.
Drug classification:
ADRENOCORTICOTROPIC
HORMONE (ACTH)
Generic name:Corticotropin
Brand Name: Acthar Gel
Recommended Dosage, Route, And
Frequency:
Multiple Sclerosis
IM,Subcut (Adults):80– 120 units/day for
2– 3 wk.
Infantile Spasms
IM (Children<2 yr):75 units/m2
twice daily for 2 wk, then taper over 2 wk.
Action:Normally produced by the pituitary,
stimulates the adrenal gland to produce both
corticosteroids (hydrocortisone) and
mineralocorticoids (aldosterone). Action
requires intact adrenal responsiveness.
Actions resemble those of corticosteroid
administration and include suppression of
the normal immune response and
inflammation. Additional numerous intense
metabolic effects. Potent mineralocorticoid
(sodium retention). Suppresses adrenal
function with chronic use. Mechanism of
anticonvulsant action is unknown.
Absorption:Slowly absorbed from IM or
subcut sites.
Distribution:Removed from plasma to
many tissues. Does not cross the placenta.
Metabolism and Excretion:Metabolic fate
unknown.
Half-life:15 min (plasma)
Route:IM (gelatin repository)
Onset:unknown
Peak:3–12 hr
Duration:10–25 hr
Drug-Drug & Drug-Food
Interactions:Drug-Drug: Concurrent use of
live vaccines orlive attenuated vaccinesis
contraindicated. Additive hypokalemia
withamphotericin B, piperacillin, ticarcillin, or
potassium-losing diuretics. Hypokalemia
may↑ the risk of digoxin
toxicity. May ↑ requirements forinsulins or
oral hypoglycemic agents. Phenytoin,
phenobarbital, and rifampin stimulate
metabolism, may↓ effectiveness.
Hormonal contraceptives may↓ metabolism.
Indications:Acute exacerbations of multiple
sclerosis. Infantile spasms.
Contraindications:Hypersensitivity to pork
proteins; Serious infections; Scleroderma;
Recent surgery; History or presence of
peptic ulcer; Heart failure; Uncontrolled
hypertension; Primary adrenocortical
insufficiency; Use of live or live attenuated
vaccines.
Side effects: CNS: depression, euphoria,
psychoses. EENT:cataracts,↑intraocular
pressure.
Page | 109
GI: nausea, ↑ appetite, peptic ulceration,
vomiting, weight gain.Derm:↓ wound
healing, petechiae, acne, ecchymoses,
fragility, hirsutism.
Adverse effects:. CV: HF,
THROMBOEMBOLISM, edema,
hypertension.Endo: ADRENAL
SUPPRESSION,↓growth
in children, hyperglycemia, menstrual
irregularities.F and E: hypokalemia, sodium
retention, hypocalcemia, metabolic
alkalosis.Local:atrophy at IM sites
(repository
dosage forms).MS:avascular necrosis of
joints, myopathy, osteoporosis, weakness.
Misc:cushingoid appearance (moon face,
buffalo hump),↑susceptibility to infections,
pancreatitis.
Responsibilities in the Nursing Process
Assessment
● Monitor BP and daily weight periodically
during therapy. If hypertension develops
during treatment, sodium restriction and
diuretic therapy are used instead of
discontinuation of corticotropin.
● Assess for signs and symptoms of
infection (fever, cough, vomiting, diarrhea) of
patient and family members throughout
therapy.
● Lab Test Considerations: Monitor CBC,
serum calcium, electrolytes, phosphorus,
serum fasting and postprandial glucose, and
renal function tests with urinalysis before
initiation of therapy.
● Monitor serum calcium, electrolytes, and
phosphorus, and urinalysis with urine
glucose periodically during therapy.
Potential Nursing Diagnoses
Deficient knowledge, related to medication
regimen (Patient/Family Teaching)
Implementation
● IM:Shake suspension well before drawing
up dose. Refrigerate. Warm to room
temperature before administering. Use 22-
gauge needle.
Patient/Family Teaching
● Instruct patient and/or parent on correct
technique for administration and to continue
medication as directed. Must be stopped
gradually. If medication is stopped
patient appears weak, loses weight or has a
decrease in appetite, appears tired or
lacking energy, appears pale, has stomach
pain, appears sick or has a fever notify
health care professional immediately.
● Instruct patient to notify health care
professional of all Rx or OTC medications,
vitamins, or herbal products being taken and
consult health care professional before
taking any new medications.
Evaluation/Desired Outcomes
● Reduction in frequency of exacerbations
with multiple sclerosis.
Drug classification:
ANTIDIURETIC HORMONE
(ADH)
Generic name:Vasopressin
Brand Name: Pitressin
Recommended Dosage, Route, And
Frequency:Diabetes insipidus
IM,Subcut (Adults):5– 10 units 2– 4 times
daily.
IM,Subcut (Children):2.5– 10 units 2– 4
times daily.
IV (Adults and Children): 0.0005
units/kg/hr, double dosage q 30 min as
needed
to a maximum of 0.01 units/kg/hr.
Pulseless VT/VF, Asystole, or PEA (ACLS
guidelines)
IV (Adults):40 units as a single dose
(unlabeled).
IV (Children):0.4 units/kg after resuscitation
and at least 2 doses of epinephrine.
Vasodilatory shock
IV (Adults):0.01– 0.1 units/min, titrate to
effect.
IV (Infants and Children):0.0003– 0.002
units/kg/min, titrate to effect.
GI Hemorrhage
IV (Adults): 0.2– 0.4 units/min then titrate to
maximum dose of 0.9 units/min; if
bleeding stops continue same dose for 12 hr
then taper off over 24– 48 hr.
IV (Children): 0.002– 0.005 units/kg/min
then titrate to maximum dose of 0.01
units/kg/min; if bleeding stops continue
same dose for 12 hr then taper off over 24–
48 hr.
Action:Alters the permeability of the renal
collecting ducts, allowing reabsorption of
water.
Directly stimulates musculature of GI tract.
In high doses acts as a nonadrenergic
peripheral vasoconstrictor.Therapeutic
Effects: Decreased urine output and
increased urine osmolality in diabetes
insipidus.
Absorption:IM absorption may be
unpredictable.
Distribution:Widely distributed throughout
extracellular fluid.
Metabolism and Excretion: Rapidly
degraded by the liver and kidneys; <5%
excreted unchanged by the kidneys.
Half-life:10– 20 min.
Route: IM, subcut; IV
Onset: unknown; unknown
Peak: unknown; unknown
Duration: 2–8 hr; 30–60 min
Indications:Central diabetes insipidus due
to deficient antidiuretic hormone.Unlabeled
Use: Management of pulseless VT/VF
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unresponsive to initial shocks, asystole, or
pulselesselectrical activity (PEA) (ACLS
guidlines). Vasodilatory
shock.Gastrointestinal haemorrhage.
Contraindicated in:Chronic renal failure
with increased BUN; Hypersensitivity to
beef or pork proteins.
Side effects: CNS: dizziness, “pounding”
sensation in head.GI:abdominal cramps,
belching, diarrhea, flatulence, heartburn,
nausea, vomiting.
Derm: paleness, perioral blanching,
sweating.
Adverse effects: CV: MI, angina, chest
pain.Neuro: trembling.Misc:allergic
reactions, fever, water intoxication (higher
doses).
Responsibilities in the Nursing Process
Assessment
● Monitor BP, HR, and ECG periodically
throughout therapy and continuously
throughout cardiopulmonary resuscitation.
● Diabetes Insipidus: Monitor urine
osmolality and urine volume frequently to
determine effects of medication.
● Lab Test Considerations:Monitor urine
specific gravity throughout therapy.
● Monitor serum electrolyte concentrations
periodically during therapy.
● Toxicity and Overdose:Signs and
symptoms of water intoxication include
confusion, drowsiness, headache, weight
gain, difficulty urinating, seizures, and
coma.
● Treatment of overdose includes water
restriction and temporary discontinuation
of vasopressin until polyuria occurs
Potential Nursing Diagnoses
Deficient fluid volume (Indications)
Excess fluid volume (Adverse Reactions)
Implementation
● Aqueous vasopressin injection may be
administered subcut or IM for diabetes
insipidus.
● Administer 1– 2 glasses of water at the
time of administration to minimize side
effects (blanching of skin, abdominal
cramps, nausea).
Patient/Family Teaching
Instruct patient to take medication as
directed. Caution patient not to use more
than prescribed amount. Take missed doses
as soon as remembered, unless almost time
for next dose.
● Caution patient to avoid concurrent use of
alcohol while taking vasopressin.
● Patients with diabetes insipidus should
carry identification at all times describing
disease process and medication regimen.
Evaluation/Desired Outcomes
● Decrease in urine volume.
● Relief of polydipsia.
● Increased urine osmolality in patients with
central diabetes insipidus.
● Resolution of VT/VF.
● Improvement in signs of septic shock.
Drug classification:
HYPOTHYROIDISM OR
THYROID REPLACEMENTS
Generic name:Levothyroxine
Brand Name:
Recommended Dosage, Route, And
Frequency:
PO (Adults): Hypothyroidism—50 mcg as
a single dose initially; may be↑q 2–3
wk by 25 mcg/day; usual maintenance dose
is 75– 125 mcg/day (1.5 mcg/kg/day).
PO (Geriatric Patients and Patients with
Increased Sensitivity to Thyroid
Hormones): 12.5– 25 mcg as a single dose
initially; may be ↑q 6– 8 wk; usual
maintenance dose is 75 mcg/day.
PO (Children>12 yr): 2– 3 mcg/kg/day
(≥150 mcg/day).
PO (Children 6– 12 yr):4– 5 mcg/kg/day
(100– 125 mcg/day).
PO (Children 1– 5 yr):5– 6 mcg/kg/day
(75– 100 mcg/day).
PO (Children 6– 12 mo):6– 8 mcg/kg/day
(50– 75 mcg/day).
PO (Infants 3– 6 mo):8– 10 mcg/kg/day
(25– 50 mcg/day).
PO (Infants 0– 3 mo or Infants at Risk for
Cardiac Failure): 10– 15 mcg/kg/
day or 25 mcg/day; may be↑ after 4– 6 wk to
50 mcg.
IM, IV (Adults):Hypothyroidism—50– 100
mcg/day as a single dose.Myxedema
coma/stupor—300– 500 mcg IV; additional
100– 300 mcg may be given on 2nd
day, followed by daily administration of
smaller doses.
IM, IV (Children):Hypothyroidism—50– 80%
of the oral dose.
Action:Replacement of or supplementation
to endogenous thyroid hormones. Principal
effect is increasing metabolic rate of body
tissues: Promote gluconeogenesis, Increase
utilization and mobilization of glycogen
stores, Stimulate protein synthesis, Promote
cell growth and differentiation, Aid in the
development of the brain and CNS.
Absorption:Levothyroxine is variably (40–
80%) absorbed from the GI tract.
Distribution: Distributed into most body
tissues. Thyroid hormones do not readily
cross the placenta; minimal amounts enter
breast milk.
Metabolism and Excretion: Metabolized by
the liver and other tissues to active
T3. Thyroid hormone undergoes
enterohepatic recirculation and is excreted
in the feces via the bile.
Half-life:6– 7 days
Route:Levothyroxine PO;Levothyroxine IV
Onset:unknown;6–8 hr
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Peak:1–3 wk;24 hr
Duration:1–3 wk; unknown
Drug-Drug & Drug-Food
Interactions:Drug-Drug:Bile acid
sequestrantsandorlistatpabsorption of orally
administered thyroid preparations. May↑ the
effects ofwarfarin.May↑ requirement
forinsulin or oral hypoglycemic agents in
diabetics. Concurrent estrogen therapy
may↑ thyroid replacement requirements. ↑
cardiovascular effects withadrenergics
(sympathomimetics).
Indications:Thyroid supplementation in
hypothyroidism. Treatment or suppression of
euthyroid goiters.Adjunctive treatment for
thyrotropin-dependent thyroid cancer.
Contraindications:Hypersensitivity; Recent
MI; Hyperthyroidism.
Side effects:CNS:
headache, insomnia, irritability.
GI: abdominal cramps, diarrhea,
vomiting.Derm:sweating
Adverse effects:CV:angina pectoris,
arrhythmias, tachycardia. Endo:
hyperthyroidism, menstrual irregularities.
Metab: heat intolerance, weight loss. MS:
accelerated bone maturation in children.
Responsibilities in the Nursing Process
Assessment
● Assess apical pulse and BP prior to and
periodically during therapy. Assess for
tachyarrhythmias and chest pain.
● Children:Monitor height, weight, and
psychomotor development.
● Lab Test Considerations:Monitor thyroid
function studies prior to and during
therapy. Monitor thyroid-stimulating
hormone serum levels in adults 8– 12 wks
after changing from one brand to another.
● Monitor blood and urine glucose in
diabetic patients. Insulin or oral
hypoglycemic dose may need to be
increased.
Potential Nursing Diagnoses
Deficient knowledge, related to medication
regimen (Patient/Family Teaching)
Patient/Family Teaching
● Instruct patient to take medication as
directed at the same time each day. Take
missed doses as soon as remembered
unless almost time for next dose. If more
than 2– 3 doses are missed, notify health
care professional. Do not discontinue
without consulting health care professional.
● Explain to patient that medication does not
cure hypothyroidism; it provides a thyroid
hormone supplement. Therapy is lifelong.
● Pedi: Discuss with parents the need for
routine follow-up studies to ensure correct
development. Inform patient that partial hair
loss may be experienced by children on
thyroid therapy. This is usually temporary.
Evaluation/Desired Outcomes
● Resolution of symptoms of hypothyroidism
and normalization of hormone levels.
Drug classification:THIONAMIDES
Generic name: Propylthiouracil
Brand Name: PTU
Recommended Dosage, Route, And
Frequency:PO (Adults): 100 mg q 8 hr;
may beqto 400 mg/day (occasional patient
may require 600– 900 mg/day); usual
maintenance dose100– 150 mg/day.
PO (Children>10 yr):50– 300 mg/day
given once daily or in 2– 4 divided doses.
PO (Children 6–10 yr): 50– 150 mg/day
given once daily or in 2– 4 divided
doses
Action
Inhibits the synthesis of thyroid
hormones.Therapeutic Effects:Decreased
signs and symptoms of hyperthyroidism.
Absorption:Rapidly absorbed from the GI
tract.
Distribution: Concentrates in the thyroid
gland; crosses the placenta and enters
breast milk in low concentrations.
Metabolism and Excretion:Metabolized by
the liver.
Half-life:1– 2 hr.
Route: PO
Onset: 10–21 days
Peak :6–10 wk
Duration: wk
Interactions
Drug-Drug: Additive bone marrow
depression with antineoplastics orradiation
therapy. Additive antithyroid effects with
lithium, potassium iodide, orsodium iodide.↑
risk of agranulocytosis withphenothiazines.
Contraindicated in:Hypersensitivity
Side Effects: CNS: drowsiness, headache,
vertigo. GI: HEPATOTOXICITY, nausea,
vomiting, diarrhea, loss of taste.Derm:rash,
skin discoloration, urticaria.
Adverse Reactions:Endo: hypothyroidism.
Hemat: AGRANULOCYTOSIS, leukopenia,
thrombocytopenia. MS: arthralgia.
Misc:fever, lymphadenopathy, parotitis.
Responsibilities in the nursing process
Assessment
● Monitor response of symptoms of
hyperthyroidism or thyrotoxicosis
(tachycardia,
palpitations, nervousness, insomnia, fever,
diaphoresis, heat intolerance, tremors,
weight loss, diarrhea).
Page | 112
● Assess patient for development of
hypothyroidism (intolerance to cold,
constipation, dry skin, headache,
listlessness, tiredness, or weakness).
● Lab Test Considerations: Thyroid
function studies should be monitored prior
to therapy, monthly during initial therapy,
and every 2– 3 mo throughout therapy.
● WBC and differential counts should be
monitored periodically throughout course of
therapy. Agranulocytosis may develop
rapidly and usually
occurs during first 2 mo. This necessitates
discontinuation of therapy.
● May cause increased AST, ALT, LDH,
alkaline phosphatase, serum bilirubin, and
prothrombin time.
Potential Nursing Diagnoses
Deficient knowledge, related to medication
regimen (Patient/Family Teaching)
Noncompliance (Patient/Family Teaching)
Implementation
● Do not confuse propylthiouracil with
Purinethol (mercaptopurine).
● Can be compounded by pharmacist into
enema or suppository.
● PO: Administer at same time in relation to
meals every day. Food may either increase
or decrease absorption.
Patient/Family Teaching
● Instruct patient to take medication exactly
as directed, around the clock. If a dose
is missed, take as soon as remembered;
take both doses together if almost time for
next dose; check with health care
professional if more than 1 dose is missed.
Consult health care professional prior to
discontinuing medication.
● Instruct patient to monitor weight 2– 3
times weekly.Report significant changes.
● May cause drowsiness. Caution patient to
avoid driving or other activities requiring
alertness until response to medication is
known.
● Advise patient to consult health care
professional regarding dietary sources of
iodine (iodized salt, shellfish).
● Advise patient to report sore throat, fever,
chills, headache, malaise,
weakness, yellowing of eyes or skin,
unusual bleeding or bruising,
symptoms of hyperthyroidism or
hypothyroidism, or rash to health care
professional promptly.
● Advise patient to notify health care
professional of all Rx or OTC medications,
vitamins, or herbal products being taken and
to consult with health care professional
before taking other medications.
. Absorption: Converted in the GI tract and
Evaluation/Desired Outcomes
● Decrease in severity of symptoms of
hyperthyroidism (lowered pulse rate and
weight gain).
● Return of thyroid function studies to
normal.
● May be used as short-term adjunctive
therapy to prepare patient for thyroidectomy
or radiation therapy or may be used in
treatment of hyperthyroidism. Treatment of
6 mo to several yr may be necessary,
usually averaging 1 yr.
Drug classification:IODIDE
Generic name:Potassium iodide
Brand Name: SSKI
Route/Dosage
Preparation for Thyroidectomy
PO (Adults and Children):Strong iodine
solution—3– 5 drops (0.1– 0.3 mL) 3
times daily for 10 days prior to surgery.
Potassium iodide saturated solution
(SSKI)— 1– 5 drops (50– 250 mg) 3 times
daily for 10 days prior to surgery.
Hyperthyroidism
PO (Adults and Children):Strong iodine
solution—1 mL in water 3 times daily.
Potassium iodide saturated solution (SSKI)
—6– 10 drops (300– 500 mg) 3
times daily.
PO (Infants<1 yr):3– 5 drops (150– 250
mg) 3 times daily. Radiation Protectant to
Radioactive Isotopes of Iodine
PO (Adults): Pima—195 mg once daily for
10 days (start 24 hr prior to exposure
(continue until risk of exposure has passed
or other measures have been implemented).
PO (Children >1 yr): 130 mg once daily for
10 days (start 24 hr prior to exposure).
PO (Infant<1 yr):65 mg once daily for 10
days (start 24 hr prior to exposure).
Reduction of Thyroid Cancer after
Nuclear Accident
PO (Adults and Children >68 kg,
including pregnant/lactating
women):Iosat, ThyroSafe, ThyroShield—
130 mg once daily (continue until risk of
exposure
has passed or other measures have been
implemented).
PO (Children 3– 18 yr):65 mg once daily.
PO (Children 1 mo– 3 yr):32.5 mg once
daily.
PO (Infants<1 mo):16.25 mg once daily.
Action
Rapidly inhibits the release and synthesis of
thyroid hormones. Decreases the vascularity
of the thyroid gland. Decreases thyroidal
uptake of radioactive iodine following
radiation emergencies or administration of
radioactive isotopes of iodine. Iodine is a
necessary component of thyroid hormone.
enters the circulation as iodine; also
absorbed through skin and lungs; may also
be obtained via recycling of iodothyronines.
Distribution: Concentrates in the thyroid
gland and muscle; also found in skin,
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skeleton, breasts, and hair. Readily crosses possible but not just before next dose; do
the placenta; enters breast milk. not double doses.
Metabolism and Excretion: Taken up by ● Advise patient to consult health care
the thyroid gland, then eliminated via professional about avoiding foods high in
kidneys, liver, skin, lungs, and intestines. iodine (seafood, iodized salt, cabbage, kale,
Half-life:Unknown. turnips) or potassium.
Route:PO Evaluation/Desired Outcomes
Onset: 24 hr ● Resolution of the symptoms of thyroid
Peak :10–15 days crisis.
Duration: variable ● Decrease in size and vascularity of the
gland before thyroid surgery. Use of iodides
in the treatment of hyperthyroidism is usually
Interactions: limited to 2 wk.
Drug-Drug: Use with lithiummay
causeqhypothyroidism.↑ antithyroid effect of Drugclassification:HYPOPARATH
methimazole and propylthiouracil.↑
hyperkalemia may result from combined YROIDISM &
use with potassium-sparing diuretics, ACE HYPOCALCEMIA:
inhibitors, angiotensin II receptor VITAMIN D ANALOGUES
antagonistsorpotassium supplements. Generic name:
Brand Name:
Contraindicated in: Hypersensitivity;
Hyperkalemia; Pulmonary edema; Impaired
renal function. Route/Dosage
Familial Hypophosphatemia
Side Effects: CNS:confusion, weakness. PO (Adults and Children):10,000– 80,000
GI: GI BLEEDING, diarrhea, nausea, IU/day (with phosphorus 1– 2 g/day).
vomiting.Derm:acneiform eruptions. Hypoparathyroidism
Adverse Reactions:Endo: hypothyroidism, PO (Adults and Children):50,000– 200,000
goiter, hyperthyroidism. F and E: IU/day (to be used with calcium
hyperkalemia.Neuro:tingling.MS:joint supplements).
pain.Misc:hypersensitivity, iodism. Vitamin D-Resistant Rickets
PO (Adults):12,000– 500,000 IU/day (to be
Responsibilities in the nursing process used with phosphate supplements).
Assessment PO (Children):40,000– 80,000 IU/day (to be
● Assess for signs and symptoms of iodism used with phosphate supplements).
(metallic taste, stomatitis, skin lesions, Adequate Intake
cold symptoms, severe GI upset). Report PO (Infants):Exclusively or partially-breast
these symptoms promptly. fed-400 IU daily.
● Monitor for hypersensitivity reaction (rash,
pruritus, laryngeal edema, wheezing). Action
● Lab Test Considerations: Monitor thyroid Requires activation in the liver and kidneys
function before and periodically to create the active form of vitamin D2.
during therapy. May alter results of Promotes the absorption of calcium and
radionuclide thyroid imaging and decreases parathyroid hormone
maypthyroidal uptake of 131I, 123I, and concentrations.
sodium pertechnetate 99mTc in thyroid Absorption:Well absorbed.
uptake tests. Distribution:Unknown.
● Monitor serum potassium levels Metabolism and Excretion: Converted to
periodically during therapy. the active form of vitamin D2
● Lab Test Considerations: Monitor thyroid by sunlight, the liver, and the kidneys.
stimulating hormone (TSH) and Half-life:Unknown
free T4 in neonates (within the first month of Route: PO
life) treated with potassium iodide for Onset:12–24 hr
development of hypothyroidism. Thyroid Peak :4 wk
hormone therapy should be instituted if Duration:unknown
hypothyroidism develops.
Potential Nursing Diagnoses Interactions
Deficient knowledge, related to medication Drug-Drug: Cholestyramine,colestipol, or
regimen (Patient/Family Teaching) mineral oilpabsorption of vitamin D
Implementation analogues. Use with thiazide diureticsmay
● Do not confuse iodine with Lodine result in hypercalcemia.
(etodolac). Corticosteroidspeffectiveness of vitamin D
. analogues. Concurrent use
Patient/Family Teaching ofmagnesiumcontaining drugs may lead to
● Instruct patient to take medication as hypermagnesemia. Calcium-containing
directed. Take missed doses as soon as drugs
mayqrisk of hypercalcemia. Concurrent use
of othervitamin D supplementsq

Page | 114
risk of hypercalcemia. professional. Explain that the best source of
Drug-Food: Ingestion of foods high in vitamins is a well-balanced diet with foods
calcium contentmay lead to hypercalcemia. from the 4 basic food groups and the
importance of sunlight exposure.
Indications ● Patients self-medicating with vitamin
Treatment of familial supplements should be cautioned not to
hypophosphatemia.Treatment of exceed RDA.
hypoparathyroidism.Treatment of vitamin D- ● Advise patient to avoid concurrent use of
resistant rickets. antacids containing magnesium.
● Review symptoms of overdose and
Contraindicated in: Hypersensitivity; instruct patient to report these promptly to
Hypercalcemia; Vitamin D toxicity; health care professional.
Lactation:Lactation ; Concurrent use of Evaluation/Desired Outcomes
magnesium-containing antacids or other ● Normalization of serum calcium,
vitaminD supplements; Malabsorption phosphate, and parathyroid hormone levels.
problems; Patients with known intolerance to ● Improvement in symptoms of vitamin D–
tartrazine. resistant rickets.

Side Effects: CNS: dizziness, headache,

malaise, somnolence, weakness.
EENT:conjunctivitis, photophobia, Drug
rhinorrhea.GI:anorexia, constipation, dry classification:HYPERPARATHYRO
mouth,↑liverenzymes, metallic taste, IDISM &
nausea,PANCREATITIS, polydipsia, HYPERCALCEMIA
vomiting, weight loss. GU: albuminuria, Generic name: Etidronate
azotemia,plibido, nocturia, polyuria.
Derm: pruritus. Brand Name: Didronel
Adverse Reactions: Resp:
dyspnea.CV:arrhythmias, edema, Route/Dosage
hypertension.F and E: Paget’s Disease
hypercalcemia.Metab: hyperthermia.MS: PO (Adults): 5– 10 mg/kg/day single dose
bone pain, metastatic calcification, muscle for up to 6 mo or 11– 20 mg/kg/day for
pain. not more than 3 mo.
Heterotopic Ossification (Hip
Assessment Replacement)
● Assess for symptoms of vitamin deficiency PO (Adults):20 mg/kg/day for 1 mo before
prior to and periodically during therapy. and 3 mo after surgery.
● Observe patient carefully for evidence of Heterotopic Ossification(Spinal Cord
hypocalcemia (paresthesia, muscle Injury)
twitching, laryngospasm, colic, cardiac PO (Adults):20 mg/kg/day for 2 wk, then
arrhythmias, and Chvostek’s or Trousseau’s decreased to 10 mg/kg/day for 10 wk.
sign). Protect symptomatic patient by raising
and padding side rails; keep Action
bed in low position. Blocks the growth of calcium hydroxyapatite
● Pedi: Monitor height and weight; growth crystals by binding to calcium
arrest may occur in prolonged highdose phosphate.Therapeutic Effects:Decreased
therapy. bone resorption and turnover.
● Rickets:Assess patient for bone pain and Absorption:Absorption is generally poor (1–
weakness prior to and during therapy. 6%) after oral administration.
● Lab Test Considerations: Serum calcium Distribution: Half of the absorbed dose is
and phosphorus concentrations bound to hydroxyapatite crystals in areas of
should be monitored every 2 wk or more increased osteogenesis.
frequently if necessary. Metabolism and Excretion:Unabsorbed
Potential Nursing Diagnoses drug is eliminated in the feces; 50% of
Imbalanced nutrition: less than body the absorbed dose is excreted unchanged
requirements (Indications) by the kidneys.
Implementation Half-life:5– 7 hr.
● PO:Measure solution accurately with Route:PO (Paget’s disease)
calibrated dropper provided by Onset:1 mo
manufacturer. May be mixed with juice, Peak : unknown
cereal, or food, or dropped directly into Duration:1 yr
mouth.
● Swallow tablets whole; do not break, Interactions:
crush, or chew. Drug-Drug: Antacids, mineral supplements,
Patient/Family Teaching or buffers(as in didanosine)
● Encourage patient to comply with dietary containingcalcium, aluminum, iron, or
recommendations of health care magnesium maypabsorption of etidronate.
Hypocalcemic effect may be additive
withcalcitonin.

Page | 115
Drug-Food: Foods containing large amounts
ofcalcium, aluminum, iron, or
magnesiummaypabsorption of etidronate.
Indications:
Treatment of Paget’s disease of bone.
Treatment and prophylaxis of heterotopic
calci-fication associated with total hip
replacement or spinal cord injury.
Contraindicated in: Hypersensitivity; Overt
osteomalacia; Abnormalities of the
esophagus which delay esophageal
emptying (i.e. strictures, achalasia).
Side Effects
GI: diarrhea, nausea, esophagitis,
esophageal cancer, esophageal ulcer.
Adverse Reactions
MS:musculoskeletal pain, microfractures,
osteonecrosis (primarily of jaw).
NURSING IMPLICATIONS
Assessment
● Assess patient for bone pain, weakness,
or loss of function before and throughout
therapy. Bone pain may persist or increase
in patients with Paget’s disease; usually
subsides days to months after therapy is
discontinued. Confer with health care
professional regarding analgesic to control
pain.
● Heterotopic Ossification: Monitor for
inflammation and pain at the site and
loss of function if ossification occurs near a
joint.
● Lab Test Considerations: Etidronate
interferes with bone uptake of technetium 99
in diagnostic scans.
● Paget’s disease:purinary excretions of
hydroxyproline and serum alkaline
phosphatase are often the first clinical signs
of effectiveness; monitor every 3 mo.
Treatment is restarted when levels return to
75% of pretreatment values. Monitor serum
phosphate levels before and 4 wk after
beginning therapy. Dose may bepif
serum phosphate isqwithout
correspondingpin urinary excretion of
hydroxyproline or serum alkaline
phosphatase.
Potential Nursing Diagnoses
Acute pain (Indications) (Side Effects)
Risk for injury (Indications)
Implementation
● PO: Administer on empty stomach,
because food decreases absorption.
Swallow
tablet whole; do not break, crush, or chew.
Patient/Family Teaching
● Advise patient to take as directed. Take
missed doses as soon as remembered
unless almost time for next dose. Do not
double up on doses. Dose should not be
taken within 2 hr of eating (especially
products high in calcium) or taking vitamins
or antacids, because absorption will be
impaired.
● Instruct patient to notify health care
professional if swallowing difficulties, chest
pain, new or worsening heartburn, or trouble
or pain when swallowing occurs;
may be signs of problems of the esophagus.
● Emphasize need for keeping follow-up
appointments to monitor progress, even
after medication is discontinued, to detect
relapse.
Evaluation/Desired Outcomes
● Decreased bone pain and fractures in
Paget’s disease.
● Prevention or treatment of heterotopic
ossification. Normal serum calcium levels
are usually attained in 2– 8 days in
hypercalcemia associated with bony
metastasis. Therapy may be repeated once
after 1 wk.
Drug classification:SHORT-
ACTING GLUCOCORTICOIDS
Generic name: Hydrocortisone
Brand Name: cortef
Recommended Dosage, Route, And
Frequency:Topical (Adults and Children):
Apply to affected area(s) 1– 4 times daily
(depends on product, preparation, and
condition being treated). Rect (Adults):
Aerosol foam—90 mg 1– 2 times/day for 2–
3wk; then adjusted.
Action: Suppress normal immune response
and inflammation. Therapeutic Effects:
Suppression of dermatologic inflammation
and immune processes.
Absorption: Minimal. Prolonged use on
large surface areas, application of large
amounts, or use of occlusive dressings may
systemic absorption.
Distribution: Remain primarily at site of
action.
Metabolism and Excretion: Usually
metabolized in skin; some have been
modified to resist local metabolism and have
a prolonged local effect.
Half-life: 1.5– 2 hr (plasma), 8– 12 hr
(tissue).
Route:Topical
Onset:mins–hrs
Peak:hrs–days
Duration: hrs–days
Drug-Drug & Drug-Food
Interactions:Drug-Drug: None significant
Indications: Management of inflammation
and pruritis associated with various
allergic/immunologic skin problems.
Contraindications: Hypersensitivity or
known intolerance to glucocorticoid or
components of vehicles (ointment or cream
base, preservative, alcohol); Untreated
bacterial or viral infections.
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Side effects: Derm:allergic contact
dermatitis, atrophy, burning, dryness,
edema, folliculitis, hypersensitivity reactions,
hypertrichosis, hypopigmentation, irritation,
maceration, miliaria, perioral dermatitis,
secondary infection, striae.
Adverse effects: Misc: adrenal
suppression (use of occlusive dressings,
long-term therapy).
Responsibilities in the Nursing Process
Assessment
● Assess affected skin before and daily
during therapy. Note degree of inflammation
and pruritus. Notify health care professional
if symptoms of infection (increased pain,
erythema, purulent exudate) develop.
● Lab Test Considerations: Periodic
adrenal function tests may be ordered to
assess degree of hypothalamic-pituitary-
adrenal (HPA) axis suppression in chronic
topical therapy if suspected. Children and
patients with dose applied to a large area,
using an occlusive dressing, or using high-
potency products are at highest risk for HPA
suppression.
● May cause increased serum and urine
glucose concentrations if significant
absorption occurs.
Potential Nursing Diagnoses
Risk for impaired skin integrity (Indications)
Risk for infection (Side Effects) Deficient
knowledge, related to medication regimen
(Patient/Family Teaching)
Implementation
● Choice of vehicle depends on site and
type of lesion. Ointments are more occlusive
and preferred for dry, scaly lesions. ● Apply
ointments, creams, or gels sparingly as a
thin film to clean, slightly moist skin. Wash
hands immediately after application.
● Apply lotion, solution, orgel to hair by
parting hair and applying a small amount to
affected area. Rub in gently. Protect area
from washing, clothing, or rubbing until
medication has dried.
● Use aerosols by shaking well and spraying
on affected area, holding container 3– 6 in.
away. Spray for about 2 sec to cover an
area the size of a hand. Do not inhale. If
spraying near face, cover eyes.
Patient/Family Teaching
● Instruct patient on correct technique of
medication administration. Emphasize
importance of avoiding the eyes. If a dose is
missed, it should be applied as soon as
remembered unless almost time for next
dose.
● Caution patient to use only as directed.
Avoid using cosmetics, bandages,
dressings, or other skin products over the
treated area unless directed by health care
professional.
● Advise parents of pediatric patients not to
apply tight-fitting diapers or plastic pants on
a child treated in the diaper area; these
garments work like an occlusive dressing
and may cause more of the drug to be
absorbed.
● Instruct patient to inform health care
professional if symptoms of underlying
disease return or worsen or if symptoms of
infection develop.
Evaluation/Desired Outcomes
● Resolution of skin inflammation, pruritus,
or other dermatologic conditions.
Drug classification:INTERMEDIATE-
ACTING
GLUCOCORTICOIDS
Generic name: Prednisone
Brand Name:
Recommended Dosage, Route, And
Frequency:
PO (Adults): Most uses—5– 60 mg/day as
a single dose or in divided doses (delayed-
release tablets should be administered once
daily). Multiple sclerosis—200 mg/day for 1
wk, then 80 mg every other day for 1 mo.
Adjunctive therapy of Pneumocystis jirovecii
pneumonia in AIDS patients—40 mg twice
daily for 5 days, then 40 mg once daily for 5
days, then 20 mg once daily for 10 days.
PO (Children): Nephrotic syndrome—2
mg/kg/day initially given in 1– 3 divided
doses (maximum 80 mg/day; delayed-
release tablets should be administered once
daily) until urine is protein free for 4– 6
weeks. Maintenance dose of 2 mg/kg/day
every other day in the morning, gradually
taper off after 4– 6 weeks. Asthma
exacerbation—1 mg/kg q 6 hr for 48 hr, then
1– 2 mg/kg/day (maximum 60 mg/day) in
divided doses twice daily.
Action:In pharmacologic doses, suppresses
inflammation and the normal immune
response. Suppresses adrenal function at
chronic doses of 5 mg/day.Replaces
endogenous cortisol in deficiency states.
Has minimal mineralocorticoid activity.
Absorption: Well absorbed after oral
administration.
Distribution: Widely distributed; crosses the
placenta and probably enters breast milk.
Metabolism and Excretion: Converted by
the liver to prednisolone, which is then
metabolized by the liver.
Half-life: 3.4– 3.8 hr (plasma), 18– 36 hr
(tissue); adrenal suppression lasts 1.25– 1.5
days.
Route: PO
Onset: hrs
Peak: unknown
Duration: 1.25–1.5 days
Page | 117
Drug-Drug & Drug-Food
Interactions:Drug-Drug: Additive
hypokalemia withthiazide and loop diuretics,
amphotericin B, piperacillin, or ticarcillin.
Hypokalemia may  risk of digoxin toxicity.
May requirement for insulins ororal
hypoglycemic agents. Phenytoin,
phenobarbital, and rifampin stimulate
metabolism; may effectiveness. Oral
contraceptives may metabolism.risk of
adverse GI effects with NSAIDs(including
aspirin). At chronic doses that suppress
adrenal function, may  antibody response
to and the risk of adverse reactions from
live virus vaccines. May risk of tendon
rupture fromfluoroquinolones.
Indications:Used systemically and locally in
a wide variety of chronic diseases including:
Inflammatory, Allergic, Hematologic,
Neoplastic, Autoimmune disorders. Suitable
for alternate-day dosing in the management
of chronic illness.
Contraindicated in: Active untreated
infections (may be used in patients being
treated for tuberculous meningitis); Some
products contain alcohol and should be
avoided in patients with known intolerance;
Lactation: Avoid chronic use.
Side effects:CNS: depression, euphoria,
headache,intracranial pressure (children
only), personality changes, psychoses,
restlessness. EENT: cataracts,intraocular
pressure.GI: PEPTIC ULCERATION,
anorexia, nausea, vomiting. Derm:
acne,wound healing, ecchymoses, fragility,
hirsutism, petechiae.
Adverse effects:CV: hypertension. Endo:
adrenal suppression, hyperglycemia.
F and E: fluid retention (long-term high
doses), hypokalemia, hypokalemic alkalosis.
Hemat: thromboembolism, thrombophlebitis.
Metab: weight gain, weight loss. MS:
muscle wasting, osteoporosis, avascular
necrosis of joints, muscle
pain.Misc:cushingoid appearance (moon
face, buffalo hump), susceptibility to
infection.
Responsibilities in the Nursing Process
Assessment
● Pedi: Children should have periodic
evaluations of growth.
● Lab Test Considerations: Monitor serum
electrolytes and glucose. May decrease
WBC counts.May  serum potassium and
calcium and serum sodium concentrations.
● Guaiac-test stools. Promptly report
presence of guaiac-positive stools.
● May serum cholesterol and lipid
values.May uptake of thyroid 123I or 131I.
Potential Nursing Diagnoses
Risk for infection (Side Effects
Deficient knowledge, related to medication
regimen (Patient/Family Teaching)
Patient/Family Teaching
● Instruct patient on correct technique of
medication administration.Advise patient to
take medication as directed. Take missed
doses as soon as remembered unless
almost time for next dose.
Evaluation/Desired Outcomes
● Decrease in presenting symptoms with
minimal systemic side effects.
● Suppression of the inflammatory and
immune responses in autoimmune
disorders, allergic reactions, and
neoplasms.● Management of symptoms in
adrenal insufficiency.
3. Classification: LONG ACTING
Generic Name: Dexamethasone
Brand Name: Decadron
Recommended Dosage, Route and
Frequency
Anti-inflammatory—0.75– 9 mg daily in
divided doses q 6– 12 hr. Airway edema or
extubation—0.5– 2 mg/kg/day divided q 6
hr; begin 24 hr prior to extubation and
continue for 24 hr post-extubation. Cerebral
edema—10 mg IV, then 4 mg IM or IV q 6 hr
until maximal response achieved, then
switch to PO regimen and taper over 5– 7
days.
Drug Action
Absorption: Well absorbed after oral
administration. Sodium phosphate salt is
rapidly absorbed after IM administration.
Absorption from local sites (intra-articular,
intralesional) is slow but complete.
Distribution: Widely distributed, crosses the
placenta, and appears to enter breast milk.
Metabolism and Excretion:Mostly
metabolized by the liver. Half-life: Low birth
weight infants with BPD: 9.3 hr; Children 3
mo– 16 yr: 4.3 hr; Adults: 3– 4.5 hr
(plasma), 36– 54 hr (tissue); adrenal
suppression lasts 2.75 days.
Interactions
Risk of hypokalemia with thiazide and loop
diuretics, amphotericin B, piperacillin,
orticarcillin. Hypokalemia may increase risk
of digoxin toxicity. Mayqrequirement for
insulin or oral hypoglycemic agents.
Mayplevels ofphenytoin and isoniazid.
Levels may beqwith oral contraceptives
increase risk of adverse GI effects with
Page | 118
NSAIDs(including aspirin),alcohol and
caffeine. At chronic doses that suppress Diagnosis
adrenal function, may decrease the antibody ● Risk for infection (Side Effects)
response to and increase risk of adverse Disturbed body image (Side Effects)
reactions fromlive-virus vaccines.
Mayqorpthe effects ofwarfarin. Planning

Indications: ● Instruct patient on correct technique of

Used systemically and locally in a wide medication administration. Advise patient to
variety of chronic diseases including: take medication as directed. Take missed
Inflammatory, Allergic, Hematologic, doses as soon as remembered unless
Endocrine, Neoplastic, Dermatologic, almost time for next dose. Do not double
Autoimmune disorders, Management of doses. Stopping the medication suddenly
cerebral edema, Diagnostic agent in adrenal may result in adrenal insufficiency (anorexia,
disorders. nausea, weakness, fatigue, dyspnea,
Contraindications hypotension, hypoglycemia). If these signs
Active untreated infections (may be used in appear, notify health care professional
patients being treated for tuberculous immediately; may be life-threatening.
meningitis); Known alcohol or bisulfite
hypersensitivity or intolerance (some ● Corticosteroids cause immunosuppression
products contain these and should be and may mask symptoms of infection.
avoided in susceptible patients); Lactation: Instruct patient to avoid people with known
Avoid chronic use. contagious illnesses and to report possible
infections immediately.
Side Effects
CNS: depression, euphoria, hallucinations, Implementation
headache,increase intracranial pressure ● If dose is ordered daily or every other day,
(children only), insomnia, personality administer in the morning to coincide with
changes, psychoses, restlessness. EENT: the body’s normal secretion of cortisol.
cataracts,increase intraocular pressure. CV: ● Periods of stress, such as surgery, may
hypertension, edema. GI: PEPTIC require supplemental systemic
ULCERATION, anorexia, nausea, increase corticosteroids.
appetite, vomiting. Derm:acne, decrease ● PO: Administer with meals to minimize GI
wound healing, ecchymoses, hirsutism, irritation.
petechiae ● Tablets may be crushed and administered
with soft food, chocolate syrup, or fluids for
Adverse Reaction patients with difficulty swallowing.
Endo:adrenal suppression, hyperglycemia. F
and E: amenorrhea, hypokalemia, alkalosis. Evaluation
Hemat: THROMBOEMBOLISM, ● Instruct patient on correct technique of
thrombophlebitis. Metab: weight gain. MS: medication administration. Advise patient to
muscle wasting, osteoporosis, avascular take medication as directed. Take missed
necrosis of joints, muscle doses as soon as remembered unless
pain.Misc:cushingoid appearance(moon almost time for next dose. Do not double
face, buffalo hump), increase susceptibility doses. Stopping the medication suddenly
to infection. may result in adrenal insufficiency (anorexia,
nausea, weakness, fatigue, dyspnea,
Nursing Responsibilities: hypotension, hypoglycemia). If these signs
appear, notify health care professional
immediately; may be life-threatening.
Assessment ● Corticosteroids cause immunosuppression
● Indicated for many conditions. Assess and may mask symptoms of infection.
involved systems before and periodically Instruct patient to avoid people with known
during therapy. contagious illnesses and to report possible
● Assess for signs of adrenal insufficiency infections immediately.
(hypotension, weight loss, weakness,
nausea, vomiting, anorexia, lethargy,
confusion, restlessness) before and
periodically during therapy.

Page | 119
4. Classification: Side Effects / Adverse Reaction:
MINERALOCORTICOIDS
Generic Name: Fluodrocortisone Side Effects

Brand Name: Florinef CNS: dizziness, headache.

CV: HF, arrhythmias, edema,
Recommended Dosage, Route and hypertension.GI:anorexia, nausea.
Frequency: Endo: adrenal suppression, weight gain.
F and E: hypokalemia, hypokalemic
PO (Adults): Adrenocortical insufficiency— alkalosis.
100 mcg/day (range 100 mcg 3 times
weekly— 200 mcg daily). Doses as small as Adverse Reaction
50 mcg daily may be required by some MS: arthralgia, muscular weakness, tendon
patients. Use with 10– 37.5 mg cortisone contractures.
daily or 10– 30 mg hydrocortisone daily. Neuro: ascending paralysis.
Adrenogenital syndrome—100– 200 Misc: hypersensitivity reactions.
mcg/day. Idiopathic hypotension— 50– 200
mcg/day (unlabeled). PO (Children): 50– Nursing Responsibilities:
100 mcg/day.
Nursing Interventions
Drug Action
Assessment
Absorption:Well absorbed following oral
administration. ● Monitor BP periodically during therapy.
Distribution:Widely distributed; probably Report significant changes. Hypotension
enters breast milk. may indicate insufficient dose.
Protein Binding: High. ● Monitor for fluid retention (weigh daily,
Metabolism and Excretion: Mostly assess for edema, and auscultate lungs for
metabolized by the liver. rales/crackles).
Half-life: 3.5 hr. ● Monitor patients with Addison’s disease
closely and stop treatment if a significant
Drug-Drug and Drug-Food Interactions: increase in weight or BP, edema, or cardiac
enlargement occurs. Patients with Addison’s
Drug-Drug disease are more sensitive to the action of
Use with thiazide or loop diuretics, fludrocortisone and may have an
piperacillin, or amphotericin B mayqrisk of exaggerated response.
hypokalemia. Hypokalemia mayqrisk of
digoxin toxicity. May produce prolonged Diagnosis
neuromuscular blockade following the use of  Deficient fluid volume (Indications)
nondepolarizing neuromuscular blocking Excess fluid volume (Side Effects)
agents. Phenobarbital or rifampin
mayqmetabolism andpeffectiveness. Planning
● Instruct patient to take medication as
Drug-Food directed. Take missed doses as soon as
Large amounts of salt or sodium-containing remembered but not just before next dose is
foods may cause excessive sodium due. Explain that lifelong therapy may be
retention and potassium loss. necessary and that abrupt discontinuation
may lead to Addisonian Crisis. Patient
Indications: should keep an adequate supply available at
Sodium loss and hypotension associated all times.
with adrenocortical insufficiency (given with
hydrocortisone or cortisone). Management Implementation
of sodium loss due to congenital PO: Tablets are scored and may be broken
adrenogenital syndrome (congenital adrenal if dose adjustment is necessary
hyperplasia).
Evaluation
Contraindications Normalization of fluid and electrolyte
 Hypersensitivity. balance without the development of
hypokalemia or hypertension.

Page | 120
B. ADRENAL HORMONE CONTRAINDCIATIONS
Hypersensitivity to active ingredients,
1. CLASSIFICATION: Glucorticoid additives, preservatives, or bases; Some
Synthesis Blocker products contain sulfites and should be
avoided in patients with known intolerance
GENERIC NAME: Ketoconazole
SIDE EFFECTS/ADVERSE REACTIONS:
BRAND NAME: Nizoral Local: burning, itching, local hypersensitivity
reactions, redness, stinging.
RECOMMENDED DOSAGE, ROUTE, AND Derm: increase hair loss (shampoo).
FREQUENCY:
Topical (Adults and Children 12 yr): Apply
NURSING RESPONSIBILITIES:
cream once daily for cutaneous candidiasis,
tinea corporis, tinea cruris, tinea pedia, and
NURSING INTERVENTIONS
tinea versicolor. Apply cream twice daily for
seborrheic dermatitis. Patients with
Assessment
cutaneous candidiasis, tinea cruris, tinea
● Inspect involved areas of skin and mucous
corporis, and tinea versicolor should be
membranes before and frequently during
treated for 2 wk. Patients with tinea pedis
therapy. Increased skin irritation may
should be treated for 6 wk. Patients with
indicate need to discontinue medication.
seborrheic dermatitis should be treated for 4
wk (2 wk with gel). For dandruff, use
Diagnosis
shampoo twice weekly (wait 3– 4 days
Risk for impaired skin integrity (Indications)
between treatments) for 4 wk, then
Risk for infection (Indications).
intermittently.
Deficient knowledge, related to medication
regimen (Patient/Family Teaching)

DRUG ACTION
Planning
● Instruct patient to apply medication as
Absorption: Minimal absorption through
directed for full course of therapy, even if
intact skin.
feeling better. Emphasize the importance of
Distribution: If absorption occurs, widely
avoiding the eyes.
distributed; crosses the placenta; enters
● Patients with athlete’s foot should be
breast milk. Action after topical
taught to wear well-fitting, ventilated shoes
administration is primarily local. Metabolism
and to change shoes and socks at least
and
once a day.
Excretion: If absorbed, partially
● Advise patient to report increased skin
metabolized by the liver then excreted in
irritation or lack of response to therapy to
feces via biliary excretion.
health care professional.
Half-life: If absorbed, 8 hr.

Implications
INTERACTIONS:
● Consult health care professional for proper
cleansing technique before applying
Drugs that affect the absorption, distribution,
medication.
metabolism, and excretion of ketoconazole
● Topical: Apply small amount to cover
may alter the plasma concentrations of
affected area completely. Avoid the use of
ketoconazole. For example, gastric acid
occlusive wrappings or dressings unless
suppressants (e.g., antacids, histamine H2-
directed by health care professional.
blockers, proton pump inhibitors) have been
shown to reduce plasma concentrations of
Evaluation
ketoconazole.
 Decrease in skin irritation and
resolution of infection. Early relief of
INDICATIONS symptoms may be seen in 2– 3 days.
For Candida, tinea cruris, and tinea
Treatment of a variety of cutaneous fungal
corporis, 2 wk are needed, and for tinea
infections, including cutaneous candidiasis,
pedis, therapeutic response may take
tinea pedis (athlete’s foot), tinea cruris (jock
4– 6 wk. Use for seborrheic for 4 wk (2
itch), tinea corporis (ringworm), dandruff (as wk with gel). Recurrent fungal infections
a shampoo), seborrheic dermatitis, and tinea may be a sign of systemic illness.
versicolor.

Page | 121
2.B Classification: 1st
GENERATION INTERMEDIATE Contraindications
Contraindicated in: Hypersensitivity;
ACTING Hypersensitivity to sulfonamides
Generic Name: Tolazamide (crosssensitivity may occur); Type 1
Brand Name: Tolinase diabetes (as monotherapy); Diabetic coma
or ketoacidosis; Severe renal, hepatic,
thyroid, or other endocrine disease;
Recommended Dosage, Route and Uncontrolled infection, serious burns, or
Frequency trauma.

PO (Adults): 100– 250 mg/day (range 100– Side Effects

1000 mg/day; doses 500 m g/day should be
given as divided doses). PO (Geriatric Adverse Reactions/Side Effects
Patients or malnourished, underweight CNS: dizziness, drowsiness, headache,
patients): 100 mg/day initially. weakness.
GI: constipation, cramps, diarrhea, drug-
Drug Action induced hepatitis, dyspepsia,qappetite,
Pharmacokinetics Absorption:Well absorbed nausea, vomiting.
following oral administration. Derm: photosensitivity, rashes.
Distribution: Unknown. Endo: hypoglycemia.
Protein Binding: 94%. Metabolism and
Excretion: Mostly metabolized by the liver; Adverse Reaction
some conversion to metabolites with a. F and E: hyponatremia.Hemat:
hypoglycemic activity. APLASTIC ANEMIA, agranulocytosis,
Half-life: 7 hr leukopenia, pancytopenia,
thrombocytopenia.
Interactions:

Drug-Drug: Ingestion of alcohol may result Nursing Responsibilities

in disulfiram-like reaction. Effectiveness may
bepby concurrent use of Assessment
diuretics,corticosteroids, phenothiazines, ● Observe patient for signs and symptoms
hormonal contraceptives, estrogens, thyroid of hypoglycemic reactions (sweating,
preparations, phenytoin, nicotinic acid, hunger, weakness, dizziness, tremor,
sympathomimetics (adrenergics), and tachycardia, anxiety). Patients on concurrent
isoniazid. Alcohol, androgens (testosterone), beta-blocker therapy may have very subtle
chloramphenicol, MAO inhibitors, NSAIDs signs and symptoms of hypoglycemia.
(except diclofenac), salicylates, ● Assess patient for allergy to
sulfonamides, and warfarin may q the risk of sulphonamides
hypoglycemia. Concurrent use with warfarin
may alter the response to both agents Diagnosis
(qeffects of both initially, thenpactivity; close Imbalanced nutrition: more than body
monitoring recommended during any requirements (Indications)
changes in dosage). Beta blockers may Noncompliance (Patient/Family Teaching)
mask the signs and symptoms of P- Patient/Family Teaching ● Instruct patient
hypoglycemia. to take medication at same time each day. If
a dose is missed, take as soon as
Drug-Natural Products: Glucosamine may remembered unless almost time for next
worsen blood glucose control. dose. Do not take if unable to eat. ● Explain
Fenugreek,chromium, and coenzyme Q-10 to patient that this medication controls
may produce additive hypoglycemic effects. hyperglycemia but does not cure diabetes.
Therapy is long-term.

Indication Implimentation
Accidental administration of oral
Control of blood sugar in type 2 diabetes hypoglycemic agents to non-diabetic adults
mellitus when diet therapy fails. Requires and children has resulted in serious harm or
some pancreatic function. death. Before administering, confirm that

Page | 122
patient has Type 2 diabetes. Do not confuse
tolazamide with tolbutamide.
● Patients stabilized on a diabetic regimen
who are exposed to stress, fever, trauma,
infection, or surgery may require
administration of insulin.
Evaluation
● Control of blood glucose levels without the
appearance of hypoglycemic or
hyperglycemic episodes.
E. ANTIDIABETICS
A. Insulin
CLASSIFICATION: SHORT
DURATION: RAPID ACTING
INSULIN
GENERIC NAME: Insulin Aspart
BRAND NAME: Novolog
RECOMMENDED DOSAGE, ROUTE, AND
FREQUENCY
Subcut (Adults and Children): Determined
by needs of the patients; generally 0.5– 1
units/kg/day total. 50– 70% may be given as
insulin aspart, and the remainder as
intermediate- or long-acting insulin. May
also be given via subcutaneous infusion
pump; initial programming based on total
daily dose of insulin given in previous
regimen with 50% of total daily dose given
as premeal boluses and 50% of total daily
dose given as basal infusion; dose can then
be adjusted based on response.
DRUG ACTION
Absorption: Rapid acting.
Distribution: Identical to endogenous
insulin.
Metabolism and Excretion: Metabolized by
liver, spleen, kidney, and muscle.
Half-life: Approximately 60– 90 min.
Drug-Drug and Drug-Food
INTERACTIONS
● Beta blockersand clonidinemay mask
some of the signs and symptoms of
hypoglycemia. Corticosteroids, thyroid
supplements, estrogens, isoniazid, niacin,
phenothiazines, and rifampinmayqinsulin
requirements. Alcohol, ACE inhibitors, MAO
inhibitors, octreotide, oral hypoglycemic
agents, and salicylates, maypinsulin
requirements. Concurrent use with
pioglitazone or rosiglitazonemayqrisk of fluid
retention and worsening HF
INDICATIONS
● Control of hyperglycemia in patients with
type 1 or type 2 diabetes mellitus
CONTRAINDCIATIONS
● Contraindicated in Hypoglycemia; Allergy
or hypersensitivity to insulin aspart
SIDE EFFECTS/ADVERSE REACTIONS
Endo
HYPOGLYCEMIA.
Local: lipodystrophy, pruritis, erythema,
swelling.
Misc:allergic reactions including
ANAPHYLAXIS.
NURSING RESPONSIBILITIES:
NURSING INTERVENTIONS:
Assessment
● Assess for symptoms of hypoglycemia
(anxiety; restlessness; tingling in hands,
feet, lips, or tongue; chills; cold sweats;
confusion; cool, pale skin; difficulty in
concentration; drowsiness; nightmares or
trouble sleeping; excessive hunger;
headache; irritability; nausea; nervousness.
● Monitor body weight periodically. Changes
in weight may necessitate changes in insulin
dose
Diagnosis
● Noncompliance
Planning
● Instruct patient on proper technique for
administration. Include type of insulin,
equipment (syringe, cartridge pens, external
pumps, alcohol swabs), storage, and place
to discard syringes. Discuss the importance
of not changing brands of insulin or
syringes, selection and rotation of injection
sites, and compliance with therapeutic
regimen. Caution patient that insulin pens
should not be shared with others, even if
clean needles are used.
Implementation
● High Alert: Medication errors involving
insulins have resulted in serious patient
harm and death. Clarify all ambiguous
orders and do not accept orders using the
abbreviation “u” for units, which can be
misread as a zero or the numeral 4 and has
Page | 123
resulted in tenfold overdoses. Insulins are coenzyme Q-10 may produce additive
available in different types and strengths. hypoglycemic effects.
Check type, dose, and expiration date with
another licensed nurse. Do not interchange
insulins without consulting physician or other Indications
health care professional. Do not confuse
Novolog with Novolin. Due to the short Control of hyperglycemia in patients with
duration of action, insulin aspart must be diabetes mellitus. Concentrated regular
used with a longer-acting insulin or insulin insulin U-500: Only for use in patients with
infusion pump therapy. insulin requirements 200 units/day.

Evaluation: Control of blood glucose levels

in diabetic patients without hypoglycemic or Contraindications
hyperglycemic episodes.
Contraindicated in: Hypoglycemia; Allergy or
hypersensitivity to a particular type of
2. Brand Name: Humilin R
insulin, preservatives, or other additives.
Generic Name: Regular Insulin
Classification: SHORT DURATION:
SLOWER ACTING Side Effects and Adverse Reaction:

Endo: HYPOGLYCEMIA. Local:

lipodystrophy, pruritus, erythema, swelling.
Recommended Dosage, Route and
Misc: allergic reactions including
Frequency
ANAPHYLAXIS.
Ketoacidosis—Regular (100 units/mL)
Insulin Only IV (Adults): 0.1 unit/kg/hr as a
Nursing Responsibilities :
continuous infusion. IV (Children): Loading
dose-0.1 unit/kg, then maintenance
continuous infusion 0.05– 0.2 unit/kg/hr,
Assessment
titrate to optimal rate of decrease of serum
glucose of 80– 100 mg/dL/hr ● Assess patient periodically for symptoms
of hypoglycemia (anxiety; restlessness;
tingling in hands, feet, lips, or tongue; chills;
Drug Action
cold sweats; confusion
Absorption: Rapidly absorbed from
● Assess patient periodically for symptoms
subcutaneous administration sites. U-100
of hypoglycemia (anxiety; restlessness;
regular insulin is absorbed slightly more
tingling in hands, feet, lips, or tongue; chills;
quickly than U-500.
cold sweats.
Distribution: Identical to endogenous insulin.

Metabolism and Excretion:Metabolized by Diagnosis

liver, spleen, kidney, and muscle. Half-life:
30– 60 min. Noncompliance (Patient/Family Teaching)

Interactions
Planning
Beta blockers, clonidine, and reserpine may
mask some of the signs and symptoms of ● Instruct patient on proper technique for
hypoglycemia. Corticosteroids,thyroid administration. Include type of insulin,
supplements, estrogens, isoniazid, niacin, equipment (syringe, cartridge pens, alcohol
phenothiazines, and rifampin mayqinsulin swabs), storage, and place to discard
requirements. Alcohol, ACE inhibitors, MAO syringes. Discuss the importance of not
inhibitors, octreotide, oral hypoglycemic changing brands of insulin or syringes,
agents, and salicylates, maypinsulin selection and rotation of injection sites, and
requirements. Concurrent use with compliance with therapeutic regimen.
pioglitazone orrosiglitazonemayqrisk of fluid Opened, unused insulin vials should be
retention and worsening HF. Drug-Natural discarded 1 mo after opening.
Products: Glucosamine may worsen blood
glucose control. Fenugreek,chromium, and

Page | 124
● Demonstrate technique for mixing insulins Drug-Drug: Beta blockers, clonidine, and
by drawing up regular insulin first and rolling reserpine may mask some of the signs and
intermediate-acting insulin vial between symptoms of hypoglycemia.
palms to mix, rather than shaking (may Corticosteroids,thyroid supplements,
cause inaccurate dose). estrogens, isoniazid, niacin, phenothiazines,
and rifampin mayqinsulin requirements.
Alcohol, ACE inhibitors, MAO inhibitors,
Implementation octreotide, oral hypoglycemic agents, and
salicylates, maypinsulin requirements.
● Do not confuse Humulin with Humalog. Do
Concurrent use with pioglitazone
not confuse Novolin with Novolog.
orrosiglitazonemayqrisk of fluid retention
● Use only insulin syringes to draw up and worsening HF. Drug-Natural Products:
dose. The unit markings on the insulin Glucosamine may worsen blood glucose
syringe must match the insulin’s units/mL. control. Fenugreek,chromium, and
Special syringes for doses 50 units are coenzyme Q-10 may produce additive
available. Prior to withdrawing dose, rotate hypoglycemic effects.
vial between palms to ensure uniform
Indications
solution; do not shake.
Control of hyperglycemia in patients with
● When mixing insulins, draw regular insulin
diabetes mellitus
into syringe first to avoid contamination of
regular insulin vial.
Contraindications

Evaluation Contraindicated in: Hypoglycemia; Allergy or

hypersensitivity to a particular type of
● Control of blood glucose levels in diabetic
insulin, preservatives, or other additives.
patients without the appearance of
hypoglycemic or hyperglycemic episodes.

3. Brand Name: Humulin N

Generic Name: NPH Insulin Side Effects and Adverse Reaction
Classification: INTERMEDIATE Endo: HYPOGLYCEMIA. Local:
DURATION INSULIN lipodystrophy, pruritus, erythema, swelling.
Misc: allergic reactions including
ANAPHYLAXIS.
Recommended Dosage, Route and
Frequency
Nursing Responsibilities
Dose depends on blood glucose, response,
and many other factors. Subcut (Adults and
Children): 0.5– 1 unit total insulin/kg/day. Assessment
Adolescents during rapid growth—0.8– 1.2
units total insulin/kg/day. Assess patient periodically for symptoms of
hypoglycemia (anxiety; restlessness; tingling
in hands, feet, lips, or tongue; chills; cold
Drug Action sweats; confusion; cool, pale skin; difficulty
in concentration; drowsiness; nightmares or
Absorption: Rapidly absorbed from
trouble sleeping; excessive hunger;
subcutaneous administration sites.
headache; irritability; nausea; nervousness;
Presence of protamine delays peak effect
tachycardia; tremor; weakness; unsteady
and prolongs action.
gait)and hyperglycemia (confusion,
Distribution: Identical to endogenous insulin.
drowsiness; flushed, dry skin; fruit-like
Metabolism and Excretion:Metabolized by
breath odor; rapid, deep breathing, polyuria;
liver, spleen, kidney, and muscle. Half-life:
loss of appetite; unusual thirst) during
Unknown.
therapy.

● Monitor body weight periodically.

Interactions
Changes in weight may necessitate changes
in insulin dose.

Page | 125
-Monitor blood glucose every 6 hr during
therapy, more frequently in ketoacidosis and
times of stress. A1C may be monitored
every 3– 6 mo to determine effectiveness
Diagnosis
Noncompliance (Patient/Family Teaching)
Planning
● Instruct patient on proper technique for
administration. Include type of insulin,
equipment (syringe, cartridge pens, alcohol
swabs), storage, and place to discard
syringes. Discuss the importance of not
changing brands of insulin or syringes,
selection and rotation of injection sites, and
compliance with therapeutic regimen.
Caution patient that insulin pens should not
be shared with others, even if clean needles
are used.
● Demonstrate technique for mixing insulins
by drawing up regular insulin or insulin lispro
first and rolling intermediate-acting insulin
vial between palms to mix, rather than
shaking (may cause inaccurate dose).
Implementation
● Do not confuse Humulin with Humalog. Do
not confuse Novolin with Novolog.
● Use only insulin syringes to draw up dose.
The unit markings on the insulin syringe
must match the insulin’s units/mL. Special
syringes for doses 50 units are available.
Prior to withdrawing dose, rotate vial
between palms to ensure uniform solution;
do not shake.
● When mixing insulins, draw regular insulin
or insulin lispro into syringe first to avoid
contamination of regular insulin vial.
Evaluation
● Control of blood glucose levels in diabetic
patients without the appearance of
hypoglycemic or hyperglycemic episodes
4. CLASSIFICATION: Long Duration
Insulin
GENERIC NAME: Insulin Glargine
(U-100)
BRAND NAME: Lantus
RECOMMENDED DOSAGE, ROUTE, AND
FREQUENCY:
SubQ (Adults and Children 6 yr): Initiation in
patients with type 2 diabetes already being
treated with oral antidiabetic agents—10
units once daily; then adjusted on the basis
of patient’s needs (range 2– 100 units/day),
Conversion from other intermediate- or long-
acting insulin Use 80% of the total daily NPH
or dose once daily, then adjust on the basis
of patient’s needs.
A: Provides slower prolonged absorption
and a relatively constant concentrations over
24 hr.
D: Identical to endogenous insulin.
M&E: Partially metabolized at the site of
injection to active insulin metabolites.
Metabolized by liver, spleen, kidney, muscle.
Half-life: 5– 6 min (prolonged in diabetic
patients; biological half-life is longer).
DRUG ACTION:
Lowers blood glucose by: stimulating
glucose uptake in skeletal muscle and fat,
inhibiting hepatic glucose production. Other
actions of insulin: inhibition of lipolysis and
proteolysis, enhanced protein synthesis.
Therapeutic Effects:
Control in hyperglycemia of diabetic
patients.
INTERACTIONS:
Drug-Drug: Beta blockers, clonidine, and
reserpine may mask some of the signs and
symptoms of hypoglycemia. Corticosteroids,
thyroid supplements, estrogens, isoniazid,
niacin, phenothiazines, and rifampin may
increase insulin requirements. Alcohol, ACE
inhibitors, MAO inhibitors, octreotide, oral
hypoglycemic agents, and salicylates, may
decrease insulin requirements. Concurrent
use with pioglitazone or rosiglitazone may
increase risk of fluid retention and worsening
INDICATIONS:
Control of hyperglycemia in patients with
type 1 and type 2 diabetes mellitus.
CONTRAINDCIATIONS:
Contraindicated in: Hypoglycemia; Allergy or
hypersensitivity to insulin glargine.
Use cautiously in: Stress and infection,
which may temporarily increase insulin
requirement); Renal/hepatic impairment
(may decrease insulin requirements);
Concomitant use with pioglitazone or
Page | 126
rosiglitazone (increased risk of fluid retention Implementation
and worsening HF); Pedi: Children 6 yr
(safety not established); OB: May ● High Alert: Medication errors involving
temporarily increase insulin requirements. insulins have resulted in serious patient
harm and death. Clarify all ambiguous
SIDE EFFECTS/ADVERSE REACTIONS:
orders and do not accept orders using the
Side Effects abbreviation “u” for units, which can be
misread as a zero or the numeral 4 and has
Endo: HYPOGLYCEMIA. resulted in tenfold overdoses. Insulins are
Local: Lipodystrophy, pruritus, erythema, available in different types and strengths.
swelling. Check type, dose, and expiration date with
Misc: Allergic reactions including another licensed nurse. Do not interchange
ANAPHYLAXIS. insulins without consulting physician or other
health care professional.
Adverse Reactions
● When transferring from once-daily NPH
Body as a Whole: Allergic reactions. human insulin to insulin glargine, the dose
Endocrine: Hypoglycemia, hypokalemia. usually remains unchanged. When
Skin: Injection site reaction, lipodystrophy, transferring from twice-daily NPH human
pruritus, rash. insulin to insulin glargine, the initial dose of
insulin glargine is usually reduced by 20%.
Nursing Interventions:
● Do not mix insulin glargine with any other
Assessment
insulin or solution, or use syringes
● Assess for symptoms of hypoglycemia
containing any other medicinal product or
(anxiety; restlessness; tingling in hands,
residue. Solution should be clear and
feet, lips, or tongue; chills; cold sweats;
colorless with no particulate matter.
confusion; cool, pale skin; difficulty in
concentration; drowsiness; nightmares or ● Use only insulin syringes to draw up dose.
trouble sleeping; excessive hunger; Insulin syringe or Solo Star can be used for
headache; irritability; nausea; nervousness; administration. Prior to withdrawing dose,
tachycardia; tremor; weakness) and rotate vial between palms to ensure uniform
hyperglycemia (confusion, drowsiness; solution; do not shake.
flushed, dry skin; fruit-like breath odor; rapid,
deep breathing, polyuria; loss of appetite; ● Store unopened vials and cartridges in the
unusual thirst) periodically during therapy. refrigerator; do not freeze. If unable to
refrigerate, the 10- mL vial can be kept in a
● Monitor body weight periodically. Changes cool place unrefrigerated for up to 28 days.
in weight may necessitate changes in insulin Once the cartridge is placed in a Solo Star,
dose. do not refrigerate.
● Lab Test Considerations: Monitor blood ● Subcut: Administer subcut once daily at
glucose every 6 hr during therapy, more any time during the day, but at the same
frequently in ketoacidosis and times of time each day. Do not administer IV or use
stress. A1C may be monitored every 3– 6 with insulin pumps.
mo to determine effectiveness.
Patient/Family Teaching
● Toxicity and Overdose: Overdose is
manifested by symptoms of hypoglycemia. ● Instruct patient on proper technique for
Mild hypoglycemia may be treated by administration. Include type of insulin,
ingestion of oral glucose. Severe equipment (syringe, cartridge pens, alcohol
hypoglycemia is a life-threatening swabs), storage, and place to discard
emergency; treatment consists of IV syringes. Discuss the importance of
glucose, glucagon, or epinephrine. Recovery selection and rotation of injection sites, and
from hypoglycemia may be delayed due to compliance with therapeutic regimen.
the prolonged effect of subcut insulin
glargine. ● Explain to patient that this medication
controls hyperglycemia but does not cure
Potential Nursing Diagnoses diabetes. Therapy is long term.

Noncompliance (Patient/Family Teaching) ● Instruct patient in proper testing of serum

glucose and ketones. These tests should be

Page | 127
 closely monitored during periods of stress or
illness and health care professional notified
of significant changes.
● Emphasize the importance of compliance
with nutritional guidelines and regular
exercise, as directed by health care
professional.
● Instruct patient to notify health care
professional of all Rx or OTC medications,
vitamins, or herbal products being taken and
to consult health care professional before
taking other Rx, OTC, herbal products, or
alcohol.
● Advise patient to notifies healthcare
professional of medication regimen prior to
treatment or surgery.
● Advise patient to notify health care
professional if nausea, vomiting, or fever
develops, if unable to eat regular diet, or if
blood sugar levels are not controlled.
● Instruct patient on signs and symptoms of
hypoglycemia and hyperglycemia and what
to do if they occur.
● Advise patient to notify health care
professional if pregnancy is planned or
suspected or if breast feeding or planning to
breast feed.
● Patients with diabetes mellitus should
carry a source of sugar (candy, glucose gel)
and identification describing their disease
and treatment regimen at all times.
● Emphasize the importance of regular
follow-up, especially during first few weeks
of therapy.
Evaluation/Desired Outcomes
● Control of blood glucose levels in diabetic
patients without the appearance of
hypoglycemic or hyperglycemic episodes.
5. CLASSIFICATION: ULTRA-
LONG DURATION INSULIN
GENERIC NAME: Insulin glargine
(U-300)
BRAND NAME: Toujeo
RECOMMENDED DOSAGE, ROUTE, AND
FREQUENCY:
 TOUJEO SoloSTAR prefilled pen contains
450 units of TOUJEO (insulin glargine 300
units/ml). With TOUJEO SoloSTAR prefilled
pen a dose of 1-80 units per single injection,
in steps of 1 unit, can be injected.
 TOUJEO DoubleSTAR prefilled pen
contains 900 units of TOUJEO (insulin
glargine 300 units/ml). With TOUJEO
DoubleSTAR prefilled pen a dose of 2-160
units per single injection, in steps of 2 units,
can be injected.
Inject TOUJEO subcutaneously once a day
into the abdominal area, thigh, buttock or
deltoid.
DRUG ACTION:
 The primary activity of insulin, including
insulin glargine, is regulation of glucose
metabolism.
 Insulin and its analogues lower blood
glucose levels by stimulating peripheral
glucose uptake, especially by skeletal
muscle and fat, and by inhibiting hepatic
glucose production. Insulin inhibits
lipolysis in the adipocyte, inhibits
proteolysis, and enhances protein
synthesis.
INTERACTIONS:
Drugs That May Increase the Risk of
Hypoglycemia
The risk of hypoglycemia associated with
TOUJEO use may be increased with
antidiabetic agents, (ACE) inhibitors,
angiotensin II receptor blocking agents,
disopyramide, fibrates, fluoxetine,
monoamine oxidase inhibitors,
pentoxifylline, pramlintide, propoxyphene,
salicylates, somatostatin analogs (e.g.,
octreotide), and sulfonamide antibiotics.
Drugs That May Decrease the Blood
Glucose Lowering Effect of TOUJEO
The glucose lowering effect of TOUJEO may
be decreased when co-administered with
atypical antipsychotics (e.g., olanzapine and
clozapine), corticosteroids, danazol,
diuretics, estrogens, glucagon, isonazid,
niacin, oral contraceptives, phenothiazines,
progestogens (e.g., in oral contraceptives),
protease inhibitors, somatropin,
sympathomimetic agents (e.g., albuterol,
epinephrine, terbutaline) and thyroid
hormones.
Drugs That May Increase or Decrease the
Blood Glucose Lowering Effect of TOUJEO
The glucose lowering effect of TOUJEO may
be increased or decreased when co
administered with alcohol, beta-blockers,
clonidine, and lithium salts. Pentamidine
may cause hypoglycemia which may
sometimes be followed by hyperglycemia.
INDICATIONS:
Page | 128
TOUJEO [insulin glargine injection (rDNA Gastrointestinal disorders: Abdominal
origin)] is indicated for once-daily discomfort, abdominal distension, abdominal
subcutaneous administration in the pain lower, constipation, nausea, vomiting
treatment of adult patients (≥18 years) with General disorders and administration site
Type 1 or Type 2 diabetes mellitus who conditions: Asthenia, fatigue, hunger,
require basal (long-acting) insulin for injection site bruising, injection site
glycemic control. discomfort, injection site erythema, injection
site hemorrhage, injection site
CONTRAINDCIATIONS: inflammation, injection site irritation, injection
TOUJEO [insulin glargine injection (rDNA site pain, injection site pruritus, injection site
origin)] is contraindicated: reaction, edema peripheral
In patients who are hypersensitive to this Infections and infestations: Acute
drug or to any ingredient in the formulation sinusitis, gastroenteritis viral Injury,
or component of the container. For a poisoning and procedural
complete listing, see DOSAGE FORMS, Complications: Accidental overdose,
COMPOSITION AND PACKAGING. During injection related reaction, intentional
the episodes of hypoglycaemia. overdose, overdose, toxicity to various
agents
SIDE EFFECTS/ADVERSE REACTIONS Investigations: Alanine aminotransferase
increased, blood glucose decreased, blood
Side effect: glucose fluctuation, weight increased
Metabolism and nutrition disorders:
Irritation where the shot is given, back pain, Abnormal weight gain, hyperglycemia,
diarrhea, headache, weight gain, signs of a increased appetite
common cold, nose or throat irritation, joint Musculoskeletal and connective tissue
pain and pain in arms or legs. disorders: Arthralgia, muscle spasms,
myalgia
Adverse Reaction: Nervous system disorders: Dizziness,
dizziness postural, headache, hypoglycemic
Type 1 diabetes unconsciousness, sensory loss, tremor
Eye disorders: Eye irritation Psychiatric disorders: Insomnia,
Gastrointestinal disorders: Dry mouth, restlessness
impaired gastric emptying. Renal and urinary disorders: Dysuria,
General disorders and administration site renal impairment
conditions: Fatigue, injection site bruising, Respiratory, thoracic and mediastinal
injection site edema, injection site pain Page disorders: Cough, dyspnea
14 of 92. Skin and subcutaneous tissue disorders:
Infections and infestations: Vulvovaginal Alopecia, erythema, hyperhidrosis, night
mycotic infection Injury, poisoning and sweats
procedural Vascular disorders: Flushing, hypotension
Complications: Contusion, overdose,
investigations, weight increased NURSING INTERVENTIONS:
Metabolism and nutrition disorders:
Dehydration, increased appetite Assessment
Nervous system disorders: Headache, ● Assess for symptoms of hypoglycemia
hypoesthesia, paresthesia, tremor (anxiety; restlessness; tingling in hands,
Psychiatric disorders: Insomnia, sleep feet, lips, or tongue; chills; cold sweats;
disorder confusion; cool, pale skin; difficulty in
Skin and subcutaneous tissue disorders: concentration; drowsiness; nightmares or
Lipohypertrophy, rash trouble sleeping; excessive hunger;
headache; irritability; nausea; nervousness;
Type 2 diabetes tachycardia; tremor; weakness) and
Blood and lymphatic system disorders: hyperglycemia (confusion, drowsiness;
Lymphadenopathy flushed, dry skin; fruit-like breath odor; rapid,
Cardiac disorders: Palpitations deep breathing, polyuria; loss of appetite;
Ear and labyrinth disorders: Tinnitus unusual thirst) periodically during therapy.
Eye disorders: Vision blurred, visual ● Monitor body weight periodically. Changes
impairment in weight may necessitate changes in insulin
dose.

Page | 129
● Lab Test Considerations: Monitor blood
glucose every 6 hr during therapy, more
frequently in ketoacidosis and times of Patient/Family Teaching
stress. A1C may be monitored every 3– 6
● Instruct patient on proper technique for
mo to determine effectiveness.
administration. Include type of insulin,
● Toxicity and Overdose: Overdose is
equipment (syringe, cartridge pens, alcohol
manifested by symptoms of hypoglycemia.
swabs), storage, and place to discard
Mild hypoglycemia may be treated by
syringes. Discuss the importance of
ingestion of oral glucose. Severe
selection and rotation of injection sites, and
hypoglycemia is a life-threatening
compliance with therapeutic regimen.
emergency; treatment consists of IV
● Explain to patient that this medication
glucose, glucagon, or epinephrine. Recovery
controls hyperglycemia but does not cure
from hypoglycemia may be delayed due to
diabetes. Therapy is long term.
the prolonged effect of subcut insulin
● Instruct patient in proper testing of serum
glargine.
glucose and ketones. These tests should be
closely monitored during periods of stress or
Potential Nursing Diagnoses
illness and health care professional notified
Noncompliance (Patient/Family Teaching)
of significant changes.
● Emphasize the importance of compliance
Implementation
with nutritional guidelines and regular
● High Alert: Medication errors involving
exercise, as directed by health care
insulins have resulted in serious patient
professional.
harm and death. Clarify all ambiguous
● Instruct patient to notify health care
orders and do not accept orders using the
professional of all Rx or OTC medications,
abbreviation “u” for units, which can be
vitamins, or herbal products being taken and
misread as a zero or the numeral 4 and
to consult health care professional before
has resulted in tenfold overdoses. Insulins
taking other Rx, OTC, herbal products, or
are available in different types and
alcohol.
strengths. Check type, dose, and expiration
● Advise patient to notify health care
date with another licensed nurse. Do
professional of medication regimen prior to
not interchange insulins without consulting
treatment or surgery.
physician or other health care professional.
● Advise patient to notify health care
● When transferring from once-daily NPH
professional if nausea, vomiting, or fever
human insulin to insulin glargine, the dose
develops, if unable to eat regular diet, or if
usually remains unchanged. When
blood sugar levels are not controlled.
transferring from twice-daily NPH human
● Instruct patient on signs and symptoms of
insulin to insulin glargine, the initial dose of
hypoglycemia and hyperglycemia and what
insulin glargine is usually reduced by 20%.
to do if they occur.
● Do not mix insulin glargine with any other
● Advise patient to notify health care
insulin or solution, or use syringes
professional if pregnancy is planned or
containing any other medicinal product or
suspected or if breast feeding or planning to
residue. Solution should be clear and
breast feed.
colorless with no particulate matter.
● Patients with diabetes mellitus should
● Use only insulin syringes to draw up dose.
carry a source of sugar (candy, glucose gel)
Insulin syringe or Solo Star can be used for
and identification describing their disease
administration. Prior to withdrawing dose,
and treatment regimen at all times.
rotate vial between palms to ensure Uniform
● Emphasize the importance of regular
solution; do not shake.
follow-up, especially during first few weeks
● Store unopened vials and cartridges in the
of therapy.
refrigerator; do not freeze. If unable to
refrigerate, the 10- mL vial can be kept in a
cool place unrefrigerated for up to 28 days.
Evaluation/Desired Outcomes
Once the cartridge is placed in a Solo Star,
● Control of blood glucose levels in diabetic
do not refrigerate.
patients without the appearance of
● Subcut: Administer subcut once daily at hypoglycemic or hyperglycemic episodes.
any time during the day, but at the same
time each day. Do not administer IV or use
with insulin pumps.

Page | 130
6. CLASSIFICATION: PREMIXED Use Cautiously in: Stress or infection (may
INSULIN COMBINATIONS temporarily increase insulin requirements);
Renal/hepatic impairment (may decrease
GENERIC NAME: 70% NPH insulin requirements); Concomitant use with
pioglitazone or rosiglitazone (increased risk
insulin/30% Regular Ins.
of fluid retention and worsening HF); OB:
BRAND NAME: Humulin 70/30, Pregnancy may temporarily increase insulin
Novolin 70/30 requirements.

RECOMMENDED DOSAGE, ROUTE, AND SIDE EFFECTS/ADVERSE REACTIONS:

FREQUENCY:
Side Effects (By System):
Dose depends on blood glucose, response,
and many other factors. Cardiovascular: Peripheral edema
Subcut (Adults and Children): 0.5– 1 unit Dermatologic: Lipodystrophy
total insulin/kg/day. Adolescents during rapid Metabolic: Hypoglycemia
growth—0.8– 1.2 units total insulin/kg/day. Ocular: Refraction anomalies, temporary
A: Rapidly absorbed from subcutaneous worsening of diabetic
administration sites. Presence of protamine retinopathyImmunologic: Anti-insulin
delays peak effect and prolongs action. antibodies
D: Identical to endogenous insulin. Nervous system: Acute painful neuropathy
M&E: Metabolized by liver, spleen, kidney,
Adverse Reactions (By System):
and muscle.
Half-life: Unknown. Endo: HYPOGLYCEMIA.
Local: lipodystrophy, pruritus, erythema,
DRUG ACTION: swelling.
Lowers blood glucose by: stimulating Misc: allergic reactions including
glucose uptake in skeletal muscle and fat, ANAPHYLAXIS.
inhibiting hepatic glucose production. Other
actions of insulin: inhibition of lipolysis and NURSING INTERVENTIONS:
proteolysis, enhanced protein synthesis. Assessment
Therapeutic Effects: Control of
hyperglycemia in diabetic patients. ● Assess patient periodically for symptoms
of hypoglycemia (anxiety; restlessness;
INTERACTIONS: tingling in hands, feet, lips, or tongue; chills;
Drug-Drug: Beta blockers, clonidine, and cold sweats; confusion; cool, pale skin;
reserpine may mask some of the signs and difficulty in concentration; drowsiness;
symptoms of hypoglycemia. Corticosteroids, nightmares or trouble sleeping; excessive
thyroid supplements, estrogens, isoniazid, hunger; headache; irritability; nausea;
niacin, phenothiazines, and rifampin may nervousness; tachycardia; tremor;
increase insulin requirements. Alcohol, ACE weakness; unsteady gait) and
inhibitors, MAO inhibitors, octreotide, oral hyperglycemia (confusion, drowsiness;
hypoglycemic agents, and salicylates, may flushed, dry skin; fruit-like breath odor; rapid,
decrease insulin requirements. Concurrent deep breathing, polyuria; loss of appetite;
use with pioglitazone or rosiglitazone may unusual thirst) during therapy.
increase risk of fluid retention and worsening
HF. ● Monitor body weight periodically. Changes
Drug-Natural Products: Glucosamine may in weight may necessitate changes in insulin
worsen blood glucose control. dose.
Fenugreek, chromium, and coenzyme Q-10
● Lab Test Considerations: Monitor blood
may produce additive hypoglycemic effects.
glucose every 6 hr during therapy, more
frequently in ketoacidosis and times of
INDICATIONS:
stress. A1C may be monitored every 3– 6
Control of hyperglycemia in patients with
mo to determine effectiveness.
diabetes mellitus.
● Toxicity and Overdose: Overdose is
CONTRAINDCIATIONS: manifested by symptoms of hypoglycemia.
Contraindicated in: Hypoglycemia; Allergy or Mild hypoglycemia may be treated by
hypersensitivity to a particular type of ingestion of oral glucose. Severe
insulin, preservatives, or other additives. hypoglycemia is a life-threatening

Page | 131
emergency; treatment consists of IV
glucose, glucagon, or epinephrine.
Potential Nursing Diagnoses
Noncompliance (Patient/Family Teaching)
Implementation
● High Alert: Medication errors involving
insulins have resulted in serious patient
harm and death. Clarify all ambiguous
orders and do not accept orders using the
abbreviation “u” for units, which can be
misread as a zero or the numeral 4 and has
resulted in tenfold overdoses. Insulins are
available in different types and strengths.
Check type, dose, and expiration date with
another licensed nurse. Do not interchange
insulins without consulting physician or other
health care professional.
● Do not confuse Humulin with Humalog. Do
not confuse Novolin with Novolog.
● Use only insulin syringes to draw up dose.
The unit markings on the insulin syringe
must match the insulin’s units/mL. Special
syringes for doses 50 units are available.
Prior to withdrawing dose, rotate vial
between palms to ensure uniform solution;
do not shake.
● When mixing insulins, draw regular insulin
or insulin lispro into syringe first to avoid
contamination of regular insulin vial.
● Insulin should be stored in a cool place but
does not need to be refrigerated.
● When transferring from once-daily NPH
human insulin to insulin glargine, the
dose usually remains unchanged. When
transferring from twice-daily NPH human
insulin to insulin glargine, the initial dose of
insulin glargine is usually reduced by
20%.
● NPH insulin should not be used in the
management of ketoacidosis.
● Subcut: Administer NPH insulin within 30–
60 min before a meal.
Patient/Family Teaching
● Instruct patient on proper technique for
administration. Include type of insulin,
equipment (syringe, cartridge pens, alcohol
swabs), storage, and place to discard
yringes. Discuss the importance of not
changing brands of insulin or syringes,
selection and rotation of injection sites, and
compliance with therapeutic regimen.
Caution patient that insulin pens should not
be shared with others, even if clean
needles are used.
● Demonstrate technique for mixing insulins
by drawing up regular insulin or insulin lispro
first and rolling intermediate-acting insulin
vial between palms to mix,
rather than shaking (may cause inaccurate
dose).
● Explain to patient that this medication
controls hyperglycemia but does not cure
diabetes. Therapy is long term.
● Instruct patient in proper testing of serum
glucose and ketones. These tests should
be closely monitored during periods of
stress or illness and health care professional
notified of significant changes.
● Emphasize the importance of compliance
with nutritional guidelines and regular
exercise as directed by health care
professional.
● Advise patient to notify health care
professional of all Rx or OTC medications,
vitamins, or herbal products being taken and
to consult with health care professional
before taking other medications or alcohol.
● Advise patient to notify health care
professional of medication regimen prior to
treatment or surgery.
● Advise patient to notify health care
professional if nausea, vomiting, or fever
develops, if unable to eat regular diet, or if
blood glucose levels are not controlled.
● Instruct patient on signs and symptoms of
hypoglycemia and hyperglycemia and what
to do if they occur.
● Advise patient to notify health care
professional if pregnancy is planned or
suspected or if breast feeding or planning to
breast feed.
● Patients with diabetes mellitus should
carry a source of sugar (candy, glucose gel)
and identification describing their disease
and treatment regimen at all times.
● Emphasize the importance of regular
follow-up, especially during first few weeks
of therapy.
Evaluation/Desired Outcomes
● Control of blood glucose levels in diabetic
patients without the appearance of
hypoglycemic or hyperglycemic episodes.
Page | 132
 B. Oral Ant diabetic Drugs
1. CLASSIFICATION: BIGUANIDES
GENERIC NAME: Metformin
BRAND NAME: Glucophage
RECOMMENDED DOSAGE, ROUTE, AND
FREQUENCY:
PO (Adults and children >17 yr): 500 mg
twice daily
PO (Children >10 yr): 500 mg twice daily
A: 50– 60% absorbed after oral
administration.
D: Enters breast milk in concentrations
similar to plasma.
M and E: Eliminated almost entirely
unchanged by the kidneys.
Half-life: 17.6 hr
DRUG ACTION:
Decreases hepatic glucose production.
Decreases intestinal glucose absorption.
Increases sensitivity to insulin.
Therapeutic Effects: Maintenance of blood
glucose.
INTERACTIONS:
Drug-Drug: Acute or chronic alcohol
ingestion or iodinated contrast media
increase risk of lactic acidosis. Amiloride,
digoxin, morphine, procainamide, quinidine,
ranitidine, triamterene, trimethoprim, calcium
channel blockers, and vancomycin may
compete for elimination pathways with
metformin. Altered responses may occur.
Cimetidine and furosemide may increase
effects of metformin. Nifedipine increase
absorption and effects.
Drug-Natural Products: Glucosamine may
worsen blood glucose control.
Chromium, and coenzyme Q-10may
produce increase hypoglycemic effects.
INDICATIONS:
Management of type 2 diabetes mellitus;
may be used with diet, insulin, or
sulfonylurea oral hypoglycemics.
CONTRAINDCIATIONS:
Contraindicated in: Hypersensitivity;
Metabolic acidosis; Dehydration, sepsis,
hypoxemia, hepatic impairment, excessive
alcohol use (acute or chronic); Renal
dysfunction (SCr >1.5 mg/dL in men or >1.4
mg/dL in women); Radiographic studies
requiring IV iodinated contrast media
(withhold metformin); HF.
Use Cautiously in: Concurrent renal disease;
Geri: Geriatric/debilitated patients
(decreases doses may be required; avoid in
patients >80 yr unless renal function is
normal);Chronic alcohol use/abuse; Serious
medical conditions (MI, stroke); Patients
undergoing stress (infection, surgical
procedures); Hypoxia; Pituitary deficiency or
hyperthyroidism; OB, Lactation, Pedi:
Pregnancy, lactation, or children <10 yr
(safety not established; extended release for
use in patients >17 yr. only).
SIDE EFFECTS/ADVERSE REACTIONS:
Side Effects (By System):
CNS: Headache, dizziness, agitation,
fatigue.
Metabolic: Lactic acidosis.
GI: Nausea, vomiting, abdominal pain, bitter
or metallic taste, diarrhea, bloatedness,
anorexia; malabsorption of amino acids,
vitamin B12, and folic acid possible.
Adverse Reactions (By System):
GI: abdominal bloating, diarrhea, nausea,
vomiting, unpleasant metallic taste.
Endo: hypoglycemia.
F and E: LACTIC ACIDOSIS.
Misc: decreased vitamin B12 levels.
NURSING INTERVENTIONS:
Assessment
● When combined with oral sulfonylureas,
observe for signs and symptoms of
hypoglycemic reactions (abdominal pain,
sweating, hunger, weakness, dizziness,
headache, tremor, tachycardia, anxiety).
● Patients who have been well controlled on
metformin who develop illness or laboratory
abnormalities should be assessed for
ketoacidosis or lactic acidosis. Assess
serum electrolytes, ketones, glucose, and, if
indicated, blood pH, lactate, pyruvate, and
metformin levels. If either form of acidosis is
present, discontinue metformin immediately
and treat acidosis.
● Lab Test Considerations: Monitor serum
glucose and glycosylated hemoglobin
periodically during therapy to evaluate
effectiveness of therapy. May cause false-
positive results for urine ketones.
● Assess renal function before initiating and
at least annually during therapy. Discontinue
metformin if renal impairment occurs.
● Monitor serum folic acid and vitamin B12
every 1– 2 yr in long-term therapy.
Metformin may interfere with absorption.
Page | 133
Potential Nursing Diagnoses
Imbalanced nutrition: more than body
requirements (Indications)
Noncompliance (Patient/Family Teaching)
Implementation
● Do not confuse metformin with
metronidazole.
● Patients stabilized on a diabetic regimen
who are exposed to stress, fever, trauma,
infection, or surgery may require
administration of insulin. Withhold metformin
and reinstitute after resolution of acute
episode.
● Metformin should be temporarily
discontinued in patients requiring surgery
involving restricted intake of food and fluids.
Resume metformin when oral intake
has resumed and renal function is normal.
● Withhold metformin before or at the time
of studies requiring IV administration of
iodinated contrast media and for 48 hr after
study.
● PO: Administer metformin with meals to
minimize GI effects.
● XR tablets must be swallowed whole; do
not crush, dissolve, or chew.
Patient/Family Teaching
● Instruct patient to take metformin at the
same time each day, as directed. Take
missed doses as soon as possible unless
almost time for next dose. Do not double
doses. Instruct parent/caregiver to read the
Medication Guide prior to use and
with each Rx refill; new information may be
available.
● Explain to patient that metformin helps
control hyperglycemia but does not cure
diabetes. Therapy is usually long term.
● Encourage patient to follow prescribed
diet, medication, and exercise regimen to
prevent hyperglycemic or hypoglycemic
episodes.
● Review signs of hypoglycemia and
hyperglycemia with patient. If hypoglycemia
occurs, advise patient to take a glass of
orange juice or 2– 3 tsp of sugar, honey, or
corn syrup dissolved in water, and notify
health care professional.
● Instruct patient in proper testing of blood
glucose and urine ketones. These tests
should be monitored closely during periods
of stress or illness and health care
professional notified if significant changes
occur.
● Explain to patient the risk of lactic acidosis
and the potential need for
discontinuation of metformin therapy if a
severe infection, dehydration,
or severe or continuing diarrhea occurs or if
medical tests or surgery is
required. Symptoms of lactic acidosis (chills,
diarrhea, dizziness, low
BP, muscle pain, sleepiness, slow heartbeat
or pulse, dyspnea, or weakness) should be
reported to health care professional
immediately.
● Advise patient to notify health care
professional of all Rx or OTC medications,
vitamins, or herbal products being taken and
to consult with health care professional
before taking other medications or alcohol.
● Inform patient that metformin may cause
an unpleasant or metallic taste that usually
resolves spontaneously.
● Inform patients taking XR tablets that
inactive ingredients resembling XR tablet
may appear in stools.
● Advise patient to inform health care
professional of medication regimen before
treatment or surgery.
● Advise patient to report the occurrence of
diarrhea, nausea, vomiting, and stomach
pain or fullness to health care professional.
● Insulin is the recommended method of
controlling blood glucose during pregnancy.
Counsel female patients to use a form of
contraception other than oral contraceptives
and to notify health care professional
promptly if pregnancy is planned
or suspected, or if breast feeding.
● Advise patient to carry a form of sugar
(sugar packets, candy) and identification
describing disease process and medication
regimen at all times.
● Emphasize the importance of routine
follow-up exams and regular testing of blood
glucose, glycosylated hemoglobin, renal
function, and hematologic parameters.
Evaluation/Desired Outcomes
● Control of blood glucose levels without the
appearance of hypoglycemic or
hyperglycemic episodes. Control may be
achieved within a few days, but full effect of
therapy may be delayed for up to 2 wk. If
patient has not responded to metformin
after 4 wk of maximum dose therapy, an oral
sulfonylurea may be added. If satisfactory
results are not obtained with 1– 3 mo of
concurrent therapy, oral agents
may be discontinued and insulin therapy
instituted.
Page | 134
2.a CLASSIFICATION: SULFONY-
LUREAS (1st GENERATION: SHORT Side Effects (By System):
ACTING)
GENERIC NAME: Tolbutamide Gastrointestinal: Nausea, epigastric
BRAND NAME: Orinase fullness, heartburn
Metabolic: Hypoglycemia, increased
RECOMMENDED DOSAGE, ROUTE, AND appetite, weight gain
FREQUENCY: Hypersensitivity: Cholestatic jaundice
Dermatologic: Photosensitivity
Type 2 Diabetes Nervous system: Headache, taste
Adult: PO 250 mg to 3 g/d in 1–2 divided disturbances, paresthesia
doses
Diagnosis of Functioning Insulinoma Adverse Reactions (By System):
Adult: IV 1 g over 2–3 min
A: Readily absorbed from GI tract. Peak: 3– CNS: dizziness, drowsiness, headache,
5 h. weakness.
D: Distributed into extracellular fluids. GI: constipation, cramps, diarrhea, drug-
M: Principally metabolized in liver. induced hepatitis, heartburn, increased
E: 75–85% excreted in urine; some appetite, nausea, vomiting.
elimination in feces. Derm: photosensitivity, rashes. Endo:
Half-Life: 7 h. hypoglycemia.
F and E: hyponatremia.
Hemat: APLASTIC ANEMIA,
DRUG ACTION: agranulocytosis, leukopenia, pancytopenia,
Lowers blood sugar by stimulating the thrombocytopenia.
release of insulin from the pancreas and CNS: dizziness, drowsiness, headache,
increasing the sensitivity to insulin at weakness.
receptor sites. May also ↓ hepatic glucose GI: constipation, cramps, diarrhea, drug-
production. induced hepatitis, heartburn, increased
appetite, nausea, vomiting.
Therapeutic Effects: Lowering of blood Derm: photosensitivity, rashes. Endo:
sugar in diabetic patients. Pronounced and hypoglycemia.
prolonged hypoglycemic effect diagnostic of
pancreatic islet cell adenoma. F and E: hyponatremia.
Hemat: APLASTIC ANEMIA,
INTERACTIONS: agranulocytosis, leukopenia, pancytopenia,
DRUG-DRUG thrombocytopenia.
DRUG-FOOD
NURSING RESPONSIBILITIES:

INDICATIONS: NURSING INTERVENTIONS:

PO: Control of blood sugar in type 2
diabetes mellitus when diet therapy fails.
Requires some pancreatic function.
IV: Diagnosis of pancreatic islet cell
adenomas.
CONTRAINDCIATIONS:
Hypersensitivity to sulfonylureas or to
sulfonamides; history of repeated episodes
of diabetic ketoacidosis (with or without
coma); type 1 diabetes as sole therapy;
diabetic coma; severe stress, infection,
trauma, or major surgery; severe renal
insufficiency, liver or endocrine disease.
Safety during pregnancy (category C) or use
in children is not established.
SIDE EFFECTS/ADVERSE REACTIONS:
Assessment
● Monitor signs of aplastic anemia (fatigue,
weakness, shortness of breath with exertion,
tachycardia, dizziness, headache),
agranulocytosis (fever, sore throat, mucosal
lesions, signs of infection, bruising),
thrombocytopenia (bruising, nose bleeds,
and bleeding gums), or unusual weakness
and fatigue that might be due to other blood
dyscrasias. Report these signs to the
physician immediately.
● Be alert for signs of hypoglycemia,
especially during and after exercise.
Common neuromuscular signs include
anxiety; restlessness; tingling in hands, feet,
lips, or tongue; chills; cold sweats;
confusion; difficulty in concentration;

Page | 135
drowsiness; excessive hunger; headache;
irritability; nervousness; tremor; weakness;
unsteady gait. Report persistent or repeated
episodes of hypoglycemia to the physician.
● Assess any dizziness (See Appendix C) or
drowsiness that might impair gait, balance,
and other complex motor tasks (driving a
car). Report balance problems and
functional limitations to the physician, and
caution the patient and family/caregivers to
guard against falls and trauma.
● Monitor signs of low sodium levels
(hyponatremia), including headache,
confusion, lethargy, irritability, decreased
consciousness, and neuromuscular
abnormalities (muscle weakness and
cramps). Report severe or prolonged signs
to the physician.
● Assess blood pressure periodically (See
Appendix F). A sudden or sustained
increase in blood pressure (hypertension)
may indicate problems in diabetes
management and should be reported to the
physician.
● Supervise closely during initial period of
therapy until dosage is established. One or 2
wk of therapy may be required before full
therapeutic effect is achieved.
●Give low initial dose before breakfast to
older adults, who may be hyperresponsive
to oral antidiabetic therapy. If blood and
urine glucose tests are negative during first
24 h of therapy, initial dose may be
continued on a daily basis.
●Monitor closely during adjustment period,
watching for S&S of impending
hypoglycemia (see Appendix F). Detection
of a hypoglycemic reaction in a diabetic
patient also receiving a beta blocker,
especially older adults, is difficult.
Interventions:
●Implement aerobic exercise and endurance
training programs to maintain optimal body
weight, improve insulin sensitivity, and
reduce the risk of macrovascular disease
(heart attack, stroke) and microvascular
problems (reduced blood flow to tissues and
organs that causes poor wound healing,
neuropathy, retinopathy, and nephropathy).
●Provide a source of oral glucose (fruit juice,
glucose gels/tablets, etc.) to treat mild
hypoglycemia. Call for emergency
assistance if symptoms persist or in cases of
severe hypoglycemia. Emergency treatment
typically consists of IV glucose, glucagon, or
epinephrine.
● Causes photosensitivity; use care if
administering UV treatments.
Diagnosis
Noncompliance (Patient/Family Teaching)
Planning
● The patient will comply the drug regimen.
Patient/Family Teaching
● Encourage patient to monitor blood
glucose before and after exercise and to
adjust food intake.
● Understand need to inform physician
promptly of symptoms of hyperglycemia and
ketoacidosis: Flushed, dry skin, weight loss,
fatigue, Kussmaul respiration, double or
blurred vision, soft eyeballs, irritability, fruity-
smelling breath, abdominal cramps, nausea,
vomiting, diarrhea, dyspnea, polydipsia,
polyphagia, polyuria, headache,
hypotension, weak and rapid pulse, positive
ketonuria and glycosuria.
● Hypoglycemia is frequently caused by
overdosage of hypoglycemic drug,
inadequate or irregular food intake, nausea,
vomiting, diarrhea, and added exercise
without caloric supplement or dose
adjustment. Its occurrence indicates need
for immediate reevaluation of patient's diet,
medication regimen, and compliance. It is
most likely to appear in patients >50 y of
age.
● Report any illness promptly. Physician
may want to evaluate need for insulin.
● Do not self-medicate with OTC drugs
unless approved or prescribed by physician.
● Be aware that alcohol, even in moderate
amounts, can precipitate a disulfiram-type
reaction (see Appendix F). A hypoglycemic
response after ingesting alcohol requires
emergency treatment.
● Protect exposed skin areas from the sun
with a sunscreen lotion (SPF 12–15)
Page | 136
because of potential photosensitivity
(especially in the alcoholic).
● Weigh at least weekly and report a
progressive gain, especially if edema is
present. These signs indicate the necessity
to discontinue tolbutamide.
PO (Children 1 mo): Diuretic, hypertension
—1.5– 3.3 mg/kg/day (60 mg/m2 / day) as a
single dose or 2– 4 divided doses. Diagnosis
of primary aldosteronism— 100– 400 mg/m2
/day in 1– 2 divided doses.
PO (Neonates): 1– 3 mg/kg/day divided q
12– 24 hr.

● Be alert to added danger of loss of control DRUG ACTION

(hyperglycemia) when a drug that affects the Causes loss of sodium bicarbonate and
hypoglycemic action of sulfonylureas calcium while saving potassium and
(see DRUG INTERACTIONS) is withdrawn hydrogen ions by antagonizing aldosterone.
or added to the tolbutamide regimen. Therapeutic Effects: Increased survival in
Monitor blood glucose carefully. patients with severe heart failure (New York
Heart Association class II-IV). Weak diuretic
● Use or add barrier contraceptive if using and antihypertensive response when
hormonal contraceptives. compared with other diuretics. Conservation
of potassium.
● Carry medical identification at all times. It Pharmacokinetics
needs to indicate medical diagnosis, Absorption: 90% absorbed.
medication(s) and doses, patient's and Distribution: Crosses the placenta; enters
physician's names, addresses, and breast milk.
telephone numbers. Protein Binding: 90%.
Metabolism and Excretion: Converted by the
● Do not breast feed while taking this drug liver to its active diuretic compound
without consulting physician. (canrenone).
Half-life: 78– 84 min (spironolactone); 13–
● Potential for hypoglycemia in breast fed 24 hr (canrenone).
infants presents the necessity to decide
whether to discontinue breast feeding or INTERACTIONS
temporarily transfer to insulin (if diet alone is Drug-Drug: Use with eplerenoneqrisk of
inadequate for blood sugar control). hyperkalemia; concurrent use
contraindicated. q hypotension with acute
ingestion of alcohol, other antihypertensive
Implications
agents, or nitrates. Use with ACE inhibitors,
Patients stabilized on a diabetic regimen
NSAIDs, potassium supplements,
who are exposed to stress, fever, trauma,
angiotensin II receptor antagonists,
infection, or surgery may require
potassium-sparing diuretics, angiotensin
administration of insulin.
converting enzyme inhibitors, or
cyclosporineqrisk of hyperkalemia.plithium
Evaluation
excretion. Antihypertensive and diuretic
Control of blood glucose levels without the
effectiveness may bepby NSAIDs. Mayqthe
appearance of hypoglycemic or
effects of digoxin.phypoprothrombinemic
hyperglycemic episode.
effect oforal anticoagulants.
Cholestyraminemayqrisk of hyperkalemic
2. CLASSIFICATION: Aldosterone metabolic acidosis.

Antagonist
INDICATIONS
GENERIC NAME: Management of primary
Spironolactone hyperaldosteronism. Management of edema
BRAND NAME: Aldactone associated with HF, cirrhosis and nephrotic
syndrome. Management of essential
hypertension. Treatment of hypokalemia
(counteracts potassium loss caused by other
RECOMMENDED DOSAGE, ROUTE, AND
diuretics).
FREQUENCY
Route/Dosage
CONTRAINDCIATIONS
PO (Adults): 25– 400 mg/day as a single
Contraindicated in: Hypersensitivity; Anuria;
dose or 2 divided doses. HF—25– 50 mg/
Acute renal insufficiency; Significant renal
day.
impairment (CCr 30 mL/min); SCr 2.5 m

Page | 137
g/dL (for patients with heart failure);
Hyperkalemia; Addison’s disease;
Concurrent use of eplerenone
SIDE EFFECTS/ADVERSE REACTIONS
CNS: dizziness, clumsiness, headache,
sedation. CV: arrhythmias. GI: GI irritation.
GU: erectile dysfunction, dysuria. Endo:
amenorrhea, gynecomastia (in males),
breast tenderness, deepening of voice,qhair
growth (in females), sexual dysfunction. F
and E: hyperkalemia, hyponatremia,
hyperchloremic metabolic acidosis.
Hemat: agranulocytosis, thrombocytopenia.
Derm: DRUG RASH WITH EOSINOPHILIA
AND SYSTEMIC SYMPTOMS (DRESS),
STEVENS-JOHNSON SYNDROME, TOXIC
EPIDERMAL NECROLYSIS, alopecia,
pruritis.MS:muscle cramps.Misc:allergic
reactions
NURSING RESPONSIBILITIES
Assessment
● Monitor intake and output ratios and daily
weight during therapy.
● If medication is given as an adjunct to
antihypertensive therapy, BP should be
evaluated before administering.
● Monitor response of signs and symptoms
of hypokalemia (weakness, fatigue, U wave
on ECG, arrhythmias, polyuria, polydipsia).
Assess patient frequently for development of
hyperkalemia (fatigue, muscle weakness,
paresthesia, confusion, dyspnea, cardiac
arrhythmias).
Potential Nursing Diagnoses
Excess fluid volume (Indications)
Implementation
● PO: Administer in AMto avoid interrupting
sleep pattern.
● Administer with food or milk to minimize
gastric irritation and to increase
bioavailability.
Patient/Family Teaching
● Emphasize the importance of continuing to
take this medication, even if feeling well.
Instruct patient to take medication at the
same time each day. Take missed doses as
soon as remembered unless almost time for
next dose. Do not double doses.
● Caution patient to avoid salt substitutes
and foods that contain high levels of
potassium unless prescribed by health care
professional.
Evaluation/Desired Outcomes
● Increase in diuresis and decrease in
edema while maintaining serum potassium
level in an acceptable range.
● Decrease in BP.
● Prevention of hypokalemia in patients
taking diuretics.
● Treatment of hyperaldosteronism.
2.c Classification GENERATION:
(SULFONYLUREAS (1st
GENERATION: LONG ACTING)
GENERIC NAME: Chlorpropramide
BRAND NAME: Diabinese
RECOMMENDED DOSAGE, ROUTE, AND
FREQUENCY
Antidiabetic
Adult: PO Initial: 100–250 mg/d with
breakfast, adjust by 50–125 mg/d q3–5d
until glycemic control is achieved, up to 750
mg/d
Antidiuretic
Adult: PO 100–250 mg/d, may adjust q2–3d
up to 500 mg/d
Oral
Give as a single morning dose with
breakfast. To reduce GI adverse effects,
drug may be prescribed as 2 or 3 doses and
taken with meals.
Store below 40° C (104° F), preferably at
15°–30° C (59°–86° F) in a tightly closed
container, unless otherwise directed.
A: Readily absorbed from GI tract.
Onset: 1 h.
Peak: 3–6 h.
D: Highly protein bound; distributed into
breast milk.
M: Metabolized in liver.
E: 80–90% excreted in urine in 96 h.
Half-Life: 36 h.
DRUG ACTION
Lowers blood sugar by stimulating the
release of insulin from the pancreas and
increasing the sensitivity to insulin at
receptor sites. May also decrease hepatic
glucose production.
Therapeutic Effects: Lowering of blood
sugar in diabetic patients.
INTERACTIONS:
DRUG-DRUG
Page | 138
Lowers blood sugar by stimulating the Hematologic: Leukopenia,
release of insulin from the pancreas and thrombocytopenia, agranulocytosis.
increasing the sensitivity to insulin at Metabolic: Hypoglycemia, antidiuretic effect
receptor sites. May also decrease hepatic (SIADH), dilutional hyponatremia, water
glucose production. Therapeutic Effects: intoxication.
Lowering of blood sugar in diabetic patients.

DRUG-FOOD NURSING RESPONSIBILITIES

Adverse effects of ORAL
ANTICOAGULANTS, phenytoin,
SALICYLATES, NSAIDS may be increased
Assessment & Drug Effects
along with those of chlorpropamide;
THIAZIDE DIURETICS may increase blood  Monitor therapeutic effectiveness:
sugar; alcohol produces disulfiram reaction; Indicated by HbA1c levels >7%.
probenecid, MAO INHIBITORS may
increase hypoglycemic effects.  Monitor blood and urine glucose to
Herbal: Garlic, ginseng may increase determine effectiveness of glycemic
hypoglycemic effects. control.

 Lab tests: Periodic fasting and

INDICATIONS:
postprandial blood glucose;
Control of blood sugar in type 2 diabetes
HbA1c every 3 mo; baseline and
mellitus when diet therapy fails. Requires periodic hematologic and hepatic
some pancreatic function. Unlabeled Use: studies are advisable, particularly in
Management of neurogenic diabetes patients receiving high doses. A
insipidus. CBC should be performed if
symptoms of anemia appear.
CONTRAINDCIATIONS
Known hypersensitivity to sulfonylureas and  Report dizziness, shortness of
to sulfonamides; diabetes complicated by breath, malaise, fatigue.
severe infection; acidosis; severe renal,
 Monitor for S&S of hypoglycemia
hepatic, or thyroid insufficiency. Safe use
(see Appendix F).
during pregnancy (category C), in nursing
mothers, and in children not established.  Monitor I&O ratio and pattern:
Infrequently, chlorpropamide
SIDE EFFECTS/ADVERSE REACTIONS produces an antidiuretic effect, with
resulting severe hyponatremia,
Side Effects edema, and water intoxication. If
CNS: anorexia, dizziness, headache. GI: fluid intake far exceeds output and
constipation, diarrhea, drug-induced edema develops (weight gain),
report to the physician.
hepatitis, increased appetite, nausea,
vomiting.
Derm: photosensitivity, rash, pruritus,
urticaria. Diagnosis
Endo: hypoglycemia, syndrome of
Noncompliance (Patient/Family Teaching)
inappropriate antidiuretic hormone (SIADH)
secretion.
F and E: hyponatremia. Patient & Family Education
Hemat: APLASTIC ANEMIA,
 Report hypoglycemic episodes to
agranulocytosis, eosinophilia, hemolytic
physician. Because chlorpropamide
anemia, leukopenia, pancytopenia, has a long half-life, hypoglycemia
thrombocytopenia. can be severe, although onset is not
Misc: disulfiram-like reaction. as fast or as dramatic as with use of
insulin.
Adverse Reactions
 Report any of the following
Body as a Whole: Flushing, immediately to physician: skin
photosensitivity, alcohol intolerance. eruptions, malaise, fever, or
photosensitivity. Immediately report
GI: GI distress, anorexia, nausea, diarrhea,
these symptoms to physician. A
constipation, cholestatic jaundice.
change to another hypoglycemic
agent may be indicated.

Page | 139
  Do not self-dose with OTC drugs
unless approved or prescribed by
the physician.
 Do not breast feed while using this
drug.
Implementation
 Implement aerobic exercise and
endurance training programs to
maintain optimal body weight,
improve insulin sensitivity, and
reduce the risk of macrovascular
disease (heart attack, stroke) and
microvascular problems (reduced
blood flow to tissues and organs
that causes poor wound healing,
neuropathy, retinopathy, and
nephropathy).
Evaluation
 Control of blood glucose levels
without the appearance of
hypoglycemic or hyperglycemic
episodes.
2.d. CLASSIFICATION:
SULFONYLUREAS (2nd
GENERATION)
GENERIC NAME: Glipizide
BRAND NAME: Glucotrol
RECOMMENDED DOSAGE, ROUTE, AND
FREQUENCY:
PO (Adults): 5 mg/day initially,qas needed
(range 2.5– 40 mg/day); XL dose form is
given once daily.
Doses 15 m g/day may be given as 2
divided doses of regular release product (not
XL).
PO (Geriatric Patients): 2.5 mg/day
initially.
A: Well absorbed following
administration.
D: Unknown. Protein Binding: 99%.
M and E: Mostly metabolized by the liver.
Half-life: 2.1– 2.6 hr.
DRUG ACTION:
 Lowers blood sugar by stimulating
the release of insulin from the
pancreas and increasing the
sensitivity to insulin at receptor
sites. May also decrease hepatic
glucose production.
 Therapeutic Effects: Lowering of
blood sugar in diabetic patients.
INTERACTIONS:
DRUG-DRUG & DRUG-FOOD
Drug-Drug: Ingestion of alcohol may result
in disulfiram-like reaction. Effectiveness may
be decrease by concurrent use of diuretics,
corticosteroids, phenothiazines, oral
contraceptives, estrogens, thyroid
preparations, phenytoin, nicotinic acid,
sympathomimetics, and isoniazid. Alcohol,
androgens (testosterone), chloramphenicol,
clofibrate, clarithromycin, fluoroquinolones,
MAO inhibitors, NSAIDs (except diclofenac),
salicylates, fluconazole sulfonamides, and
warfarin may increase risk of hypoglycemia.
Concurrent use with warfarin may alter the
response to both agents (increase effects of
both initially, then decrease activity); close
monitoring recommended during any
changes in dose. Beta-adrenergic blockers
may mask the signs and symptoms of
hypoglycemia. May increase cyclosporine
levels. Colesevelam may decrease effects;
administer glipizide >4 hr before
colesevelam.
INDICATIONS:
PO: Controls of blood sugar in type 2
diabetes mellitus when diet therapy fails.
Requires some pancreatic function.
CONTRAINDCIATIONS:
Hypersensitivity; Hypersensitivity to
sulfonamides (cross sensitivity may occur);
Insulin-dependent diabetics; Diabetic coma
or ketoacidosis.
SIDE EFFECTS/ADVERSE REACTIONS:
CNS: dizziness, drowsiness, headache,
weakness.
GI: constipation, cramps, diarrhea, drug-
induced hepatitis, dyspepsia, increase
appetite, nausea, vomiting.
Derm: photosensitivity, rashes.
oral
Endo: hypoglycemia. F and E:
hyponatremia.
Hemat: APLASTIC ANEMIA,
agranulocytosis, hemolytic anemia,
leukopenia, pancytopenia,
thrombocytopenia.
NURSING RESPONSIBILITIES:
NURSING INTERVENTIONS:
Assessment
● Observe for signs and symptoms of
hypoglycemic reactions (sweating, hunger,
weakness, dizziness, tremor, tachycardia,
anxiety). Patients on concurrent betablocker
Page | 140
therapy may have very subtle signs and followed by release of insulin. Requires
symptoms of hypoglycemia. functioning pancreatic beta cells.
● Assess patient for allergy to sulfonamides.
● Lab Test Considerations: Monitor serum Therapeutic Effects:
glucose and glycosylated hemoglobin Significantly reduces postprandial blood
periodically during therapy to evaluate glucose in type 2 diabetics and improves
effectiveness of treatment. glycemic control when given before meals.
● Monitor CBC periodically during therapy. There is minimal risk of hypoglycemia.
Reportpin blood counts Indicated by preprandial blood glucose
promptly. between 80–120 mg/dL and HbA1c <6.5–
● May cause anqin AST, LDH, BUN, and 7.0%. Lowering of blood glucose.
serum creatinine.
INTERACTIONS:
Diagnosis
Imbalanced nutrition: more than body DRUG-DRUG
requirements (Indications) Drug: NSAIDs, SALICYLATES, MAO
INHIBITORS, BETA-ADRENERGIC
Noncompliance (Patient/Family Teaching) BLOCKERS, may potentiate hypoglycemic
effects; THIAZIDE DIURETICS,
CORTICOSTEROIDS, THYROID
Evaluation PREPARATIONS, SYMPATHOMIMETIC
● Control of blood glucose levels without the AGENTS may attenuate hypoglycemic
appearance of hypoglycemic or effects.
hyperglycemic episodes.
DRUG-FOOD
Herbal: Garlic, ginseng may potentiate
3. CLASSIFICATION: hypoglycemic effects.
MEGLITINIDES (GLINIDES)
GENERIC NAME: Nateglinide INDICATIONS
BRAND NAME: Starlix
To improve glycemic control in patients with
type 2 diabetes (with diet and exercise); may
RECOMMENDED DOSAGE, ROUTE, AND
also be used with metformin or a
FREQUENCY:
thiazolidinedione (pioglitazone,
rosiglitazone).
Adult: PO 60–120 mg t.i.d. 1–30 min prior
to meals
CONTRAINDCIATIONS
Oral
Give, preferably, 10 min before meals. Omit Prior hypersensitivity to nateglinide. Type 1
the dose if the meal is skipped. Add a dose (insulin-dependent) diabetes mellitus,
if an extra meal is eaten. Never double the diabetic ketoacidosis; pregnancy (category
dose. B), lactation.
Store at 15°–30° C (59°–86° F).
A: Rapidly absorbed, 73% bioavailability. SIDE EFFECTS/ADVERSE REACTIONS
Peak: 1 h.
D: 98% protein bound. Side Effects (By System):
M: Metabolized in liver by CYP2C9 (70%) CNS: dizziness.
and CYP3A4 (30%). Resp: bronchitis, coughing, upper
E: Primarily excreted in urine. Half-Life: 1.5 respiratory infection.
h. GI: diarrhea.
Endo: HYPOGLYCEMIA.
DRUG ACTION: MS: arthropathy, back pain.
Lowers blood glucose levels by stimulating Misc: flu symptoms.
the release of insulin from the pancreatic
cells of a type 2 diabetic. Adverse Reactions (By System):
Body as a Whole: Back pain, flu-like
Stimulates the release of insulin from symptoms.
pancreatic beta cells by closing potassium CV: Dizziness.
channels, which results in the opening of GI: Diarrhea.
calcium channels in beta cells. This is Metabolic: Hypoglycemia.

Page | 141
Musculoskeletal: Arthropathy.
Respiratory: Upper respiratory infection,
bronchitis, cough.
NURSING RESPONSIBILITIES
NURSING INTERVENTIONS
Assessment
Be alert for signs of hypoglycemia,
especially during and after exercise.
Common neuromuscular signs include
anxiety; restlessness; tingling in hands, feet,
lips, or tongue; chills; cold sweats;
confusion; difficulty in concentration;
drowsiness; excessive hunger; headache;
irritability; nervousness; tremor; weakness;
unsteady gait. Report episodes of severe
hypoglycemia to the physician immediately.
Monitor symptoms of upper respiratory tract
infection and bronchitis, including cough,
production of mucous, wheezing, chest
discomfort, shortness of breath, fatigue,
chills, and fever. Report severe or prolonged
symptoms to the physician.
Assess dizziness that might affect gait,
balance, and other functional activities (See
Appendix C). Report balance problems to
the physician, and caution the patient and
family/caregivers to guard against falls and
trauma.
Assess any back or joint pain to rule out
musculoskeletal pathology; that is, try to
determine if pain is drug induced rather than
caused by anatomic or biomechanical
problems.
Assess blood pressure periodically (See
Appendix F). A sudden or sustained
increase in blood pressure (hypertension)
may indicate problems in diabetes
management, and should be reported to the
physician.
Diagnosis
Noncompliance (Patient/Family Teaching)
Planning
 The patient will follow the drug
regimen.
 Patient teaching.
Implementation
Implement aerobic exercise and endurance
training programs to maintain optimal body
weight, improve insulin sensitivity, and
reduce the risk of macrovascular disease
(heart attack, stroke) and microvascular
problems (reduced blood flow to tissues and
organs that causes poor wound healing,
neuropathy, retinopathy, and nephropathy).
Patient/Client-Related Instruction
Encourage patient to monitor blood glucose
before and after exercise and to adjust food
intake to maintain normal glycemic levels.
Emphasize the importance of adhering to
nutritional guidelines, and the need for
periodic assessment of glycemic control
(serum glucose and glycosylated
hemoglobin levels) throughout the
management of diabetes mellitus.
Advise patient about symptoms of
hyperglycemia (confusion, drowsiness;
flushed, dry skin; fruit-like breath odor; rapid,
deep breathing, polyuria; loss of appetite;
unusual thirst).
Take only before a meal to lessen the
chance of hypoglycemia.
When transferred to nateglinide from
another oral hypoglycemia drug, start
nateglinide the morning after the other agent
is stopped, unless directed otherwise by
physician.
Watch for S&S of hyperglycemia or
hypoglycemia (see Appendix F); report poor
blood glucose control to physician.
Report gastric upset or other bothersome GI
symptoms to physician.
Do not breast feed while taking this drug.
Evaluation
● Control of blood glucose levels without the
appearance of hypoglycemic or
hyperglycemic episodes.
4.CLASSIFICATION:
THIAZOLIDINEDIONES
(GLITAZONES)
GENERIC NAME: Rosiglitazone
BRAND NAME: Avandia
RECOMMENDED DOSAGE, ROUTE, AND
FREQUENCY:
PO (Adults): 4 mg as a single dose once
daily or 2 mg twice daily; after 8 wk, may be
increased if necessary to 8 mg once daily or
4 mg twice daily
Page | 142
A:Well absorbed (99%) following
administration.
D: Unknown. Protein Binding: 99.8% bound
to plasma proteins.
M and E: Entirely metabolized by the liver.
Half-life: 3.2– 3.6 hr (qin liver disease).
DRUG ACTION:
Improves sensitivity to insulin by acting as
an agonist at receptor sites involved in
insulin responsiveness and subsequent
glucose production and utilization. Requires
insulin for activity.
Therapeutic Effects: Decreased insulin
resistance, resulting in glycemic control
without hypoglycemia.
INTERACTIONS:
DRUG-DRUG
Concurrent use with rifampin decrease
levels and may decrease effectiveness.
Gemfibrozil increase levels and may
increase risk of hypoglycemia (decrease
dose of rosiglitazone).
DRUG-FOOD
Drug-Natural Products: Glucosamine may
worsen blood glucose control. Chromium
and coenzyme Q-10may produce additive
hypoglycemic effects.
INDICATIONS
Type 2 diabetes mellitus (with diet and
exercise); may be used with metformin,
sulfonylureas, or insulin (patients should
only be newly initiated on this drug if they
are unable to achieve glucose control with
other medications and are unable to take
pioglitazone).
CONTRAINDCIATIONS
Hypersensitivity; Diabetic ketoacidosis;
Clinical evidence of active liver disease or
increased ALT (2.5 times upper limit of
normal); Renal dysfunction (creatinine over
1.5 mg/dL in males or 1.4 mg/dL in females;
OB, Lactation: Potential for fetal or infant
harm. Insulin monotherapy should be used;
Pedi: Safety and effectiveness not
established.
Use Cautiously in: Edema; HF (avoid use in
moderate to severe HF unless benefits
outweigh risks); Concurrent use with insulin
(may increase risk of adverse cardiovascular
reactions); Hepatic impairment; OB: May
oral restore ovulation and risk of pregnancy in
premenopausal women; Geri: Dose
decrease and careful titration recommended
due to age-related decrease in renal
function. Avoid maximum dose. Should not
be given to patients >80 yr.
SIDE EFFECTS/ADVERSE REACTIONS
Side Effects (By System):
CNS: STROKE.
CV: HF, MYOCARDIAL INFARCTION,
edema.
EENT: new onset and worsening diabetic
macular edema.
Derm: urticaria. GI: hepatitis, increase liver
enzymes.
Hemat: anemia. Metab: increase total
cholesterol, LDL and HDL, weight gain.
Misc: ANGIOEDEMA, fractures (arm, hand,
foot) in female patients.
Adverse Reactions (By System):
Body as a Whole: Edema, anemia,
headache, back pain, fatigue.
CV: edema, fluid retention, exacerbation of
heart failure.
GI: Diarrhea.
Respiratory: Upper respiratory tract
infection, sinusitis.
Other: Hyperglycemia.
NURSING RESPONSIBILITIES:
NURSING INTERVENTIONS
Assessment
● Observe patient taking concurrent insulin
for signs and symptoms of hypoglycemia
(sweating, hunger, weakness, dizziness,
tremor, tachycardia, anxiety).
● Assess patient for edema and signs of HF
(dyspnea, rales/crackles, peripheral edema,
weight gain, jugular venous distention). May
require discontinuation of rosiglitazone.
● Lab Test Considerations: Monitor serum
glucose and glycosylated hemoglobin
periodically during therapy to evaluate
effectiveness.
● Monitor CBC with differential periodically
during therapy. May causepin hemoglobin,
hematocrit, and WBC, usually during the first
4– 8 wk of therapy; then levels stabilize.
● Monitor AST and ALT prior to initiating
therapy and periodically thereafter or if
jaundice or symptoms of hepatic dysfunction
Page | 143
occur. May cause irreversibleqin AST and
ALT or hepatic failure (rare). If ALT
increases to 3 times the upper limit of
normal, recheck ALT promptly. Discontinue
rosiglitazone if ALT remains 3 times normal.
● May causeqin total cholesterol, LDL, and
HDL andpin free fatty acids.
● Monitor renal function tests prior to
initiating therapy and periodically thereafter
(BUN, creatinine, creatinine clearance),
especially in older adults. Potential Nursing
Diagnoses Imbalanced nutrition: more than
body requirements (Indications)
Diagnosis
Noncompliance (Patient/Family Teaching)
Implementation
● Do not confuse Avandia (rosiglitazone)
with Prandin (repaglinide) or Coumadin
(warfarin).
● Rosiglitazone is available only through a
restricted distribution program called the
Rosiglitazone REMS Program. Both
prescribers and patients need to enroll in the
program. To enroll, call 1-800-AVANDIA or
visit www.AVANDIA.com.
● Patients stabilized on a diabetic regimen
who are exposed to stress, fever, trauma,
infection, or surgery may require
administration of insulin.
● PO: May be administered with or without
meals.
Patient/Family Teaching
● Instruct patient to take medication as
directed. If dose for 1 day is missed, do not
double dose the next day. Explain the
Rosiglitazone REMS Program to patient.
● Explain to patient that this medication
controls hyperglycemia but does not cure
diabetes. Therapy is long term.
● Review signs of hypoglycemia and
hyperglycemia with patient. If hypoglycemia
occurs, advise patient to take a glass of
orange juice or 2– 3 tsp of sugar, honey, or
corn syrup dissolved in water and notify
health care professional.
● Encourage patient to follow prescribed
diet, medication, and exercise regimen to
prevent hypoglycemic or hyperglycemic
episodes.
● Instruct patient in proper testing of serum
glucose and ketones. These tests should be
closely monitored during periods of stress or
illness and health care professional notified
if significant changes occur.
● Advise patient to notify health care
professional immediately if signs of hepatic
dysfunction or HF occur.
● Advise patient to inform health care
professional of medication regimen prior to
treatment, studies using IV contrast, or
surgery.
● Advise patient to carry a form of sugar
(sugar packets, candy) and identification
describing disease process and medication
regimen at all times. Insulin is the preferred
method of controlling blood glucose during
pregnancy. Counsel female patients that
higher doses of oral contraceptives or a form
of contraception other than oral
contraceptives may be required and to notify
health care professional promptly if
pregnancy is planned or suspected.
● Emphasize the importance of routine
follow-up exams.
Implementation
Implement aerobic exercise and endurance
training programs to maintain optimal body
weight, improve insulin sensitivity, and
reduce the risk of macrovascular disease
(heart attack, stroke) and microvascular
problems (reduced blood flow to tissues and
organs that causes poor wound healing,
neuropathy, retinopathy, and nephropathy).
Evaluation
● Control of blood glucose levels.
5. CLASSIFICATION: ALPHA-
GLUCOSIDASE INHIBITORS
GENERIC NAME: Acarbose
BRAND NAME: Precose
RECOMMENDED DOSAGE, ROUTE, AND
FREQUENCY
PO (Adults): 25 mg 3 times daily; may be
increased q 4– 8 wk as needed/tolerated
(range 50– 100 mg 3 times daily; not to
exceed 50 mg 3 times daily in patients 60 kg
or 100 mg 3 times daily in patients >60 kg).
A: 2% systemically absorbed; action is
primarily local (in the GI tract).
D: Unknown.
Page | 144
M and E: Minimal amounts absorbed are
excreted by the kidneys. Side Effects
GI: abdominal pain, diarrhea, flatulence,
Half-life: 2 hr. increase transaminases.

DRUG ACTION Adverse Reactions

Lowers blood glucose by inhibiting the CNS: Sleepiness, weakness, dizziness,
enzyme alpha-glucosidase in the GI tract. headache, vertigo (may be due to poor
Delays and reduces glucose absorption. diabetic control).
Endocrine: Hypoglycemia (especially in
Therapeutic Effects: Lowering of blood
combination with sulfonylureas and insulin).
glucose in diabetic patients, especially
GI: Diarrhea, flatulence, abdominal
postprandial hyperglycemia.
distention, borborygmi, increased liver
function tests.
INTERACTIONS Hematologic: Anemia (especially iron
deficiency).
DRUG-DRUG Skin: Erythema, exanthema, urticaria.
Thiazide diuretics and loop diuretics,
corticosteroids, phenothiazines, thyroid NURSING RESPONSIBILITIES
preparations, estrogens (conjugated),
progestins, hormonal contraceptives, NURSING INTERVENTIONS
phenytoin, niacin, sympathomimetics, Assessment
calcium channel blockers, and isoniazid may ● Observe patient for signs and symptoms
increase glucose levels in diabetic patients of hypoglycemia (sweating, hunger,
and lead top control of blood glucose.
weakness, dizziness, tremor, tachycardia,
Effects are decrease by intestinal
anxiety) when taking concurrently with
adsorbents, including activated charcoal and
digestive enzyme preparations (amylase, other oral hypoglycemic agents.
pancreatic); avoid concurrent use. Increase
effects of sulfonylurea hypoglycemic agents. ● Lab Test Considerations: Monitor serum
May decrease absorption of digoxin; may glucose and glycosylated hemoglobin
require dosage adjustment. periodically during therapy to evaluate
effectiveness.

DRUG-FOOD ● Monitor AST and ALT every 3 mo for the

Drug-Natural Products: Glucosamine may
worsen blood glucose control. Chromium
and coenzyme Q-10mayqhypoglycemic
effects.
INDICATIONS
Management of type 2 diabetes in
conjunction with dietary therapy; may be
used with insulin or other hypoglycemic
agents.
CONTRAINDCIATIONS
Hypersensitivity; Diabetic ketoacidosis;
Cirrhosis; Serum creatinine >2 mg/dL;
OB, Lactation, Pedi: Safety not established.
Use Cautiously in: Presence of fever,
infection, trauma, stress (may cause
hyperglycemia, requiring alternative
therapy).
SIDE EFFECTS/ADVERSE REACTIONS
1st yr and then periodically. Elevated levels
may require dose reduction or
discontinuation of acarbose. Elevations
occur
more commonly in patients taking more than
300 mg/day and in female patients.
Levels usually return to normal without other
evidence of liver injury after discontinuation.
● Toxicity and Overdose: Symptoms of
overdose are transient increase in
flatulence, diarrhea, and abdominal
discomfort. Acarbose alone does not cause
hypoglycemia; however, other concurrently
administered hypoglycemic agents may
produce hypoglycemia requiring treatment.
Diagnosis
● Imbalanced nutrition: more than body
requirements (Indications)
● Noncompliance (Patient/Family Teaching)
Planning

Page | 145
● Patient will follow the drug regimen. Control of blood glucose levels without the
● Patient teaching. appearance of hypoglycemic or
Implementation hyperglycemic episodes.
● Patients stabilized on a diabetic regimen
who are exposed to stress, fever, trauma, 6. CLASSIFICATION: DPP-4
infection, or surgery may require INHIBITORS (GLIPTINS)
administration of insulin.
GENERIC NAME: Alogliptin
● Does not cause hypoglycemia when taken
while fasting, but may increase BRAND NAME: Nesina
hypoglycemic effect of other hypoglycemic
agents. RECOMMENDED DOSAGE, ROUTE, AND
● PO: Administer with first bite of each meal FREQUENCY
3 times/day.
PO (Adults): 25 mg once daily.
Patient/Family Teaching Renal Impairment
● Instruct patient to take acarbose at same PO (Adults): CCr >30 mL/min– <60 mL/min
time each day. If a dose is missed and the — 12.5 once daily; CCr <30 mL/ min– 6.25
meal is completed without taking the dose, once daily.
skip missed dose and take next dose
with the next meal. Do not double doses. A: Completely absorbed following oral
● Explain to patient that acarbose controls administration (100%).
hyperglycemia but does not cure diabetes. D: Well distributed into tissues.
Therapy is longterm. M and E: Not extensively metabolized, 76%
● Review signs of hypoglycemia and excreted unchanged in urine.
hyperglycemia (blurred vision; drowsiness; Half-life: 21 hr
dry
mouth; flushed, dry skin; fruit-like breath DRUG ACTION
odor; increased urination; ketones in Acts as a competitive inhibitor of dipeptidyl
urine; loss of appetite; stomachache; peptidase-4 (DDP-4) which slows the
nausea or vomiting; tiredness; rapid, deep inactivation of incretin hormones, thereby
breathing; unusual thirst; unconsciousness) increasing their concentrations and reducing
with patient. If hypoglycemia occurs, fasting and postprandial glucose
advise patient to take a form of oral glucose concentrations.
(e.g., glucose tablets, liquid gel glucose)
Therapeutic Effects: Improved control of
rather than sugar (absorption of sugar is
blood glucose.
blocked by acarbose) and notify
health care professional.
INTERACTIONS:
● Encourage patient to follow prescribed
diet, medication, and exercise regimen to
DRUG-DRUG
prevent hypoglycemic or hyperglycemic
Drug-Drug: increase risk of hypoglycemia
episodes.
with sulfonylureas and insulin, dose
● Instruct patient in proper testing of serum
adjustments may be necessary.
glucose and urine ketones. Monitor
closely during periods of stress or illness.
INDICATIONS
Notify health care professional if significant
changes occur.
Adjunct with diet and exercise to improve
● Caution patient to avoid using other
glycemic control in adults with type 2
medications without consulting health care
diabetes mellitus.
professional.
● Advise patient to inform health care
CONTRAINDCIATIONS
professional of medication regimen before
treatment or surgery.
Contraindicated in: Type 1 diabetes;
● Advise patient to carry a form of oral
Diabetic ketoacidosis; Previous severe
glucose and identification describing disease
hypersensitivity reactions.
process and medication regimen at all times.
● Emphasize the importance of routine
Use Cautiously in: Liver disease; Geri:
follow-up examinations.
Elderly patients may have increased
sensitivity to effects;
Evaluation

Page | 146
Lactation: Use cautiously; OB: Use during
pregnancy only if clearly needed;
Pedi: Safe and effective use has not been
established.
SIDE EFFECTS/ADVERSE REACTIONS
Side Effects
Cns: headache.
Gi: hepatotoxicity, pancreatitis, increase
liver enzymes.
Misc: hypersensitivity reactions including
anaphylaxis, angioedema, severe cutaneous
reactions including stevens-johnson
syndrome.
Adverse reactions
Cns: headache. Gi: hepatotoxicity,
pancreatitis, increase liver enzymes.
Misc: hypersensitivity reactions including
anaphylaxis, angioedema, severe cutaneous
reactions including stevens-johnson
syndrome.
NURSING RESPONSIBILITIES
NURSING INTERVENTIONS
Assessment
● Observe for signs and symptoms of
hypoglycemic reactions (abdominal pain,
sweating, hunger, weakness, dizziness,
headache, tremor, tachycardia, anxiety).
● Monitor for signs of pancreatitis (nausea,
vomiting, anorexia, persistent severe
abdominal pain, sometimes radiating to the
back) during therapy. If pancreatitis occurs,
discontinue alogliptin and monitor serum
and urine amylase, amylase/creatinine
clearance ratio, electrolytes, serum calcium,
glucose, and lipase.
● Assess for rash periodically during
therapy. May cause Stevens-Johnson
syndrome. Discontinue therapy if severe or if
accompanied with fever, general malaise,
fatigue, muscle or joint aches, blisters, oral
lesions, conjunctivitis, hepatitis and/or
eosinophilia.
● Lab Test Considerations: Monitor
hemoglobin A1C prior to and periodically
during therapy.
● Monitor renal function prior to and
periodically during therapy
Diagnosis
Imbalanced nutrition: more than body
requirements (Indications)
Noncompliance (Patient/Family Teaching)
Implementation
● Patients stabilized on a diabetic regimen
who are exposed to stress, fever, trauma,
infection, or surgery may require
administration of insulin.
● PO:May be administered without regard to
food.
Patient/Family Teaching
● Instruct patient to take alogliptin as
directed. Take missed doses as soon as
remembered, unless it is almost time for
next dose; do not double doses. Advise
patient to read Medication Guide before
starting and with each Rx refill in case of
changes.
● Explain to patient that alogliptin helps
control hyperglycemia but does not cure
diabetes. Therapy is usually long term.
● Instruct patient not to share this
medication with others, even if they have the
same
symptoms; it may harm them.
● Encourage patient to follow prescribed
diet, medication, and exercise regimen to
prevent hyperglycemic or hypoglycemic
episodes.
● Review signs of hypoglycemia and
hyperglycemia with patient. If hypoglycemia
occurs, advise patient to take a glass of
orange juice or 2– 3 tsp of sugar, honey, or
corn syrup dissolved in water, and notify
health care professional.
● Instruct patient in proper testing of blood
glucose and urine ketones. These tests
should be monitored closely during periods
of stress or illness and health care
professional notified if significant changes
occur.
● Advise patient to stop taking alogliptin and
notify health care professional promptly if
symptoms of hypersensitivity reactions
(rash; hives;
swelling of face, lips, tongue, and throat;
difficulty in breathing or swallowing) or
pancreatitis occur.
● Advise patient to notify health care
professional of all Rx or OTC medications,
vitamins, or herbal products being taken and
to consult with health care professional
before taking other medications.
● Advise patient to notify health care
professional if pregnancy is planned or
suspected or if breast feeding.
Evaluation
● Improved hemoglobin A1C, fasting plasma
glucose and 2-hr post-prandial glucose
levels.
Page | 147
7. CLASSIFICATION: SODIUM- Concurrent use with NSAIDs, diuretics, ACE
GLUCOSE CO-TRANSPORTER inhibitors, or angiotensin receptor blockers
may ↑ risk of acute kidney injury.
(SGLT-2) INHIBITORS
GENERIC NAME: Canagliflozin INDICATIONS
BRAND NAME: Invokana Adjunct to diet and exercise in the
management of type 2 diabetes mellitus.
RECOMMENDED DOSAGE, ROUTE, AND May be used with other antidiabetic agents.
FREQUENCY:
PO (Adults) eGFR ≥ 60 mL/min/1.73 m2– CONTRAINDCIATIONS:
100 mg once daily initially, may be ↑ to 300 Hypersensitivity;
mg once daily; Concurrent use of UGT Severe renal impairment (eGFR <45
inducers (phenobarbital, phenytoin, rifampin, mL/min/1.73 m2), end-stage renal disease
ritonavir)–if maintenance dose is 100 mg or on dialysis;
daily, may require ↑ to 300 mg daily. Type 1 diabetes;
Severe hepatic impairment;
Renal Impairment Lactation: Avoid use, discontinue breast
PO (Adults) eGFR 45–60 mL/min/1.73 m2– feeding or discontinue canagliflozin.
100 mg once daily.
SIDE EFFECTS/ADVERSE REACTIONS:
A: Well absorbed (65%) following oral Side Effects (By System):
administration. Urinary: urinary tract infections,
D: Extensive tissue distribution. Protein increased urination,
Binding: 99% Reproductive: yeast infections,
M and E: Mostly metabolized by UDP- vaginal itching
glucuronyl transferases (UGT) to inactive Abdominal: constipation
metabolites, minimal metabolism by Derm: skin sensitivity to sunlight,
CYP3A4 (7%). 50% excreted in feces as hypersensitivity reactions (including skin
parent drug and metabolites, 33% as redness, rash, itching, hives, and swelling)
metabolites in urine, <1% excreted in urine
as unchanged drug. Adverse Reactions (By System):
Half-life: 10.6 hr CV: hypotension
GI: abdominal pain, constipation, nausea
DRUG ACTION: GU: UROSEPSIS, female mycotic
Inhibits proximal renal tubular sodium- infections, acute kidney injury, glucosuria,
glucose co-transporter 2 (SGLT2), which male mycotic infections, ↓ renal function,
determines reabsorption of glucose from the urinary tract infection (including
tubular lumen. Inhibits reabsorption of pyelonephritis), ↑ urination, vulvovaginal
glucose, lowers renal threshold for glucose, pruritus
and increases excretion of glucose in urine. Endo: hypoglycemia (↑ with other
medications)
Therapeutic Effect(s): Improved glycemic
F and E: KETOACIDOSIS, hyperkalemia,
control.
hypermagnesemia, hyperphosphatemia,
thirst
INTERACTIONS:
Metabolic: hyperlipidemia
DRUG-DRUG
MS: bone fractures
Blood levels are ↓ by UGT inducers
Misc: HYPERSENSITIVITY REACTIONS
including phenobarbital, phenytoin, rifampin,
(INCLUDING ANAPHYLAXIS OR
and ritonavir; ↑dose may be required.
ANGIOEDEMA)
↑ risk of hypoglycemia with insulin or insulin
secretagogues; dose adjustments may be
NURSING RESPONSIBILITIES:
required.
NURSING INTERVENTIONS:
May ↑ blood levels and effects of digoxin;
Assessment
levels should be monitored.
Observe patient for signs and symptoms of
↑ risk of hyperkalemia with potassium-
hypoglycemic reactions (abdominal pain,
sparing diuretics or medications that
sweating, hunger, weakness, dizziness,
interfere with the renin-angiotensin-
headache, tremor, tachycardia, anxiety).
aldosterone system.
Monitor for signs and symptoms of volume
depletion (dizziness, feeling faint, weakness,

Page | 148
orthostatic hypotension) after initiating
therapy.
Monitor for infection, new pain, tenderness,
sores, or ulcers involving lower limbs;
discontinue canagliflozin if these occur.
Lab Test Considerations: Monitor
hemoglobin A1C prior to and periodically
during therapy.
May cause ↑ uric acid levels.
May ↑ serum creatinine and ↓ eGFR.
Monitor renal function, especially in patients
with eGFR <60 mL/min/1.73 m2.
May cause ↑ serum potassium, magnesium,
and phosphate levels. Monitor electrolytes
periodically during therapy.
May cause ↑ LDL-C. Monitor serum lipid
levels periodically during therapy.
Causes positive test for urine glucose.
Diagnosis
Imbalanced nutrition: more than body
requirements (Indications)
Noncompliance (Patient/Family/Teaching)
Implementation
Patients stabilized on a diabetic regimen
who are exposed to stress, fever, trauma,
infection, or surgery may require
administration of insulin.
Correct volume depletion prior to beginning
therapy with canagliflozin.
PO Administer before the first meal of the
day.
Patient/Family Teaching
Instruct patient to take canagliflozin as
directed. Take missed doses as soon as
remembered, unless it is almost time for
next dose; do not double doses. Advise
patient to read the Medication Guide before
starting and with each Rx refill in case of
changes.
Explain to patient that canagliflozin helps
control hyperglycemia but does not cure
diabetes. Therapy is usually long term.
Instruct patient not to share this medication
with others, even if they have the same
symptoms; it may harm them.
Encourage patient to follow prescribed diet,
medication, and exercise regimen to prevent
hyperglycemic or hypoglycemic episodes.
Review signs of hypoglycemia and
hyperglycemia with patient. If hypoglycemia
occurs, advise patient to take a glass of
orange juice or 2–3 tsp of sugar, honey, or
corn syrup dissolved in water, and notify
health care professional.
Instruct patient in proper testing of blood
glucose and urine ketones. Inform patient
that canagliflozin will cause a positive test
result when testing for urine glucose.
Monitored closely during periods of stress or
illness and health care professional notified
if significant changes occur.
Inform patient that canagliflozin may cause
yeast infections. Women may have signs
and symptoms of a vaginal yeast infection
(vaginal odor, white or yellow vaginal
discharge [may be lumpy or look like cottage
cheese], vaginal itching).
Men may have signs and symptoms of a
yeast infection of the penis (redness, itching,
or swelling of penis; rash on penis; foul
smelling discharge from penis; pain in skin
around penis). Advise patient to notify health
care professional if yeast infection occurs.
Advise patient to notify health care
professional promptly if rash; hives; or
swelling of face, lips, or throat occur.
Inform patient of increased risk for urinary
tract infections, hypotension, and bone
fractures and discuss factors that may
increase risk.
Advise patient to notify health care
professional of all Rx or OTC medications,
vitamins, or herbal products being taken and
to consult with health care professional
before taking other medications, especially
other oral hypoglycemic medications.
Advise patient to notify health care
professional if pregnancy is planned or
suspected or if breast feeding.
Evaluation
Improved hemoglobin A1C and glycemic
control in adults with Type II diabetes.
Page | 149
8. CLASSIFICATION: DOPAMINE
AGONIST
GENERIC NAME: Bromocriptine
BRAND NAME: Cycloset
RECOMMENDED DOSAGE, ROUTE, AND
FREQUENCY
Adult dosage (ages 16 years and older)
● Typical starting dosage: One 0.8-mg tablet
taken once daily, with food, within two hours
of waking in the morning.
● Increasing dosage: Your doctor may
increase your dosage by 1 tablet once per
week until you reach the appropriate dosage
for you.
● Typical maintenance dosage: 1.6–4.8 mg
taken once daily, with food, within two hours
of waking in the morning.
● Maximum daily dosage: 6 tablets (4.8 mg)
taken once daily, with food, within two hours
of waking in the morning.
Child dosage (ages 0–15 years)
It hasn’t been established that Cycloset is
safe or effective for children younger than 16
years.
DRUG ACTION:
Activates dopamine receptors in the CNS.
Decreases prolactin secretion. Therapeutic
Effects: Relief of rigidity and tremor in
parkinsonism. Restoration of fertility in
hyperprolactinemia. Decreased growth
hormone in acromegaly. Cycloset lowers
your blood sugar levels by boosting the
action of dopamine, a chemical in the brain
that sends messages between cells.
Dopamine levels are often low in people with
type 2 diabetes. By jump-starting dopamine,
Cycloset helps make the body more
effective at changing blood sugar to energy.
INTERACTIONS
Antibiotics
When used with bromocriptine, certain
antibiotics can increase the amount of
bromocriptine in your body. This raises your
risk of side effects from bromocriptine.
Examples of these drugs include:
erythromycin,clarithromycin
HIV drugs
When used with bromocriptine, certain drugs
used to treat HIV called protease inhibitors
can increase the amount of bromocriptine in
your body. This raises your risk of side
effects from bromocriptine. Examples of
protease inhibitors include: ritonavir,
lopinavir, saquinavir
Psychiatric drugs
When used with bromocriptine, certain drugs
used to treat psychiatric disorders can make
bromocriptine less effective. This means it
may not work well to treat your condition.
Examples of these psychiatric drugs include:
haloperidol, pimozide
Other drugs
Metoclopramide is used to treat several
conditions, including gastroesophageal
reflux disease (GERD). Using this drug with
bromocriptine can make bromocriptine less
effective. This means it may not work well to
treat your condition.
Taking ergot-related drugs, such as
ergotamine and dihydroergotamine, with
bromocriptine may cause an increase in
nausea, vomiting, and fatigue. It may also
make these ergot-related drugs less
effective when used to treat migraine. Ergot-
related drugs should not be taken within six
hours of taking bromocriptine.
INDICATIONS:
Adjunct to levodopa in the treatment of
parkinsonism. Treatment of
hyperprolactinemia
(amenorrhea/galactorrhea), including
associated female infertility. Treatment of
acromegaly.
Unlabeled Use: Management of pituitary
prolactinomas. Management of neuroleptic
malignant syndrome.
CONTRAINDCIATIONS:
For people with liver disease: It’s not known
how safe or effective bromocriptine is for
people with liver disease. Talk with your
doctor about whether taking this drug is safe
for you.
For people with kidney disease: It’s not
known how safe or effective bromocriptine is
for people with kidney disease. Talk with
your doctor about whether taking this drug is
safe for you.
For people with a history of psychosis:
Bromocriptine can worsen psychotic
conditions. Talk with your doctor about
whether this drug is safe for you.
For people with a history of cardiovascular
disease: Bromocriptine can worsen this
condition. Talk with your doctor about
whether this drug is safe for you.
Page | 150
For people with certain types of sugar
intolerance: You shouldn’t take
bromocriptine if you have certain types of
sugar intolerance. These include galactose
intolerance, severe lactase deficiency, or
problems with absorbing certain types of
sugars.
SIDE EFFECTS/ADVERSE REACTIONS:
Side Effects (By System):
CV: Heart Attack
Neuro: Stroke
Respi: Pulmonary Fibrosis
Adverse Reactions (By System):
CNS: dizziness, confusion, drowsiness,
hallucinations, headache, insomnia,
nightmares.
EENT: burning eyes, nasal stuffiness, visual
disturbances.
Resp: effusions, pulmonary infiltrates.
CV: MI, hypotension. GI: nausea, abdominal
pain, anorexia, dry mouth, metallic taste,
vomiting.
Derm: urticaria.
MS: leg cramps.
Misc: digital vasospasm (acromegaly only).
NURSING RESPONSIBILITIES:
Examination and Evaluation
Monitor cardiac symptoms at rest and during
exercise. Seek immediate medical
assistance if symptoms of MI develop,
including sudden chest pain, pain radiating
into the arm or jaw, shortness of breath,
dizziness, sweating, anxiety, and nausea.
Assess patient's motor function to help
determine antiparkinson effects, especially
when starting drug therapy, or during dosing
changes or addition of other antiparkinson
drugs. Motor function should be assessed at
different times of the day, such as when
drugs are reaching peak therapeutic levels
(i.e., 1–2 hr after oral dose), as well as when
drug effects are minimal (just before the next
dose).
Document increased side effects such as
involuntary movements (dyskinesias) or
fluctuations in response (on-off
phenomenon, end-of-dose akinesia). Notify
physician because increased side effects
might require dose adjustment or a change
in medication regimen.
Assess dizziness and drowsiness that might
affect gait, balance, and other functional
activities (See Appendix C). Report balance
problems and functional limitations to the
physician, and caution the patient and
family/caregivers to guard against falls and
trauma.
Monitor confusion, hallucinations, and other
psychologic problems. Repeated or
excessive symptoms may require change in
dose or medication.
Assess blood pressure (BP) periodically and
compare to normal values (See Appendix
F). Report low BP (hypotension), especially
if patient experiences increased dizziness,
syncope, or other symptoms.
Monitor respiratory function at rest and
during exercise. Notify physician if patient
experiences signs of pulmonary infiltrates or
effusion, including cough, shortness of
breath, chest pain, or labored breathing.
If used to treat acromegaly, periodically
assess body weight and other
anthropometric measures (body mass index,
limb circumferences) to help document
whether drug therapy is effective in reducing
the effects of increased growth hormone.
If treating acromegaly, watch for signs of
digital vasospasm as indicated by
decreased circulation to the fingers and toes
resulting in pain, numbness, swelling, and
color changes in the affected digits. Report
these signs to the physician, and educate
patient about how to avoid the onset of
symptoms.
Diagnosis
Noncompliance (Patient/Family/Teaching)
Patient & Family Education
Make position changes slowly and in stages,
especially from lying down to standing, and
to dangle legs over bed for a few minutes
before walking. Lie down immediately if
light-headedness or dizziness occurs.
Do not drive or engage in other potentially
hazardous activities until response to drug is
known.
Avoid exposure to cold and report the onset
of pallor of fingers or toes.
Note: Restoration of regular menses usually
occurs in 6–8 wk. Since fertility may be
restored during therapy, advise patients
being treated for amenorrhea and
galactorrhea to use barrier-type
contraceptive measures until normal
ovulating cycle is restored. Oral
contraceptives are contraindicated.
Page | 151
C.NON-INSULIN INJECTABLE
DRUGS
1. CLASSIFICATION: INCRETIN
MIMETICS
GENERIC NAME: Exenatide
BRAND NAME: Byetta
RECOMMENDED DOSAGE, ROUTE, AND
FREQUENCY
Immediate Release (Byetta) Subcut (Adults):
5 mcg within 60 min before morning and
evening meal; after 1 mo, dose may be
increased to 10 mcg depending on
response. Renal Impairment Subcut
(Adults): CCr 30– 50 mL/min— Use caution
when increase dose from 5 mcg to 10 mcg.
Extended Release (Bydureon) Subcut
(Adults): 2 mg every 7 days.
A: Well absorbed following subcutaneous
administration.
D: Unknown.
M and E: Excreted mostly by glomerular
filtration followed by degradation.
Half-life: Immediate-release—2.4 hr.
Contraindicated in: Hypersensitivity; Type 1
diabetes or diabetic ketoacidosis;
Severe renal impairment or end-stage renal
disease (CCr 30 mL/min); Severe
gastrointestinal disease; Personal or family
history of medullary thyroid carcinoma
(extended-release only); Multiple Endocrine
Neoplasia syndrome (extended-release
only); OB: Has caused fetal physical defects
and neonatal death in animal studies;
Lactation: Excretion into breast milk
unknown.
Use Cautiously in: History of pancreatitis;
Moderate renal impairment (CCr 30–
50 mL/min); Concurrent use of insulin
(extended-release only); Pedi: Safety not
established.
SIDE EFFECTS/ADVERSE REACTIONS:
Side Effects (By System):
CV: dizziness, headache, jitteriness,
weakness. GI: PANCREATITIS, diarrhea,
nausea,
vomiting, dyspepsia, gastroinestinal reflux.
Endo: THYROID T-CELL TUMORS
(extended-release), hypoglycemia.
GU: acute renal failure.
Derm: hyperhydrosis.
Metab: pappetite, weight loss.

DRUG ACTION: Adverse Reactions (By System):

Mimics the action of incretin which promotes CNS: Asthenia, dizziness, restlessness,
endogenous insulin secretion and promotes jittery feeling.
other mechanisms of glucose-lowering. GI: Nausea, vomiting, diarrhea, dyspepsia,
anorexia, gastroesophageal reflux.
Therapeutic Effects: Improved control of Metabolic: Hypoglycemia, excessive
blood glucose. sweating (hyperhidrosis or diaphoresis).

INTERACTIONS: NURSING RESPONSIBILITIES:

DRUG-DRUG
Drug-Drug: Concurrent use with NURSING INTERVENTIONS:
sulfonylureas or insulin may increase risk of Assessment
hypoglycemia (decrease dose of ● Observe for signs and symptoms of
sulfonylurea or insulin if hypoglycemia hypoglycemic reactions (abdominal pain,
occurs); concomitant use of insulin with sweating, hunger, weakness, dizziness,
extended-release exenatide not headache, drowsiness, tremor, tachycardia,
recommended. Concurrent use with anxiety, confusion, irritability, jitteriness),
nateglinide or repaglinidec may increase risk especially when combined with oral
of hypoglycemia. Due to slowed gastric sulfonylureas.
emptying, may decrease absorption of orally ● Assess for signs and symptoms of
administered medications, especially those pancreatitis (persistent severe abdominal
requiring rapid GI absorption or require a pain, sometimes radiating to the back, may
specific level for efficacy; take oral or may not be accompanied by vomiting) at
antiinfectives and oral contraceptives at beginning of therapy and with dose
least 1 hr before injecting exenatide). increases. If suspected, promptly
discontinue therapy and initiate appropriate
INDICATIONS: management. If pancreatitis is confirmed, do
Management of type 2 diabetes as an not restart exenatide. Consider other
adjunct to diet and exercise. antidiabetic therapies in patients with a
history of pancreatitis.
CONTRAINDCIATIONS:

Page | 152
● Lab Test Considerations: Monitor serum
glucose and glycolysated hemoglobin
periodically during therapy to evaluate
effectiveness of therapy.
● Monitor renal function prior to and
periodically during therapy. Renal
dysfunction may be reversed with
discontinuation of therapy.
Diagnosis
Imbalanced nutrition: more than body
requirements (Indications)
Noncompliance (Patient/Family Teaching)
Implementation
● Some medications may need to be taken
1 hr before exenatide.
● Patients stabilized on a diabetic regimen
who are exposed to stress, fever, trauma,
infection, or surgery may require
administration of insulin.
● Subcut: Immediate release: Follow
directions for New Pen Setup in Information
for Patient prior to use of each new pen.
Inject exenatide in thigh, abdomen,
or upper arm at any time within the 60–min
period before the morning and evening
meals. Do not administer after a meal. Do
not mix with insulin. Solution
should be clear and colorless; do not
administer solutions that are discolored or
contain particulate matter. Refrigerate;
discard pen 30 days after 1st use, even if
some drug remains in pen. Do not freeze.
Do not store pen with needle attached;
medication may leak from pen or air bubbles
may form in the cartridge.
● Subcut: Extended release: Dilute with
diluent and needles included in tray.
Suspension should be white or off-white and
cloudy. Administer without regard to
meals. Inject into upper arm, abdomen, or
thigh; change site each week. Refrigerate;
each tray can be kept at room temperature
of not.
Patient/Family Teaching
● Instruct patient to take exenatide
immediate release as directed within 60 min
before a meal. Do not take after a meal. If a
dose is missed, skip the dose and take the
next dose at the prescribed time. Do not
take an extra dose or increase the
amount of the next dose to make up for
missed dose. If a dose of exenatide
extended release is missed, administer as
soon as remembered as long as the next
dose is due at least 3 days later; if 1 or 2
days later skip dose and administer next
dose as scheduled. The day of weekly
administration can be changed as long as
the
last dose was administered 3 or more days
before.
● Instruct patient in proper technique for
administration, timing of dose and
concurrent oral medications, storage of
medication and disposal of used needles.
Patients should read the Information for
Patient insert prior to initiation of therapy
and with each Rx refill. Advise patient that
New Pen Setup should be done only
with each new pen, not with each dose.
● Inform patient that pen needles are not
included with pen and must be purchased
separately. Advise patient which needle
length and gauge should be used. Caution
patient not to share pen and needles.
● Explain to patient that exenatide helps
control hyperglycemia but does not cure
diabetes. Therapy is usually long term.
● Encourage patient to follow prescribed
diet, medication, and exercise regimen to
prevent hyperglycemic or hypoglycemic
episodes.
● Review signs of hypoglycemia and
hyperglycemia with patient. If hypoglycemia
occurs, advise patient to take a glass of
orange juice or 2– 3 tsp of sugar, honey, or
corn syrup dissolved in water, and notify
health care professional. Risk of
hypoglycemia is increased if sulfonates are
taken concurrently with exenatide.
● Advise patient to notify health care
professional immediately if symptoms of
pancreatitis (unexplained, persistent, severe
abdominal pain
which may or may not be accompanied by
vomiting) occur.
● Inform patient that therapy may result in
reduction of appetite, food intake, and/or
body weight. Dose modification is not
necessary. Nausea is more common at
initiation of therapy and usually decreases
over time.
Evaluation
● Control of blood glucose levels without the
appearance of hypoglycemic or
hyperglycemic episodes.
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2. CLASSIFICATION: AMYLIN
MIMETICS
GENERIC NAME: Pramlintide
BRAND NAME: Symlin
RECOMMENDED DOSAGE, ROUTE, AND
FREQUENCY
Insulin-using Type 2 Diabetes
Subcut (Adults): 60 mcg, immediately prior
to major meals initially, if no significant
nausea occurs, dose may be increase to
120 mcg.
Type 1 Diabetes Subcut (Adults): 15 mcg,
immediately prior to major meals initially, if
no significant nausea occurs, dose may be
increase by 15 mcg every 3 days up to 60
mcg.
A: 30– 40% absorbed following
subcutaneous administration.
D: Does not appear to significantly cross the
placenta.
M and E: Metabolized by the kidneys; major
metabolite has pharmacologic properties
similar to the parent compound.
Half-life: 48 min
DRUG ACTION
Acts as a synthetic analogue of amylin, an
endogenous pancreatic hormone that helps
to control postprandial hyperglycemia;
effects include slowed gastric emptying,
suppression of glucagon secretion and
regulation of food intake..
Therapeutic Effects: Improved control of
postprandial hyperglycemia.
INTERACTIONS
Drug-Drug: increased likelihood of
hypoglycemia with short-acting insulin;
decrease dose of short-acting pre-meal
insulin by 50%. Avoid concurrent use with
other agents that decrease GI motility,
including atropine and other anticholinergics.
Avoid concurrent use with other agents that
decrease GI absorption of nutrients,
including-glucosidase inhibitors including
acarbose and miglitol. May delay oral
absorption of concurrently administered
drugs; if prompt absorption is desired,
administer 1 hr before or 2 hr after
pramlintide.
INDICATIONS
Used with mealtime insulin in the
management of diabetics whose blood
sugar cannot be controlled by optimal insulin
therapy; can be used with other agents
(sulfonylureas, metformin).
CONTRAINDCIATIONS
Contraindicated in: Hypersensitivity;
Inability to identify hypoglycemia;
Gastroparesis or need for medications to
stimulate gastric motility; Poor compliance
with current insulin regimen or self-
monitoring; HbA1c 9%; Recurring severe
hypoglycemia within the last 6 mo, requiring
treatment; OB: Insulin is the drug of choice
for blood glucose control during pregnancy;
Pedi: Safety not established.
Use Cautiously in: Lactation
SIDE EFFECTS/ADVERSE REACTIONS:
Side Effects (By System):
Noted for concurrent use with insulin
CNS: dizziness, fatigue, headache.
Resp: cough.
GI: nausea, abdominal pain, anorexia,
vomiting.
Endo: HYPOGLYCEMIA.
Derm: local allergy.
MS: arthralgia.
Misc: injection site reactions, systemic
allergic reactions.
Adverse Reactions (By System):
CNS: Dizziness, fatigue, headache.
GI: Abdominal pain, anorexia, nausea,
vomiting.
Musculoskeletal: Arthralgia.
Respiratory: Coughing, pharyngitis.
Body as a Whole: Allergic reaction, inflicted
injury.
NURSING RESPONSIBILITIES:
NURSING INTERVENTIONS:
Assessment
● Assess hemoglobin A1c, recent blood
glucose monitoring data, history of insulin
induced hypoglycemia, current insulin
regimen, and body weight prior to initiation
of therapy.
● Assess for signs and symptoms of
hypoglycemia (hunger, headache, sweating,
tremor, irritability, difficulty concentrating,
loss of consciousness, coma, seizure),
occurs within 3 hr of injection. Pramlintide
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alone does not cause hypoglycemia, may ● Instruct patient to contact health care
increase risk when administered with insulin. professional at least once a week until target
dose of pramlintide is achieved, pramlintide
● Lab Test Considerations: Monitor blood is well-tolerated, and blood glucose
glucose frequently, including preand post- concentrations are stable.
meals and at bedtime. ● May cause difficulty concentrating.
Caution patient to avoid driving or other
activities requiring alertness until response
Diagnosis
to medication is known.
Noncompliance (Patient/Family Teaching)
● Inform patient that signs of local allergy
(redness, swelling, itching at site of injection)
Implementation
usually resolve within a few days to a few
● High Alert: Dose errors are a potential
weeks; may be related to pramlintide,
problem with administration of pramlintide.
irritants in skin cleansing agent or improper
Pramlintide is available in a concentration of
injection technique.
0.6 mg/mL, dosing is in mcg,
● Advise patient to contact health care
and insulin syringe for administration is in
professional if recurrent nausea or
units. Carefully review dosing and
hypoglycemia occur; may lead to increased
conversion table prior to administration.
risk of severe hypoglycemia. Discontinue
● Administer pramlintide and insulin as
pramlintide therapy if recurrent unexplained
separate injections; do not mix.
hypoglycemia requiring medical assistance,
● Adjust insulin doses to optimize glycemic
persistent clinically significant nausea, or
control once target dose of pramlintide
noncompliance with self-monitoring of blood
is achieved and nausea has subsided.
glucose concentrations, insulin dose
● Subcut: Administer immediately prior to
adjustments, or scheduled
major meals 250 kcal or containing
health care professional contacts or
30 g of carbohydrate. Reduce preprandial
recommended clinic visits occur.
rapid-acting, short-acting, and fixedmix
● Advise patient to contact health care
insulin doses by 50%. Use a U-100 syringe
professional before taking other Rx, OTC,
(preferably a 0.3 mL size) for optimal
vitamins, or herbal products with pramlintide
accuracy. Administer into abdomen or thigh,
and to avoid concurrent alcohol use.
rotating injection sites. Do not
● Advise female patients to notify health
administer solutions that are cloudy. Store
care professional if pregnancy is planned or
unopened vials in refrigerator. Opened
suspected or if breast feeding.
vials may be refrigerated or kept at room
temperature for up to 28 days.
Evaluation/Desired Outcomes
● Reduction in postprandial glucose
Patient/Family Teaching
concentrations.
● Instruct patient in proper use of
pramlintide (injection technique, timing of
doses,
storage, and disposal of equipment). Make A. THERAPEUTIC DRUG &
sure patient understands dosing HERBAL USE IN PREGNANCY
and preparation of correct dose. Emphasize
importance of adherence to meal 1.CLASSIFICATION: IRON
planning, physical activity, recognition and
GENERIC NAME: Ferrous sulfate
management of hypoglycemia and
hyperglycemia, and assessment of diabetes BRAND NAME:
complications. Advise patient to read the
Medication Guide before use and with each RECOMMENDED DOSAGE, ROUTE, AND
refill for new information. FREQUENCY
● Review with patient how to handle illness
or stress, inadequate or omitted insulin PO (Adults): Deficiency– 2– 3 mg/kg/day in
dose, inadvertent administration of 2– 4 divided doses or 60– 100 mg elemental
increased dose of insulin or pramlintide, iron twice daily. Prophylaxis—60– 100 mg
inadequate food intake or missed meals. If a elemental iron daily.
dose is missed, wait until the next meal PO (Infants and Children): Severe
and take usual dose; do not give an deficiency—4– 6 mg/kg/day in 3 divided
additional injection. doses. Mild to moderate deficiency—3
mg/kg/day in 1– 2 divided doses.

Page | 155
Prophylaxis—1– 2 mg/kg/day in 1– 2 divided
dose (maximum: 15 mg/day).
PO (Neonates , premature): 2– 4
mg/kg/day in 1– 2 divided doses, maximum
of 15 mg/day.
A: Approximately 5– 10% of dietary iron is
absorbed (up to 30% in deficiency states).
Therapeutically administered PO iron is up
to 60% absorbed via active
and passive transport processes.
D: Remains in the body for many months.
Crosses the placenta; enters
breast milk. Protein Binding: 90%.
M and E: Mostly recycled; small daily losses
occurring via desquamation, sweat, urine,
and bile.
DRUG ACTION
An essential mineral found in hemoglobin,
myoglobin, and many enzymes. Enters the
bloodstream and is transported to the
organs of the reticuloendothelial system
(liver,
spleen, bone marrow) where it becomes part
of iron stores.
Therapeutic Effects:
Resolution or prevention of iron deficiency
anemia.
INTERACTIONS
Drug-Drug: decrease absorption of
tetracyclines, fluoroquinolones
bisphosphonates, levothyroxine,
mycophenolate mofetil, and penicillamine
(simultaneous administration should be
avoided). Decrease absorption of and may
decrease effects of levodopa
and methyldopa. Concurrent administration
of proton pump inhibitors, histamine H2
antagonists, and cholestyramine may
decrease absorption of iron. Doses of
ascorbic acid 200 mg may increase
absorption of iron by up to 30%.
Chloramphenicol and vitamin E may
decrease hematologic response to iron
therapy.
Drug-Food: Iron absorption is decrease 33–
50% by concurrent administration of food.
INDICATIONS
PO: Treatment & prevention iron deficiency
anemia
CONTRAINDCIATIONS
Contraindicated in: Anemia not due to iron
deficiency; Hemochromatosis;
Hemosiderosis; Hypersensitivity to iron
products.
Use Cautiously in: Peptic ulcer disease;
Ulcerative colitis or regional enteritis
(condition may be aggravated); Alcoholism;
Severe hepatic impairment; Severe renal
impairment.
SIDE EFFECTS/ADVERSE REACTIONS
Side Effects
CNS: dizziness, headache, syncope.
GI: nausea, constipation, dark stools,
epigastric pain, GI bleeding, vomiting.
Misc: temporary staining of teeth (liquid
preparations).
Adverse Reactions
GI: Nausea, heartburn, anorexia,
constipation, diarrhea, epigastric pain,
abdominal distress, black stools.
Special Senses: Yellow-brown discoloration
of eyes and teeth (liquid forms.)
Large Chronic Doses in Infants Rickets (due
to interference with phosphorus absorption).
Massive Overdosage: Lethargy, drowsiness,
nausea, vomiting, abdominal pain, diarrhea,
local corrosion of stomach and small
intestines, pallor or cyanosis, metabolic
acidosis, shock, cardiovascular collapse,
convulsions, liver necrosis, coma, renal
failure, death.
NURSING RESPONSIBILITIES
NURSING INTERVENTIONS
Assessment
● Assess nutritional status and dietary
history to determine possible cause of
anemia and need for patient teaching.
● Assess bowel function for constipation or
diarrhea. Notify physician or other
health care professional and use appropriate
nursing measures should these occur.
● Lab Test Considerations: Monitor
hemoglobin, hematocrit, and reticulocyte
values prior to and every 3 wk during the
first 2 mo of therapy and periodically
thereafter. Serum ferritin and iron levels may
also be monitored to assess effectiveness of
therapy.
● Occult blood in stools may be obscured by
black coloration of iron in stool.
Guaiac test results may occasionally be
false-positive. Benzidine test results are not
affected by iron preparations.
● Toxicity and Overdose: Early symptoms of
overdose include stomach pain, fever,
nausea, vomiting (may contain blood), and
diarrhea. Late symptoms include
Page | 156
bluish lips, fingernails, and palms;
drowsiness; weakness; tachycardia;
seizures;
metabolic acidosis; hepatic injury; and
cardiovascular collapse. Patient may appear
to recover prior to the onset of late
symptoms. Therefore, hospitalization
continues for 24 hr after patient becomes
asymptomatic to monitor for delayed
onset of shock or GI bleeding. Late
complications of overdose include intestinal
obstruction, pyloric stenosis, and gastric
scarring.
● If patient is comatose or seizing, gastric
lavage with sodium bicarbonate is
performed. Deferoxamine is the antidote.
Additional supportive treatments to maintain
fluid and electrolyte balance and correction
of metabolic acidosis are also indicated.
stored in the original childproof container
and kept out of reach of children. Do
not refer to vitamins as candy. In the event
of a suspected overdose, parents should
contact poison control center (1– 800– 222–
1222) or emergency medical services (911)
immediately.
Evaluation/Desired Outcomes
● Increase in hemoglobin, which may reach
normal parameters after 1– 2 mo of
therapy. May require 3– 6 mo for
normalization of body iron stores.
● Improvement in or prevention of iron
deficiency anemia.
2. CLASSIFICATION:FOLIC ACID
GENERIC NAME: Folic acid
BRAND NAME: Vitamin B9, Folate

RECOMMENDED DOSAGE, ROUTE, AND

Diagnoses
FREQUENCY
Activity intolerance (Indications)

PO, IM, IV, Subcut (Adults and Children >11

Implementation
yr): 1 mg/day initial dose then 0.5
● Discontinue oral iron preparations prior to
mg/day maintenance dose.
parenteral administration.
PO, IM, IV, Subcut (Children >1 yr): 1
● Oral preparations are most effectively
mg/day initial dose then 0.1– 0.4 mg/day
absorbed if administered 1 hr before or 2 hr
maintenance dose.
after meals. If gastric irritation occurs,
PO, IM, IV, Subcut (Infants): 15
administer with meals. Take tablets and
mcg/kg/dose daily or 50 mcg/day.
capsules with a full glass of water or juice.
Do not crush or chew enteric coated tablets
Recommended Daily Allowance
and do not open capsules.
PO (Adults and Children >15 yr): 0.2
● Liquid preparations may stain teeth. Dilute
mg/day.
in water or fruit juice, full glass (240
PO (Adults): Females of childbearing
mL) for adults and glass (120 mL) for
potential– 0.4– 0.8 mg/day.
children, and administer with a straw or 1⁄2
PO (Children 11– 14 yr): 0.15 mg/day.
place drops at back of throat.
PO (Children 7– 10 yr): 0.1 mg/day.
● Avoid using antacids, coffee, tea, dairy
PO (Children 4– 6 yr): 0.075 mg/day.
products, eggs, or whole-grain breads with
PO (Infants 6 mo– 3 yr): 0.05 mg/day.
or within 1 hr after administration of ferrous
salts. Iron absorption is decreased by
A: Well absorbed from the GI tract and IM
33% if iron and calcium are given with
and subcut sites.
meals.
D: Half of all stores are in the liver. Enters
breast milk. Crosses the placenta. Protein
Patient/Family Teaching
Binding: Extensive.
● Explain purpose of iron therapy to patient.
M and E: Converted by the liver to its active
● Encourage patient to comply with
metabolite, dihydrofolate reductase. Excess
medication regimen. Take missed doses as
amounts are excreted unchanged by the
soon
kidneys.
as remembered within 12 hr; otherwise,
return to regular dosing schedule. Do not
DRUG ACTION
double doses.
Required for protein synthesis and red blood
● Advise patient that stools may become
cell function. Stimulates the production of
dark green or black.
red blood cells, white blood cells, and
● Instruct patient to follow a diet high in iron.
platelets. Necessary for normal fetal
● Discuss with parents the risk of a child
development.
overdosing on iron. Medication should be

Page | 157
Therapeutic Effects: Restoration and
maintenance of normal hematopoiesis.
INTERACTIONS
Drug-Drug: Pyrimethamine, methotrexate,
trimethoprim, and triamterene
prevent the activation of folic acid
(leucovorin should be used instead to treat
overdoses of these drugs). Absorption of
folic acid is decrease by sulfonamides
(including sulfasalazine), antacids, and
cholestyramine. Folic acid requirements are
increase by estrogens, phenytoin,
phenobarbital, primidone, carbamazepine,
or corticosteroids. May decrease phenytoin
levels
INDICATIONS
Prevention and treatment of megaloblastic
and macrocytic anemias. Given during
pregnancy to promote normal fetal
development.
CONTRAINDCIATIONS
Contraindicated in: Uncorrected pernicious,
aplastic, or normocytic anemias (neurologic
damage will progress despite correction of
hematologic abnormalities); Pedi:
Preparations containing benzyl alcohol
should not be used in newborns.
Use Cautiously in: Undiagnosed anemias.
SIDE EFFECTS/ADVERSE REACTIONS
Side Effects
Derm: rash.
CNS: irritability, difficulty sleeping, malaise,
confusion.
Misc: fever.
Adverse Reactions
[Reportedly nontoxic. Slight flushing and
feeling of warmth following IV
administration.]
NURSING RESPONSIBILITIES
NURSING INTERVENTIONS
Assessment
● Assess patient for signs of megaloblastic
anemia (fatigue, weakness, dyspnea) before
and periodically throughout therapy.
● Lab Test Considerations: Monitor plasma
folic acid levels, hemoglobin, hematocrit,
and reticulocyte count before and
periodically during therapy.
● May cause decrease serum
concentrations of other B complex vitamins
when given in high continuous doses.
Potential Nursing Diagnoses
Imbalanced nutrition: less than body
requirements (Indications)
Activity intolerance (Indications)
Implementation
● Do not confuse folic acid with folinic acid
(leucovorin calcium).
● Because of infrequency of solitary vitamin
deficiencies, combinations are commonly
administered
Patient/Family Teaching
● Encourage patient to comply with diet
recommendations of health care
professional. Explain that the best source of
vitamins is a well-balanced diet with foods
from the four basic food groups. A diet low in
vitamin B and folate will be used to diagnose
folic acid deficiency without concealing
pernicious anemia.
● Folic acid in early pregnancy is necessary
to prevent neural tube defects.
● Foods high in folic acid include
vegetables, fruits, and organ meats; heat
destroys folic acid in foods.
● Patients self-medicating with vitamin
supplements should be cautioned not to
exceed RDA. The effectiveness of
megadoses for treatment of various medical
conditions is unproven and may cause side
effects.
● Explain that folic acid may make urine
more intensely yellow.
● Instruct patient to notify health care
professional if rash occurs, which may
indicate hypersensitivity.
● Emphasize the importance of follow-up
exams to evaluate progress.
Evaluation/Desired Outcomes
● Reticulocytosis 2– 5 days after beginning
therapy.
● Resolution of symptoms of megaloblastic
anemia.
● Prevention of neural tube defects.
Page | 158
3. CLASSIFICATION: MULTIPLE Unlabeled Use: Prevention of the common
VITAMINS & MINERALS cold.

GENERIC NAME: Ascorbic Acid CONTRAINDCIATIONS

BRAND NAME: Contraindicated in: Tartrazine
hypersensitivity (some products contain
RECOMMENDED DOSAGE, ROUTE, AND tartrazine— FDC yellow dye #5).
FREQUENCY Use Cautiously in: Recurrent kidney stones;
OB: Avoid chronic use of large doses
PO (Adults): Scurvy—500 mg/day for at in pregnant women.
least 14 days. Prevention of deficiency—50–
100 mg/day. SIDE EFFECTS/ADVERSE REACTIONS
PO (Children): Scurvy—100– 300 mg/day
for at least 14 days. Prevention of deficiency Side Effects
—30– 45 mg/day. CNS: drowsiness, fatigue, headache,
IM (Adults): Scurvy—100– 500 mg/day for at insomnia.
least 14 days. GI: cramps, diarrhea, heartburn,
IM (Children): Scurvy—100– 300 mg/day for nausea, vomiting.
at least 14 days. IV (Adults and Children): GU: kidney stones.
Prevention of deficiency—determined by Derm: flushing.
need. Hemat: deep vein thrombosis, hemolysis (in
A: Actively absorbed after oral G6PD deficiency), sickle cell crisis.
administration by a saturable process. Local: pain at subcut or IM sites.
D: Widely distributed. Crosses the placenta;
enters breast milk. Adverse Reactions
M and E: Converted to compounds that are GI: Nausea, vomiting, heartburn, diarrhea,
excreted by the kidneys. or abdominal cramps (high doses).
Hematologic: Acute hemolytic anemia
DRUG ACTION (patients with deficiency of G6PD); sickle
Necessary for collagen formation and tissue cell crisis.
repair. Involved in oxidation reduction CNS: Headache or insomnia (high doses).
reactions; tyrosine, folic acid, iron, and Urogenital: Urethritis, dysuria, crystalluria,
carbohydrate metabolism; lipid and protein hyperoxaluria, or hyperuricemia (high
synthesis; cellular respiration; and doses).
resistance to infection. Other: Mild soreness at injection site;
Therapeutic Effects: Replacement in dizziness and temporary faintness with rapid
deficiency states. Supplementation during IV administration.
increased requirements.
NURSING RESPONSIBILITIES
INTERACTIONS
Drug-Drug: If urinary acidification occurs, NURSING INTERVENTIONS
may increase excretion and decrease
effects of mexiletine, amphetamine, or
tricyclic antidepressants. Large doses (10 Assessment
g/day) ● Vitamin C Deficiency: Assess for signs of
May increase response to warfarin. vitamin C deficiency (faulty bone and
Increase iron toxicity when given tooth development, gingivitis, bleeding
concurrently with deferoxamine gums, loosened teeth) before and during
therapy.
INDICATIONS ● Lab Test Considerations: Megadoses of
Treatment and prevention of vitamin C ascorbic acid (10 times the RDA
deficiency (scurvy) with dietary requirement) may cause false-negative
supplementation. Supplemental therapy in results for occult blood in the stool.
some GI diseases during long-term ● May causepserum bilirubin andqurine
parenteral nutrition oxalate, urate, and cysteine levels.
or chronic hemodialysis. States of increased Potential Nursing Diagnoses
requirements such as: Pregnancy, Lactation, Imbalanced nutrition: less than body
Stress, Hyperthyroidism, Trauma, Burns, requirements (Indications)
Infancy.

Page | 159
Deficient knowledge, related to diet and 4. DRUGS FOR MINOR
medication regimen (Patient/Family DISCOMFORTS OF PREGANCY
Teaching).

Implementation 4.a CLASSIFICATION: DRUGS

FOR NAUSEA & VOMITING
● Often ordered as a part of multivitamin GENERIC NAME: Doxylamine
supplementation, because inadequate diet BRAND NAME: Unisom
often results in multiple-vitamin deficiency.
RECOMMENDED DOSAGE, ROUTE, AND
● Pressure in ampules may be increased at
FREQUENCY
room temperature; wrap with protective
PO (Adults) Day 1–2 tablets (doxylamine 10
cover before breaking.
mg/pyridoxine 10 mg) at bedtime, if
● PO: Extended-release tablets and
symptoms are controlled continue this
capsules should be swallowed whole without
regimen; Day 2, if symptoms persist into
crushing, breaking, or chewing; contents of
afternoon on day 2–2 tablets at bedtime on
capsules may be mixed with jelly or
day 2 and then 1 tablet in the morning on
jam. Chewable tablets should be chewed
day 3 and 2 tablets in the evening, if
well or crushed before swallowing. Oral
symptoms are controlled, continue this
solution may be taken directly by mouth or
regimen; Day 4, if symptoms persist–1 tablet
mixed with fruit juice, cereal, or other
in the morning, 1 tablet mid-afternoon and 2
food.
tablets at bedtime (not to exceed four tablets
daily).
Patient/Family Teaching
● Advise patient to take medication as
A: Well absorbed following oral
directed and not to exceed dose prescribed.
administration. Food delays/decreases
Excess doses may lead to diarrhea and
absorption.
urinary stone formation. If a dose is
D: Doxylamine probably enters breast milk
missed, skip dose and return to dose
M and E: Doxylamine is mostly metabolized
schedule.
by the liver, inactive metabolites are renally
● Vitamin C Deficiency: Encourage patient
excreted. Pyridoxine is a pro-drug,
to comply with diet recommendations
converted to its active metabolite by the
of health care professional. Explain that the
liver.
best source of vitamins is a well-balanced
Half-life: Doxylamine–12.5 hr;
diet.
● Foods high in ascorbic acid include citrus
DRUG ACTION
fruits, tomatoes, strawberries, cantaloupe,
Combination of an antihistamine and a
and raw peppers. Gradual loss of ascorbic
vitamin B6 analog. Mechanism not known.
acid occurs when fresh food is
Therapeutic Effect(s): Decreased nausea
stored, but not when it is frozen. Rapid loss
and vomiting associated with pregnancy.
is caused by drying, salting, and cooking.
● Patients self-medicating with vitamin
INTERACTIONS
supplements should be cautioned not to
Drug-Drug
exceed RDA. The effectiveness of
megadoses of vitamins for treatment of
↑ risk of CNS depression with other CNS
various
depressants including alcohol, other
medical conditions is unproven and may
antihistamines, opioid analgesics, and
cause side effects. Abrupt withdrawal of
sedative/hypnotics.
megadoses of ascorbic acid may cause
Concurrent use of MAOIs ↑
rebound deficiency.
intensity/duration of adverse CNS
(anticholinergic) reactions.
Evaluation
● Decrease in the symptoms of ascorbic
INDICATIONS
acid deficiency.
Treatment of nausea and vomiting during
pregnancy that has not responded to
conservative management.

CONTRAINDCIATIONS
Hypersensitivity to doxylamine or pyridoxine

Page | 160
Concurrent use of MAOIs
Lactation: Doxylamine probably enters
breast milk and may cause irritability,
excitement, or sedation in infants; breast
feeding should be avoided.
Assess for frequency and amount of emesis
daily during therapy. Reassess need for
medication as pregnancy progresses.
Monitor hydration status to prevent
dehydration.

Use Cautiously in: Potential Diagnoses

Nausea (Indications)
Asthma Risk for injury (Adverse Reaction)
↑ intraocular pressure or narrow angle
glaucoma
Stenosing peptic ulcer or pyloroduodenal Implementation
obstruction
PO Administer on an empty stomach with a
Urinary bladder-neck obstruction
full glass of water; food delays onset of
Pedi: Safety and effectiveness not
medication. Swallow tablets whole; do not
established
crush, break, or chew.
SIDE EFFECTS/ADVERSE REACTIONS
Patient/Family Teaching
Instruct patient to take as directed.
Side Effects
May cause drowsiness. Caution patient to
avoid driving and other activities requiring
Neurogic: drowsiness, headache,
alertness until response to medication is
restlessness, dizziness
known.
Musculo: muscle pain or weakness
Advise patient to avoid alcohol and CNS
Abdominal: stomach pain, constipation,
depressants, including sedatives,
diarrhea
tranquilizers, antihistamines, opioids, and
Derm: rash
some cough and cold medications with
doxylamine pyridoxine.
Adverse Reactions
Instruct patient to notify health care
Cardiac disorders: Dyspnea, palpitation, professional of all Rx or OTC medications,
tachycardia vitamins, or herbal products being taken and
Ear and labyrinth disorders: Vertigo consult health care professional before
Eye disorders: Vision blurred, visual taking any new medications.
disturbances Advise female patient to avoid breast
Gastrointestinal disorders: Abdominal feeding during therapy.
distension, abdominal pain, constipation,
diarrhea Evaluation/Desired Outcomes
General disorders and administration site Decrease in frequency of nausea and
conditions: Chest discomfort, fatigue, vomiting during pregnancy.
irritability, malaise
Immune system disorders: Hypersensitivity 4.bCLASSIFICATION: DRUGS
Nervous system disorders: Dizziness, FOR HEARTBURN
headache, migraines, paresthesia, GENERIC NAME: Sucralfate
psychomotor hyperactivity
BRAND NAME: Carafate
Psychiatric disorders: Anxiety,
disorientation, insomnia, nightmares
RECOMMENDED DOSAGE, ROUTE, AND
Renal and urinary disorders: Dysuria,
FREQUENCY
urinary retention
Treatment of Ulcers
PO (Adults): 1 g 4 times daily, given 1 hr
Skin and subcutaneous tissue disorders:
before meals and at bedtime; or 2 g twice
Hyperhidrosis, pruritus, rash, rash
daily, on waking and at bedtime.
maculopapular

Prevention of Ulcers
PO (Adults): 1 g twice daily, given 1 hr
NURSING RESPONSIBILITIES before a meal.

NURSING INTERVENTIONS Gastroesophageal Reflux

Assessment

Page | 161
PO (Adults): 1 g 4 times daily, given 1 hr
before meals and at bedtime (unlabeled).
PO (Children): 40– 80 mg/kg/day divided q 6
hr, given 1 hr before meals and at
bedtime (unlabeled).
Stomatitis
PO (Adults and Children): 5– 10 mL of
suspension swish and spit or swish and
swallow 4 times daily.
Proctitis
Rect (Adults): 2 g of suspension given as an
enema once or twice daily
A: Systemic absorption is minimal (5%).
D: Unknown.
M and E: >90% is eliminated in the feces.
Half-life: 6– 20 hr.
DRUG ACTION
Aluminum salt of sulfated sucrose reacts
with gastric acid to form a thick paste, which
selectively adheres to the ulcer surface.
Therapeutic Effects: Protection of ulcers,
with subsequent healing.
INTERACTIONS
Drug-Drug: May decrease absorption of
phenytoin, fat-soluble vitamins, or
tetracycline. Decrease effectiveness when
used with antacids, cimetidine, or ranitidine.
Decrease absorption of fluoroquinolones
(separate administration by 2 hours).
INDICATIONS
Short-term management of duodenal ulcers.
Maintenance (preventive) therapy of
duodenal ulcers.
Unlabeled Use: Management of gastric ulcer
or gastroesophageal reflux. Prevention of
gastric mucosal injury caused by high-dose
aspirin or other NSAIDs in patients with
rheumatoid arthritis or in high-stress
situations (e.g., intensive care unit).
Suspension: Mucositis/stomatitis/rectal or
oral ulcerations from various etiologies.
CONTRAINDCIATIONS
Contraindicated in: Hypersensitivity.
Use Cautiously in: Renal failure
(accumulation of aluminum can occur);
Diabetes (increased risk of hyperglycemia
with suspension); Impaired swallowing
(increased risk of tablet aspiration).
SIDE EFFECTS/ADVERSE REACTIONS
Side Effects
CNS: dizziness, drowsiness.
GI: constipation, diarrhea, dry mouth, gastric
discomfort, indigestion, nausea. Derm:
pruritus, rashes.
Endo: hyperglycemia (with suspension).
Misc: ANAPHYLAXIS.
Adverse Reactions
GI: Nausea, gastric discomfort, constipation,
diarrhea.
NURSING RESPONSIBILITIES
NURSING INTERVENTIONS
Assessment
● Assess patient routinely for abdominal
pain and frank or occult blood in the stool.
Potential Nursing Diagnoses
Acute pain (Indications)
Constipation (Side Effects)
Deficient knowledge, related to medication
regimen (Patient/Family Teaching)
Implementation
● PO: Administer on an empty stomach, 1 hr
before meals and at bedtime. Tablet
may be broken or dissolved in water before
ingestion. Shake suspension well before
administration.
● If nasogastric or feeding tube
administration is required, consult
pharmacist; protein-binding properties of
sucralfate have resulted in formation of a
bezoar when administered with enteral
feedings and other medications.
● If antacids are also required for pain,
administer 30 min before or after sucralfate
dosage.
Patient/Family Teaching
● Advise patient to continue with course of
therapy for 4– 8 wk, even if feeling better, to
ensure ulcer healing. If a dose is missed,
take as soon as remembered unless almost
time for next dose; do not double doses.
● Advise patient that increase in fluid intake,
dietary bulk, and exercise may prevent drug-
induced constipation.
● Emphasize the importance of routine
examinations to monitor progress.
Evaluation/Desired Outcomes
● Decrease in abdominal pain.
● Prevention and healing of duodenal
ulcers, seen by x-ray examination and
endoscopy.
Page | 162
4.c CLASSIFICATION: DRUGS
FOR CONSTIPATION
GENERIC NAME: Docusate Sodium
BRAND NAME: Colace
RECOMMENDED DOSAGE, ROUTE, AND
FREQUENCY
PO (Adults and Children 12 yr): 2 tablets
once daily at bedtime; maximum 4 tablets
twice daily.
PO (Children 6– 12 yr): 1 tablet once daily at
bedtime; maximum: 2 tablets twice daily.
PO (Children 2– 6 yr): 1/2 tablet once daily
at bedtime; maximum: 1 tablet twice daily.
A: Docusate: small amounts may be
absorbed from the small intestine
after oral administration.
D: Unknown.
M and E: Senna: metabolized in the liver
and eliminated in bile and urine. Docusate:
eliminated in bile.
DRUG ACTION
Senna’s metabolite acts as a local irritant on
the colon stimulating peristalsis. Docusate
promotes incorporation of water into stool,
resulting in softer fecal mass. Therapeutic
Effects: Softening and passage of stool.
INTERACTIONS
Drug-Drug: None significant
INDICATIONS
PO: Treatment of constipation associated
with dry, hard stools and decreased
intestinal motility. Prevention of opioid-
induced constipation.
CONTRAINDCIATIONS
Contraindicated in: Hypersensitivity;
Abdominal pain, nausea, or vomiting,
especially when associated with fever or
other signs of an acute abdomen;
Concomitant use of mineral oil.
Use Cautiously in: Excessive or prolonged
use may lead to dependence, fluid and
electrolyte imbalance, and vitamin and
mineral deficiencies.
SIDE EFFECTS/ADVERSE REACTIONS
Side Effects
F and E: electrolyte imbalances,
dehydration.
GI: abdominal cramps, nausea, vomiting,
diarrhea.
Derm: rashes.
GU: urine discoloration.
Adverse Reactions
GI: Occasional mild abdominal cramps,
diarrhea, nausea, bitter taste.
Other: Throat irritation (liquid preparation),
rash.
NURSING RESPONSIBILITIES
NURSING INTERVENTIONS
Assessment
● Assess for abdominal distention, presence
of bowel sounds, and usual pattern of
bowel function.
● Assess color, consistency, and amount of
stool produced.
Potential Nursing Diagnoses
Constipation (Indications)
Implementation
● This medication does stimulate intestinal
peristalsis.
● PO: Administer with a full glass of water or
juice preferably in the evening.
● Do not administer within 2 hr of other
laxatives, especially mineral oil. May cause
increased absorption.
Patient/Family Teaching
● Advise patients that laxatives should be
used only for short-term therapy. Long term
therapy may cause electrolyte imbalance
and dependence.
● Encourage patients to use other forms of
bowel regulation, such as increasing
bulk in the diet, increasing fluid intake (6– 8
full glasses/day), and increasing mobility.
Normal bowel habits are variable and may
vary from 3 times/day to 3 times/
wk.
● Instruct patients with cardiac disease to
avoid straining during bowel movements
(Valsalva maneuver).
● Advise patient not to use laxatives when
abdominal pain, nausea, vomiting, or fever
is present.
Evaluation/Desired Outcomes
● A soft, formed bowel movement, usually
within 6– 24 hr.
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 A: Oral formulation is well absorbed (80%)
from the GI tract; IV administration results in
complete bioavailability.

5. CLASSIFICATION: DRUGS FOR DRUG ACTION

PAIN Inhibits prostaglandin synthesis.
GENERIC NAME: Ibuprofen Therapeutic Effects: Decreased pain and
BRAND NAME: inflammation. Reduction of fever.

INTERACTIONS
RECOMMENDED DOSAGE, ROUTE, AND
Drug-Drug: May limit the cardioprotective
FREQUENCY
effects of low-dose aspirin. Concurrent use
Analgesia
with aspirin may decrease effectiveness of
PO (Adults): Anti-inflammatory—400– 800
ibuprofen. Additive adverse GI side effects
mg 3– 4 times daily (not to exceed
with aspirin, oral potassium, other NSAIDs,
3200 mg/day). Analgesic/anti-
corticosteroids, or alcohol.
dysmenorrheal/antipyretic—200– 400 mg q
Chronic use with acetaminophen may
4– 6
increase risk of adverse renal reactions.
hr (not to exceed 1200 mg/day).
May decrease effectiveness of diuretics,
ACE inhibitors, or other antihypertensives.
PO (Children 6 mo– 12 yr): Anti-
May increase hypoglycemic effects of insulin
inflammatory—30– 50 mg/kg/day in 3– 4
or oral hypoglycemic agents. May increase
divided doses (maximum dose: 2.4 g/day).
serum lithium levels and risk of toxicity.
Antipyretic—5 mg/kg for temperature
Increase risk of toxicity from methotrexate.
<102.5F (39.17C) or 10 mg/kg for higher
Probenecid increase risk
temperatures (not to exceed 40 mg/kg/
of toxicity from ibuprofen. Increase risk of
day); may be repeated q 4– 6 hr. Cystic
bleeding with cefotetan, cefoperazone,
fibrosis (unlabeled)—20– 30 mg/kg/day
corticosteroids, valproic acid, thrombolytics,
divided twice daily.
warfarin, and drugs affecting
platelet function including clopidogrel,
PO (Infants and Children): Analgesic—4– 10
ticlopidine, abciximab, eptifibatide,
mg/kg/dose q 6– 8 hr.
ortirofiban. Increase risk of adverse
hematologic reactions with antineoplastics
IV (Adults): Analgesic—400– 800 mg q 6 hr
orradiation therapy. Increase risk of
as needed (not to exceed 3200 mg/
nephrotoxicity with cyclosporine.
day); Antipyretic—400 mg initially, then 400
mg q 4– 6 hr or 100– 200 mg q 4 hr
Drug-Natural Products: increase bleeding
as needed (not to exceed 3200 mg/day).
risk with, arnica, chamomile, feverfew,
garlic, ginger, ginkgo, Panax ginseng, and
Pediatric OTC Dosing PO (Children 11
others.
yr/72– 95 lb): 300 mg q 6– 8 hr.
PO (Children 9– 10 yr/60– 71 lb): 250 mg q
INDICATIONS
6– 8 hr.
PO, IV: Treatment of: Mild to moderate pain,
PO (Children 6– 8 yr/48– 59 lb): 200 mg q
Fever.
6– 8 hr.
PO Treatment of: Inflammatory disorders
PO (Children 4– 5 yr/36– 47 lb): 150 mg q
including rheumatoid arthritis (including
6– 8 hr.
juvenile) and osteoarthritis, dysmenorrhea.
PO (Children 2– 3 yr/24– 35 lb): 100 mg q
IV Moderate to severe pain with opioid
6– 8 hr.
analgesics. Closure of a clinically
PO (Children 12– 23 mo/18– 23 lb): 75 mg q
significant PDA in neonates weighing 500–
6– 8 hr.
1500 g and 32 weeks gestational age
PO (Infants 6– 11 mo/12– 17 lb): 50 mg q 6–
(ibuprofen lysine only)
8 hr.

CONTRAINDCIATIONS
PDA Closure
Contraindicated in: Hypersensitivity (cross-
IV (Neonates Gestational age 32 weeks,
sensitivity may exist with other
500– 1500 g): 10 mg/kg followed by two
NSAIDs, including aspirin); Active GI
doses of 5 mg/kg at 24 and 48 hr after initial
bleeding or ulcer disease; Chewable tablets
dose.
contain aspartame and should not be used
in patients with phenylketonuria; Peri-

Page | 164
operative pain from coronary artery bypass Skin: Maculopapular and vesicobullous skin
graft (CABG) surgery; OB: Avoid after 30 wk eruptions, erythema multiforme, pruritus,
gestation (may cause premature closure of rectal itching, acne.
fetal ductus arteriosus); Body as a Whole: Fluid retention with
Pedi: Ibuprofen edema, Stevens-Johnson syndrome, toxic
lysine: Preterm neonates with untreated hepatitis, hypersensitivity reactions,
infection, congenital heart disease where anaphylaxis, bronchospasm, serum
patency of PDA is necessary for pulmonary sickness, SLE, angioedema
or systemic blood flow, bleeding,
thrombocytopenia, coagulation defects, NURSING RESPONSIBILITIES
necrotizing enterocolitis, significant renal
dysfunction. NURSING INTERVENTIONS

SIDE EFFECTS/ADVERSE REACTIONS

Side Effects Assessment
CNS: headache, dizziness, drowsiness, ● Patients who have asthma, aspirin-
intraventricular hemorrhage (ibuprofen induced allergy, and nasal polyps are
lysine), psychic disturbances. at increased risk for developing
EENT: amblyopia, blurred vision, tinnitus. hypersensitivity reactions. Assess for
CV: arrhythmias, edema, hypertension. rhinitis, asthma, and urticaria.
GI: GI BLEEDING, HEPATITIS, ● Assess for signs and symptoms of GI
constipation, dyspepsia, nausea, necrotizing bleeding (tarry stools, lightheadedness,
enterocolitis (ibuprofen lysine), vomiting, hypotension), renal dysfunction (elevated
abdominal discomfort. BUN and creatinine levels, decreased urine
GU: cystitis, hematuria, renal failure. output), and hepatic impairment (elevated
Derm: EXFOLIATIVE DERMATITIS, liver enzymes, jaundice).Geri:Higher
STEVENS-JOHNSON SYNDROME, TOXIC risk for poor outcomes or death from GI
EPIDERMAL NECROLYSIS, rashes, bleeding. Age-related renal impairment
injection site reaction. increases risk of hepatic and renal toxicity.
Hemat: anemia, blood dyscrasias, prolonged ● Assess patient for skin rash frequently
bleeding time. during therapy. Discontinue ibuprofen at first
Misc: allergic reactions including sign of rash; may be life-threatening.
ANAPHYLAXIS. Stevens-Johnson
syndrome or toxic epidermal necrolysis may
Adverse Effects develop. Treat symptomatically; may recur
CNS: Headache, dizziness, light- once treatment is stopped.
headedness, anxiety, emotional lability, ● Pain: Assess pain (note type, location, and
fatigue, malaise, drowsiness, anxiety, intensity) prior to and 1– 2 hr following
confusion, depression, aseptic meningitis. administration.
CV: Hypertension, palpitation, congestive ● Arthritis: Assess pain and range of motion
heart failure (patient with marginal cardiac prior to and 1– 2 hr following administration.
function); peripheral edema. ● Fever: Monitor temperature; note signs
Special Senses: Amblyopia (blurred vision, associated with fever (diaphoresis,
decreased visual acuity, scotomas, changes tachycardia, malaise).
in color vision); nystagmus, visual-field ● PDA Closure: Monitor preterm neonates
defects; tinnitus, impaired hearing. for signs of bleeding, infection and
GI: Dry mouth, gingival ulcerations, decreased urine output. Monitor IV site for
dyspepsia, heartburn, nausea, vomiting, signs of extravasation.
anorexia, diarrhea, constipation, bloating, ● Lab Test Considerations: BUN, serum
flatulence, epigastric or abdominal creatinine, CBC, and liver function tests
discomfort or pain, GI ulceration, occult should be evaluated periodically in patients
blood loss. receiving prolonged therapy.
Hematologic: Thrombocytopenia,
neutropenia, hemolytic or aplastic anemia, Implementation
leukopenia; decreased Hgb, Hct; transitory ● Do not confuse Motrin (ibuprofen) with
rise in AST, ALT, serum alkaline Neurontin (gabapentin).
phosphatase; rise in (Ivy) bleeding time. ● Administration of higher than
GU: Acute renal failure, polyuria, azotemia, recommended doses does not provide
cystitis, hematuria, nephrotoxicity, increased
decreased creatinine clearance.

Page | 165
pain relief but may increase incidence of
side effects.
● Patient should be well hydrated before
administration to prevent renal adverse
reactions. Do not give to neonates with urine
output 0.6 mL/kg/hour.
● Use lowest effective dose for shortest
period of time, especially in the elderly.
● Coadministration with opioid analgesics
may have additive analgesic effects and
may permit lower opioid doses.
● PO: For rapid initial effect, administer 30
min before or 2 hr after meals. May be
administered with food, milk, or antacids to
decrease GI irritation. Tablets may be
crushed and mixed with fluids or food; 800-
mg tablet can be dissolved in water.
● Dysmenorrhea: Administer as soon as
possible after the onset of menses.
Prophylactic treatment has not been shown
to be effective.
IV Administration
● Intermittent Infusion: Diluent: 0.9% NaCl,
D5W, or LR. Concentration:
Ibuprofen injection: Dilute the 800 mg dose
in at least 200 mL and the 400 mg
dose in at least 100 mL for a concentration
of 4 mg/mL. Ibuprofen lysine: Dilute
in appropriate volume of D5W or 0.9%NaCl
and infuse over 15 minutes Do not
administer solutions that are discolored or
contain particulate matter. Stable for
up to 24 hr at room temperature. Rate:
Infuse over at least 30 min.
Patient/Family Teaching
● Advise patients to take ibuprofen with a
full glass of water and to remain in an
upright position for 15– 30 min after
administration.
● Instruct patient to take medication as
directed. Take missed doses as soon as
remembered but not if almost time for next
dose. Do not double doses. Pedi: Teach
parents and caregivers to calculate and
measure doses accurately and to use
measuring device supplied with product.
● May cause drowsiness or dizziness.
Advise patient to avoid driving or other
activities requiring alertness until response
to medication is known.
● Caution patient to avoid the concurrent
use of alcohol, aspirin, acetaminophen,
and other OTC or herbal products without
consulting health care professional.
● Advise patient to inform health care
professional of medication regimen prior to
treatment or surgery.
● Instruct patients not to take OTC ibuprofen
preparations for more than 10 days for
pain or more than 3 days for fever, and to
consult health care professional if symptoms
persist or worsen. Many OTC products
contain ibuprofen; avoid duplication.
● Caution patient that use of ibuprofen with
3 or more glasses of alcohol
per day may increase the risk of GI
bleeding.
● Advise patient to consult health care
professional if rash, itching, visual
disturbances, tinnitus, weight gain, edema,
epigastric pain, dyspepsia, black stools,
hematemasis, persistent headache, or
influenza-like syndrome (chills, fever,
muscle
aches, pain) occurs.
● Pedi: Advise parents or caregivers not to
administer ibuprofen to children who
may be dehydrated (can occur with
vomiting, diarrhea, or poor fluid intake);
dehydration increases risk of renal
dysfuntion.
● Advise female patients to notify health
care professional if pregnancy is planned or
suspected.
Evaluation/Desired Outcomes
● Decrease in severity of pain.
● Improved joint mobility. Partial arthritic
relief is usually seen within 7 days, but
maximum effectiveness may require 1– 2 wk
of continuous therapy. Patients who
do not respond to one NSAID may respond
to another.
● Reduction in fever.
B. DRUGS THAT DECREACE
UTERINE MUSCLE
CONTRACTILITY
TOCOLYTIC THERAPY
1. CLASSIFICATION: BETA2-
ADRENERGIC RECEPTOR
ANTAGONISTS
GENERIC NAME: Terbutaline
BRAND NAME:
RECOMMENDED DOSAGE, ROUTE, AND
FREQUENCY
PO (Adults and Children >15 yr):
Bronchodilation—2.5– 5 mg 3 times daily,
given q 6 hr (not to exceed 15 mg/24 hr).
PO (Children 12– 15 yr): Bronchodilation—
2.5 mg 3 times daily (given q 6 hr)
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(not to exceed 7.5 mg/24 hr).
PO (Children <12 yr): Bronchodilation—0.05
mg/kg 3 times daily; may increase gradually
(not to exceed 0.15 mg/kg 3– 4 times daily
or 5 mg/24 hr.
Subcut (Adults and Children >12 yr):
Bronchodilation—250 mcg; may repeat
in 15– 30 min (not to exceed 500 mcg/4 hr).
Subcut (Children <12 yr): Bronchodilation—
0.005– 0.01 mg/kg; may repeat
in 15– 20 min.
IV (Adults): Tocolysis—2.5– 10 mcg/min
infusion; increase by 5 mcg/min q 10 min
until contractions stop (not to exceed 30
mcg/min). After contractions have stopped
for 30 min, decrease infusion rate to lowest
effective amount and maintain for 4– 8 hr
(unlabeled).
A: 35– 50% absorbed following oral
administration but rapidly undergoes first-
pass metabolism. Well absorbed following
subcut administration.
D: Enters breast milk.
M and E: Partially metabolized by the liver;
60% excreted unchanged by the kidneys
following subcut administration.
DRUG ACTION
Results in the accumulation of cyclic
adenosine monophosphate (cAMP) at beta-
adrenergic receptors. Produces
bronchodilation. Inhibits the release of
mediators of immediate hypersensitivity
reactions from mast cells. Relatively
selective for
beta2(pulmonary)-adrenergic receptor sites,
with less effect on beta1(cardiac)-adrenergic
receptors.
Therapeutic Effects: Bronchodilation.
INTERACTIONS
Drug-Drug: Concurrent use with other
adrenergics (sympathomimetic) will have
additive adrenergic side effects. Use with
MAO inhibitors may lead to hypertensive
crisis. Beta blockers may negate therapeutic
effect.
Drug-Natural Products: Use with caffeine-
containing herbs (cola nut, guarana, mate,
tea, coffee) increase stimulant effect.
INDICATIONS
Management of reversible airway disease
due to asthma or COPD; inhalation and
subcut used for short-term control and oral
agent as long-term control.
Unlabeled Use: Management of preterm
labor (tocolytic) (the FDA has recommended
that injectable terbutaline should not be
used in pregnancy for the prevention or
prolonged treatment [48– 72 hr] of preterm
labor in either the inpatient or outpatient
settings because of the potential for serious
maternal heart problems and death; oral
terbutaline should not be used for the
prevention or any treatment of preterm labor
because of a lack of efficacy and the
potential for serious material heart problems
and death).
CONTRAINDCIATIONS
Contraindicated in: Hypersensitivity to
adrenergic amines.
Use Cautiously in: Cardiac disease;
Hypertension; Hyperthyroidism; Diabetes;
Glaucoma;
Geri: More susceptible to adverse reactions;
may require dosep; Excessive use may lead
to tolerance and paradoxical bronchospasm
(inhaler);
OB, Lactation: Pregnancy (near term) and
lactation.
SIDE EFFECTS/ADVERSE REACTIONS
Side Effects
CNS: nervousness, restlessness, tremor,
headache, insomnia.
Resp: pulmonary edema.
CV: angina, arrhythmias, hypertension,
myocardial ischemia, tachycardia.
GI: nausea, vomiting.
Endo: hyperglycemia.
F and E: hypokalemia.
Adverse Reactions
CNS: Nervousness, tremor, headache, light-
headedness, drowsiness, fatigue, seizures.
CV: Tachycardia, hypotension or
hypertension, palpitation, maternal and fetal
tachycardia.
GI: Nausea, vomiting.
Body as a Whole: Sweating, muscle cramps.
NURSING RESPONSIBILITIES
NURSING INTERVENTIONS
Assessment
● Bronchodilator: Assess lung sounds,
respiratory pattern, pulse, and BP before
administration and during peak of
medication. Note amount, color, and
character
of sputum produced, and notify health care
professional of abnormal findings.
Monitor pulmonary function tests before
initiating therapy and periodically
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throughout therapy to determine
effectiveness of medication.
● Preterm Labor: Monitor maternal pulse
and BP, frequency and duration of
contractions, and fetal heart rate. Notify
health care professional if contractions
persist or increase in frequency or duration
or if symptoms of maternal or fetal distress
occur. Maternal side effects include
tachycardia, palpitations, tremor,
anxiety, and headache.
● Assess maternal respiratory status for
symptoms of pulmonary edema (increased
rate, dyspnea, rales/crackles, frothy
sputum).
● Monitor mother and neonate for symptoms
of hypoglycemia (anxiety; chills; cold
sweats; confusion; cool, pale skin; difficulty
in concentration; drowsiness; excessive
hunger; headache; irritability; nausea;
nervousness; rapid pulse; shakiness;
unusual tiredness; or weakness) and mother
for hypokalemia (weakness, fatigue,
U wave on ECG, arrhythmias).
● Lab Test Considerations: May cause
transient decrease in serum potassium
concentrations with higher than
recommended doses.
● Monitor maternal serum glucose and
electrolytes. May cause hypokalemia and
hypoglycemia. Monitor neonate’s serum
glucose, because hypoglycemia may also
occur in neonates.
● Toxicity and Overdose: Symptoms of
overdose include persistent agitation,
chest pain or discomfort, decreased BP,
dizziness, hyperglycemia, hypokalemia,
seizures, tachyarrhythmias, persistent
trembling, and vomiting.
● Treatment includes discontinuing beta-
adrenergic agonists and symptomatic,
supportive therapy. Cardio selective beta
blockers are used cautiously, because
they may induce bronchospasm.
Potential Nursing Diagnoses
Ineffective airway clearance (Indications)
Implementation
● Do not confuse Brethine (terbutaline) with
Methergine (methylergonovine).
● PO: Administer with meals to minimize
gastric irritation.
● Tablet may be crushed and mixed with
food or fluids for patients with difficulty
swallowing.
● Subcut: Administer subcut injections in
lateral deltoid area. Do not use solution if
discolored.
IV Administration
● pH: 3.0– 5.0.
● Continuous Infusion: Diluent: May be
diluted in D5W, 0.9% NaCl, or 0.45%
NaCl. Concentration: 1 mg/mL (undiluted).
Rate: Use infusion pump to ensure accurate
dose. Begin infusion at 10 mcg/min.
Increase dosage by 5 mcg every
10 min until contractions cease. Maximum
dose is 80 mcg/min. Begin to taper
dose in 5-mcg decrements after a 30– 60
min contraction-free period is attained.
Switch to oral dose form after patient is
contraction-free 4– 8 hr on the lowest
effective dose.
● Y-Site Compatibility: insulin.
Patient/Family Teaching
● Instruct patient to take medication as
directed. If on a scheduled dosing regimen,
take a missed dose as soon as possible;
space remaining doses at regular intervals.
Do not double doses. Caution patient not to
exceed recommended dose; may
cause adverse effects, paradoxical
bronchospasm, or loss of effectiveness of
medication.
● Instruct patient to contact health care
professional immediately if shortness of
breath is not relieved by medication or is
accompanied by diaphoresis, dizziness,
palpitations, or chest pain.
● Advise patient to consult health care
professional before taking any OTC
medications or alcoholic beverages
concurrently with this therapy. Caution
patient also to
avoid smoking and other respiratory irritants.
● Preterm Labor: Notify health care
professional immediately if labor resumes or
if significant side effects occur.
Evaluation/Desired Outcomes
● Prevention or relief of bronchospasm.
● Increase in ease of breathing.
● Control of preterm labor in a fetus of 20–
36 wk gestational age.
2. CLASSIFICATION: MAGNESIUM
SULFATE
GENERIC NAME: Magnesium
sulfate
BRAND NAME:
RECOMMENDED DOSAGE, ROUTE, AND
FREQUENCY
Treatment of Deficiency (Expressed as mg
of Magnesium)
IM, IV (Adults): Severe deficiency—8– 12
g/day in divided doses; mild deficiency—1 g
q 6 hr for 4 doses or 250 mg/kg over 4 hr.
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IM, IV (Children >1 mo): 25– 50 mg/kg/dose
q 4– 6 hr for 3– 4 doses, maximum single
dose: 2 g.
IV (Neonates): 25– 50 mg/kg/dose q 8– 12
hr for 2– 3 doses.
Seizures/Hypertension
IM, IV (Adults): 1 g q 6 hr for 4 doses as
needed.
IM, IV (Children): 20– 100 mg/kg/dose q 4–
6 hr as needed, may use up to 200
mg/kg/dose in severe cases.
Torsade de Pointes
IV (Infants and Children): 25– 50
mg/kg/dose, maximum dose: 2 g.
Bronchodilation
IV (Adults): 2 g single dose.
IV (Children): 25 mg/kg/dose, maximum
dose: 2 g.
Eclampsia/Pre-Eclampsia
IV, IM (Adults): 4– 5 g by IV infusion,
concurrently with up to 5 g IM in each
buttock; then 4– 5 g IM q 4 hr or 4 g by IV
infusion followed by 1– 2 g/hr continuous
infusion (not to exceed 40 g/day or 20 g/48
hr in the presence of severe renal
insufficiency).
Part of Parenteral Nutrition
IV (Adults): 4– 24 mEq/day.
IV (Children): 0.25– 0.5 mEq/kg/day.
A: IV administration results in complete
bioavailability; well absorbed from IM sites.
D: Widely distributed. Crosses the placenta
and is present in breastmilk.
M and E: Excreted primarily by the kidneys.
DRUG ACTION
Essential for the activity of many enzymes.
Plays an important role in neurotransmission
and muscular excitability.
Therapeutic Effects: Replacement in
deficiency states. Resolution of eclampsia.
INTERACTIONS
Drug-Drug: May potentiate calcium channel
blockers and neuromuscular blocking
agents.
INDICATIONS
Treatment/prevention of hypomagnesemia.
Treatment of hypertension. Prevention of
seizures associated with severe eclampsia,
pre-eclampsia, or acute nephritis.
Unlabeled Use: Preterm labor. Treatment of
torsade de pointes. Adjunctive treatment for
bronchodilation in moderate to severe acute
asthma.
CONTRAINDCIATIONS
Contraindicated in: Hypermagnesemia;
Hypocalcemia; Anuria; Heart block; OB:
Avoid using for more than 5– 7 days for
preterm labor (may increase risk of
hypocalcemia and bone changes in
newborn); avoid continuous use during
active labor or within 2hr of delivery due to
potential for magnesium toxicity in newborn.
Use Cautiously in: Any degree of renal
insufficiency;
Geri: May require decrease dosage due to
age-related decrease in renal function.
SIDE EFFECTS/ADVERSE REACTIONS
Side Effects
CNS: drowsiness.Resp:prespiratory rate.
CV: arrhythmias, bradycardia, hypotension.
GI: diarrhea.
MS: muscle weakness.
Derm: flushing, sweating.
Metab: hypothermia.
Adverse Reactions
Body as a Whole: Flushing, sweating,
extreme thirst, sedation, confusion,
depressed reflexes or no reflexes, muscle
weakness, flaccid paralysis, hypothermia.
CV: Hypotension, depressed cardiac
function, complete heart block, circulatory
collapse.
Respiratory: Respiratory paralysis.
Metabolic: Hypermagnesemia,
hypocalcemia, dehydration, electrolyte
imbalance including hypocalcemia with
repeated laxative use.
NURSING RESPONSIBILITIES
NURSING INTERVENTIONS
Assessment
● Hypomagnesemia/Anticonvulsant: Monitor
pulse, BP, respirations, and ECG
frequently throughout administration of
parenteral magnesium sulfate. Respirations
should be at least 16/min before each dose.
● Monitor neurologic status before and
throughout therapy. Institute seizure
precautions. Patellar reflex (knee jerk)
should be tested before each parenteral
dose of magnesium sulfate. If response is
absent, no additional doses should be
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administered until positive response is
obtained.
● Monitor newborn for hypotension,
hyporeflexia, and respiratory depression if
mother has received magnesium sulfate.
● Monitor intake and output ratios. Urine
output should be maintained at a level of at
least 100 mL/4 hr.
● Lab Test Considerations: Monitor serum
magnesium levels and renal function
periodically throughout administration of
parenteral magnesium sulfate.
Potential Nursing Diagnoses
Risk for injury (Indications) (Side Effects)
Implementation
● High Alert: Accidental overdosage of IV
magnesium has resulted in serious patient
harm and death. Have second practitioner
independently double check original order,
dose calculations, and infusion pump
settings. Do not confuse milligram (mg),
gram (g), or millequivalent (mEq) dosages.
● IM: Administer deep IM into gluteal sites.
Administer subsequent injections in
alternate sides. Dilute to a concentration of
200 mg/mL prior to injection.
IV Administration
● Direct IV: Diluent: 50% solution must be
diluted in 0.9% NaCl or D5W to a
concentration of 20% prior to administration.
Concentration: 20%. Rate:
Administer at a rate not to exceed 150
mg/min.
● Continuous Infusion: Diluent: Dilute in
D5W, 0.9% NaCl, or LR. Concentration: 0.5
mEq/mL (60 mg/mL) (may use maximum
concentration of 1.6 mEq/
mL (200 mg/mL) in fluid-restricted patients).
Rate: Infuse over 2-4 hr. Do not
exceed a rate of 1 mEq/kg/hr (125
mg/kg/hr). When rapid infusions are needed
(severe asthma or torsade de pointes) may
infuse over 10– 20 min.
● Y-Site Compatibility: acyclovir,
aldesleukin, alemtuzumab, alfentanil,
amifostine, amikacin, argatroban, ascorbic
acid, atropine, azithromycin, aztreonam,
benztropine, bivalirudin, bleomycin,
bumetanide, buprenorphine, butorphanol,
calcium gluconate, carboplatin, carmustine,
caspofungin, cefotaxime, cefoxitin.
Patient/Family Teaching
● Explain purpose of medication to patient
and family.
Evaluation/Desired Outcomes
● Normal serum magnesium concentrations.
● Control of seizures associated with
toxemias of pregnancy
3. CLASSIFICATION: CALCIUM
CHANNEL BLOCKERS
GENERIC NAME: Nifedipine
BRAND NAME: Procardia
RECOMMENDED DOSAGE, ROUTE, AND
FREQUENCY
PO (Adults): 10– 30 mg 3 times daily (not to
exceed 180 mg/day), or 10– 20 mg
twice daily as immediate-release form, or
30– 90 mg once daily as sustained-release
(CC, XL) form (not to exceed 90– 120
mg/day).
Absorption: Well absorbed after oral
administration, but large amounts are rapidly
metabolized (primarily by CYP3A4 enzyme
system), resulting in decrease bioavailability
(45– 70%); bioavailability is increase (80%)
with long-acting (CC, PA, XL) forms.
Distribution: Unknown. Protein Binding: 92–
98%.
M and E: Mostly metabolized by the liver.
Half-life: 2– 5 hr.
DRUG ACTION
Inhibits calcium transport into myocardial
and vascular smooth muscle cells, resulting
in inhibition of excitation-contraction
coupling and subsequent contraction.
Therapeutic Effects: Systemic vasodilation,
resulting in decreased BP. Coronary
vasodilation, resulting in decreased
frequency and severity of attacks of angina.
INTERACTIONS
Drug-Drug: Rifampin, rifabutin,
phenobarbital, phenytoin, or carbamazepine
may significantly decrease levels and
effects; concurrent use is contraindicated.
Ketoconazole, fluconazole, itraconazole,
clarithromycin, erythromycin, nefazodone,
saquinavir, indinavir, nelfinavir, or ritonavir
may increase levels and effects; consider
initiating nifedipine at lowest dose. Additive
hypotension may occur when used
concurrently with fentanyl, other
antihypertensives, nitrates, acute ingestion
of alcohol, or quinidine. Antihypertensive
effects may be decrease by concurrent use
of NSAIDs. May increase serum levels and
risk of toxicity from digoxin. Concurrent use
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with beta blockers, digoxin, or disopyramide Hemat: anemia, leukopenia,
may result in bradycardia, conduction thrombocytopenia.
defects, or HF. Cimetidine and propranolol Metab: weight gain. MS: joint stiffness,
may decrease metabolism and increase risk muscle cramps.
of toxicity. Neuro: paresthesia, tremor.

Drug-Natural Products: St. John’s wort Adverse Reactions

may significantly decrease levels and
effects; concurrent use is contraindicated. Body as a Whole: Sore throat, weakness,
fever, sweating, chills, febrile reaction. CNS:
Drug-Food: Grapefruit and grapefruit juice Dizziness, light-headedness, nervousness,
increase serum levels and effect; avoid mood changes, weakness, jitteriness, sleep
concurrent use. disturbances, blurred vision, retinal
ischemia, difficulty in balance, headache.
CV: Hypotension, facial flushing, heat
INDICATIONS
sensation, palpitations, peripheral edema,
Management of: Hypertension (extended-
MI (rare), prolonged systemic hypotension
release only), Angina pectoris, Vasospastic
with overdose.
(Prinzmetal’s) angina.
GI: Nausea, heartburn, diarrhea,
Unlabeled Use: Prevention of migraine
constipation, cramps, flatulence, gingival
headache. Management of HF or
hyperplasia, hepatotoxicity.
cardiomyopathy.
Musculoskeletal: Inflammation, joint
stiffness, muscle cramps. Respiratory: Nasal
congestion, dyspnea, cough, wheezing.
CONTRAINDCIATIONS
Skin: Dermatitis, pruritus, urticaria.
Urogenital: Sexual difficulties, possible male
Contraindicated in: Hypersensitivity; Sick infertility.
sinus syndrome; 2nd- or 3rd-degree
AV block (unless an artificial pacemaker is in NURSING RESPONSIBILITIES
place); Systolic BP <90 mm Hg;
Coadministration with grapefruit juice,
Assessment
rifampin, rifabutin, phenobarbital, phenytoin,
● Monitor BP and pulse before therapy,
carbamazepine, or St. John’s wort.
during dose titration, and periodically during
therapy. Monitor ECG periodically during
SIDE EFFECTS/ADVERSE REACTIONS
prolonged therapy.
● Monitor intake and output ratios and daily
Side Effects weight. Assess for signs of HF
(peripheral edema, rales/crackles, dyspnea,
CNS: headache, abnormal dreams, anxiety, weight gain, jugular venous
confusion, dizziness, drowsiness, jitteriness, distention).
nervousness, psychiatric disturbances, ● Patients receiving digoxin concurrently
weakness. with nifedipine should have routine tests
EENT: blurred vision, disturbed equilibrium, of serum digoxin levels and be monitored for
epistaxis, tinnitus. Resp: cough, dyspnea, signs and symptoms of digoxin toxicity.
shortness of breath. ● Assess for rash periodically during
CV: ARRHYTHMIAS, HF, peripheral edema, therapy. May cause Stevens-Johnson
bradycardia, chest pain, hypotension, syndrome. Discontinue therapy if severe or if
palpitations, syncope, tachycardia. accompanied with fever,
GI: increase liver enzymes, anorexia, general malaise, fatigue, muscle or joint
constipation, diarrhea, dry mouth, aches, blisters, oral lesions,
dysgeusia, dyspepsia, GI obstruction, conjunctivitis, hepatitis and/or eosinophilia.
nausea, ulcer, vomiting. GU: ● Angina: Assess location, duration,
dysuria, nocturia, polyuria, sexual intensity, and precipitating factors of
dysfunction, urinary frequency. patient’s
Derm: flushing, dermatitis, erythema anginal pain.
multiforme, increase sweating, ● Lab Test Considerations: Total serum
photosensitivity, pruritus/urticaria, calcium concentrations are not affected
rash. Endo: gynecomastia, hyperglycemia. by calcium channel blockers.

Page | 171
● Monitor serum potassium periodically.
Hypokalemia increases risk of arrhythmias;
should be corrected.
● Monitor renal and hepatic functions
periodically during long-term therapy.
Several days of therapy may cause increase
hepatic enzymes, which return to normal
upon discontinuation of therapy.
Potential Nursing Diagnoses
Decreased cardiac output (Indications)
Acute pain (Indications)
Implementation
● Do not confuse with nicardipine or
nimodipine.
● PO: May be administered without regard
to meals. May be administered with
meals if GI irritation becomes a problem.
● Do not open, break, crush, or chew
extended-release tablets. Empty tablets that
appear in stool are not significant.
● Avoid administration with grapefruit juice.
● Sublingual use is not recommended due
to serious adverse drug reactions.
Patient/Family Teaching
● Advise patient to take medication as
directed, even if feeling well. Take missed
doses as soon as possible unless almost
time for next dose; do not double doses.
May need to be discontinued gradually.
● Instruct patient on technique for
monitoring pulse. Instruct patient to contact
health care professional if heart rate is 50
bpm.
● Advise patient to avoid grapefruit or
grapefruit juice during therapy.
● Caution patient to change positions slowly
to minimize orthostatic hypotension.
● May cause drowsiness or dizziness.
Advise patient to avoid driving or other
activities requiring alertness until response
to the medication is known.
Evaluation/Desired Outcomes
● Decrease in BP.
● Decrease in frequency and severity of
anginal attacks.
● Decrease in need for nitrate therapy.
● Increase in activity tolerance and sense of
well-being.
4.CLASSIFICATION:
PROSTAGLANDIN INHIBITORS
GENERIC NAME:
PROSTAGLANDIN INHIBITORS
BRAND NAME: Indocin
RECOMMENDED DOSAGE, ROUTE, AND
FREQUENCY
Anti-inflammatory
PO (Adults): Antiarthritic—25– 50 mg 2– 4
times daily or 75-mg extended-release
capsule once or twice daily (not to exceed
200 mg or 150 mg of SR/day). A single
bedtime dose of 100 mg may be used.
Antigout—100 mg initially, followed by 50
mg 3 times daily for relief of pain, then
decrease further.
PO (Children >2 yr): 1– 2 mg/kg/day in 2– 4
divided doses (not to exceed 4 mg/ kg/day
or 150– 200 mg/day).
PDA Closure
IV (Neonates): Treatment— 0.2 mg/kg
initially, then 2 subsequent doses at 12– 24
hr intervals of 0.1 mg/kg if age <48 hr at
time of initial dose; 0.2 mg/kg if 2– 7 days at
initial dose; 0.25 mg/kg if age >7 days at
initial dose Prophylaxis— 0.1– 0.2 mg/ kg
initially, then 0.1 mg/kg q 12– 24 hr for 2
doses.
A: Well absorbed after oral administration in
adults, incomplete oral absorption in
neonates.
D: Crosses the blood-brain barrier and the
placenta. Enters breast
milk. Protein Binding: 99%.
M and E: Mostly metabolized by the liver.
Half-life: Neonates <2 weeks: 20 hr; >2
weeks: 11 hr; Adults: 2.6– 11 hr.
DRUG ACTION
Inhibits prostaglandin synthesis. In the
treatment of PDA, decreased prostaglandin
production allows the ductus to close.
Therapeutic Effects: PO: Suppression of
pain and inflammation.
IV: Closure of PDA.
INTERACTIONS
Drug-Drug: Concurrent use with aspirin
may decrease effectiveness. Additive
adverse GI effects with aspirin, other
NSAIDs, corticosteroids, or alcohol. Chronic
use of acetaminophen increases risk of
adverse renal reactions. May increase
effectiveness of diuretics or
antihypertensives. May increase
hypoglycemia from insulins or oral
hypoglycemic agents.
Drug-Natural Products: increase bleeding
risk with anise, arnica, chamomile, clove,
dong quai, feverfew, garlic, ginger, ginkgo,
Panax ginseng.
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INDICATIONS
PO: Inflammatory disorders including:
Rheumatoid arthritis, Gouty arthritis,
Osteoarthritis, Ankylosing spondylitis.
Generally reserved for patients who do not
respond to less toxic agents.
IV Alternative to surgery in the management
of patent ductus arteriosus (PDA) in
premature neonates.
CONTRAINDCIATIONS
Contraindicated in: Hypersensitivity; Known
alcohol intolerance (suspension);
Cross-sensitivity may exist with other
NSAIDs, including aspirin; Active GI
bleeding; Ulcer disease; Proctitis or recent
history of rectal bleeding; Intraventricular
hemorrhage; Thrombocytopenia;
Pedi: increase risk of necrotizing
enterocolitis and bowel perforation in
premature infants with PDA.
SIDE EFFECTS/ADVERSE REACTIONS
Side Effects
CNS: dizziness, drowsiness, headache,
psychic disturbances. EENT: blurred vision,
tinnitus.
CV: hypertension, edema.
GI: PO—DRUG-INDUCED HEPATITIS, GI
BLEEDING,
constipation, dyspepsia, nausea, vomiting,
discomfort, necrotizing enterocolitis.
GU: cystitis, hematuria, renal failure.
Derm: rashes.
F and E: hyperkalemia IV, dilutional
hyponatremia IV, hypoglycemia.
Hemat: thrombocytopenia, blood dyscrasias,
prolonged bleeding time.
Local: phlebitis at IV site.
Misc: allergic reactions including
ANAPHYLAXIS.
Adverse Reactions
Body as a Whole: Hypersensitivity (rash,
purpura, pruritus, urticaria, angioedema,
angiitis, rapid fall in blood pressure,
dyspnea, asthma syndrome in aspirin-
sensitive patients), edema, weight gain,
flushing, sweating.
CNS: Headache, dizziness, vertigo, light-
headedness, syncope, fatigue, muscle
weakness, ataxia, insomnia, nightmares,
drowsiness, confusion, coma, convulsions,
peripheral neuropathy, psychic disturbances
(hallucinations, depersonalization,
depression), aggravation of epilepsy,
parkinsonism.
CV: Elevated BP, palpitation, chest pains,
tachycardia, bradycardia, CHF. Special
Senses: Blurred vision, lacrimation, eye
pain, visual field changes, corneal deposits,
retinal disturbances including macula,
tinnitus, hearing disturbances, epistaxis.
GI: Nausea, vomiting, diarrhea, anorexia,
bloating, abdominal distention, ulcerative
stomatitis, proctitis, rectal bleeding, GI
ulceration, hemorrhage, perforation, toxic
hepatitis.
Hematologic: Hemolytic anemia, aplastic
anemia (sometimes fatal), agranulocytosis,
leukopenia, thrombocytopenic purpura,
inhibited platelet aggregation. Urogenital:
Renal function impairment, hematuria,
urinary frequency; vaginal bleeding, breast
changes.
Skin: Hair loss, exfoliative dermatitis,
erythema nodosum, tissue irritation with
extravasation.
Metabolic: Hyponatremia, hypokalemia,
hyperkalemia, hypoglycemia or
hyperglycemia, glycosuria (rare).
NURSING RESPONSIBILITIES
Assessment
● Patients who have asthma, aspirin-
induced allergy, and nasal polyps are
at increased risk for developing
hypersensitivity reactions. Monitor for
rhinitis, asthma, and urticaria.
● Arthritis: Assess limitation of movement
and pain— note type, location, and intensity
before and 1– 2 hr after administration.
● PDA: Monitor respiratory status, heart
rate, BP, echocardiogram, and heart
sounds routinely throughout therapy.
● Monitor intake and output. Fluid restriction
is usually instituted throughout therapy.
● Lab Test Considerations: Evaluate BUN,
serum creatinine, CBC, serum potassium
levels, and liver function tests periodically in
patients receiving prolonged
therapy.
Potential Nursing Diagnoses
Acute pain (Indications)
Impaired physical mobility (Indications)
Implementation
Page | 173
● If prolonged therapy is used, dose should
be reduced to the lowest level that controls
symptoms.
● PO: Administer after meals, with food, or
with antacids to decrease GI irritation.
Do not break, crush, or chew sustained-
release capsules.
● Shake suspension before administration.
Do not mix with antacid or any other liquid.
IV Administration
● pH: 6.0– 7.5.
Evaluation/Desired Outcomes
● Decrease in severity of moderate pain.
● Improved joint mobility. Partial arthritic
relief is usually seen within 2 wk, but
maximum effectiveness may require up to 1
mo of continuous therapy. Patients
who do not respond to one NSAID may
respond to another.
● Successful PDA closure.
Patient/Family Teaching
● Advise patient to take this medication with
a full glass of water and to remain in an
upright position for 15– 30 min after
administration.
● Instruct patient to take medication exactly
as directed. Take missed doses as soon
as remembered if not almost time for next
dose. Do not double doses.
C. CLASSIFICATION:
CORTICOSTEROID THERAPY IN
PRETERM LABOR
GENERIC NAME: Betamethasone
BRAND NAME:
RECOMMENDED DOSAGE, ROUTE, AND
FREQUENCY
IM (Adults): 0.5– 9 mg/day as
betamethasone sodium phosphate/acetate
suspension in 1– 2 divided doses.
Prevention of respiratory distress syndrome
in newborn—12 mg daily for 2– 3 days
before delivery (unlabeled).
IM (Children): Adrenocortical insufficiency—
17.5 mcg/kg (500 mcg/m2 )/day in 3 divided
doses every 3rd day or 5.8– 8.75 mcg/kg
(166– 250 mcg/m2 )/day as a single dose.
Other uses—20.8– 125 mcg/kg (0.625– 3.75
mg/m2 ) of the base q 12– 24 hr.
A: Sodium phosphate salt is rapidly
absorbed after IM administration.
Acetate salt is slowly but completely
absorbed after IM administration. Absorption
from local sites (intra-articular, intralesional)
is slow but complete.
D: Widely distributed; crosses the placenta
and probably enters breast
milk.
M and E : Metabolized mostly by the liver.
Half-life: 3– 5 hr (plasma), 36– 54 hr
(tissue); adrenal suppression lasts 3.25
days.
DRUG ACTION
In pharmacologic doses, suppresses
inflammation and the normal immune
response. Has numerous intense metabolic.
Suppresses adrenal function at chronic
doses of 0.6 mg/day. Has negligible
mineralocorticoid activity. Therapeutic
Effects: Suppression of inflammation and
modification of the normal immune
response. Replacement therapy in adrenal
insufficiency.
INTERACTIONS
Drug-Drug: Additive hypokalemia with
thiazide and loop diuretics, or amphotericin
B. Hypokalemia may increase risk of digitalis
glycoside toxicity. May increase requirement
for insulins or oral hypoglycemic agents.
Phenytoin, phenobarbital, and rifampin
stimulate metabolism; may increase
effectiveness
INDICATIONS
Management of adrenocortical insufficiency;
chronic use in other situations is limited
because of mineralocorticoid activity. Used
systemically and locally in a wide variety of
chronic diseases including: Inflammatory,
Allergic, Hematologic, Neoplastic,
Autoimmune disorders. Replacement
therapy in adrenal insufficiency.
Unlabeled Use: Short-term administration to
high-risk mothers before delivery to prevent
respiratory distress syndrome in the
newborn.
CONTRAINDCIATIONS
Active untreated infections (may be used in
patients being treated for tuberculous
meningitis); Traumatic brain injury (high
doses may increase mortality);
Lactation: Avoid chronic use; Some products
contain bisulfites and should be avoided in
patients with known hypersensitivity.
SIDE EFFECTS/ADVERSE REACTIONS
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Side Effects
CNS: depression, euphoria, headache,
increase intracranial pressure (children
only), personality changes, psychoses,
restlessness.
EENT: cataracts, increase intraocular
pressure.
CV: hypertension.
GI: PEPTIC ULCERATION, anorexia,
nausea, vomiting.
Derm: acne, decrease wound healing,
ecchymoses, fragility, hirsutism, petechiae.
Endo: adrenal suppression, hyperglycemia.
F and E: fluid retention (long-term high
doses), hypokalemia, hypokalemic alkalosis.
Hemat: THROMBOEMBOLISM,
thrombophlebitis.
Metab: weight gain, weight loss. MS: muscle
wasting, osteoporosis, avascular necrosis of
joints, muscle pain.
Misc: cushingoid appearance (moon face,
buffalo hump), increase susceptibility to
infection.
Adverse Reactions
Body as a Whole: Hypersensitivity or
anaphylactoid reactions; aggravation or
masking of infections; malaise, weight gain,
obesity. Most adverse effects are dose and
treatment duration dependent.
NURSING RESPONSIBILITIES
Assessement
● Indicated for many conditions. Assess
involved systems before and periodically
during therapy.
● Assess patient for signs of adrenal
insufficiency (hypotension, weight loss,
weakness, nausea, vomiting, anorexia,
lethargy, confusion, restlessness) before
and
periodically during therapy.
● Monitor intake and output ratios and daily
weights. Observe patient for peripheral
edema, steady weight gain, rales/crackles,
or dyspnea. Notify health care professional if
these occur.
● Pedi: Children should have periodic
growth evaluations.
Potential Nursing Diagnoses
Risk for infection (Side Effects)
Disturbed body image (Side Effects)
Implementation
● If dose is ordered daily or every other day,
administer in the morning to coincide
with the body’s normal secretion of cortisol.
● IM: Shake suspension well before drawing
up. Do not dilute with other solution or
admix. Do not administer suspensions IV.
Patient/Family Teaching
● Stopping the medication suddenly may
result in adrenal insufficiency
(anorexia, nausea, weakness, fatigue,
dyspnea, hypotension, hypoglycemia). If
these signs appear, notify health care
professional immediately. This can be life-
threatening.
● Glucocorticoids cause
immunosuppression and may mask
symptoms of infection. Instruct patient to
avoid people with known contagious
illnesses and to report possible infections
immediately.
● Caution patient to avoid vaccinations
without first consulting health care
professional.
Evaluation/Desired Outcomes
● Decrease in presenting symptoms with
minimal systemic side effects.
● Suppression of the inflammatory and
immune responses in autoimmune
disorders, allergic reactions, and neoplasms.
● Management of symptoms in adrenal
insufficiency.
D. CLASSIFICATION: DRUGS FOR
GESTATIONAL HYPERTENSION
GENERIC NAME: Labetalol
BRAND NAME: Trandate
RECOMMENDED DOSAGE, ROUTE, AND
FREQUENCY
PO (Adults): 100 mg twice daily initially, may
be increase by 100 mg twice daily q 2– 3
days as needed (usual range 400– 800
mg/day in 2– 3 divided doses; doses up to
1.2– 2.4 g/day have been used).
PO (Infants and Children): 1– 3 mg/kg/day
divided BID (maximum dose: 10– 12
mg/kg/day, up to 1200 mg/day).
IV (Adults): 20 mg (0.25 mg/kg) initially,
additional doses of 40– 80 mg may be given
q 10 min as needed (not to exceed 300 mg
total dose) or 2 mg/min infusion (range 50–
300 mg total dose required).
IV (Infants and Children): 0.2– 1 mg/kg/dose
(maximum: 40 mg/dose).
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A: Well absorbed but rapidly undergoes
extensive first-pass hepatic metabolism,
resulting in 25% bioavailability.
D: Some CNS penetration; crosses the
placenta. Protein Binding: 50%.
Mand E: Undergoes extensive hepatic
metabolism.
Half-life: 3– 8 hr.
DRUG ACTION
Blocks stimulation of beta1 (myocardial)-
and beta2 (pulmonary, vascular, and
uterine)-adrenergic receptor sites. Also has
alpha1-adrenergic blocking activity, which
may result in more orthostatic hypotension.
Therapeutic Effects: Decreased BP.
INTERACTIONS
Blocks stimulation of beta1 (myocardial)-
and beta2 (pulmonary, vascular, and
uterine)-adrenergic receptor sites. Also has
alpha1-adrenergic blocking activity, which
may result in more orthostatic hypotension.
Therapeutic Effects: Decreased BP. alcohol,
or nitrates.
INDICATIONS
Management of hypertension.
CONTRAINDCIATIONS
Uncompensated HF; Pulmonary edema;
Cardiogenic shock; Bradycardia or heart
block.
SIDE EFFECTS/ADVERSE REACTIONS
Side Effects
CNS: fatigue, weakness, anxiety,
depression, dizziness, drowsiness,
insomnia, memory loss, mental status
changes, nightmares.
EENT: blurred vision, dry eyes,
intraoperative floppy iris syndrome, nasal
stuffiness. Resp: bronchospasm, wheezing.
CV: ARRHYTHMIAS, BRADYCARDIA,
CHF, PULMONARY EDEMA, orthostatic
hypotension.
GI: constipation, diarrhea, nausea.
GU: erectile dysfunction,plibido.
Derm: itching, rashes.
Endo: hyperglycemia, hypoglycemia.
MS: arthralgia, back pain, muscle cramps.
Neuro: paresthesia.
Adverse Reactions
CNS: Dizziness, fatigue/malaise, headache,
tremors, transient paresthesias (especially
scalp tingling), hypoesthesia (numbness)
following IV, mental depression, drowsiness,
sleep disturbances, nightmares.
CV: Postural hypotension, angina pectoris,
palpitation, bradycardia, syncope, pedal or
peripheral edema, pulmonary edema, CHF,
flushing, cold extremities, arrhythmias
(following IV), paradoxical hypertension
(patients with pheochromocytoma).
Special Senses: Dry eyes, vision
disturbances, nasal stuffiness, rhinorrhea.
GI: Nausea, vomiting, dyspepsia,
constipation, diarrhea, taste disturbances,
cholestasis with or without jaundice,
increases in serum transaminases, dry
mouth.
NURSING RESPONSIBILITIES
NURSING INTERVENTIONS
● Monitor BP and pulse frequently during
dose adjustment and periodically during
therapy. Assess for orthostatic hypotension
when assisting
patient up from supine position.
● Check frequency of refills to determine
compliance.
● Patients receiving labetalol IV must be
supine during and for 3 hr after
administration. Vital signs should be
monitored every 5– 15 min during and for
several
hours after administration.
● Monitor intake and output ratios and daily
weight. Assess patient routinely for evidence
of fluid overload (peripheral edema,
dyspnea, rales/
crackles, fatigue, weight gain, jugular
venous distention).
● Lab Test Considerations: May cause
increase BUN, serum lipoprotein, potassium,
triglyceride, and uric acid levels.
Potential Nursing Diagnoses
Decreased cardiac output (Side Effects)
Noncompliance (Patient/Family Teaching)
Implementation
● High Alert: IV vasoactive medications are
inherently dangerous. Before administering
intravenously, have second practitioner
independently check original order, dosage
calculations, and infusion pump settings.
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Patient/Family Teaching
● Instruct patient to take medication as
directed, at the same time each day, even if
feeling well; do not skip or double up on
missed doses. Take missed doses as soon
as possible up to 8 hr before next dose.
Abrupt withdrawal may precipitate life-
threatening arrhythmias, hypertension, or
myocardial ischemia.
● Advise patient to make sure enough
medication is available for weekends,
holidays, and vacations. A written
prescription may be kept in wallet in case of
emergency.
● Teach patient and family how to check
pulse and BP. Instruct them to check pulse
daily and BP biweekly. Advise patient to
hold dose and contact health care
professional if pulse is 50 bpm or BP
changes significantly.
● May cause drowsiness or dizziness.
Caution patients to avoid driving or other
activities that require alertness until
response to the drug is known. Caution
patients receiving labetalol IV to call for
assistance during ambulation or transfer.
● Advise patients to make position changes
slowly to minimize orthostatic hypotension,
especially during initiation of therapy or
when dose is increased. Patients taking oral
labetalol should be especially cautious when
drinking alcohol, standing for long periods,
or exercising, and during hot weather,
because orthostatic hypotension is
enhanced.
Evaluation/Desired Outcomes
● Decrease in BP.
B. FEMALE REPRODUCTION
CYCLE II: LABOR, DELIVERY AND
PRETERM NEONATAL DRUGS
A. ANALGESICS/SEDATION
1.a CLASSIFICATION: SEDATIVE-
TRANQUILIZERS
(BARBITURATES/HYPNOTICS)
GENERIC NAME: Pentobarbital
Sodium
BRAND NAME: Nembutal
RECOMMENDED DOSAGE, ROUTE, AND
FREQUENCY
Status Epilepticus
IV (Adults and Children >1 mo): 15– 18
mg/kg in a single or divided dose, maximum
loading dose 20 mg/kg.
IV (Neonates): 15– 20 mg/kg in a single or
divided dose.
Maintenance Anticonvulsant
IV, PO (Adults and Children >12 yr): 1– 3
mg/kg/day as a single dose or 2 divided
doses.
IV, PO (Children 5–12 yr): 4– 6 mg/kg/day in
1– 2 divided doses.
IV, PO (Children 1–5 yr): 6– 8 mg/kg/day in
1– 2 divided doses.
IV, PO (Infants): 5– 6 mg/kg/day in 1– 2
divided doses.
IV, PO (Neonates): 3– 4 mg/kg/day once
daily, may need to increase up to 5 mg/
kg/day by 2nd week of therapy.
Sedation
PO, IM (Adults): 30– 120 mg/day in 2– 3
divided doses. Preoperative sedation—
100– 200 mg IM 1– 1.5 hours before the
procedure.
PO (Children): 2 mg/kg 3 times daily.
Preoperative sedation—1– 3 mg/kg PO/
IM/IV 1– 1.5 hours before the procedure.
Hypnotic
PO, Subcut, IV, IM (Adults): 100– 320 mg at
bedtime.
IV, IM, Subcut (Children): 3– 5 mg/kg at
bedtime.
Hyperbilirubinemia
PO (Adults): 90– 180 mg/day in 2– 3 divided
doses.
PO (Children <12 yr): 3– 8 mg/kg/day in 2–
3 divided doses, doses up to 12 mg/ kg/day
have been used.
A: Absorption is slow but relatively complete
(70– 90%).
D: Unknown.
M and E: 75% metabolized by the liver, 25%
excreted unchanged by the kidneys.
Half-life: Neonates: 1.8– 8.3 days; Infants:
0.8– 5.5 days; Children: 1.5– 3 days;
Adults: 2– 6 days.
DRUG ACTION
Produces all levels of CNS depression.
Depresses the sensory cortex, decreases
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motor activity, and alters cerebellar function.
Inhibits transmission in the nervous system
and raises the seizure threshold. Capable of
inducing (speeding up) enzymes in the liver
that metabolize drugs, bilirubin, and other
compounds. Therapeutic Effects:
Anticonvulsant activity. Sedation.
INTERACTIONS
Drug-Drug: Additive CNS depression with
other CNS depressants, including alcohol,
antihistamines, opioid analgesics, and other
sedative/hypnotics. May
induce hepatic enzymes that metabolize
other drugs, increase their effectiveness,
including
hormonal contraceptives, warfarin,
chloramphenicol, cyclosporine, dacarbazine,
corticosteroids, tricyclic antidepressants,
felodipine, clonazepam,
carbamazepine, verapamil, theophylline,
metronidazole, and quinidine.
May increase risk of hepatic toxicity of
acetaminophen. MAO inhibitors, valproic
acid, or divalproex may decrease
metabolism of phenobarbital, increase
sedation. Rifampin may increase
metabolism of and decrease effects of
phenobarbital. May increase risk of
hematologic toxicity with cyclophosphamide.
Drug-Natural Products: Concomitant use
of kava-kava, valerian, chamomile, or hops
can increase CNS depression. St. John’s
wort may decrease effects.
INDICATIONS
Anticonvulsant in tonic-clonic (grand mal),
partial, and febrile seizures in children.
Preoperative sedative and in other situations
in which sedation may be required. Hypnotic
(short-term). Unlabeled Use:
Prevention/treatment of hyperbilirubinemia
in neonates.
CONTRAINDCIATIONS
Hypersensitivity; Comatose patients or those
with pre-existing CNS depression; Severe
respiratory disease with dyspnea or
obstruction; Uncontrolled severe pain;
Known alcohol intolerance (elixir only);
Lactation: Discontinue drug or bottle feed.
SIDE EFFECTS/ADVERSE REACTIONS
Side Effects
CNS: hangover, delirium, depression,
drowsiness, excitation, lethargy, vertigo.
Resp: respiratory
depressionIV,LARYNGOSPASM,
bronchospasm. CV: IV— hypotension.
GI: constipation, diarrhea, nausea, vomiting.
Derm: photosensitivity, rashes, urticaria.
Local: phlebitis at IV site.
MS: arthralgia, myalgia, neuralgia.
Misc: hypersensitivity reactions including
ANGIOEDEMA and SERUM SICKNESS,
physical dependence, psychological
dependence.
Adverse Reactions
Body as a Whole: Drowsiness, lethargy,
hangover, paradoxical excitement in the
older adult patient.
CV: Hypotension with rapid IV.
Respiratory: With rapid IV (respiratory
depression, laryngospasm, bronchospasm,
apnea).
NURSING RESPONSIBILITIES
Assessment
● Monitor respiratory status, pulse, and BP
and signs and symptoms of angioedema
(swelling of lips, face, throat, dyspnea)
frequently in patients
receiving phenobarbital IV. Equipment for
resuscitation and artificial
ventilation should be readily available.
Respiratory depression is dosedependent.
● Prolonged therapy may lead to
psychological or physical dependence.
Restrict
amount of drug available to patient,
especially if depressed, suicidal, or with a
history of addiction.
● Geri: Elderly patients may react to
phenobarbital with marked excitement,
depression, and confusion. Monitor for these
adverse reactions.
● Seizures: Assess location, duration, and
characteristics of seizure activity.
● Sedation: Assess level of consciousness
and anxiety when used as a preoperative
sedative.
Potential Nursing Diagnoses
Risk for injury (Indications) (Side Effects)
Acute confusion (Side Effects)
Implementation
● Do not confuse phenobarbital with
pentobarbital.
● Supervise ambulation and transfer of
patients following administration. Two side
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rails should be raised and call bell within
reach at all times. Keep bed in low position.
Institute seizure and fall precautions.
● When changing from phenobarbital to
another anticonvulsant, gradually decrease
phenobarbital dose while concurrently
increasing dose of replacement medication
to maintain anticonvulsant effects.
● PO: Tablets may be crushed and mixed
with food or fluids (do not administer dry)
for patients with difficulty swallowing. Oral
solution may be taken undiluted or
mixed with water, milk, or fruit juice. Use
calibrated measuring device for accurate
measurement of liquid doses.
Patient/Family Teaching
● Advise patient to take medication as
directed. Take missed doses as soon as
remembered if not almost time for next
dose; do not double doses.
● Advise patients on prolonged therapy not
to discontinue medication without consulting
health care professional. Abrupt withdrawal
may precipitate seizures or
status epilepticus.
● Medication may cause daytime
drowsiness. Caution patient to avoid driving
and
other activities requiring alertness until
response to medication is known. Do not
resume driving until physician gives
clearance based on control of seizure
disorder.
● Caution patient to avoid taking alcohol or
other CNS depressants concurrently with
this medication.
Evaluation/Desired Outcomes
● Decrease or cessation of seizure activity
without excessive sedation. Several weeks
may be required to achieve maximum
anticonvulsant effects.
● Preoperative sedation.
● Improvement in sleep patterns.
● Decrease in serum bilirubin levels.
1.b.CLASSIFICATION: SEDATIVE-
TRANQUILIZERS
(PHENOTHIAZINE DERIVATIVES &
HYDROXYZINE)
GENERIC NAME: Hydroxyzine
hydrochloride
BRAND NAME: Vistaril
RECOMMENDED DOSAGE, ROUTE, AND
FREQUENCY
PO (Adults): Antianxiety—25– 100 mg 4
times/day, not to exceed 600 mg/day.
Preoperative sedation—50– 100 mg single
dose. Antipruritic—25 mg 3– 4
times daily.
PO (Children): — 2 mg/kg/day divided q 6–
8 hr.
IM (Adults): Preoperative sedation—25– 100
mg single dose. Antiemetic, adjunct to opioid
analgesics—25– 100 mg q 4– 6 hr as
needed.
IM (Children): — 0.5– 1 mg/kg/dose q 4– 6
hr as needed.
A:Well absorbed following PO/IM
administration.
D: Unknown.
M and E: Completely metabolized by the
liver; eliminated in the feces via biliary
excretion.
Half-life: 3 hr.
DRUG ACTION
Acts as a CNS depressant at the subcortical
level of the CNS. Has anticholinergic,
antihistaminic, and antiemetic properties.
Blocks histamine 1 receptors. Therapeutic
Effects: Sedation. Relief of anxiety.
Decreased nausea and vomiting. Decreased
allergic symptoms associated with release of
histamine, including pruritus.
INTERACTIONS
Drug-Drug: Additive CNS depression with
other CNS depressants, including alcohol,
antidepressants, antihistamines, opioid
analgesics, and sedative/
hypnotics. Additive anticholinergic effects
with other drugs possessing anticholinergic
properties, including antihistamines,
antidepressants, atropine,
haloperidol, phenothiazines, quinidine, and
disopyramide. Can antagonize
the vasopressor effects of epinephrine.
Drug-Natural Products: Concomitant use of
kava-kava, valerian, or chamomile can
increase CNS depression. Increase
anticholinergic effects with angel’s trumpet,
jimson weed, and scopolia.
INDICATIONS
Treatment of anxiety. Preoperative sedation.
Antiemetic. Antipruritic. May be combined
with opioid analgesics.
CONTRAINDCIATIONS
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Hypersensitivity; OB: Potential for congenital
defects (oral
clefts and hypoplasia of cerebral
hemisphere;
Lactation: Safety not established.
SIDE EFFECTS/ADVERSE REACTIONS
Side Effects
CNS: drowsiness, agitation, ataxia,
dizziness, headache, weakness.
Resp: wheezing.
GI: dry mouth, bitter taste, constipation,
nausea. GU: urinary retention.
Derm: flushing.
Local: pain at IM site, abscesses at IM sites.
Misc:chest tightness.
Adverse Reactions
CNS: Drowsiness (usually transitory),
sedation, dizziness, headache.
CV: Hypotension.
GI: Dry mouth.
Body as a Whole: Urticaria, dyspnea, chest
tightness, wheezing, involuntary motor
activity (rare).
Hematologic: Phlebitis, hemolysis,
thrombosis.
Skin: Erythematous macular eruptions,
erythema multiforme, digital gangrene from
inadvertent IV or intraarterial injection,
injection site reactions.
NURSING RESPONSIBILITIES
Assessment
● Assess patient for profound sedation and
provide safety precautions as indicated
(side rails up, bed in low position, call bell
within reach, supervision of ambulation and
transfer). Geri: Older adults are more
sensitive to CNS and anticholinergic effects
(delirium, acute confusion, dizziness, dry
mouth, blurred vision, urinary retention,
constipation, tachycardia). Monitor for
drowsiness, agitation, over sedation, and
other systemic side effects. Assess falls risk
and implement prevention strategies.
Anxiety: Assess mental status (orientation,
mood, and behavior).
Potential Nursing Diagnoses
Anxiety (Indications)
Impaired skin integrity (Indications)
Risk for injury (Side Effects)
Ineffective coping (Side Effects)
Implementation
● Do not confuse hydroxyzine with
hydralazine or Atarax (hydroxyzine)
with Ativan (lorazepam).
● PO: Tablets may be crushed and capsules
opened and administered with food or
fluids for patients having difficulty
swallowing.
Patient/Family Teaching
● Instruct patient to take medication exactly
as directed. Missed doses should be
taken as soon as remembered unless it is
almost time for next dose; do not double
doses.
● May cause drowsiness or dizziness.
Caution patient to avoid driving and other
activities requiring alertness until response
to medication is known. Geri:Warn patients
or caregivers that older adults are at
increased risk for CNS effects and falls.
● Advise patient to avoid concurrent use of
alcohol or other CNS depressants with
this medication.
Evaluation/Desired Outcomes
● Decrease in anxiety.
● Relief of nausea and vomiting.
● Relief of pruritus.
● Sedation when used as a
sedative/hypnotic.
2.CLASSIFICATION: NARCOTICS
AGONISTS
GENERIC NAME: Fentanyl citrate
BRAND NAME: Sublimaze
RECOMMENDED DOSAGE, ROUTE, AND
FREQUENCY
Preoperative Use
IM, IV (Adults and Children >12 yr): 50– 100
mcg 30– 60 min before surgery.
Adjunct to General Anesthesia
IM, IV (Adults and Children >12 yr): Low
dose–minor surgery—2 mcg/kg.
Moderate dose–major surgery—2– 20
mcg/kg. High dose–major surgery—
20– 50 mcg /kg.
Adjunct to Regional Anesthesia
IM, IV (Adults and Children >12 yr): 50– 100
mcg.
Postoperative Use (Recovery Room)
IM, IV (Adults and Children >12 yr): 50– 100
mcg; may repeat in 1– 2 hr.
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A: Well absorbed after IM administration.
D: Unknown.
M and E: Mostly metabolized by the liver,
10– 25% excreted unchanged by the
kidneys.
Half-life: Children: Bolus dose— 2.4 hr, long-
term continuous infusion— 11– 36
hr; Adults: 2– 4 hr (increase after
cardiopulmonary bypass and in geriatric
patients).
DRUG ACTION
Binds to opiate receptors in the CNS,
altering the response to and perception of
pain. Produces CNS depression.
Therapeutic Effects: Supplement in
anesthesia. Decreased pain.
INTERACTIONS
Drug-Drug: Avoid use in patients who have
received MAO inhibitors within
the previous 14 days (may produce
unpredictable, potentially fatal reactions).
Concomitant use of CYP3A4 inhibitors
including ritonavir, ketoconazole,
itraconazole, clarithromycin, nelfinavir,
nefazodone, diltiazem, aprepitant,
fluconazole, fosamprenavir, verapamil, and
erythromycin may result in increase plasma
levels and increase risk of CNS and
respiratory depression.
Drug-Food: Grapefruit juice is a moderate
inhibitor of the CYP3A4 enzyme system;
concurrent use may increase blood levels
and the risk of respiratory and CNS
depression. Careful monitoring and dose
adjustment is recommended.
INDICATIONS
Analgesic supplement to general
anesthesia; usually with other agents (ultra–
short acting barbiturates, neuromuscular
blocking agents, and inhalation anesthetics)
to produce balanced anesthesia.
Induction/maintenance of anesthesia (with
oxygen or oxygen/nitrous oxide and a
neuromuscular blocking agents).
Neuroleptanalgesia/ neuroleptanesthesia
(with or without nitrous oxide). Supplement
to regional/local anesthesia. Preoperative
and postoperative analgesia.
Unlabeled Use: Continuous IV infusion as
part of PCA.
CONTRAINDCIATIONS
Hypersensitivity; cross-sensitivity among
agents may occur; Known intolerance.
SIDE EFFECTS/ADVERSE REACTIONS
Side Effects
CNS: confusion, paradoxical
excitation/delirium, postoperative
depression, postoperative drowsiness.
EENT: blurred/double vision.
Resp: APNEA, LARYNGOSPASM, allergic
bronchospasm, respiratory depression.
CV: arrhythmias, bradycardia, circulatory
depression, hypotension.
GI: biliary spasm, nausea/vomiting.
Derm: facial itching.
MS: skeletal and thoracic muscle rigidity
(with rapid IV infusion).
Adverse Reactions
CNS: Sedation, euphoria, dizziness,
diaphoresis, delirium, convulsions with high
doses.
CV: Hypotension, bradycardia, circulatory
depression, cardiac arrest. Special Senses:
Miosis, blurred vision.
GI: Nausea, vomiting, constipation, ileus.
Respiratory: Laryngospasm,
bronchoconstriction, respiratory depression
or arrest. Body as a Whole: Muscle rigidity,
especially muscles of respiration after rapid
IV infusion, urinary retention,
Skin: Rash, contact dermatitis from patch.
NURSING RESPONSIBILITIES
Assessment
● Monitor respiratory rate and BP frequently
throughout therapy. Report
significant changes immediately. The
respiratory depressant effects of
fentanyl may last longer than the analgesic
effects. Initial doses of other
opioids should be reduced by 25– 33% of
the usually recommended
dose. Monitor closely.
● Geri: Opioids have been associated with
increased risk of falls in geriatric patients.
Assess risk and implement fall prevention
strategies.
● IV, IM: Assess type, location, and intensity
of pain before and 30 min after IM
administration or 3– 5 min after IV
administration when fentanyl is used to treat
pain.
Potential Nursing Diagnoses
Acute pain (Indications)
Ineffective breathing pattern (Adverse
Reactions)
Risk for injury (Side Effects)
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Implementation
● High Alert: Accidental overdosage of
opioid analgesics has resulted in fatalities.
Before administering, clarify all ambiguous
orders; have second practitioner
independently check original order, dose
calculations, route of administration, and
infusion pump programming.
● Do not confuse fentanyl with sufentanil.
Patient/Family Teaching
● Discuss the use of anesthetic agents and
the sensations to expect with the patient
before surgery.
● Explain pain assessment scale to patient.
● Caution patient to change positions slowly
to minimize orthostatic hypotension.
Geri: Geriatric patients may be a greater risk
for orthostatic hypotension and,
consequently, falls. Teach patient to take
precautions until drug effects have
completely resolved.
Evaluation/Desired Outcomes
● General quiescence.
● Reduced motor activity.
● Pronounced analgesia.
3. CLASSIFICATION: MIXED
NARCOTIC AGONISTS-
ANTAGONISTS
GENERIC NAME: Nalbuphine
BRAND NAME: Nubain
opioid withdrawal in physically dependent
patients.
Therapeutic Effects: Decreased pain.
INTERACTIONS
Drug-Drug: Use with extreme caution in
patients receiving MAO inhibitors (may
result in unpredictable, severe reactions—
decrease initial dose of nalbuphine to 25%
of usual dose). Additive CNS depression
with alcohol, antihistamines, and
sedative/hypnotics. May precipitate
withdrawal in patients who are physically
dependent on opioid agonists.
Drug-Natural Products: Concomitant use
of kava-kava, valerian, skullcap, chamomile,
or hops can increase CNS depression.
INDICATIONS
Moderate to severe pain. Also provides:
Analgesia during labor, Sedation before
surgery, Supplement to balanced
anesthesia. Prevention or treatment of
opioid-induced pruritus.
CONTRAINDCIATIONS
Contraindicated in: Hypersensitivity to
nalbuphine or bisulfites; Patients physically
dependent on opioids and who have not
been detoxified (may precipitate withdrawal).
SIDE EFFECTS/ADVERSE REACTIONS
Side Effects

CNS: dizziness, headache, sedation,

RECOMMENDED DOSAGE, ROUTE, AND confusion, dysphoria, euphoria, floating
FREQUENCY feeling, hallucinations, unusual dreams.
Analgesia EENT: blurred vision, diplopia, miosis (high
IM, Subcut, IV (Adults): Usual dose is 10 mg doses).
q 3– 6 hr (maximum: 20 mg/dose or Resp: respiratory depression.
160 mg/day). CV: hypertension, orthostatic hypotension,
IM, Subcut, IV (Children): 0.1– 0.15 mg/kg q palpitations.
3– 6 hr (maximum: 20 mg/dose or GI: dry mouth, nausea, vomiting,
160 mg/day). constipation, ileus.
Supplement to Balanced Anesthesia GU: urinary urgency.
IV (Adults): Initial—0.3– 3 mg/kg over 10–
15 min. Maintenance—0.25– 0.5 Adverse Reactions
mg/kg as needed.
Opioid-induced pruritus CV: Hypertension, hypotension,
IV (Adults): 2.5– 5 mg; may repeat dose. bradycardia, tachycardia, flushing.
GI: Abdominal cramps, bitter taste, nausea,
DRUG ACTION vomiting, dry mouth.
Binds to opiate receptors in the CNS. Alters CNS: Sedation, dizziness, nervousness,
the perception of and response to painful depression, restlessness, crying, euphoria,
stimuli while producing generalized CNS dysphoria, distortion of body image, unusual
depression. In addition, has partial dreams,
antagonist properties, which may result in

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NURSING RESPONSIBILITIES scopolamine.
● Syringe Incompatibility: diazepam,
NURSING INTERVENTIONS ketorolac, pentobarbital.
● Y-Site Compatibility: amifostine,
aztreonam, bivalirudin, cisatracurium,
Assessment cladribine, dexmedetomidine, etoposide
● Assess type, location, and intensity of pain phosphate, fenoldopam, filgrastim,
before and 1 hr after IM or 30 min fludarabine, gemcitabine, granisetron,
(peak) after IV administration. When titrating lansoprazole, linezolid, melphalan,
opioid doses, increases of 25– 50% oxaliplatin,
should be administered until there is either a paclitaxel, propofol, remifentanil, teniposide,
50% reduction in the patient’s pain thiotepa, vinorelbine.
rating on a numeric or visual analogue scale ● Y-Site Incompatibility: allopurinol,
or the patient reports satisfactory amphotericin B cholesteryl sulfate complex,
pain relief. A repeat dose can be safely cefepime, docetaxel, methotrexate,
administered at the time of the peak if pemetrexed, piperacillin/tazobactam,
previous dose is ineffective and side effects sargramostim, sodium bicarbonate.
are minimal. Patients requiring doses
higher than 20 mg should be converted to Patient/Family Teaching
an opioid agonist. Nalbuphine is not ● Instruct patient on how and when to ask
recommended for prolonged use or as first- for pain medication.
line therapy for acute or cancer pain. ● May cause drowsiness or dizziness.
● An equianalgesic chart (see Appendix B) Advise patient to call for assistance when
should be used when changing routes or ambulating and to avoid driving or other
when changing from one opioid to another. activities requiring alertness until response
to the medication is known.
Potential Nursing Diagnoses ● Caution patient to change positions slowly
Acute pain (Indications) to minimize orthostatic hypotension.
Risk for injury (Side Effects) ● Advise patient that frequent mouth rinses,
good oral hygiene, and sugarless gum or
Implementation
candy may decrease dry mouth.
● High Alert: Accidental overdose of opioid
● Encourage patient to turn, cough, and
analgesics has resulted in fatalities.
breathe deeply every 2 hr to prevent
Before administering, clarify all ambiguous
atelectasis.
orders; have second practitioner
● Advise patient to avoid concurrent use of
independently check original order, dose
alcohol or other CNS depressants with
calculations, and infusion pump settings.
this medication.
● Explain therapeutic value of medication
before administration to enhance the
Evaluation/Desired Outcomes
analgesic effect.
● Decrease in severity of pain without
● Regularly administered doses may be
significant alteration in level of
more effective than prn administration.
consciousness
Analgesic is more effective if administered
or respiratory status.
before pain becomes severe.
● Coadministration with nonopioid
B. REGIONAL ANESTHESIA
analgesics may have additive effects and
permit
lower opioid doses. 1. CLASSIFICATION: SPINAL
● IM: Administer deep into well-developed BLOCK OR SUBARACHNOID
muscle. Rotate sites of injections. BLOCK
IV Administration
GENERIC NAME: Bupivacaine
● pH: 3.0– 4.5.
● Direct IV: May give IV undiluted. BRAND NAME:
● Concentration: 10– 20 mg/mL. Rate:
Administer slowly, each 10 mg over 3–
5 min. RECOMMENDED DOSAGE, ROUTE, AND
● Syringe Compatibility: atropine, cimetidine, FREQUENCY
diphenhydramine, droperidol, Infiltration (Adults): Bunionectomy—106 mg
glycopyrrolate, hydroxyzine, lidocaine, (8 mL) given as 7 mL into osteotomy and 1
midazolam, prochlorperazine, ranitidine, mL into subcutaneous tissue;

Page | 183
Hemorrhoidectomy—266 mg (20 mL) diluted
to a volume of 30 mL and given as six 5 mL
aliquots.
A: Depends on amount injected and
vascularity of administration site.
Some systemic absorption occurs; however,
action is primarily local.
D: Widely distributed following release from
liposomes, high concentrations in highly
perfused organs (heart, lungs, liver, brain)
Crosses the placenta. Protein Binding: 95%.
M and E: Mostly metabolized by the liver,
metabolites are
primarily renally excreted; 6% excreted
unchanged in urine.
Half-life: Following bunionectomy— 34.1 hr;
following hemorrhoidectomy—
23.8 hr.
DRUG ACTION
Local anesthetics inhibit initiation and
conduction of sensory nerve impulses by
altering the influx of sodium and efflux of
potassium in neurons, slowing or stopping
pain transmission. Liposome formulation
prolongs the duration of action.
Therapeutic Effects: Lessened postoperative
pain.
INTERACTIONS
Drug-Drug: Should not be administered
concurrently with local lidocaine, wait at
least 20 minutes before infiltration with
bupivacaine liposome. Should not be
admixed with other local anesthetics. Should
not be used within 96 hr of other
formulations of bupivacaine; overall
exposure and risk of toxicity/adverse
reactions will be increase.
INDICATIONS
Postoperative single-use infiltration of
surgical sites
CONTRAINDCIATIONS
Hypersensitivity; cross-sensitivity with other
amide local anesthetics (ropivacaine,
lidocaine, mepivacaine, prilocaine) may
occur; OB: Obstetrical paracervical block
anesthesia (may cause fetal
bradycardia/death).
SIDE EFFECTS/ADVERSE REACTIONS
Side Effects
CNS: CENTRAL NERVOUS SYSTEM
TOXICITY, dizziness, drowsiness,
headache, insomnia.
CV: peripheral edema, prolonged AV
conduction, tachycardia.
GI: constipation, nausea, vomiting.
Derm: pruritus.Hemat:anemia.
MS: back pain, muscle spasm.
Misc: hypersensitivity reactions including
ANAPHYLACTOID-LIKE REACTIONS and
LARYNGEAL EDEMA, fever, procedural
pain.
Adverse Reactions
Body as a Whole: Hypersensitivity
[cutaneous lesions, urticaria, sneezing,
diaphoresis, syncope, hyperthermia,
angioneurotic edema (including laryngeal
edema), anaphylaxis, anaphylactoid
reaction].
CNS: Nervousness, unusual anxiety,
excitement, dizziness, drowsiness, tremors,
convulsions, unconsciousness, respiratory
arrest.
Special Senses: Pupillary constriction;
blurred or double vision; tinnitus.
GI: Nausea, vomiting.
Other: Inflammation or sepsis at injection
site, chills, pupillary constriction. Associated
with Epidural Anesthesia,
Body as a Whole: Total spinal block,
persistent analgesia, paresthesia.
Urogenital: Urinary retention, fecal
incontinence, loss of perineal sensation and
sexual function.
Other: Slowing of labor, increased incidence
of forceps delivery, cranial nerve palsies
(with inadvertent intrathecal injection).
NURSING RESPONSIBILITIES
Assessment
● Assess infiltrated area for pain following
administration and periodically during
therapy.
● Monitor cardiovascular and respiratory
status (vital signs, level of consciousness)
constantly following infiltration. Notify health
care professional immediately if signs of
cardiac toxicity (atrioventricular block,
ventricular arrhythmias, cardiac arrest)
occur.
● Monitor for central nervous system
toxicity. Notify health care professional.
Potential Nursing Diagnoses
Acute pain (Indications)
Implementation
● Do not confuse with propofol. In a syringe
suspension is milky white and
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may be mistaken for other medications.
Label syringe to ensure dose is
not administered IV.
● Infiltration: May be administered undiluted
or diluted with preservative– free
0.9% NaCl up to 0.89 mg/mL. Invert vial
multiple times to re-suspend particles
immediately prior to withdrawal from vial.
Injected with a 25 gauge or larger bore
needle slowly into soft tissues of surgical
site with frequent aspiration to check for
blood and minimize risk of intravascular
injection. Use diluted suspension within
4 hrs of preparation in a syringe. Vials are
for single dose; discard unused portions.
May be stored in refrigerator for up to 1
month prior to opening. Do not use
if solution is discolored or has been frozen;
freeze indicator turns from green to
white if exposed to freezing temperatures.
Evaluation/Desired Outcomes
● Prolongation of postoperative analgesia.
2. CLASSIFICATION: LUMBAR
EPIDURAL BLOCK
GENERIC NAME: Lidocaine
BRAND NAME:
RECOMMENDED DOSAGE, ROUTE, AND
FREQUENCY
Tachycardia/Ventricular Fibrillation
IV (Adults): 1– 1.5 mg/kg bolus; may repeat
doses of 0.5– 0.75 mg/kg q 5– 10 min up to
a total dose of 3 mg/kg; may then start
continuous infusion of 1– 4 mg/min.
Endotracheal (Adults): Give 2– 2.5 times the
IV loading dose down the endotracheal tube,
followed by a 10 mL saline flush.
IV (Children): 1 mg/kg bolus (not to exceed
100 mg), followed by 20– 50 mcg/kg/ min
continuous infusion (range 20– 50
mcg/kg/min); may administer second bolus
of 0.5– 1 mg/kg if delay between bolus and
continuous infusion.
Endotracheal
(Children): Give 2– 3 mg/kg down the
endotracheal tube followed by a 5 mL saline
flush.
IM (Adults and Children 50 kg): 300 mg (4.5
mg/kg); may be repeated in 60– 90 min.
A: Well absorbed after administration into
the deltoid muscle; some absorption follows
local use.
D: Widely distributed. Concentrates in
adipose tissue. Crosses the
blood-brain barrier and placenta; enters
breast milk.
M and E: Mostly metabolized by the liver;
10% excreted in urine as unchanged drug.
Half-life: Biphasic— initial phase, 7– 30 min;
terminal phase, 90– 120 min; increase in HF
and liver impairment.
DRUG ACTION
IV, IM: Suppresses automaticity and
spontaneous depolarization of the ventricles
during diastole by altering the flux of sodium
ions across cell membranes with little or no
effect on heart rate. Local: Produces local
anesthesia by inhibiting transport of ions
across neuronal membranes, thereby
preventing initiation and conduction of
normal nerve impulses.
Therapeutic Effects: Control of ventricular
arrhythmias. Local anesthesia.
INTERACTIONS
Drug-Drug: increase cardiac depression
and toxicity with phenytoin, amiodarone,
quinidine, procainamide, or propranolol.
Cimetidine, azole antifungals, clarithromycin,
erythromycin, fluoxetine, nefazodone,
paroxetine, protease inhibitors, ritonavir,
verapamil, and beta blockers may decrease
metabolism and
increase risk of toxicity. Lidocaine may
increase levels of calcium channel blockers.
INDICATIONS
IV: Ventricular arrhythmias.
IM: Self-injected or when IV unavailable
(during transport to hospital facilities). Local:
Infiltration/mucosal/topical anesthetic.
Patch: Pain due to post-herpetic neuralgia.
CONTRAINDCIATIONS
Hypersensitivity; cross-sensitivity may occur;
Third-degree heart block.
SIDE EFFECTS/ADVERSE REACTIONS
Side Effects
CNS: SEIZURES, confusion, drowsiness,
blurred vision, dizziness, nervousness,
slurred speech, tremor.
EENT: mucosal use—por absent gag reflex.
CV: CARDIAC ARREST, arrhythmias,
bradycardia, heart block, hypotension.
GI: nausea, vomiting.
Resp: bronchospasm.
Hemat: methemoglobinemia.
Local: stinging, burning, contact dermatitis,
erythema.
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MS: chondrolysis.
Misc: allergic reactions, including
ANAPHYLAXIS.
Adverse Reactions
CNS: Drowsiness, dizziness, light-
headedness, restlessness, confusion,
disorientation, irritability, apprehension,
euphoria, wild excitement, numbness of lips
or tongue and other paresthesias including
sensations of heat and cold, chest
heaviness, difficulty in speaking, difficulty in
breathing or swallowing, muscular twitching,
tremors, psychosis. With high doses:
convulsions, respiratory depression and
arrest.
NURSING RESPONSIBILITIES
Assessment
● Antiarrhythmic: Monitor ECG continuously
and BP and respiratory
status frequently during administration.
● Anesthetic: Assess degree of numbness
of affected part.
● Transdermal: Monitor for pain intensity in
affected area periodically during
therapy.
● Lab Test Considerations: Serum
electrolyte levels should be monitored
periodically during prolonged therapy.
● IM administration may cause increase
CPK levels.
● Toxicity and Overdose: Serum lidocaine
levels should be monitored periodically
during prolonged or high-dose IV therapy.
Therapeutic serum lidocaine levels range
from 1.5 to 5 mcg/mL.
● Signs and symptoms of toxicity include
confusion, excitation, blurred or double
vision, nausea, vomiting, ringing in ears,
tremors, twitching, seizures, difficulty
breathing, severe dizziness or fainting, and
unusually slow heart rate.
● If symptoms of overdose occur, stop
infusion and monitor patient closely.
Potential Nursing Diagnoses
Decreased cardiac output (Indications)
Acute pain (Indications)
Implementation
● High Alert: Lidocaine is readily absorbed
through mucous membranes. Inadvertent
overdosage of lidocaine jelly and spray has
resulted in patient harm or death
from neurologic and/or cardiac toxicity. Do
not exceed recommended doses.
● Throat Spray: Ensure that gag reflex is
intact before allowing patient to drink or
eat.
● IM: IM injections are recommended only
when ECG monitoring is not available
and benefits outweigh risks. Administer IM
injections only into deltoid muscle
● High Alert: Lidocaine is readily absorbed
through mucous membranes. Inadvertent
overdosage of lidocaine jelly and spray has
resulted in patient harm or death
from neurologic and/or cardiac toxicity. Do
not exceed recommended doses.
● Throat Spray: Ensure that gag reflex is
intact before allowing patient to drink or
eat.
● IM: IM injections are recommended only
when ECG monitoring is not available
and benefits outweigh risks. Administer IM
injections only into deltoid muscle while
frequently aspirating to prevent IV injection.
Patient/Family Teaching
● May cause drowsiness and dizziness.
Advise patient to call for assistance during
ambulation and transfer.
● IM: Available in LidoPen Auto-Injector for
use outside the hospital setting. Advise
patient to telephone health care professional
immediately if symptoms of a heart
attack occur. Do not administer unless
instructed by health care professional. To
administer, remove safety cap and place
back end on thickest part of thigh or deltoid
muscle. Press hard until needle prick is felt.
Hold in place for 10 sec, then
massage area for 10 sec. Do not drive after
administration unless absolutely necessary.
Evaluation/Desired Outcomes
● Decrease in ventricular arrhythmias.
● Local anesthesia.
3.CLASSIFICATION:
CONTINUOUS LUMBAR EPIDURAL
BLOCK
GENERIC NAME: Ropivacaine
BRAND NAME:
RECOMMENDED DOSAGE, ROUTE, AND
FREQUENCY
Surgical Anesthesia
Epidural (Adults):Lumbar epidural—15– 30
mL of 0.5% solution or 15– 25 mL
of 0.75% solution or 15– 20 mL of 1%
solution;Lumbar epidural for cesarean
section—20– 30 mL of 0.5% solution or 15–
Page | 186
20 mL of 0.75% solution; Thoracic epidural CV: CARDIOVASCULAR COLLAPSE,
—5– 15 mL of 0.5– 0.75% solution. arrhythmias, bradycardia, chest pain,
Major nerve block (Adults): 35– 50 mL of hypertension, hypotension, tachycardia.
0.5% solution or 10– 40 mL of 0.75% GI: nausea, vomiting.
solution. GU: urinary retention.
Field block (Adults): 1– 40 mL of 0.5% Derm: pruritus.
solution. F and E: hypokalemia,
metabolic acidosis.
Labor Pain Hemat: anemia.
Epidural (Adults):Lumbar epidural—10– 20 Neuro: circumoral tingling/numbness,
mL of 0.2% solution initially, then paresthesia.
continuous infusion of 6– 14 mL/hr of 0.2% Resp: dyspnea.
solution with incremental injection of MS: chondrolysis.
10– 15 mL/hr of 0.2% solution. Misc: allergic reactions, fever.

Postoperative Pain Adverse Reactions (By System):

Epidural (Adults):Lumbar or thoracic Body as a Whole: Pain, fever, rigors,
epidural—Continuous infusion of 6– 14 hypoesthesia.
mL/hr of 0.2% solution. CNS: Paresthesia, headache, dizziness,
Infiltration (minor nerve block)(Adults): 1– anxiety.
100 mL of 0.2% solution or 1– 40 CV: Hypotension, bradycardia,
mL of 0.5% solution. hypertension, tachycardia, chest pain, fetal
bradycardia.
GI: Nausea.
DRUG ACTION Skin: Pruritus.
Local anesthetics inhibit initiation and Urogenital: Urinary retention, oliguria.
conduction of sensory nerve impulses by Hematologic: Anemia.
altering the influx of sodium and efflux of
potassium in neurons, slowing or stopping NURSING RESPONSIBILITIES
pain transmission.
Therapeutic Effects: Decreased pain or NURSING INTERVENTIONS
induction of anesthesia;
low doses have minimal effect on sensory or Assessment
motor function; higher doses may produce ● Monitor for sensation during procedure
complete motor blockade. and return of sensation after procedure.
● Systemic Toxicity: Assess for systemic
INTERACTIONS toxicity (circumoral tingling and numbness,
Drug-Drug: Additive toxicity may occur with ringing in ears, metallic taste, dizziness,
concurrent use of other amide local blurred vision, tremors, slow
anesthetics (including lidocaine, speech, irritability, twitching, seizures,
mepivacaine, and prilocaine). Fluvoxamine, cardiac dysrhythmias). Report to
amiodarone, ciprofloxacin, and propofol may anesthesiologist.
increase the effects of ropivacaine. ● Orthostatic Hypotension: Monitor BP,
heart rate, and respiratory rate continuously
INDICATIONS while patient is receiving this medication.
Local or regional anesthesia for surgery. Mild hypotension is common because of the
Acute pain management. effect of local anesthetic block of nerve
fibers on the sympathetic nervous system,
CONTRAINDCIATIONS causing vasodilation. Significant
Hypersensitivity; cross-sensitivity with other hypotension and bradycardia may
amide local anesthetics may occur occur, especially when rising from a prone
(bupivacaine, lidocaine, mepivacaine, position or following large dose increases or
prilocaine). boluses. Treatment of unresolved
hypotension may include hydration,
SIDE EFFECTS/ADVERSE REACTIONS decreasing the epidural infusion rate, and/or
removal of local anesthetic from analgesic
Side Effects (By System): solution.

CNS: SEIZURES, anxiety, dizziness, Potential Nursing Diagnoses

headache, rigors. Acute pain, acute (Indications)

Page | 187
Impaired physical mobility
Implementation
● See Route and Dosage section.
Patient/Family Teaching
● Instruct patient to notify nurse if signs or
symptoms of systemic toxicity occur.
● Advise patient to request assistance
during ambulation until orthostatic
hypotension and motor deficits are ruled out.
Drug-Drug: Should not be administered
concurrently with local lidocaine, wait at
least 20 minutes before infiltration with
bupivacaine liposome. Should not be
admixed with other local anesthetics. Should
not be used within 96 hr of other
formulations of bupivacaine; overall
exposure and risk of toxicity/adverse
reactions will be increase.

Evaluation/Desired Outcomes INDICATIONS

● Decrease in postoperative pain without Postoperative single-use infiltration of
unwanted sensory or motor deficits. surgical sites

CLASSIFICATION: COMBINED
SPINAL- EPIDURAL
GENERIC NAME: Bupivacaine
BRAND NAME:
RECOMMENDED DOSAGE, ROUTE, AND
FREQUENCY
Infiltration (Adults): Bunionectomy—106 mg
(8 mL) given as 7 mL into osteotomy and 1
mL into subcutaneous tissue;
Hemorrhoidectomy—266 mg (20 mL) diluted
to a volume of 30 mL and given as six 5 mL
aliquots.
A: Depends on amount injected and
vascularity of administration site.
Some systemic absorption occurs; however,
action is primarily local.
D: Widely distributed following release from
liposomes, high concentrations in highly
perfused organs (heart, lungs, liver, brain)
Crosses the placenta. Protein Binding: 95%.
M and E: Mostly metabolized by the liver,
metabolites are
primarily renally excreted; 6% excreted
unchanged in urine.
Half-life: Following bunionectomy— 34.1 hr;
following hemorrhoidectomy—
23.8 hr.
DRUG ACTION
Local anesthetics inhibit initiation and
conduction of sensory nerve impulses by
altering the influx of sodium and efflux of
potassium in neurons, slowing or stopping
pain
transmission. Liposome formulation
prolongs the duration of action.
Therapeutic Effects: Lessened postoperative
pain.
INTERACTIONS
CONTRAINDCIATIONS
SIDE EFFECTS/ADVERSE REACTIONS
Side Effects
CNS: CENTRAL NERVOUS SYSTEM
TOXICITY, dizziness, drowsiness,
headache, insomnia.
CV: peripheral edema, prolonged AV
conduction, tachycardia.
GI: constipation, nausea, vomiting.
Derm: pruritus.Hemat:anemia.
MS: back pain, muscle spasm.
Misc: hypersensitivity reactions including
ANAPHYLACTOID-LIKE REACTIONS and
LARYNGEAL EDEMA, fever, procedural
pain.
Adverse Effects
Body as a Whole: Hypersensitivity
[cutaneous lesions, urticaria, sneezing,
diaphoresis, syncope, hyperthermia,
angioneurotic edema (including laryngeal
edema), anaphylaxis, anaphylactoid
reaction].
CNS: Nervousness, unusual anxiety,
excitement, dizziness, drowsiness, tremors,
convulsions, unconsciousness, respiratory
arrest.
Special Senses: Pupillary constriction;
blurred or double vision; tinnitus.
GI: Nausea, vomiting.
Other: Inflammation or sepsis at injection
site, chills, pupillary constriction. Associated
with Epidural Anesthesia,
Body as a Whole: Total spinal block,
persistent analgesia, paresthesia.
Urogenital: Urinary retention, fecal
incontinence, loss of perineal sensation and
sexual function.

Page | 188
Other: Slowing of labor, increased incidence
of forceps delivery, cranial nerve palsies
(with inadvertent intrathecal injection).
NURSING RESPONSIBILITIES
NURSING INTERVENTIONS
Assessment
● Assess infiltrated area for pain following
administration and periodically during
therapy.
● Monitor cardiovascular and respiratory
status (vital signs, level of consciousness)
constantly following infiltration. Notify health
care professional immediately if signs of
cardiac toxicity (atrioventricular block,
ventricular arrhythmias, cardiac arrest)
occur.
Potential Nursing Diagnoses
Acute pain (Indications)
Implementation
● Do not confuse with propofol. In a syringe
suspension is milky white and
may be mistaken for other medications.
Label syringe to ensure dose is
not administered IV.
● Infiltration: May be administered undiluted
or diluted with preservative– free
0.9% NaCl up to 0.89 mg/mL. Invert vial
multiple times to re-suspend particles
immediately prior to withdrawal from vial.
Injected with a 25 gauge or larger bore
needle slowly into soft tissues of surgical
site with frequent aspiration to check for
blood and minimize risk of intravascular
injection. Use diluted suspension within
4 hrs of preparation in a syringe. Vials are
for single dose; discard unused portions.
May be stored in refrigerator for up to 1
month prior to opening. Do not use
if solution is discolored or has been frozen;
freeze indicator turns from green to white if
exposed to freezing temperatures.
Patient/Family Teaching
● Inform patient that infiltration may cause
temporary loss of sensation or motor activity
in infiltrated area.
● Instruct patient to notify health care
professional of pregnancy is known or
suspected or if breast feeding.
Evaluation/Desired Outcomes
● Prolongation of postoperative analgesia.
5. CLASSIFICATION: LOCAL
INFILTRATION
GENERIC NAME: Lidocaine
BRAND NAME:
RECOMMENDED DOSAGE, ROUTE, AND
FREQUENCY:
Tachycardia/Ventricular Fibrillation
IV (Adults): 1– 1.5 mg/kg bolus; may repeat
doses of 0.5– 0.75 mg/kg q 5– 10 min up to
a total dose of 3 mg/kg; may then start
continuous infusion of 1– 4 mg/min.
Endotracheal (Adults): Give 2– 2.5 times the
IV loading dose down the endotracheal tube,
followed by a 10 mL saline flush.
IV (Children): 1 mg/kg bolus (not to exceed
100 mg), followed by 20– 50 mcg/kg/ min
continuous infusion (range 20– 50
mcg/kg/min); may administer second bolus
of 0.5– 1 mg/kg if delay between bolus and
continuous infusion.
Endotracheal
(Children): Give 2– 3 mg/kg down the
endotracheal tube followed by a 5 mL saline
flush.
IM (Adults and Children 50 kg): 300 mg (4.5
mg/kg); may be repeated in 60– 90 min.
A: Well absorbed after administration into
the deltoid muscle; some absorption follows
local use.
D: Widely distributed. Concentrates in
adipose tissue. Crosses the
blood-brain barrier and placenta; enters
breast milk.
M and E: Mostly metabolized by the liver;
10% excreted in urine as unchanged drug.
Half-life: Biphasic— initial phase, 7– 30 min;
terminal phase, 90– 120 min; increase in HF
and liver impairment.
DRUG ACTION:
IV, IM: Suppresses automaticity and
spontaneous depolarization of the ventricles
during diastole by altering the flux of sodium
ions across cell membranes with little or no
effect on heart rate. Local: Produces local
anesthesia by inhibiting transport of ions
across neuronal membranes, thereby
preventing initiation and conduction of
normal nerve impulses.
Therapeutic Effects: Control of ventricular
arrhythmias. Local anesthesia.
Page | 189
 NURSING RESPONSIBILITIES:
INTERACTIONS: Assessment
Drug-Drug: increase cardiac depression and ● Antiarrhythmic: Monitor ECG continuously
toxicity with phenytoin, amiodarone, and BP and respiratory
quinidine, procainamide, or propranolol. status frequently during administration.
Cimetidine, azole antifungals, clarithromycin, ● Anesthetic: Assess degree of numbness
erythromycin, fluoxetine, nefazodone, of affected part.
paroxetine, protease inhibitors, ritonavir, ● Transdermal: Monitor for pain intensity in
verapamil, and beta blockers may decrease affected area periodically during
metabolism and therapy.
increase risk of toxicity. Lidocaine may ● Lab Test Considerations: Serum
increase levels of calcium channel blockers, electrolyte levels should be monitored
certain benzodiazepines, cyclosporine, periodically during prolonged therapy.
fluoxetine, lovastatin, simvastatin, ● IM administration may cause increase
mirtazapine, paroxetine, ritonavir, CPK levels.
tacrolimus, theophylline, tricyclic ● Toxicity and Overdose: Serum lidocaine
antidepressants, and venlafaxine. Effects of levels should be monitored periodically
lidocaine may be decrease by during prolonged or high-dose IV therapy.
carbamazepine, phenobarbital, phenytoin, Therapeutic serum lidocaine levels range
and rifampin. from 1.5 to 5 mcg/mL.
● Signs and symptoms of toxicity include
INDICATIONS: confusion, excitation, blurred or double
IV: Ventricular arrhythmias. vision, nausea, vomiting, ringing in ears,
IM: Self-injected or when IV unavailable tremors, twitching, seizures, difficulty
(during transport to hospital facilities). Local: breathing, severe dizziness or fainting, and
Infiltration/mucosal/topical anesthetic. unusually slow heart rate.
Patch: Pain due to post-herpetic neuralgia. ● If symptoms of overdose occur, stop
infusion and monitor patient closely.
CONTRAINDCIATIONS:
Hypersensitivity; cross-sensitivity may occur; Potential Nursing Diagnoses
Third-degree heart block. Decreased cardiac output (Indications)
Acute pain (Indications)
SIDE EFFECTS/ADVERSE REACTIONS:
Implementation
Side Effects ● High Alert: Lidocaine is readily absorbed
CNS: SEIZURES, confusion, drowsiness, through mucous membranes. Inadvertent
blurred vision, dizziness, nervousness, overdosage of lidocaine jelly and spray has
slurred speech, tremor. resulted in patient harm or death.
EENT: mucosal use—por absent gag reflex. Patient/Family Teaching
CV: CARDIAC ARREST, arrhythmias, ● May cause drowsiness and dizziness.
bradycardia, heart block, hypotension. Advise patient to call for assistance during
GI: nausea, vomiting. ambulation and transfer.
Resp: bronchospasm. ● IM: Available in LidoPen Auto-Injector for
Hemat: methemoglobinemia. use outside the hospital setting. Advise
Local: stinging, burning, contact dermatitis, patient to telephone health care professional
erythema. immediately if symptoms of a heart
MS: chondrolysis. attack occur. Do not administer unless
Misc: allergic reactions, including instructed by health care professional. To
ANAPHYLAXIS. administer, remove safety cap and place
back end on thickest part of thigh or deltoid
Adverse Effects muscle. Press hard until needle prick is felt.
CNS: Drowsiness, dizziness, light- Hold in place for 10 sec, then
headedness, restlessness, confusion, massage area for 10 sec. Do not drive after
disorientation, irritability, apprehension, administration unless absolutely necessary.
euphoria, wild excitement, numbness of lips ● Topical: Apply Lidoderm Patch to intact
or tongue and other paresthesias including skin to cover the most painful area.
sensations of heat and cold, chest Patch may be cut to smaller sizes with
heaviness, difficulty in speaking, difficulty in scissors before removing release liner.
breathing or swallowing, muscular Clothing may be worn over patch. If irritation
or burning sensation occurs during

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application, remove patch until irritation A: IV administration results in 100%
subsides. Wash hands after application; bioavailability.
avoid contact with eyes. Dispose of used
patch to avoid access by children or pets. D: Widely distributed in extracellular fluid.
● Caution women to consult health care Small amounts reach fetal circulation.
professional before using a topical
M and E: Rapidly metabolized by liver and
anesthetic for a mammogram or other
kidneys.
procedures. If recommended, use lowest
drug Half-life: 3– 9 min.
concentration, and apply it sparingly. Do not
apply to broken or irritated skin, do DRUG ACTION:
not wrap skin, and do not apply heat to area Drug-Drug: Severe hypertension may occur
(heating pad/electric blanket), to decrease if oxytocin follows administration of
chance that drug may be absorbed into the vasopressors.
body. May result in seizures,
cardiac arrhythmias, respiratory failure, INDICATIONS:
coma, and death. IV: Induction of labor at term. IV: Facilitation
● Advise patient referred for MRI test to of threatened abortion. IV, IM: Postpartum
discuss patch with referring health care control of bleeding after expulsion of the
professional and MRI facility to determine if placenta.
removal of patch is necessary prior to test
and for directions for replacing patch. CONTRAINDCIATIONS:
Hypersensitivity; Anticipated nonvaginal
Evaluation/Desired Outcomes delivery.
● Decrease in ventricular arrhythmias.
● Local anesthesia. SIDE EFFECTS/ADVERSE REACTIONS:

Side Effects
UTEROTROPICS
CNS: maternal—COMA, SEIZURES; fetal,
A. CLASSIFICATION: Oxytocin INTRACRANIAL HEMORRHAGE. Resp:
fetal—ASPHYXIA, hypoxia.
GENERIC NAME: Oxytocin
BRAND NAME: CV: maternal— hypotension; fetal,
arrhythmias. F and E: maternal
RECOMMENDED DOSAGE, ROUTE, AND hypochloremia,
FREQUENCY:
hyponatremia, water intoxication.
Induction/Stimulation of Labor
Misc: maternal—increase uterine motility,
IV (Adults): 0.5– 1 milliunits/min; increase by
painful contractions, abruptio placentae,
1– 2 milliunits/min q 30– 60 min until desired
decrease uterine blood flow,
contraction pattern established; dose may
hypersensitivity.
be decrease after desired frequency of
contractions is reached and labor has
Adverse Effects
progressed to 5-6 cm dilation.
Body as a Whole: Fetal trauma from too
rapid propulsion through pelvis, fetal death,
anaphylactic reactions, postpartum
Postpartum Hemorrhage hemorrhage, precordial pain, edema,
cyanosis or redness of skin.
IV (Adults): 10 units infused at 20– 40
milliunits/min. CV: Fetal bradycardia and arrhythmias,
maternal cardiac arrhythmias, hypertensive
IM (Adults): 10 units after delivery of episodes, subarachnoid hemorrhage,
placenta. increased blood flow, fatal afibrinogenemia,
ECG changes, PVCs, cardiovascular spasm
Incomplete/Inevitable Abortion
and collapse.
IV (Adults): 10 units at a rate of 20– 40
GI: Neonatal jaundice, maternal nausea,
milliunits/min
vomiting.

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Endocrine: ADH effects leading to severe
water intoxication and hyponatremia,
hypotension.
CNS: Fetal intracranial hemorrhage, anxiety.
Respiratory: Fetal hypoxia, maternal
dyspnea.
Urogenital: Uterine hypertonicity, tetanic
contractions, uterine rupture, pelvic
hematoma.
NURSING RESPONSIBILITIES:
NURSING INTERVENTIONS:
Assessment
● Fetal maturity, presentation, and pelvic
adequacy should be assessed prior to
administration of oxytocin for induction of
labor.
● Assess character, frequency, and duration
of uterine contractions; resting uterine
tone; and fetal heart rate frequently
throughout administration. If contractions
occur 2 min apart and are 50– 65 mm Hg
on monitor, if they last 60– 90 sec or
longer, or if a significant change in fetal
heart rate develops, stop infusion and turn
patient on her left side to prevent fetal
anoxia. Notify health care professional
immediately.
50– 65 mm Hg on monitor, if they last 60–
90 sec or
longer, or if a significant change in fetal
heart rate develops, stop infusion and turn
patient on her left side to prevent fetal
anoxia. Notify health care professional
immediately.
● Monitor maternal BP and pulse frequently
and fetal heart rate continuously
throughout administration.
● This drug occasionally causes water
intoxication. Monitor patient for signs and
symptoms (drowsiness, listlessness,
confusion, headache, anuria).
Potential Nursing Diagnoses
Deficient knowledge, related to medication
regimen (Patient/Family Teaching)
Implementation
● Do not administer oxytocin simultaneously
by more than one route.
IV Administration
● Continuous Infusion: Rotate infusion
container to ensure thorough mixing.
Store solution in refrigerator, but do not
freeze.
● Infuse via infusion pump for accurate
dose. Oxytocin should be connected via
Ysite injection to an IV of 0.9% NaCl for use
during adverse reactions.
● Magnesium sulfate should be available if
needed for relaxation of myometrium.
● Induction of Labor: Diluent: Dilute 1 mL
(10 units) in 1 L of compatible infusion fluid
(0.9% NaCl, D5W, or LR). Concentration: 10
milliunits/mL. Rate:
Begin infusion at 0.5– 2 milliunits/min (0.05–
0.2 mL); increase in increments of
1– 2 milliunits/min at 15– 30-min intervals
until contractions simulate normal labor.
Patient/Family Teaching
● Advise patient to expect contractions
similar to menstrual cramps after
administration has started.
Evaluation/Desired Outcomes
● Onset of effective contractions.
● Increase in uterine tone.
● Reduction in postpartum bleeding
B. CLASSIFICATION: Dinoprostone
GENERIC NAME: Dinoprostone
cervical gel
BRAND NAME:
RECOMMENDED DOSAGE, ROUTE, AND
FREQUENCY:
Cervical Ripening
Vag (Adults, Cervical): Endocervical gel—
0.5 mg; if response is unfavorable,
may repeat in 6 hr. (not to exceed 1.5 mg/24
hr). Vaginal insert—one 10-mg insert.
Abortifacient
Vag (Adults): One 20-mg suppository,
repeat q 3– 5 hr (not to exceed 240 mg total
or longer than 48 hr).
Absorption: Rapidly absorbed.
Distribution: Unknown. Action is mostly
local.
Metabolism and Excretion: Metabolized by
enzymes in lung, kidneys, spleen,
and liver tissue.
DRUG ACTION:
Produces contractions similar to those
occurring during labor at term by stimulating
the myometrium (oxytocic effect). Initiates
softening, effacement, and dilation of the
cervix (“ripening”). Also stimulates GI
smooth muscle. Therapeutic Effects:
Initiation of labor. Expulsion of fetus.
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INTERACTIONS:
Drug-Drug: Augments the effects of other
oxytocics.
INDICATIONS:
Endocervical Gel, Vaginal Insert: Used to
“ripen” the cervix in pregnancy at or near
term when induction of labor is indicated.
Vaginal Suppository: Induction of midtri
mester abortion, Management of missed
abortion up to 28 wk, Management of
nonmetastatic gestational trophoblastic
disease (benign hydatidiform mole).
CONTRAINDCIATIONS:
Endocervical Gel, Vaginal Insert: Used to
“ripen” the cervix in pregnancy at or near
term when induction of labor is indicated.
Vaginal Suppository: Induction of midtri
mester abortion, Management of missed
abortion up to 28 wk, Management of
nonmetastatic gestational trophoblastic
disease (benign hydatidiform mole).
SIDE EFFECTS/ADVERSE REACTIONS:
Side Effects
Endocervical Gel, Vaginal Insert
GU: uterine contractile abnormalities, warm
feeling
in vagina.
MS: back pain.
Misc: AMNIOTIC FLUID EMBOLISM, fever
Adverse Effects
CNS: Headache, tremor, tension.
CV: Transient hypotension, flushing,
cardiac arrhythmias.
GI: Nausea, vomiting, diarrhea. Urogenital:
Vaginal pain, endometritis, uterine rupture.
Respiratory: Dyspnea, cough, hiccups. Body
as a Whole: Chills, fever, dehydration,
diaphoresis, rash.
NURSING RESPONSIBILITIES:
Assessment
● Abortifacient: Monitor frequency, duration,
and force of contractions and uterine resting
tone. Opioid analgesics may be
administered for uterine pain
● Monitor temperature, pulse, and BP
periodically throughout therapy.
Dinoprostone-induced fever .
Potential Nursing Diagnoses
Deficient knowledge, related to medication
regimen (Patient/Family Teaching)
Implementation
● Abortifacient: Warm the suppository to
room temperature just before use.
● Wear gloves when handling unwrapped
suppository to prevent absorption
through skin.
● Patient should remain supine for 10 min
after insertion of suppository; then she
may be ambulatory.
● Vaginal Insert: Place vaginal insert
transversely in the posterior vaginal fornix
immediately after removing from foil
package. Warming of insert and sterile
conditions are not required. Use vaginal
insert only with a retrieval system. Use
minimal amount of water-soluble lubricant
during insertion; avoid excess because it
may hamper release of dinoprostone from
insert. Patient should remain supine
for 2 hr after insertion, then may ambulate.
Patient/Family Teaching
● Explain purpose of medication and vaginal
exams.
● Abortifacient: Instruct patient to notify
health care professional immediately if
fever and chills, foul-smelling vaginal
discharge, lower abdominal pain, or
increased bleeding occurs.
● Provide emotional support throughout
therapy.
● Cervical Ripening: Inform patient that she
may experience a warm feeling in her
vagina during administration.
● Advise patient to notify health care
professional if contractions become
prolonged.
Evaluation/Desired Outcomes
● Complete abortion. Continuous
administration for more than 2 days is not
usually
recommended.
● Cervical ripening and induction of labor.
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C. CLASSIFICATION: ERGOT Lactation: Do not breast feed during
ALKALOIDS treatment and for 12 hours after the last
dose;
GENERIC NAME: Methylergonovine Concurrent use of potent CYP3A4 inhibitors.
BRAND NAME: Methergine
SIDE EFFECTS/ADVERSE REACTIONS:
RECOMMENDED DOSAGE, ROUTE, AND
FREQUENCY: Side Effects
PO (Adults): 200– 400 mcg (0.4– 0.6 mg) q CNS: STROKE, dizziness, headache
6– 12 hr for 2– 7 days. EENT: tinnitus.
IM, IV (Adults): 200 mcg (0.2 mg) q 2– 4 hr Resp: dyspnea.
for up to 5 doses. CV: HYPERTENSION, arrhythmias, AV
Absorption: Well absorbed following oral or block, chest pain, palpitations.
IM administration. GI: nausea, vomiting.
Distribution: Unknown. Enters breast milk in GU: cramps. Derm: diaphoresis. Neuro:
small quantities. paresthesia.
Metabolism and Excretion: Probably Misc: allergic reactions.
metabolized by the liver.
Half-life: 30– 120 min Adverse Effects
GI: Nausea, vomiting (especially with IV
doses).
DRUG ACTION: CV: Severe hypertensive episodes,
Directly stimulates uterine and vascular bradycardia. Body as a Whole: Allergic
smooth muscle. phenomena including shock, ergotism.
Therapeutic Effects: Uterine contraction.
NURSING RESPONSIBILITIES:
INTERACTIONS:
Drug-Drug: Excessive vasoconstriction may
result when used with heavy cigarette Assessment
smoking (nicotine), other vasopressors, ● Monitor BP, heart rate, and uterine
such as dopamine, or beta-blockers. response frequently during medication
Potent CYP3A4 inhibitors, including administration. Notify health care
erythromycin, clarithromycin, troleando professional promptly if uterine
mycin, ritonavir, indinavir, nelfinavir, relaxation becomes prolonged or if character
delavirdine, ketoconazole, itraconazole, or of vaginal bleeding
voriconazole may increase levels and changes.
increase risk of ischemia; concurrent use ● Assess for signs of ergotism (cold, numb
contraindicated. Moderate CYP3A4 fingers and toes, chest pain, nausea,
inhibitors including saquinavir, nefazodone, vomiting, headache, muscle pain,
fluconazole, fluoxetine, fluvoxamine, weakness).
zileuton, or clotrimazole may increase ● Lab Test Considerations: If no response to
levels; use with caution. CYP3A4 inducers methylergonovine, calcium levels
including nevirapine and rifampin may need to be assessed. Effectiveness of
may increase levels. Anestheticsmaypits medication is decrease with hypocalcemia.
oxytocic properties. May decrease the ● May cause decrease serum prolactin
antianginal effects levels.
of nitrates.
Drug-Food: Grapefruit juicemayqlevels; use Potential Nursing Diagnoses
with caution Acute pain (Side Effects)

INDICATIONS: Implementation
Prevention and treatment of postpartum or
post abortion hemorrhage caused by uterine IV Administration
atony or subinvolution.
● IV: IV administration is used for
emergencies only. Oral and IM routes are
preferred.
CONTRAINDCIATIONS:
Hypersensitivity; OB: Should not be used to ● Direct IV: Diluent: May be given undiluted
induce labor; or diluted in 5 mL of 0.9% NaCl and

Page | 194
administered through Y site. Do not add to
IV solutions. Do not mix in syringe with
any other drug. Refrigerate; stable for
storage at room temperature for 60 days;
deteriorates with age. Use only solution that
is clear and colorless and that contains no
precipitate. Concentration: 0.2 mg/mL. Rate:
Administer at a rate of 0.2 mg over at least 1
min.
● Y-Site Compatibility: heparin,
hydrocortisone sodium succinate, potassium
chloride, vitamin B complex with C.
Patient/Family Teaching
● Instruct patient to take medication as
directed; do not skip or double up on missed
doses. If a dose is missed, omit it and return
to regular dose schedule.
● Advise patient that medication may cause
menstrual-like cramps.
● Caution patient to avoid smoking, because
nicotine constricts blood vessels.
● Instruct patient to notify health care
professional if infection develops, as this
may cause increased sensitivity to the
medication.
● Advise patient to notify health care
professional of all Rx or OTC medications,
vitamins, or herbal products being taken and
to consult with health care professional
before taking other medications.
Evaluation/Desired Outcomes
● Contractions that maintain uterine tone
and prevent postpartum hemorrhage.
CLASSIFICATION: SURFACTANT
THERAPY IN PRETERM BIRTH
GENERIC NAME: Beractant
BRAND NAME: Survanta
RECOMMENDED DOSAGE, ROUTE, AND
FREQUENCY:
Neonate: Intratracheal Instill 100 mg/kg (4
mL/kg) birth weight through endotracheal
tube, may repeat no more frequently than
q6h (max: 4 doses in the first 48 h of life)
A: Absorbed from the alveolus into lung
tissue, where it can be extensively
catabolized and reutilized for further
phospholipid synthesis and secretion.
Onset: 0.5–4 h. Peak: 2 h.
D: 48–72 h; may need multiple doses to
sustain improvement. Distribution: Not
distributed to the systemic circulation.
M: Surfactant is recycled and metabolized
exclusively in the lungs.
E: Recycling may be a dominant metabolic
pathway by which surfactant is taken up by
type II pneumocytes and reused. Half-Life:
20–30 h.
DRUG ACTION:
Beractant is a sterile nonpyrogenic
pulmonary surfactant. Endogenous
pulmonary surfactant lowers surface tension
on alveolar surfaces during respiration and
stabilizes the alveoli against collapse at
resting pressures. Deficiency of surfactant
causes respiratory distress syndrome (RDS)
in premature infants.
Therapeutic Effects: Beractant lowers
minimum surface tension and restores
pulmonary compliance and oxygenation in
premature infants.
INTERACTIONS:
Amikacin: (Major) Some surfactant
antiinfective mixtures have been shown to
affect the in vivo activity of exogenous
pulmonary surfactants when they are
administered via inhalation. A reduced
activity of tobramycin, a commonly
nebulized aminoglycoside, has been
reported in the presence of surfactant. Use
the combination of amikacin and surfactants
with caution.
INDICATIONS:
Prevention and treatment of RDS in
premature infants, especially those weighing
<1250 g.
Unlabeled Uses: Infants weighing <600 g or
>1750 g; treatment of RDS in adults.
CONTRAINDCIATIONS:
Bovine protein hypersensitivity
Beractant is extracted from bovine lung
surfactant. Immunogenic sensitization has
not been documented in newborns after the
use of beractant. However, because
surfactants might be used in children or
adults in investigational settings, beractant
should be used with caution in those with
known bovine protein hypersensitivity.
SIDE EFFECTS/ADVERSE REACTIONS:
Side Effects
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Cardiovascular: hypotension, hypertension, Ensure and confirm correct position of the
tachycardia, ventricular tachycardia, aortic endotracheal tube (ETT) via chest x-ray
thrombosis, cardiac failure, cardio- prior to giving surfactant. Auscultation of the
respiratory arrest, increased apical pulse, chest for equal bilateral air entry confirmed
persistent fetal circulation, air embolism, by a NICU fellow or consultant is an
total anomalous pulmonary venous return. additional method of confirming ETT
placement.
Adverse Effects If neonate is not intubated (eg. a premature
CV: Transient bradycardia. neonate on continuous positive airway
Respiratory: Oxygen desaturation. pressure (CPAP)), an in-out intubation will
Other: Increased probability of posttreatment be performed to administer the surfactant
nosocomial sepsis in surfactant-treated (INSURE technique – Intubation, Surfactant
infants was observed in the controlled then Extubation). Refer to the guideline on
clinical trials but was not associated with elective intubation. .
increased mortality. Check and prepare emergency equipment at
bedside (e.g. Neopuff, suction). If performing
NURSING RESPONSIBILITIES: intubation, also prepare intubation drugs,
laryngoscope with appropriate blade size,
Assessment & Drug Effects appropriate size ETT, and Pedicap/CO2
detector.
Ensure patency of ETT. Suction ETT as
Monitor heart rate, color, chest expansion, necessary prior to administration.
facial expressions, oximeter, and Slowly warm the vial of surfactant to room
endotracheal tube patency and position, temperature before administration
during administration. Most adverse effects Administering medical practitioner performs
occur during dosing. hand hygiene and dons sterile gloves.
Monitor frequently with arterial or Using surgical aseptic technique, cut a
transcutaneous measurement of systemic sterile 5 fg feeding tube to the length so that
oxygen and CO2. the tip lies 1 cm above the end of the
Note: Rales and moist breath sounds may endotracheal tube. This ensures that the
occur transiently following drug surfactant is administered intra-tracheal.
administration. These do not necessarily Curosurf should not be instilled into a main
indicate a need for suctioning. stem bronchus.
Slowly withdraw a little over the required
Planning and Implementation: dose into a 3 or 5 mL plastic syringe using a
large-gauge needle. Attach the pre-cut 5 Fr
Prepare equipment/supplies: catheter to the syringe, prime or fill the
Continuous cardiovascular monitoring catheter with surfactant to the end. Discard
equipment excess surfactant through the catheter so
Transcutaneous CO2 monitor (TCM) or end that only the dose to be given remains in the
tidal CO2 monitor (etCO2) if appropriate syringe.
Surfactant Ensure bed is flat. Place the neonate in
Size 5 Fr feeding tube supine position. There is no evidence to
3ml or 5ml syringe (dose dependent) support the practice of placing the neonate
Large gauge needle (18g, 19g or 20g) in multiple positions during administration.
Alcohol swab 70% Assistant disconnects the ETT from the
Sterile towel or drape ventilator.
Tape measure Medical practitioner or NNP to administer
Sterile scissors the surfactant via the pre-cut 5 Fr catheter in
Emergency equipment: Neopuff and mask, a single bolus dose as quickly as the
suction neonate tolerates. The total dose is usually
Surfactant administration is a two-person given less than a minute.
procedure. It should be performed by at Surfactant can occlude the ETT and it may
least one medical practitioner or a neonatal be necessary to cease administration until
nurse practitioner (NNP) who administers the tube is cleared and chest wall movement
the surfactant and one registered nurse as resumes
the assistant Reconnect ETT to ventilator as soon as
Record baseline observations: heart rate, possible. If neonate was on CPAP, positive
respiration rate, oxygen saturation, pressure ventilation is given via the Neopuff.
TCO2/etCO2, plus a blood gas if required Holding the ETT upright may facilitate

Page | 196
surfactant drainage and minimize reflux up
the ventilator circuit
Ventilator support or inspired oxygen may
need to be temporarily increased.
Medical practitioner/NNP to remain at
bedside until the neonate is stable.
C.POSTPARTUM AND NEWBORN
DRUGS
DRUGS USED DURING THE
POSTPARTUM PERIOD
1.CLASSIFICATION: ANALGESIC
GENERIC NAME: Acetaminophen
BRAND NAME: Tylenol
RECOMMENDED DOSAGE, ROUTE, AND
FREQUENCY
Route/Dosage
Children 12 yr should not receive 5 PO or
rectal doses/24 hr without notifying
physician or other health care professional.
No dosage adjustment needed when
converting between IV and PO
acetaminophen in adults and children 50 kg.
PO (Adults and Children 12 yr): 325– 650
mg q 6 hr or 1 g 3– 4 times daily or
1300 mg q 8 hr (not to exceed 3 g or 2 g/24
hr in patients with hepatic/renal impairment).
PO (Children 1– 12 yr): 10– 15 mg/kg/dose
q 6 hr as needed (not to exceed 5
doses/24 hr).
PO (Infants): 10– 15 mg/kg/dose q 6 hr as
needed (not to exceed 5 doses/24 hr).
PO (Neonates): 10– 15 mg/kg/dose q 6– 8
hr as needed.
DRUG ACTION
Inhibits the synthesis of prostaglandins that
may serve as mediators of pain and fever,
primarily in the CNS. Has no significant anti-
inflammatory properties or GI toxicity.
Therapeutic Effects: Analgesia. Antipyresis
Absorption: Well absorbed following oral
administration. Rectal absorption is
variable. Intravenous administration results
in complete bioavailability.
Distribution: Widely distributed. Crosses the
placenta; enters breast milk in low
concentrations.
Metabolism and Excretion: 85– 95%
metabolized by the liver (CYP2E1 enzyme
system). Metabolites may be toxic in
overdose situation. Metabolites excreted by
the
kidneys.
Half-life: Neonates: 7 hr; Infants and
Children: 3– 4 hr; Adults: 1– 3 hr.
INTERACTIONS
Drug-Drug: Chronic high-dose
acetaminophen (2 g/day) may increase risk
of bleeding
with warfarin (INR should not exceed 4).
Hepatotoxicity is additive with other
hepatotoxic substances, including alcohol.
Concurrent use of isoniazid, rifampin,
rifabutin, phenytoin, barbiturates, and
carbamazepine may increase the risk of
acetaminophen-induced liver damage (limit
self-medication); these agents will also
decrease
therapeutic effects of acetaminophen.
Concurrent use of NSAIDs may increase the
risk of
adverse renal effects (avoid chronic
concurrent use). Propranolol decrease
metabolism
and may increase effects. May decrease
effects of lamotrigine and zidovudine.
INDICATIONS
PO, Rect: Treatment of: Mild pain, Fever.
IV Treatment of: Mild to moderate pain,
Moderate to severe pain with opioid
analgesics, Fever.
CONTRAINDCIATIONS
Previous hypersensitivity; Products
containing alcohol, aspartame, saccharin,
sugar, or tartrazine (FDC yellow dye #5)
should be avoided in patients who have
hypersensitivity or intolerance to these
compounds; Severe hepatic
impairment/active liver disease.
SIDE EFFECTS/ADVERSE REACTIONS
Side Effects
(IV), fatigue (IV), insomnia (IV) Resp:
atelectasis (qin children) (IV), dyspnea
(IV).CV: hypertension
(IV), hypotension (IV).
GI: HEPATOTOXICITY (increase DOSES),
constipation (qin children)
(IV), increase liver enzymes, nausea (IV),
vomiting (IV). F and E: hypokalemia (IV).
GU: renal failure (high doses/chronic use).
Hemat: neutropenia, pancytopenia.
Page | 197
MS: muscle spasms (IV), trismus (IV). Derm: ● To prevent fatal medication errors ensure
ACUTE GENERALIZED dose in milligrams (mg) and milliliters
EXANTHEMATOUS PUSTULOSIS, (mL) is not confused; dosing is based on
STEVENS-JOHNSON SYNDROME, TOXIC weight for patients under 50 kg;
EPIDERMAL NECROLYSIS, rash, urticaria. programming of infusion pump accurate;
and total daily dose of acetaminophen from
Adverse Effects all sources does not exceed maximum daily
Body as a Whole: Negligible with limits.
recommended dosage; rash. Acute ● When combined with opioids do not
poisoning: Anorexia, nausea, vomiting, exceed the maximum recommended daily
dizziness, lethargy, diaphoresis, chills, dose of acetaminophen.
epigastric or abdominal pain, diarrhea; onset ● PO: Administer with a full glass of water.
of hepatotoxicity—elevation of serum ● May be taken with food or on an empty
transaminases (ALT, AST) and bilirubin; stomach.
hypoglycemia, hepatic coma, acute renal IV Administration
failure (rare). Chronic ingestion:
Neutropenia, pancytopenia, leukopenia, Patient/Family Teaching
thrombocytopenic purpura, hepatotoxicity in ● Advise patient to take medication exactly
alcoholics, renal damage. as directed and not to take more than the
recommended amount. Chronic excessive
NURSING RESPONSIBILITIES use of 4 g/day (2 g in chronic alcoholics)
may lead to hepatotoxicity, renal or cardiac
NURSING INTERVENTION damage. Adults should not take
acetaminophen longer than 10 days and
children not longer than 5 days unless
Assessment directed by health care professional. Short-
● Assess overall health status and alcohol term doses of acetaminophen with
usage before administering salicylates or NSAIDs should not exceed the
acetaminophen. Patients who are recommended daily dose of either drug
malnourished or chronically abuse alcohol alone.
are at higher risk of developing
hepatotoxicity with chronic use of
usual doses of this drug.
● Assess amount, frequency, and type of Evaluation/Desired Outcomes
drugs taken in patients self-medicating, ● Relief of mild to moderate pain.
especially with OTC drugs. Prolonged use of ● Reduction of fever.
acetaminophen increases the risk of
adverse renal effects. For short-term use,
combined 2. CLASSIFICATION: ANALGESIC
doses of acetaminophen and salicylates W/ OPIOIDS
should not exceed the recommended dose
GENERIC NAME:
of either drug given alone. Do not exceed
maximum daily Acetaminophen/Codiene
dose of acetaminophen when considering all
routes of administration BRAND NAME: Tylenol No. 3
and all combination products containing
acetaminophen.
● Pain: Assess type, location, and intensity RECOMMENDED DOSAGE, ROUTE, AND
prior to and 30– 60 min following FREQUENCY
administration. Analgesic
Adult: PO/IM/SC 15–60 mg q.i.d.
Potential Nursing Diagnoses Child: PO/IM/SC 0.5–1 mg/kg q4–6h prn
(max: 60 mg/dose)
Acute pain (Indications)
Risk for imbalanced body temperature Antitussive
(Indications) Adult: PO 10–20 mg q4–6h prn (max: 120
mg/24 h)
Implementation Child: PO 6–12 y: 5–10 mg q4–6h (max: 60
mg/24 h); 2–6 y: 2.5–5 mg q4–6h (max: 30
● Do not confuse Tylenol with Tylenol PM. mg/24 h)

Page | 198

A: Readily absorbed from GI tract.
(Onset: 15–30 min. Peak: 1–1.5 h. Duration:
4–6 h.)
D: Crosses placenta; distributed into breast
milk.
M: Metabolized in liver.
E: Excreted in urine. Half-Life: 2.5–4 h.
DRUG ACTION
Opium derivative similar to morphine. In
equianalgesic doses, parenteral codeine
produces degree of respiratory depression
similar to that of morphine. In contrast to
morphine, orally administered codeine is
about 60% as potent as the parenteral form.
Histamine-releasing action appears to be
more potent than that of morphine and may
result in hypotension, flushing, and rarely
bronchoconstriction.
Therapeutic Effects: Analgesic potency is
about one-sixth that of morphine; antitussive
activity is also a little less than that of
morphine.
INTERACTIONS
Drug: Alcohol and other CNS
DEPRESSANTS augment CNS depressant
effects. Herbal: St. John's wort may cause
increase sedation.
INDICATIONS
Symptomatic relief of mild to moderately
severe pain when control cannot be
obtained by nonnarcotic analgesics and to
suppress hyperactive or nonproductive
cough.
CONTRAINDCIATIONS
Hypersensitivity to codeine or other
morphine derivatives; acute asthma, COPD;
increased intracranial pressure, head injury,
acute alcoholism, hepatic or renal
dysfunction, hypothyroidism. Pregnancy
(category C), lactation. Safe use in neonates
not established.
Cautious Use: Prostatic hypertrophy,
debilitated patients, very young and very old
patients; history of drug abuse.
SIDE EFFECTS/ADVERSE REACTIONS
Side Effects
Cardiovascular system: faintness, flushing,
hypotension, palpitations, syncope
Digestive System: abdominal cramps,
anorexia, diarrhea, dry mouth,
gastrointestinal distress, pancreatitis
Nervous system: anxiety, drowsiness,
fatigue, headache, insomnia, nervousness,
shakiness, somnolence, vertigo, visual
disturbances, weakness
Skin and Appendages: rash, sweating,
urticaria
Adverse Effects
Body as a Whole: Shortness of breath,
anaphylactoid reaction.
CV: Palpitation, hypotension, orthostatic
hypotension, bradycardia, tachycardia,
circulatory collapse.
GI: Nausea, vomiting, constipation.
CNS: Dizziness, light-headedness,
drowsiness, sedation, lethargy, euphoria,
agitation; restlessness, exhilaration,
convulsions, narcosis, respiratory
depression. Skin: Diffuse erythema, rash,
urticaria, pruritus, excessive perspiration,
facial flushing, fixed-drug eruption. Special
Senses: Miosis.
Urogenital: Urinary retention.
NURSING RESPONSIBILITIES
Assessment & Drug Effects
Record relief of pain and duration of
analgesia.
Evaluate effectiveness as cough
suppressant. Treatment of cough is directed
toward decreasing frequency and intensity
of cough without abolishing cough reflex,
need to remove bronchial secretions.
Although codeine has less abuse liability
than morphine, dependence is a major
unwanted effect.
Supervision of ambulation and use other
safety precautions as warranted since drug
may cause dizziness and light-headedness.
Monitor for nausea, a common side effect.
Report nausea accompanied by vomiting.
Change to another analgesic may be
warranted.
Patient & Family Education
Make position changes slowly and in stages
particularly from recumbent to upright
posture. Lie down immediately if light-
headedness or dizziness occurs.
Lie down when feeling nauseated and to
notify physician if this symptom persists.
Nausea appears to be aggravated by
ambulation.
Avoid driving and other potentially
hazardous activities until reaction to drug is
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known. Codeine may impair ability to
perform tasks requiring mental alertness.
Do not take alcohol or other CNS
depressants unless approved by physician.
Hyperactive cough may be lessened by
avoiding irritants such as smoking, dust,
fumes, and other air pollutants.
Humidification of ambient air may provide
some relief.
Do not breast feed while taking this drug.
3. CLASSIFICATION: NSAIDs
GENERIC NAME: Ibuprofen
BRAND NAME: Motrin
RECOMMENDED DOSAGE, ROUTE, AND
FREQUENCY
Analgesia
PO (Adults): Anti-inflammatory—400– 800
mg 3– 4 times daily (not to exceed
3200 mg/day).
Analgesic/antidysmenorrheal/antipyretic—
200– 400 mg q 4– 6
hr (not to exceed 1200 mg/day).
PO (Children 6 mo– 12 yr): Anti-
inflammatory—30– 50 mg/kg/day in 3– 4
divided doses (maximum dose: 2.4 g/day).
Antipyretic—5 mg/kg for temperature
102.5F (39.17C) or 10 mg/kg for higher
temperatures (not to exceed 40 mg/kg/
day); may be repeated q 4– 6 hr. Cystic
fibrosis (unlabeled)—20– 30 mg/kg/day
divided twice daily.
PO (Infants and Children): Analgesic—4– 10
mg/kg/dose q 6– 8 hr.
IV (Adults): Analgesic—400– 800 mg q 6 hr
as needed (not to exceed 3200 mg/
day); Antipyretic—400 mg initially, then 400
mg q 4– 6 hr or 100– 200 mg q 4 hr
as needed (not to exceed 3200 mg/day).
Pediatric OTC Dosing
PO (Children 11 yr/72– 95 lb): 300 mg q 6–
8 hr.
PO (Children 9– 10 yr/60– 71 lb): 250 mg q
6– 8 hr.
PO (Children 6– 8 yr/48– 59 lb): 200 mg q
6– 8 hr.
PO (Children 4– 5 yr/36– 47 lb): 150 mg q
6– 8 hr.
PO (Children 2– 3 yr/24– 35 lb): 100 mg q
6– 8 hr.
PO (Children 12– 23 mo/18– 23 lb): 75 mg q
6– 8 hr.
PO (Infants 6– 11 mo/12– 17 lb): 50 mg q 6–
8 hr.
DRUG ACTION
Inhibits prostaglandin synthesis. Therapeutic
Effects: Decreased pain and inflammation.
Reduction of fever.
Absorption: Oral formulation is well
absorbed (80%) from the GI tract; IV
administration results in complete
bioavailability.
Distribution: Does not enter breast milk in
significant amounts.
Protein Binding: 99%.
Metabolism and Excretion: Mostly
metabolized by the liver; small amounts
(1%) excreted unchanged by the kidneys.
Half-life: Neonates: 26– 43 hr; Children: 1– 2
hr; Adults: 2– 4 hr.
INTERACTIONS
Drug-Drug: May limit the cardioprotective
effects of low-dose aspirin. Concurrent use
with aspirin may decrease effectiveness of
ibuprofen. Additive adverse GI side effects
with aspirin, oral potassium, other NSAIDs,
corticosteroids, or alcohol.
Chronic use with acetaminophen may
increase risk of adverse renal reactions.
May decrease effectiveness of diuretics,
ACE inhibitors, or other antihypertensives.
May increase hypoglycemic effects of insulin
or oral hypoglycemic agents. May increase
serum lithium
levels and risk of toxicity. increase risk of
toxicity from methotrexate. Probenecid
increase risk
of toxicity from ibuprofen. Increase risk of
bleeding with cefotetan, cefoperazone,
corticosteroids, valproic acid, thrombolytics,
warfarin, and drugs affecting
platelet function including clopidogrel
, ticlopidine, abciximab, eptifibatide,
ortirofiban. Increase risk of adverse
hematologic reactions with anti-neoplastic or
radiation therapy. Risk of nephrotoxicity with
cyclosporine.
Drug-Natural Products: increase bleeding
risk with, arnica, chamomile, feverfew,
garlic, ginger, ginkgo, Panax ginseng, and
others.
INDICATIONS
PO, IV: Treatment of: Mild to moderate pain,
Fever. PO Treatment of: Inflammatory
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disorders including rheumatoid arthritis
(including juvenile) and osteoarthritis,
Dysmenorrhea.
IV Moderate to severe pain with opioid
analgesics. Closure of a clinically
significant PDA in neonates weighing 500–
1500 g and 32 weeks gestational age
(ibuprofen lysine only).
CONTRAINDCIATIONS
Hypersensitivity (cross-sensitivity may exist
with other
NSAIDs, including aspirin); Active GI
bleeding or ulcer disease; Chewable tablets
contain aspartame and should not be used
in patients with phenylketonuria; Peri-
operative pain from coronary artery bypass
graft (CABG) surgery;OB: Avoid after 30 wk
gestation (may cause premature closure of
fetal ductus arteriosus); Pedi: Ibuprofen
lysine: Preterm neonates with untreated
infection, congenital heart disease where
patency of PDA is necessary for pulmonary
or systemic blood flow, bleeding,
thrombocytopenia, coagulation defects,
necrotizing enterocolitis, significant renal
dysfunction.
SIDE EFFECTS/ADVERSE REACTIONS
Side Effects
CNS: headache, dizziness, drowsiness,
intraventricular hemorrhage (ibuprofen
lysine), psychic disturbances.
EENT: amblyopia, blurred vision, tinnitus.
CV: arrhythmias, edema, hypertension.
GI: GI BLEEDING, HEPATITIS,
constipation, dyspepsia, nausea, necrotizing
enterocolitis (ibuprofen lysine), vomiting,
abdominal
discomfort. GU: cystitis, hematuria, renal
failure. Derm: EXFOLIATIVE DERMATITIS
Adverse Effects
CNS: Headache, dizziness, light-
headedness, anxiety, emotional lability,
fatigue, malaise, drowsiness, anxiety,
confusion, depression, aseptic meningitis.
CV: Hypertension, palpitation, congestive
heart failure (patient with marginal cardiac
function); peripheral edema. Special
Senses: Amblyopia (blurred vision,
decreased visual acuity, scotomas, changes
in color vision); nystagmus, visual-field
defects; tinnitus, impaired hearing. GI: Dry
mouth, gingival ulcerations, dyspepsia,
heartburn, nausea, vomiting, anorexia,
diarrhea, constipation, bloating, flatulence,
epigastric or abdominal discomfort or pain,
GI ulceration, occult blood loss.
NURSING RESPONSIBILITIES
NURSING INTERVENTION
Assessment
● Patients who have asthma, aspirin-
induced allergy, and nasal polyps are
at increased risk for developing
hypersensitivity reactions. Assess for
rhinitis, asthma, and urticaria.
● Assess for signs and symptoms of GI
bleeding (tarry stools, lightheadedness,
hypotension), renal dysfunction (elevated
BUN and creatinine levels, decreased urine
output), and hepatic impairment (elevated
liver enzymes, jaundice).Geri:Higher
risk for poor outcomes or death from GI
bleeding. Age-related renal impairment
increases risk of hepatic and renal toxicity.
● Assess patient for skin rash frequently
during therapy. Discontinue ibuprofen at first
sign of rash; may be life-threatening.
Stevens-Johnson
syndrome or toxic epidermal necrolysis may
develop. Treat symptomatically; may recur
once treatment is stopped.
● Pain: Assess pain (note type, location, and
intensity) prior to and 1– 2 hr following
administration.
Potential Nursing Diagnoses
Acute pain (Indications)
Impaired physical mobility (Indications)
Ineffective thermoregulation (Indications)
Implementation
● Do not confuse Motrin (ibuprofen) with
Neurontin (gabapentin).
● Administration of higher than
recommended doses does not provide
increased
pain relief but may increase incidence of
side effects.
● Patient should be well hydrated before
administration to prevent renal adverse
reactions. Do not give to neonates with urine
output 0.6 mL/kg/hour.
● Use lowest effective dose for shortest
period of time, especially in the elderly.
Patient/Family Teaching
● Advise patients to take ibuprofen with a
full glass of water and to remain in an
upright position for 15– 30 min after
administration.
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● Instruct patient to take medication as
directed. Take missed doses as soon as
remembered but not if almost time for next
dose. Do not double doses. Pedi: Teach
parents and caregivers to calculate and
measure doses accurately and to use
measuring device supplied with product.
Evaluation/Desired Outcomes
● Decrease in severity of pain.
● Improved joint mobility. Partial arthritic
relief is usually seen within 7 days, but
maximum effectiveness may require 1– 2 wk
of continuous therapy. Patients who
do not respond to one NSAID may respond
to another.
CLASSIFICATION: Opiates
GENERIC NAME: Codeine sulfate
BRAND NAME:
RECOMMENDED DOSAGE, ROUTE, AND
FREQUENCY
PO (Adults): Analgesic—15– 60 mg q 3– 6
hr as needed. Antitussive—10– 20
mg q 4– 6 hr as needed (not to exceed 120
mg/day). Antidiarrheal —30 mg up to 4
times daily.
PO (Children 6– 12 yr): Analgesic—0.5– 1
mg/kg (up to 60 mg) q 4– 6 hr (up
to 4 times daily) as needed. Antitussive—5–
10 mg q 4– 6 hr as needed (not to exceed
60 mg/day). Antidiarrheal—0.5 mg/kg up to
4 times daily.
PO (Children 2– 5 yr): Analgesic—0.5– 1
mg/kg (up to 60 mg) q 4– 6 hr (up to 4
times daily) as needed. Antitussive—1– 1.5
mg/kg divided q 4– 6 hr as needed.
Antidiarrheal—0.5 mg/kg up to 4 times daily.
DRUG ACTION
Binds to opiate receptors in the
CNS. Alters the perception of and response
to painful
stimuli while producing generalized CNS
depression. Decreases cough reflex.
Decreases GI motility.
Therapeutic Effects: Decreased severity of
pain. Suppression
of the cough reflex. Relief of diarrhea.
Absorption: 50% absorbed from the GI tract.
Distribution: Widely distributed. Crosses the
placenta; enters breast milk.
Protein Binding: 7%.
Metabolism and Excretion: Mostly
metabolized by the liver (primarily via
CYP2D6); 10% converted to morphine; the
CYP2D6 enzyme system exhibits genetic
polymorphism (some patients [1– 10%
Whites, 3% African Americans, 16–
28% North Africans/Ethiopians/Arabs] may
be ultra-rapid metabolizers and may
Have increase morphine concentrations and
an increase risk of adverse effects); 5– 15%
excreted
unchanged in urine.
Half-life: 2.5– 4 hr.
INTERACTIONS
Drug-Drug: Use with extreme caution in
patients receiving MAOinhibitors
(pinitial dose to 25% of usual dose). Additive
CNS depression with alcohol,
antidepressants, antihistamines, and
sedative/hypnotics. Administration of partial
antagonists (buprenorphine, butorphanol,
nalbuphine, or pentazocine) may precipitate
opioid withdrawal in physically dependent
patients.
Nalbuphine or pentazocine may decrease
analgesia.
Drug-Natural Products: Concomitant use of
kava-kava, valerian, skullcap,
chamomile, or hop scan increase CNS
depression
INDICATIONS
Management of mild to moderate pain.
Antitussive (in smaller doses). Unlabeled
Use: Management of diarrhea.
CONTRAINDCIATIONS
Hypersensitivity.
SIDE EFFECTS/ADVERSE REACTIONS
Side Effects
CNS: confusion, sedation, dysphoria,
euphoria, floating feeling, hallucinations,
headache, unusual dreams.
EENT: blurred vision, diplopia, miosis.
Resp: respiratory depression.
CV: hypotension, bradycardia. GI:
constipation, nausea, vomiting.
GU: urinary retention. Derm: flushing,
sweating.
Misc: physical dependence, psychological
dependence, tolerance.
Adverse Effects
Body as a Whole: Shortness of breath,
anaphylactoid reaction. CV: Palpitation,
hypotension, orthostatic hypotension,
bradycardia, tachycardia, circulatory
collapse. GI: Nausea, vomiting, constipation.
CNS: Dizziness, light-headedness,
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drowsiness, sedation, lethargy, euphoria,
agitation; restlessness, exhilaration,
convulsions, narcosis, respiratory
depression. Skin: Diffuse erythema, rash,
urticaria, pruritus, excessive perspiration,
facial flushing, fixed-drug eruption. Special
Senses: Miosis. Urogenital: Urinary
retention.
NURSING RESPONSIBILITIES
NURSING INTERVENTION
Assessment
● Assess BP, pulse, and respirations before
and periodically during administration.
If respiratory rate is 10/min, assess level of
sedation. Physical stimulationmay be
sufficient to prevent significant
hypoventilation. Dose may need to be
decreased by
25– 50%. Initial drowsiness will diminish with
continued use.
● Assess bowel function routinely.
Prevention of constipation should be
instituted
with increased intake of fluids, bulk, and
laxatives to minimize constipating effects.
Stimulant laxatives should be administered
routinely if opioid use exceeds
2– 3 days, unless contraindicated.
● Pain: Assess type, location, and intensity
of pain before and 1 hr (peak) after
administration. When titrating opioid doses,
increases of 25– 50% should be
administered until there is either a 50%
reduction in the patient’s pain rating on a
numerical or visual analogue scale or the
patient reports satisfactory pain relief.
Arepeat dose can be safely administered at
the time of the peak if previous dose
isineffective and side effects are minimal.
Potential Nursing Diagnoses
Acute pain (Indications)
Disturbed sensory perception (visual,
auditory) (Side Effects)
Risk for injury (Side Effects)
Implementation
● High Alert: Accidental overdosage of
opioid analgesics has resulted in fatalities.
Before administering, clarify all ambiguous
orders; have second practitioner
independently check dose calculations and
route of administration.
● High Alert: Do not confuse codeine with
Lodine (etodolac).
● Explain therapeutic value of medication
before administration to enhance the
analgesic effect.
● Regularly administered doses may be
more effective than prn administration.
Analgesic is more effective if given before
pain becomes severe.
● Coadministration with nonopioid
analgesics may have additive analgesic
effects
and permit lower doses.
● Medications should be discontinued
gradually after long-term use to prevent
withdrawal symptoms.
Patient/Family Teaching
● Instruct patient on how and when to ask
for and take pain medication.
● May cause drowsiness or dizziness.
Advise patient to call for assistance when
ambulating or smoking. Caution ambulatory
patient to avoid driving or other activities
requiring alertness until response to
medication is known.
● Advise patient to change positions slowly
to minimize orthostatic hypotension.
● Caution patient to avoid concurrent use of
alcohol or other CNS depressants with
this medication.
● Encourage patient to turn, cough, and
breathe deeply every 2 hr to prevent
atelectasis.
● Advise patient that good oral hygiene,
frequent mouth rinses, and sugarless gum
or candy may decrease dry mouth.
Evaluation/Desired Outcomes
● Decrease in severity of pain without a
significant alteration in level of
consciousness or respiratory status.
● Suppression of cough.
● Control of diarrhea.
5. CLASSIFICATION: OPIOIDS
AGONISTS- ANTAGONISTS
GENERIC NAME: Nalbuphine
oxycodone
BRAND NAME: Percocet
RECOMMENDED DOSAGE, ROUTE, AND
FREQUENCY
Larger doses may be required during
chronic therapy.
PO (Adults >50 kg): 5– 10 mg q 3– 4 hr
initially, as needed. Controlled-release
tablets (Oxycontin) may be given q 12 hr.
PO (Adults <50 kg ): 0.2 mg/kg q 3– 4 hr
initially, as needed.
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PO (Children): 0.05– 0.15 mg/kg q 4– 6 hr
as needed, as immediate-release product.
Rect (Adults): 10– 40 mg 3– 4 times daily
initially, as needed.
Absorption: Well absorbed from the GI tract.
Distribution: Widely distributed. Crosses the
placenta; enters breast milk.
Protein Binding: 38– 45%.
Metabolism and Excretion: Mostly
metabolized by the liver by the CYP3A4
isoenzyme.
Half-life: 2– 3 hr
Side Effects
CNS: confusion, sedation, dizziness,
dysphoria, euphoria, floating feeling,
hallucinations, headache, unusual dreams.
EENT: blurred vision, diplopia, miosis.
Resp: RESPIRATORY DEPRESSION.
CV: orthostatic hypotension.
GI: constipation, dry mouth,
choking, GI obstruction, nausea, vomiting.
GU: urinary retention.
Derm: flushing, sweating.
Misc: physical dependence, psychological
dependence, tolerance.

DRUG ACTION Adverse Effects

Binds to opiate receptors in the CNS. Alters CNS: Euphoria, dysphoria, light-
the perception of and response to painful headedness, dizziness, sedation.
stimuli, while producing generalized CNS GI: Anorexia, nausea, vomiting,
depression. constipation, jaundice, hepatotoxicity
Therapeutic Effects: Decreased pain. (combinations containing acetaminophen).
Respiratory: Shortness of breath, respiratory
INTERACTIONS depression.
Skin: Pruritus, skin rash.
CV: Bradycardia.
Drug-Drug: Use with caution in patients Body as a Whole: Unusual bleeding or
receiving MAO inhibitors (may bruising.
result in unpredictable reactions— decrease Urogenital: Dysuria, frequency of urination,
initial dose of oxycodone to 25% of urinary retention.
usual dose). Additive CNS depression with
alcohol, antihistamines, and NURSING RESPONSIBILITIES
sedative/hypnotics. Administration of partial-
antagonist opioid analgesics may NURSING INTERVENTION
precipitate withdrawal in physically
dependent patients. Nalbuphine, Assessment
buprenorphine, or pentazocine may ● Assess type, location, and intensity of pain
decrease analgesia. Potent CYP3A4 prior to and 1 hr (peak) after administration.
inhibitors including When titrating opioid doses, increases of
erythromycin, ketoconazole, itraconazole, 25– 50% should be administered until there
voriconazole, or ritonavir may is either a 50% reduction in the patient’s
increase levels. Potent CYP3A4 inducers pain rating on a numerical or visual analog
including rifampin, carbamazepine, and scale or the patient reports satisfactory pain
phenytoin may decrease levels. relief. A repeat
dose can be safely administered at the time
INDICATIONS of the peak if previous dose is ineffective
Moderate to severe pain; extended release and side effects are minimal.
product should be used for patients requiring
around-the-clock management of chronic
Potential Nursing Diagnoses
pain.
Acute pain (Indications)
Chronic pain (Indications)
CONTRAINDCIATIONS
Risk for injury (Side Effects)
Hypersensitivity; Some products contain
alcohol or bisulfites and should be avoided
Implementation
in patients with known intolerance or
● High Alert: Accidental overdose of opioid
hypersensitivity; Significant respiratory
analgesics has resulted in fatalities.
depression; Paralytic ileus; Acute or severe
Before administering, clarify all ambiguous
bronchial asthma; Acute, mild, intermittent,
orders; have second practitioner
or postoperative pain (extended-release).
independently check original order and dose
calculations.
SIDE EFFECTS/ADVERSE REACTIONS

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● Do not confuse short-acting oxycodone
with long-acting Oxycontin. Do
not confuse oxycodone with hydrocodone.
Do not confuse Oxycontin
with MS Contin.
Patient/Family Teaching
● Instruct patient on how and when to ask
for and take pain medication.
● Advise patient that oxycodone is a drug
with known abuse potential. Protect it from
theft, and never give to anyone other than
the individual for whom it was prescribed.
● Medication may cause drowsiness or
dizziness. Advise patient to call for
assistance
when ambulating or smoking. Caution
patient to avoid driving and other activities
requiring alertness until response to
medication is known.
● Advise patients taking Oxycontin tablets
that empty matrix tablets may appear in
Stool atelectasis.
● Advise patient to notify health care
professional if pregnancy is planned or
suspected, or if breast feeding.
Evaluation/Desired Outcomes
● Decrease in severity of pain without a
significant alteration in level of
consciousness or respiratory status.
5.CLASSIFICATION:
PHENYLACETIC ACID
GENERIC NAME: Ketorolac
tromethamine
BRAND NAME: Toradol
RECOMMENDED DOSAGE, ROUTE, AND
FREQUENCY
Route/Dosage
Oral therapy is indicated only as a
continuation of parenteral therapy. Total
duration
of therapy by all routes should not exceed 5
days.
PO (Adults 65 yr): 20 mg initially, followed
by 10 mg q 4– 6 hr (not to exceed 40
mg/day).
PO (Adults 65 yr, 50 kg, or with renal
impairment): 10 mg q 4– 6 hr (not to
exceed 40 mg/day).
PO (Children 2– 16 yr, 50 kg): 1 mg/kg as a
single dose. No data available for
multiple doses.
IM (Adults 65 yr): Single dose—60 mg.
Multiple dosing—30 mg q 6 hr (not to
exceed 120 mg/day).
IM (Adults 65 yr, 50 kg, or with renal
impairment): Single dose—30 mg.
Multiple dosing—15 mg q 6 hr (not to
exceed 60 mg/day).
DRUG ACTION
Inhibits prostaglandin synthesis, producing
peripherally mediated analgesia. Also
has antipyretic and anti-inflammatory
properties.
Therapeutic Effects: Decreased pain.
Absorption: Rapidly and completely
absorbed following all routes of
administration.
Distribution: Enters breast milk in low
concentrations.
Protein Binding: 99%.
Metabolism and Excretion: Primarily
metabolized by the liver. Ketorolac and
its metabolites are excreted primarily by the
kidneys (92%); 6% excreted in feces.
Half-life: 4.5 hr (range 3.8– 6.3 hr; increase
in geriatric patients and patients with
impaired renal function).
INTERACTIONS
Drug-Drug: Probenecid increase levels and
the risk of adverse reactions; concurrent
use is contraindicated. Increase risk of
bleeding when used with pentoxifylline;
concurrent use is contraindicated.
Concurrent use with aspirin may decrease
effectiveness. Increase adverse GI effects
with aspirin, other NSAIDs, potassium
supplements, corticosteroids, or alcohol.
May decrease effectiveness of diuretics or
antihypertensives. May increase serum
lithium levels and increase risk of toxicity.
increase risk of toxicity from methotrexate.
Increase risk of bleeding with cefotetan,
cefoperazone, valproic acid, clopidogrel,
ticlopidine, tirofiban, eptifibatide,
thrombolytic agents, or anticoagulants.
Increase risk of adverse hematologic
reactions with antineoplastic or radiation
therapy. May increase risk of nephrotoxicity
from cyclosporine.
Drug-Natural Products: increase bleeding
risk with arnica, chamomile, clove,
dong quai, feverfew, garlic, ginger, ginkgo,
Panax ginseng.
INDICATIONS
Short-term management of pain (not to
exceed 5 days total for all routes combined).
CONTRAINDCIATIONS
Hypersensitivity; Cross-sensitivity with other
NSAIDs may exist; Preoperative use; Active
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or history of peptic ulcer disease or GI
bleeding; Known alcohol intolerance
(injection only); Perioperative pain from
coronary artery bypass
graft (CABG) surgery; Cerebrovascular
bleeding; Advanced renal impairment or at
risk for renal failure due to volume depletion;
Concurrent use of pentoxifylline or
probenecid; OB: Chronic use in 3rd trimester
may cause constriction of ductus arteriosus.
May inhibit labor and increase maternal
bleeding at delivery.
SIDE EFFECTS/ADVERSE REACTIONS
Side Effects
CNS: STROKE, drowsiness, abnormal
thinking, dizziness, euphoria, headache.
EENT: increase lacrimation (spray), nasal
discomfort (spray), throat irritation (spray).
Resp: asthma, dyspnea. CV: MYOCARDIAL
INFARCTION, edema, pallor, vasodilation.
GI: GI BLEEDING, abnormal taste, diarrhea,
dry mouth, dyspepsia, GI pain, increase liver
enzymes, nausea. GU: oliguria, renal
toxicity, urinary frequency.
Adverse Effects
Derm: EXFOLIATIVE
DERMATITIS, STEVENS-JOHNSON
SYNDROME, TOXIC EPIDERMAL
NECROLYSIS, pruritus, purpura, sweating,
urticaria. Hemat: prolonged bleeding time.
Local: injection site
pain. neuro: paresthesia.
Misc: allergic reactions including,
anaphylaxis.
NURSING RESPONSIBILITIES
NURSING INTERVENTION
Assessment
● Patients who have asthma, aspirin-
induced allergy, and nasal polyps are
at increased risk for developing
hypersensitivity reactions. Assess for
rhinitis, asthma, and urticaria.
● Assess for rash periodically during
therapy. May cause Stevens-Johnson
syndrome or toxic epidermal necrolysis.
Discontinue therapy if severe
or if accompanied with fever, general
malaise, fatigue, muscle or joint
aches, blisters, oral lesions, conjunctivitis,
hepatitis and/or eosinophilia.
● Pain: Assess pain (note type, location, and
intensity) prior to and 1– 2 hr following
administration.
● Lab Test Considerations: Evaluate liver
function tests, especially AST and ALT,
periodically in patients receiving prolonged
therapy. May causeqlevels.
● May cause prolonged bleeding time that
may persist for 24– 48 hr following
discontinuation of therapy.
● May causeqBUN, serum creatinine, or
potassium concentrations.
Potential Nursing Diagnoses
Acute pain (Indications)
Implementation
● Do not confuse Toradol (ketorolac) with
tramadol (Ultram).
● Administration in higher-than-
recommended doses does not provide
increased
effectiveness but may cause increased side
effects. Duration of ketorolac therapy, by all
routes combined, should not exceed 5 days.
Use lowest effective
dose for shortest period of time.
● Coadministration with opioid analgesics
may have additive analgesic effects and
may permit lower opioid doses.
● PO: Ketorolac therapy should always be
given initially by the IM or IV route. Use
oral therapy onlyas a continuation of
parenteral therapy.
Patient/Family Teaching
● Instruct patient on how and when to ask
for and take pain medication.
● Instruct patient to take medication exactly
as directed. Take missed doses as soon
as remembered if not almost time for next
dose. Do not double doses. Do not take
more than prescribed or for longer than 5
days.
● May cause drowsiness or dizziness.
Advise patient to avoid driving or other
activities requiring alertness until response
to the medication is known.
● Caution patient to avoid the concurrent
use of alcohol, aspirin, NSAIDs,
acetaminophen, or other OTC medications
without consulting health care professional.
● Advise patient to inform health care
professional of medication regimen prior to
treatment or surgery.
● Advise patient to consult health care
professional if rash, itching, visual
disturbances, tinnitus, weight gain, edema,
black stools, persistent headache, or
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influenza-like syndrome (chills, fever,
muscle aches, pain) occurs.
● Intranasal: Instruct patient on correct
technique for administration, need to
open a new bottle every 24 hr, and the 5-
day limit for use.
Evaluation/Desired Outcomes
● Decrease in severity of pain. Patients who
do not respond to one NSAID may respond
to another.
B. PAIN RELIEF FOR
1.CLASSIFICATION: PERINEAL
WOUNDS
GENERIC NAME: Benzocaine
topical
BRAND NAME: Americaine,
Dermoplast
RECOMMENDED DOSAGE, ROUTE, AND
FREQUENCY
Route/Dosage
Benzocaine
Topical/Mucosal (Adults and Children):
Apply cream, ointment, topical solutions,
or dental/oral products as needed. Lozenges
may be used hourly (not to exceed 12
lozenges/day). Rectal products may be used
twice daily.
Dibucaine
Topical (Adults and Children): Apply as
needed (not to exceed 30 g/day in adults
or 7.5 g/day in children). Can be used 3– 4
times daily.
Dyclonine
Mucosal (Adults): 2- or 3-mg lozenge may
be dissolved in the mouth q 2 hr (not to
exceed 10 lozenges/day), or solution may
be used 4 times daily.
Mucosal (Children 2 yr): 1.2-mg lozenge
may be dissolved in mouth q 2 hr (not
to exceed 10 lozenges/day).Pramoxine
Topical/Mucosal (Adults): Topical products
may be used q 3 hr as needed. Rectal
products may be used up to 5 times daily.
DRUG ACTION
Inhibit initiation and conduction of sensory
nerve impulses. Therapeutic Effects:
Local anesthesia with subsequent loss of
sensation or relief of pain and/or pruritus
Inhibit initiation and conduction of sensory
nerve impulses. Therapeutic Effects:
Local anesthesia with subsequent loss of
sensation or relief of pain and/or pruritus
Absorption:
Benzocaine is poorly absorbed through
intact skin. Other agents may
be readily absorbed. Degree of absorption
with surface area; presence of lesions,
cuts, or abrasions; and amount of agent
applied.
Distribution: Unknown.
Metabolism and Excretion: Ester-type
agents (PABA derivatives, benzocaine)
are metabolized by plasma and liver
cholinesterase’s. Small amounts of amide-
type
agents (dibucaine) that may be absorbed
are mostly metabolized by the liver.
INTERACTIONS
Toxicity of ester-type agents may be
increased by concurrent use of
cholinesterase inhibitors.
INDICATIONS
Topical: Relief of pruritus or pain associated
with minor skin disorders including
burns, abrasions, bruises, insect
stings/bites, dermatitis, hemorrhoids, or
other
forms of skin irritation. Mucosal: Provide
local anesthesia to mucosal surfaces before
instrumentation, minor procedures, or
endoscopy. Decrease irritation caused
by minor mouth and throat conditions
including sore throat, gingivitis, stomatitis, or
teething. Also used to suppress the gag
reflex during endoscopy or intubation.
CONTRAINDCIATIONS
Hypersensitivity. Cross-sensitivity may occur
among related
agents (amide types— dibucaine; ester
types— benzocaine, tetracaine);
Hypersensitivity to any components of
preparations including stabilizers, colorants,
or bases;
Active, untreated infection of affected area;
Not to be used in the eye; Some products
contain alcohol and should be avoided in
patients with known alcohol intolerance;
Pedi: Topical benzocaine products should
not be used in children 2 yr.
SIDE EFFECTS/ADVERSE REACTIONS
Side Effects
EENT: mucosal use—por absent gag reflex.
Derm: topical use— burning,
edema, irritation, stinging, tenderness,
urticaria.
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Misc: allergic reactions including
ANAPHYLAXIS.
Adverse Effects
Body as a Whole: Low toxicity; sensitization
in susceptible individuals; allergic reactions,
anaphylaxis. Methemoglobinemia reported
in infants.
NURSING RESPONSIBILITIES
Assessment
● Assess type, location, and intensity of pain
before and a few minutes after
administration of anesthetic.
● Assess integrity of involved skin and
mucous membranes before and periodically
throughout course of therapy. Notify health
care professional if signs of infection
or irritation develop.
Potential Nursing Diagnoses
Acute pain (Indications)
Implementation
● High Alert: Overuse of topical anesthetic
sprays on mucous membranes can result in
methemoglobinemia. Avoid overuse or too
liberal application.
● Topical: Alcohol-free preparation is
available for teething pain in babies. Apply
to
gums by rubbing gel on with fingers or
cotton swab.
● Throat Spray: Ensure that gag reflex is
intact before allowing patient to drink or
eat.
Patient/Family Teaching
● Instruct patient on correct application
technique. High Alert: Inform patient of
potential harm from overuse. Emphasize
need to avoid contact with eyes.
● Caution patient that these agents should
not be applied for prolonged periods or to
large areas, especially if skin is abraded or
broken, without consulting health care
professional. Patient should also consult
health care professional before using
these agents for conditions other than
indicated.
● Advise patient to discontinue use and
notify health care professional if erythema,
rash, or irritation at site of administration
occurs; area becomes infected; medication
is swallowed; or condition worsens or does
not improve within 7 days.
● Caution patient to read list of active
ingredients on OTC products. Brand names
frequently change and may be misleading
as to actual contents.
● Advise adults using liquid form around the
mouth to avoid smoking until solution
is dry.
● Teething Gel: Instruct patients to notify
health care professional if pain is excessive
or prolonged. Advise parents to avoid
feeding immediately after application to
prevent choking from diminished gag reflex.
● Lozenge: Instruct patient to suck on
lozenge and allow it to slowly dissolve.
Consult health care professional if throat
pain persists more than 2 days. Avoid use in
young children because of danger of
choking
Evaluation/Desired Outcomes
● Temporary relief of discomfort associated
with minor irritations of skin or mucous
membranes.
● Temporary local anesthesia of mucosal
surfaces.
2.CLASSIFICATION:
HEMORRHOIDS
GENERIC NAME: Hydrocortisone
acetate 10 mg
BRAND NAME: Anusol-HC
RECOMMENDED DOSAGE, ROUTE, AND
FREQUENCY
Route/Dosage
PO (Adults and Children 12 yr): 20– 240
mg/day in 1– 4 divided doses.
PO (Children): Physiologic replacement—
0.5– 0.75 mg/kg/day or 20– 25 mg/
m2
/day divided q 6 hr. Anti-inflammatory or
immunosuppressive—2.5– 10 mg/
kg/day or 75– 300 mg/m2
/day in 3– 4 divided doses.
PO (Neonates): Congenital adrenal
hyperplasia—10– 20 mg/m2
/day in 3 divided doses.
PO, IV (Neonates): Refractory hypoglycemia
—5 mg/kg/day divided q 8– 12 hr
or 1– 2 mg/kg/dose q 6 hr.
Rect (Adults): Retention enema—100 mg
nightly for 21 days or until remission
occurs.
IM, IV (Adults): 100– 500 mg q 2– 6 hr
(range 100– 8000 mg/day).
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IM, IV (Children and Infants): Adrenocortical
insufficiency—1– 2 mg/kg/
dose bolus, then 25– 250 mg/day in divided
doses q 6– 8 hr. Anti-inflammatory or
immunosuppressive—1– 5 mg/kg/day or
30– 150 mg/m2
/day divided q 12– 24
hr; Physiologic replacement—0.25– 0.35
mg/kg/day or 12– 15 mg/m2
/day once
daily;Shock—50 mg/kg bolus then 50 mg/kg
as a 24 hr infusion.
DRUG ACTION
In pharmacologic doses, suppresses
inflammation and the normal immune
response. Has numerous intense metabolic
effects (see Adverse Reactions and Side
Effects). Suppresses adrenal function at
chronic doses of 20 mg/day. Replaces
endogenous cortisol in deficiency states.
Also has potent mineralocorticoid
(sodium-retaining) activity. Therapeutic
Effects: Replacement therapy in adrenal
insufficiency. Suppression of inflammation
and modification of the normal immune
response.
Absorption: Well absorbed following oral
administration. Sodium succinate salt is
rapidly absorbed following IM administration.
Absorption from local sites (intra-articular,
intralesional) is slow but complete.
Distribution: Widely distributed, crosses the
placenta, and probably enters breast
Milk.
disorders including: Inflammatory, Allergic,
Hematologic, Neoplastic, Autoimmune
disorders, Septic shock.
CONTRAINDCIATIONS
Active untreated infections (may be used in
patients being
treated for tuberculous meningitis or septic
shock); Lactation: Avoid chronic use;
Known alcohol, bisulfite, or tartrazine
hypersensitivity or intolerance (some
products
contain these and should be avoided in
susceptible patients).
Use Cautiously in: Chronic treatment (will
lead to adrenal suppression; use lowest
possible dose for shortest period of time);
Pedi: Chronic use will result inp
growth; use lowest possible dose for
shortest period of time; Hypothyroidism;
Cirrhosis; Ulcerative colitis; Stress (surgery,
infections); supplemental doses may be
needed; Potential infections may mask signs
(fever, inflammation); OB: Safety not
established.
SIDE EFFECTS/ADVERSE REACTIONS
Side Effects
Adverse reactions/side effects are much
more common with high-dose/long-term
therapy CNS: depression, euphoria,
headache, increase intracranial pressure
(children only), personality changes,
psychoses, restlessness.
EENT: cataracts, increase intraocular

INTERACTIONS Adverse Effects

In pharmacologic doses, suppresses Body as a Whole: Hypersensitivity or
inflammation and the normal immune anaphylactoid reactions; aggravation or
response. Has numerous intense metabolic masking of infections; malaise, weight gain,
effects (see Adverse Reactions and Side obesity; urogenital urinary frequency and
Effects). Suppresses adrenal function at urgency, enuresis increased or decreased
chronic doses of 20 mg/day. Replaces motility and number of sperm. CNS: Vertigo,
endogenous cortisol in deficiency states. headache, nystagmus, ataxia (rare),
Also has potent mineralocorticoid increased intracranial pressure with
(sodium-retaining) activity. Therapeutic papilledema (usually after discontinuation of
Effects: Replacement therapy in adrenal medication), mental disturbances,
insufficiency. Suppression of inflammation aggravation of preexisting psychiatric
and modification of the normal immune conditions, insomnia, anxiety, mental
response. suppress adrenal function, may confusion, depression.
decrease antibody response to and increase CV: Syncopal episodes, thrombophlebitis,
risk of adverse reactions from live-virus thromboembolism or fat embolism,
vaccines. palpitation, tachycardia, necrotizing angiitis,
CHF, hypertension edema. Endocrine:
INDICATIONS Suppressed linear growth in children,
Management of adrenocortical insufficiency; decreased glucose tolerance;
chronic use in other situations is limited hyperglycemia, manifestations of latent
because of mineralocorticoid activity. Used diabetes mellitus; hypocorticism;
systemically and locally in a wide variety of amenorrhea and other menstrual difficulties

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moonfacies. GI: Cramping, bleeding. Special
Senses: Posterior subcapsular cataracts
(especially in children), glaucoma,
exophthalmos, increased intraocular
pressure with optic nerve damage,
perforation of the globe, fungal infection of
the cornea, decreased or blurred vision.
Metabolic: Hypocalcemia; sodium and fluid
retention; hypokalemia and hypokalemic
alkalosis decreased serum concentration of
vitamins A and C; hyperglycemia,
hypernatremia.
NURSING RESPONSIBILITIES
Assessment
● Indicated for many conditions. Assess
involved systems prior to and periodically
during therapy.
● Assess patient for signs of adrenal
insufficiency (hypotension, weight loss,
weakness, nausea, vomiting, anorexia,
lethargy, confusion, restlessness) prior to
and
periodically during therapy.
● Monitor intake and output ratios and daily
weights. Observe patient for peripheral
edema, steady weight gain, rales/crackles,
or dyspnea. Notify health care professional
should these occur.
● Children should have periodic evaluations
of growth.
● Rect: Assess symptoms of ulcerative
colitis (diarrhea, bleeding, weight loss,
anorexia, fever, leukocytosis) periodically
during therapy.
● Lab Test Considerations: Systemic—
Monitor serum electrolytes and glucose.
May cause hyperglycemia, especially in
persons with diabetes. May cause
hypokalemia. Monitor hematologic values,
serum electrolytes, and serum and urine
glucose routinely in patients on prolonged
therapy. May cause decrease WBC counts.
Potential Nursing Diagnoses
Risk for infection (Side Effects)
Disturbed body image (Side Effects)
Implementation
● Do not confuse hydrocortisone with
hydrocodone. Do not confuse SoluCortef
with Solu-Medrol (methylprednisolone).
● If dose is ordered daily or every other day,
administer in the morning to coincide
with the body’s normal secretion of cortisol.
● Periods of stress, such as surgery, may
require supplemental systemic
corticosteroids.
● PO: Administer
Patient/Family Teaching
● Instruct patient on correct technique of
medication administration. Advise patient
to take medication as directed. Take missed
doses as soon as remembered unless
almost time for next dose. Do not double
doses. Stopping the medication suddenly
Evaluation/Desired Outcomes
● Decrease in presenting symptoms with
minimal systemic side effects.
● Suppression of the inflammatory and
immune responses in autoimmune
disorders, allergic reactions, and neoplasms.
● Management of symptoms in adrenal
insufficiency.
● Improvement in symptoms of ulcerative
colitis. Clinical symptoms usually improve
in 3– 5 days. Mucosal appearance may
require 2– 3 mo to improve.
C.LACTATION
CLASSIFICATION: LACTATION
SUPPRESSANTS
GENERIC NAME: Bromocriptine
mesylate
BRAND NAME: Parlodel
RECOMMENDED DOSAGE, ROUTE, AND
FREQUENCY
Amenorrhea or Galactorrhea, Female
Infertility
Adult: PO 1.25–2.5 mg/d (max: 2.5 mg 2–3
times/d)
Suppression of Postpartum Lactation
Adult: PO 2.5 mg b.i.d. starting at least 4 h
after delivery for 14–21 d
Parkinson's Disease
Adult: PO 1.25–2.5 mg/d (max: 100 mg/d in
divided doses)
Acromegaly
Adult: PO 1.25–2.5 mg/d for 3 d, then
increase by 1.25–2.5 mg q3–7d until desired
effect is achieved, usually 30–60 mg/d in
divided doses
Absorption: Approximately 28% absorbed
from GI tract.
(Peak: 1–2 h. Duration: 4–8 h.)
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Metabolism: Metabolized in liver.
Elimination: 85% excreted in feces in 5 d; 3– Adverse Effects
6% eliminated in urine. Body as a Whole: Mostly dose related.
Half-Life: 50 h CNS: Headache, dizziness, vertigo, light-
headedness, fainting, sedation, nightmares,
DRUG ACTION insomnia, dyskinesia, ataxia; mania,
Activates dopamine receptors in the CNS. nervousness, anxiety, depression.
Decreases prolactin secretion. Therapeutic CV: Orthostatic hypotension, shock,
Effects: Relief of rigidity and tremor in postpartum hypertension, palpitation,
parkinsonism. Restoration of fertility in extrasystoles, Raynaud's phenomenon, red,
hyperprolactinemia. Decreased growth tender, hot, edematous extremities
hormone in acromegaly. (erythromelalgia), exacerbation of angina,
arrhythmias, acute MI.
INTERACTIONS Special Senses: Blurred vision, burning
sensation in eyes, blepharospasm, diplopia.
GI: Nausea, vomiting, abdominal cramps,
Drug: Possibility of decreased tolerance to epigastric pain, constipation (long-term use)
alcohol; ANTIHYPERTENSIVE AGENTS or diarrhea; metallic taste, dry mouth,
add to hypotensive effects; ORAL dysphagia, anorexia, peptic ulcers. Skin:
CONTRACEPTIVES, estrogen, progestins Urticaria, rash, mottling, livedo reticularis.
may interfere with effect of bromocriptine by Other: Fatigue, nasal congestion, asthenia.
causing amenorrhea and galactorrhea;
PHENOTHIAZINES, TRICYCLIC NURSING RESPONSIBILITIES
ANTIDEPRESSANTS, methyldopa,
reserpine can cause an increase in Examination and Evaluation
prolactin, which may interfere with
bromocriptine activity. Monitor cardiac symptoms at rest and during
exercise. Seek immediate medical
INDICATIONS assistance if symptoms of MI develop,
Adjunct to levodopa in the treatment of including sudden chest pain, pain radiating
parkinsonism. Treatment of into the arm or jaw, shortness of breath,
hyperprolactinemia dizziness, sweating, anxiety, and nausea.
(amenorrhea/galactorrhea), including
associated female infertility. Treatment of
acromegaly. Assess patient's motor function to help
determine antiparkinson effects, especially
CONTRAINDCIATIONS when starting drug therapy, or during dosing
Hypersensitivity to ergot alkaloids; changes or addition of other antiparkinson
uncontrolled hypertension; severe ischemic drugs. Motor function should be assessed at
heart disease or peripheral vascular different times of the day, such as when
disease; pituitary tumor; normal prolactin drugs are reaching peak therapeutic levels
levels, lactation. Safe use during pregnancy (i.e., 1–2 hr after oral dose), as well as when
(category C) or in children <15 y is not drug effects are minimal (just before the next
established. dose).

SIDE EFFECTS/ADVERSE REACTIONS

Document increased side effects such as

Side Effects
involuntary movements (dyskinesias) or
CNS: dizziness, confusion, drowsiness,
fluctuations in response (on-off
hallucinations, headache, insomnia,
phenomenon, end-of-dose akinesia). Notify
nightmares.
physician because increased side effects
EENT: burning eyes, nasal stuffiness, visual
might require dose adjustment or a change
disturbances.
in medication regimen.
Resp: effusions, pulmonary infiltrates.
CV: MI, hypotension.
GI: nausea, abdominal pain, anorexia, dry
mouth, metallic taste, vomiting. Derm: Assess dizziness and drowsiness that might
urticaria. affect gait, balance, and other functional
MS: leg cramps. activities (See Appendix C). Report balance
Misc: digital vasospasm (acromegaly only). problems and functional limitations to the

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physician, and caution the patient and
family/caregivers to guard against falls and
trauma.
Monitor confusion, hallucinations, and other
psychologic problems. Repeated or
excessive symptoms may require change in
dose or medication.
Assess blood pressure (BP) periodically and
compare to normal values (See Appendix
F). Report low BP (hypotension), especially
if patient experiences increased dizziness,
syncope, or other symptoms.
Monitor respiratory function at rest and
during exercise. Notify physician if patient
experiences signs of pulmonary infiltrates or
effusion, including cough, shortness of
breath, chest pain, or labored breathing.
If used to treat acromegaly, periodically
assess body weight and other
anthropometric measures (body mass index,
limb circumferences) to help document
whether drug therapy is effective in reducing
the effects of increased growth hormone.
D.DRUGS THAT PROMOTE
BOWEL FUNCTION 7 diarrhea.
ANTIFLATUELENTS
1.CLASSIFICATION: STOOL
SOFTENERS
GENERIC NAME: Docusate sodium
BRAND NAME: Colace
RECOMMENDED DOSAGE, ROUTE, AND
FREQUENCY
PO (Adults and Children 12 yr): 2 tablets
once daily at bedtime; maximum 4
tablets twice daily.
PO (Children 6– 12 yr): 1 tablet once daily at
bedtime; maximum: 2 tablets twice
daily.
PO (Children 2– 6 yr): 1/2 tablet once daily
at bedtime; maximum: 1 tablet twice
daily.
Absorption: Docusate: small amounts may
be absorbed from the small intestine
after oral administration.
Distribution: Unknown.
Metabolism and Excretion: Senna:
metabolized in the liver and eliminated in
bile and urine. Docusate: eliminated in bile.
DRUG ACTION
Senna’s metabolite acts as a local irritant on
the colon stimulating peristalsis. Docusate
promotes incorporation of water into stool,
resulting in softer fecal mass. Therapeutic
Effects: Softening and passage of stool.
INTERACTIONS
Drug-Drug: None significant
INDICATIONS
PO: Treatment of constipation associated
with dry, hard stools and decreased
intestinal motility. Prevention of opioid-
induced constipation.
CONTRAINDCIATIONS
Hypersensitivity; Abdominal pain, nausea, or
vomiting, especially when associated with
fever or other signs of an acute abdomen;
Concomitant
use of mineral oil
SIDE EFFECTS/ADVERSE REACTIONS
Side Effects
F and E: electrolyte imbalances,
dehydration.
GI: abdominal cramps, nausea, vomiting,
Adverse Effects
GI: Occasional mild abdominal cramps,
diarrhea, nausea, bitter taste. Other: Throat
irritation (liquid preparation), rash.
NURSING RESPONSIBILITIES
Assessment
● Assess for abdominal distention, presence
of bowel sounds, and usual pattern of
bowel function.
● Assess color, consistency, and amount of
stool produced.
Potential Nursing Diagnoses
Constipation (Indications)
Implementation
● This medication does stimulate intestinal
peristalsis.
● PO: Administer with a full glass of water or
juice preferably in the evening.
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● Do not administer within 2 hr of other liver.
laxatives, especially mineral oil. May cause
increased absorption. INTERACTIONS
Drug-Drug: Antacids, histamine H2-receptor
Patient/Family Teaching antagonists, and gastric acid–
● Advise patients that laxatives should be pump inhibitors may remove enteric coating
used only for short-term therapy. Longterm of tablets resulting in gastric
therapy may cause electrolyte imbalance irritation/dyspepsia. May decrease the
and dependence. absorption of other orally administered drugs
● Encourage patients to use other forms of because
bowel regulation, such as increasing of increase motility and decrease transit time
bulk in the diet, increasing fluid intake (6– 8
full glasses/day), and increasing mo-bility. Drug-Food: Milk may remove enteric coating
Normal bowel habits are variable and may of tablets, resulting in gastric
vary from 3 times/day to 3 times/ irritation/dyspepsia.
wk.
● Instruct patients with cardiac disease to INDICATIONS
avoid straining during bowel movements Treatment of constipation. Evacuation of the
(Valsalva maneuver). bowel before radiologic studies or surgery.
● Advise patient not to use laxatives when Part of a bowel regimen in spinal cord injury
abdominal pain, nausea, vomiting, or fever patients.
is present.
CONTRAINDCIATIONS
Evaluation/Desired Outcomes Hypersensitivity; Abdominal pain;
● A soft, formed bowel movement, usually Obstruction; Nausea or
within 6– 24 hr.
vomiting (especially with fever or other signs
of an acute abdomen).
2. CLASSIFICATION:LAXATIVES
GENERIC NAME: Bisacodyl Use Cautiously in: Severe cardiovascular
BRAND NAME: Dulcolax disease; Anal or rectal fissures; Excess
or prolonged use (may result in
dependence); OB, Lactation: May be used
RECOMMENDED DOSAGE, ROUTE, AND during
FREQUENCY pregnancy and lactation.
PO (Adults and Children 12 yr): 5– 15
mg/day (up to 30 mg/day) as a single SIDE EFFECTS/ADVERSE REACTIONS
dose.
PO (Children 3– 11 yr): 5– 10 mg/day (0.3 Side Effects
mg/kg) as a single dose. GI: abdominal cramps, nausea, diarrhea,
Rect (Adults and Children 12 yr): 10 mg/day rectal burning.
single dose. F and E: hypokalemia
Rect (Children 2– 11 yr): 5– 10 mg/day (with chronic use). MS: muscle weakness
single dose. (with chronic use).
Rect (Children 2 yr): 5 mg/day single dose. Misc: protein-losing
enteropathy, tetany (with chronic use).

Adverse Effects
DRUG ACTION Systemic effects not reported. Mild
Stimulates peristalsis. Alters fluid and cramping, nausea, diarrhea, fluid and
electrolyte transport, producing fluid electrolyte disturbances .(especially
accumulation in the colon. Therapeutic potassium and calcium).
Effects: Evacuation of the colon.
Absorption: Variable absorption follows oral NURSING RESPONSIBILITIES
administration; rectal absorption is
minimal; action is local in the colon.
Distribution: Small amounts of metabolites NURSING INTERVENTION
excreted in breast milk.
Metabolism and Excretion: Small amounts
absorbed are metabolized by the Assessment

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● Assess patient for abdominal distention,
presence of bowel sounds, and usual
pattern of bowel function.
● Assess color, consistency, and amount of
stool produced.
Potential Nursing Diagnoses
Constipation (Indications)
Implementation
● Do not confuse Dulcolax (bisacodyl) with
Dulcolax (docusate sodium).
● May be administered at bedtime for
morning results.
● PO: Taking on an empty stomach will
produce more rapid results.
● Do not crush or chew enteric-coated
tablets. Take with a full glass of water or
juice.
● Do not administer oral doses within 1 hr of
milk or antacids; this may lead to premature
dissolution of tablet and gastric or duodenal
irritation
● Rect: Suppository or enema can be given
at the time a bowel movement is desired.
Lubricate suppositories with water or water-
soluble lubricant before insertion.
Encourage patient to retain the suppository
or enema 15– 30 min before expelling.
Patient/Family Teaching
● Advise patients, other than those with
spinal cord injuries, that laxatives should be
used only for short-term therapy. Prolonged
therapy may cause electrolyte imbalance
and dependence.
● Advise patient to increase fluid intake to at
least 1500– 2000 mL/day during therapy to
prevent dehydration.
● Encourage patients to use other forms of
bowel regulation (increasing bulk in the
diet, increasing fluid intake, or increasing
mobility). Normal bowel habits may
vary from 3 times/day to 3 times/wk.
● Instruct patients with cardiac disease to
avoid straining during bowel movements
(Valsalva maneuver).
● Advise patient that bisacodyl should not
be used when constipation is accompanied
by abdominal pain, fever, nausea, or
vomiting.
Evaluation/Desired Outcomes
● Soft, formed bowel movement when used
for constipation.
● Evacuation of colon before surgery or
radiologic studies, or for patients with spinal
cord injuries.
3. CLASSIFICATION:
ANTIFLATULENTS
GENERIC NAME: Simethicone
BRAND NAME: Gas-X Chewable
tabs
RECOMMENDED DOSAGE, ROUTE, AND
FREQUENCY
PO (Adults): 40– 125 mg qid, after meals
and at bedtime (up to 500 mg/day).
PO (Children 2– 12 yr): 40 mg 4 times daily.
PO (Children 2 yr): 20 mg 4 times daily (up
to 240 mg/day).
Absorption: No systemic absorption occurs.
Distribution: Not systemically distributed.
Metabolism and Excretion: Excreted
unchanged in the feces.
DRUG ACTION
Causes the coalescence of gas bubbles.
Does not prevent the formation of gas.
Therapeutic Effects: Passage of gas through
the GI tract by belching or passing flatus
INTERACTIONS
Drug-Drug: None significant.
INDICATIONS
Relief of painful symptoms of excess gas in
the GI tract that may occur postoperatively
or as a consequence of: Air swallowing,
Dyspepsia, Peptic ulcer, Diverticulitis.
CONTRAINDCIATIONS
Contraindicated in: Not recommended for
infant colic.
Use Cautiously in: Abdominal pain of
unknown cause, especially when
accompanied by fever;OB: Lactation: Has
been used safely.
SIDE EFFECTS/ADVERSE REACTIONS
None significant.
NURSING RESPONSIBILITIES
Assessment
● Assess patient for abdominal pain,
distention, and bowel sounds prior to and
periodically throughout course of therapy.
Frequency of belching and passage of flatus
should also be assessed.
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Potential Nursing Diagnoses
Acute pain (Indications)
Implementation
● PO: Administer after meals and at bedtime
for best results. Shake liquid preparations
well prior to administration. Chewable
tablets should be chewed thoroughly
before swallowing, for faster and more
complete results.
● Drops can be mixed with 30 mL of cool
water, infant formula, or other liquid as
directed. Shake well before using
Patient/Family Teaching
● Explain to patient the importance of diet
and exercise in the prevention of gas. Also
explain that this medication does not prevent
the formation of gas.
● Advise patient to notify health care
professional if symptoms are persistent.
Evaluation/Desired Outcomes
● Decrease in abdominal distention and
discomfort.
E. IMMUNIZATION TO THE
MOTHER
1. CLASSIFICATION: IMMUNE
GLOBULI
GENERIC NAME: Human D Rho(D)-positive fetus, Transfusion of
Immune Globulin
BRAND NAME: RhoGAM, Rho (D)
RECOMMENDED DOSAGE, ROUTE, AND
FREQUENCY
Dosage, Route & Frequency
(Recommended):
Rho(D) Immune Globulin (for IM use only)
Following Delivery
IM (Adults): HyperRHO S/D Full Dose,
RhoGAM—1 vial standard dose (300 mcg)
within 72 hr of delivery.
Before Delivery
IM (Adults): HyperRHO S/D Full Dose,
RhoGAM—1 vial standard dose (300 mcg)
at 26– 28 wk.Termination of Pregnancy (13
wk Gestation)
IM (Adults): HyperRHO S/D Mini-Dose,
MICRhoGAM—1 vial of microdose (50
mcg) within 72 hr.
DRUG ACTION
Prevent production of anti-Rho(D) antibodies
in Rho(D)-negative patients who were
exposed to Rho(D)-positive blood. Increase
platelet counts in patients with ITP.
Therapeutic Effects: Prevention of antibody
response and hemolytic disease of
the newborn (erythroblastosis fetalis) in
future pregnancies of women who have
conceived a Rho(D)-positive fetus.
Prevention of Rho(D) sensitization following
transfusion accident. Decreased bleeding in
patients with ITP.
Absorption: Completely absorbed with IV
administration. Well absorbed from IM
sites.
Distribution: Unknown.
Metabolism and Excretion: Unknown.
Half-life:approximately 25– 30 days
INTERACTIONS
May decrease antibody response to some
live-virus vaccines (measles, mumps,
rubella).
INDICATIONS
IM, IV: Administered to Rho(D)-negative
patients who have been exposed to Rho(D)-
positive blood by: Pregnancy or delivery of a
Rho(D)-positive infant, Abortion of a
Rho(D)-positive fetus, Fetal-maternal
hemorrhage due to amniocentesis, other
obstetrical manipulative procedure, or intra-
abdominal trauma while carrying a
Rho(D)-positive blood or blood products to a
Rho(D)-negative patient. IV Management of
immune thrombocytopenic purpura
(ITP).
CONTRAINDCIATIONS
Prior hypersensitivity reaction to human
immune globulin;
Rho(D)- or Du-positive patients.
Use Cautiously in: ITP patients with pre-
existing anemia (decrease dose if Hgb
10 g/dL). May also cause disseminated
intravascular coagulation in ITP patients.
SIDE EFFECTS/ADVERSE REACTIONS
Side Effects
CNS: dizziness, headache.
CV: hypertension, hypotension.
Derm: rash.
GI: diarrhea, nausea, vomiting.
GU: acute renal failure.
Hemat: ITP—DISSEMINATED
INTRAVASCULAR COAGULATION,
INTRAVASCULAR HEMOLYSIS, anemia.
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MS: arthralgia, myalgia. Local: pain at
injection site.
Misc: fever.
Adverse Effects
Body as a Whole: Injection site irritation,
slight fever, myalgia, lethargy.
NURSING RESPONSIBILITIES
Assessment
● IV: Assess vital signs periodically during
therapy in patients receiving IV Rho(D)
immune globulin.
● ITP: Monitor patient for signs and
symptoms of intravascular hemolysis
(IVH) (back pain, shaking chills, fever,
hemoglobinuria), anemia, and
renal insufficiency. If transfusions are
required, use Rho(D)-negative
packed red blood cells to prevent
exacerbation of IVH.
● Lab Test Considerations: Pregnancy:
Type and crossmatch of mother and
newborn’s cord blood must be performed to
determine need for medication.
Mother must be Rho(D)-negative and Du-
negative. Infant must be Rho(D)-positive. If
there is doubt regarding infant’s blood type
or if father is Rho(D)-positive,
medication should be given.
● An infant born to a woman treated with
Rho(D) immune globulin antepartum may
have a weakly positive direct Coombs’ test
result on cord or infant blood.
● ITP: Monitor platelet counts, RBC counts,
hemoglobin, and reticulocyte levels to
determine effectiveness of therapy.
Potential Nursing Diagnoses
Deficient knowledge, related to medication
regimen (Patient/Family Teaching)
Implementation
● Do not give to infant, to Rho(D)-positive
individual, or to Rho(D)-negative individual
previously sensitized to the Rho(D) antigen.
However, there is no more risk
than when given to a woman who is not
sensitized. When in doubt, administer
Rho(D) immune globulin.
● Do not confuse IM and IV formulations. Rh
immune globulin for IV administration
is labelled ‘Rh Immune Globulin
Intravenous.’ Rh Immune Globulin
Intravenous
may be given IM; however, Rh Immune
Globulin (microdose and standard dose)
is for IM use only and cannot be given IV.
● When using prefilled syringes, allow
solution to reach room temperature before
administration.
● IM: Reconstitute Rho(D) immune globulin
IV for IM use immediately before use
with 1.25 mL of 0.9% NaCl. Inject diluent
onto inside wall of vial and wet pellet by
gently swirling until dissolved. Do not shake.
● Administer into the deltoid muscle. Dose
should be given within 3 hr but may be
given up to 72 hr after delivery, miscarriage,
abortion, or transfusion.
IV Administration
● pH: 6.5– 7.6.
● Direct IV: Reconstitute Rho(D) immune
globulin IV for IV administration immediately
before use with 2.5 mL of 0.9% NaCl. Inject
diluent onto inside wall of vial and wet pellet
by gently swirling until dissolved. Do not
shake. Rate: Administer
over 3– 5 min.
Patient/Family Teaching
● Pregnancy: Explain to patient that the
purpose of this medication is to protect
future Rho(D)-positive infants.
● ITP: Explain purpose of medication to
patient.
Evaluation/Desired Outcomes
● Prevention of erythroblastosis fetalis in
future Rho(D)-positive infants.
● Prevention of Rho(D) sensitization
following incompatible transfusion.
● Decreased bleeding episodes in patients
with ITP.
2. CLASSIFICATION: VACCINE
GENERIC NAME: Rubella Virus
Vaccine
BRAND NAME:
RECOMMENDED DOSAGE, ROUTE, AND
FREQUENCY
Primary Immunodeficiency Disorder
Subcut (Adults and Children): Dose is
administered 1 wk after IGIV dose. Dose is
determined by multiplying previous IGIV
dose by 1.37, then divide into weekly doses
based on frequency of previous treatment.
Recommended dose is 100– 200 mg/kg/
wk.
IV (Adults and Children): 300– 600 mg (3– 6
mL)/kg q 3– 4 wk.
Hepatitis A Prophylaxis (IM)
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IM (Adults and Children): 0.02 mL/kg (for
pre-exposure prophylaxis, higher
doses— 0.06 mL/kg q 4– 6 mo are used if
exposure will last 3 mo).
Measles Prophylaxis (IM)
IM (Adults and Children): 0.25 mL/kg (0.5
mL/kg if immunosuppressed; not to
exceed 15 mL).
Immunoglobulin Deficiency (IM)
IM (Adults and Children): 1.3 mL/kg initially,
then 0.66 mL/kg q 3– 4 wk.
Varicella (IM)
IM (Adults and Children): 0.6– 1.2 mL/kg if
varicella zoster immune globulin is
unavailable.
Rubella (IM)
IM (Adults and Children): 0.55 mL/kg.
Immunodeficiency (IV)
IV (Adults and Children): 200– 800 mg (4– 8
mL)/kg monthly; if response is inadequate,
may be given twice monthly.
infections in patients with B-cell chronic
lymphocytic leukemia (Gammagard S/D
only). Prevention of bacterial infections in
children infected with HIV. Treatment of
idiopathic thrombocytopenic purpura
(Carimune NF, Gammagard S/D, and
Gamunex-C). Treatment of Kawasaki
syndrome (Iveegam EN and Gammagard
SD). Treatment of chronic inflammatory
demyelinating polyneuropathy (Gamunex—
C only).
CONTRAINDCIATIONS
Hypersensitivity to immune globulins or
additives (maltose,
thimerosal, glycine, polyethylene glycol,
albumin); Selective IgA deficiency; IgE
mediated antibodies to IgA.
SIDE EFFECTS/ADVERSE REACTIONS

Side Effects
DRUG ACTION CNS: aseptic meningitis syndrome,
A human serum fraction containing gamma headache, lightheadedness, malaise.
globulin antibodies (IgG). Therapeutic Resp: dyspnea, wheezing.
Effects: Provision of passive immunity CV: THROMBOEMBOLIC EVENTS, chest
against many infections. Decreased pain, vascular occlusion.
consequences of idiopathic thrombopenia GI: nausea. GU: RENAL FAILURE, diuresis
purpura. Decreased incidence of coronary (maltose containing-products), nephrotic
artery damage in Kawasaki syndrome. syndrome.
Improvement in symptoms of chronic Derm: cyanosis, urticaria. Local: at Subcut
inflammatory demyelinating polyneuropathy. or
Absorption: IV administration results in IM site—muscle stiffness, pain, tenderness
complete bioavailability. Well absorbed at IV site, local inflammation, phlebitis,
following IM administration; 73% urticaria.
bioavailable following Subcut administration. Hemat: hemolytic anemia.
Distribution: Rapidly and evenly distributed. MS: arthralgia, back pain, hip pain.
Metabolism and Excretion: Removed by Misc: allergic reactions including
redistribution, tissue binding, and ANAPHYLAXIS, angioedema, chills, fever,
catabolism. sweating.
Half-life: 21– 24 days
Adverse Effects
INTERACTIONS Body As A Whole
Drug-Drug: May interfere with the immune Panniculitis; atypical measles; fever;
response to some live-virus vaccines, syncope; headache; dizziness; malaise;
including measles, mumps, and rubella virus irritability.
vaccine (do not administer Cardiovascular System
within 3 mo of immune globulin) Vasculitis.
Digestive System
INDICATIONS Pancreatitis; diarrhea; vomiting; parotitis;
nausea.
IM: Provides passive immunity to a variety of Endocrine System
infections including: Hepatitis A, Measles Diabetes mellitus.
(rubeola) when immune sera are unavailable Hemic And Lymphatic System
or when there is insufficient time Thrombocytopenia (see WARNINGS,
for active immunization to take place. IV Thrombocytopenia); purpura; regional
Useful in patients with immunodeficiency lymphadenopathy; leukocytosis.
syndromes who are unable to produce IgG- Immune System
type antibodies. Prevention of bacterial

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Anaphylaxis and anaphylactoid reactions
have been reported as well as related
phenomena such as angioneurotic edema
(including peripheral or facial edema) and
bronchial spasm in individuals with or
without an allergic history.
Musculoskeletal System
Arthritis; arthralgia; myalgia.
NURSING RESPONSIBILITIES
NURSING INTERVENTION
Assessment
● For passive immunity, determine the date
of exposure to infection.Immune globulin
should be administered within 2 wk of
exposure to hepatitis A and within 6 days
after exposure to measles.
● Monitor vital signs continuously during
infusion of immune globulin IV
and assess patient for signs of anaphylaxis
(hypotension, flushing, chest
tightness, wheezing, fever, dizziness,
nausea, vomiting, diaphoresis)
for 1 hr following initiation of infusion.
Epinephrine and antihistamines
should be available for treatment of
anaphylactic reactions.
● Assess patient for aseptic meningitis
syndrome (AMS). Occurs infrequently,
usually within several hrs to two days of
treatment. Symptoms include severe
headache, nuchal rigidity, drowsiness, fever,
photophobia, painful eye movements,
nausea and vomiting. Patients receiving
high doses (2g/kg) are at higher risk.
Conduct a complete neurological exam with
CSF to rule out other causes of meningitis.
AMS usually resolves within several days
with discontinuation of immune
globulin.
● Leukemia: Monitor patient for signs of
infection (vital signs, WBC) during therapy.
● Lab Test Considerations: Monitor platelet
counts in patients being treated for
idiopathic thrombocytopenic purpura.
● Monitor serum IgG weekly to determine
dose of subcut product.
● Monitor renal function periodically during
therapy
Potential Nursing Diagnoses
Risk for infection (Indications)
Implementation
● Subcut: Administer in abdomen, thighs,
upper arm or lateral hip. Allow solution
to reach room temperature prior to
administration. Do not shake. May vary from
colorless to light brown, do not administer
solutions that are cloudy, contain particulate
matter, or are beyond expiration date. Inject
air into vial equivalent to
amount of solution required and withdraw
solution. Follow manufacturer’s instructions
for filling pump reservoir, priming the pump,
administration tubing,
and Y-site tubing. Administer no more than
15 mL/site. Determine location and
number of sites; sites should be at least 2
inches apart.
Patient/Family Teaching
● Explain the use and purpose of immune
globulin therapy to the patient.
● Instruct patient and parents administering
subcut immune globulin at home the
correct technique for administration and care
of equipment
● Advise patient to report symptoms of
anaphylaxis immediately.
● Inform patients that pain, tenderness, and
muscle stiffness at the injection site may
occur following IM injections of immune
globulin. These may persist for several
hours following administration.
● Instruct patient to notify health care
professional immediately if decreased urine
output, sudden weight gain, edema, or
shortness of breath occur
Evaluation/Desired Outcomes
● Prevention of certain infectious diseases
by provision of passive immunity in patients
exposed to the infections or patients with
immunodeficiency diseases.
● Increased platelet counts in patients with
idiopathic thrombocytopenic purpura.
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● Prevention of bacterial infections in Metabolism: most of iron released
patients with hypogammaglobulinemia from hemoglobin is reused in body;
associated with B-cell chronic lymphocytic small amounts are lost in
leukemia. desquamation of skin, gi mucosa,
● Improved muscle function in patients with nails, and hair; 12–30 mg/mo lost
chronic inflammatory demyelinating through menstruation
polyneuropathy (Gamunex only).
Excretion: unknown
Half life:
XVI. DRUGS FOR DEFICIENCY ANEMIAS Onset: 4 days
Peak: 7-10 days
Brand Name: Feosol Duration: 2-4 months
Generic Name: Ferrous sulfate
Classification: Drugs for Iron Deficiency
Anemia
Drug: & Drug – Food Interactions:
Drug: Antacids decrease iron
absorption; iron decreases
Recommended Drugs, Dosage & absorption of tetracyclines,
Frequency: ciprofloxacin, ofloxacin;
Iron Deficiency chloramphenicol may delay iron's
Adult: PO Sulfate (30% elemental effects; iron may decrease
iron) 750–1500 mg/d in 1–3 divided absorption of penicillamine.
doses; Fumarate (33% elemental Drug-Food: Food decreases
iron) 200 mg t.i.d. or q.i.d.; absorption of iron; ascorbic acid
Gluconate (12% elemental iron) (vitamin C) may increase iron
325–600 mg q.i.d., may be gradually absorption.
increased to 650 mg q.i.d. as needed
and tolerated Indications:
Child: :PO Sulfate (30% elemental -To correct simple iron deficiency
iron) <6 y, 75–225 mg/d in divided and to treat iron deficiency
doses; 6–12 y, 600 mg/d in divided (microcytic, hypochromic) anemias.
doses; Fumarate (33% elemental Also may be used prophylactically
iron) 3 mg/kg t.i.d.; Gluconate (12% during periods of increased iron
elemental iron) <6 y, 100–300 mg/d needs, as in infancy, childhood, and
in divided doses; 6–12 y, 100–300 pregnancy.
mg t.i.d.
Iron Supplement Contraindications:
Adult: PO Sulfate Pregnancy, 300– -Peptic ulcer, regional enteritis,
600 mg/d in divided doses; Fumarate ulcerative colitis; hemolytic anemias
200 mg once/d; Gluconate 325–600 (in absence of iron deficiency),
mg once/d hemochromatosis, hemosiderosis,
patients receiving repeated
Drug Action: transfusions, pyridoxine-responsive
-An essential mineral found in anemia; cirrhosis of liver.
hemoglobin, myoglobin, and many
enzymes. Enters the bloodstream Side Effects/ Adverse Reactions:
and is transported to the organs of CNS: dizziness, headache, syncope.
the reticuloendothelial system (liver, GI: nausea, constipation, dark stools,
spleen, bone marrow) where it epigastric pain, GI bleeding,
becomes part of iron stores. vomiting. Misc: temporary staining of
teeth (liquid preparations)
Absorption: 5–10% absorbed in
healthy individuals; 10–30% Nursing Responsibilities (ADPIE):
absorbed in iron-deficiency; food ASSESSMENT
decreases amount absorbed  Assess nutritional status and
Distribution: transported by dietary history to determine
transferring to bone marrow, where it possible cause of anemia and
is incorporated into hemoglobin; need for patient teaching.
crosses placenta

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  Assess bowel function for
constipation or diarrhea.
measures should these occur
DIAGNOSIS
 Activity intolerance
IMPLEMENTATION
 Oral preparations are most
effectively absorbed if
administered 1 hr before or 2
hr after meals. If gastric
irritation occurs, administer
with meals. Take tablets and
capsules with a full glass of
water or juice.
 Be aware that milk, eggs, or
caffeine beverages when taken
with the iron preparation may
inhibit absorption.
EVALUATION
 Increase in hemoglobin, which
may reach normal parameters
after 1– 2 mo of therapy.
Brand Name: Cobalamin
Generic Name: Cyanocobalamin Oral
Classification: Drugs for Vitamin B12
Deficiency
Absorption: oral absorption in gi tract
requires intrinsic factor and calcium
Distribution: stored in the liver and
bone marrow; crosses placenta,
enters breast milk.
Metabolism: converted in tissues to
active co-enzymes; enterohepatically
cycled
Excretion: primarily excreted
unchanged in urine.
Half life: 6 d (400 d in liver)
Drug: & Drug – Food Interactions:
Drug: Alcohol, aminosalicylic acid,
neomycin, colchicine may decrease
absorption of oral cyanocobalamin;
chloramphenicol may interfere with
therapeutic response to
cyanocobalamin.
Indications:
-Indicated for Vitamin B12
deficiency and hematologic
remission.
Contraindications:
-History of sensitivity to vitamin B12,
other cobalamins, or cobalt; early
Leber's disease (hereditary optic
nerve atrophy), indiscriminate use in
folic acid deficiency. 

Recommended Dosage, Route & Side Effects / Adverse Reactions:

Frequency: CNS: headache
Vitamin B12Deficiency CV: heart failure GI: diarrhea Derm:
PO (Adults and Children): Amount itching, swelling of the body F and E:
depends on deficiency (up to 1000 hypokalemia
mcg/day have been used). Hemat: thrombocytosis Resp:
Pernicious Anemia pulmonary edema
PO (Adults): For hematologic Misc: hypersensitivity reactions
remission only—1000– 2000 including anaphylaxis
mcg/day
NOTE: Oral products are usually not Nursing Responsibilities (ADPIE):
recommended due to poor ASSESSMENT
absorption and should be used only  Assess patient for signs of vitamin
if patient refuses the intramuscular, B12 deficiency (pallor; neuropathy;
psychosis; red, inflamed tongue)
deep subcutaneous, or intranasal before and periodically during
route of administration. therapy.
 Obtain a careful history of
Drug Action: sensitivities. Sensitization to
Necessary coenzyme for metabolic cyanocobalamin can take as long
processes, including fat and as 8 y to develop.
carbohydrate metabolism and
DIAGNOSIS
protein synthesis. Required for cell  Imbalanced nutrition less than
reproduction and hematopoiesis. body requirements

IMPLEMENTATION

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  Administer with meals to increase large amounts excreted in urine with
absorption. high doses.
 May be mixed with fruit juices.
Half life:
Administer immediately after
mixing; ascorbic acid alters Onset:
stability. Peak: 30–60 min po
 Obtain a complete diet and drug Duration:
history and inquire into alcohol
drinking patterns for all patients Drug: & Drug – Food Interactions:
receiving cyanocobalamin to
identify and correct poor habits. Drug: Chloramphenicol may
 Patients self-medicating with antagonize effects of folate therapy;
vitamin supplements should be phenytoin metabolism may be
cautioned not to exceed RDA. increased, thus decreasing its levels
Effectiveness of megadoses for in folate-deficient patients.
treatment of various medical
conditions is unproved and may
cause side effects. Indications:
-Folate deficiency, macrocytic
EVALUATION anemia, and megaloblastic anemias
 Resolution of the symptoms of associated with malabsorption
vitamin B12 deficiency. syndromes, alcoholism, primary liver
disease, inadequate dietary intake,
Brand Name: Folvite pregnancy, infancy, and childhood.
Generic Name: Folic Acid oral
Classification: Drugs for Folic Acid
Deficiency Anemia Contraindications:
-Folic acidalone for pernicious
anemia or other vitamin
Recommended Dosage, Route & B12 deficiency states; normocytic,
Frequency: refractory, aplastic, or undiagnosed
TherapeuticAdult: PO 1 mg/d anemia.
Child: :PO 1 mg/d
Maintenance Side Effects / Adverse Reactions:
Adult: PO 0.4 mg/d Abdominal cramps, diarrhea, rash,
Child: :PO <4 y, 0.3 mg/d; >4 y, 0.4 sleep disorders, irritability,
mg/d confusion, nausea, stomach upset,
Infant: PO 0.1 mg/d behavior changes, skin reactions,
seizures, gas, excitability, and other
Drug Action: side effects.
Vitamin B complex essential for
nucleoprotein synthesis and Nursing Responsibilities (ADPIE):
maintenance of normal ASSESSMENT
erythropoiesis. Acts against folic acid  Obtain a careful history of dietary
deficiency that impairs thymidylate intake and drug and alcohol usage
synthesis and results in production of prior to start of therapy. Drugs
defective DNA that leads to reported to cause folate deficiency
include oral contraceptives, alcohol,
megaloblast formation and arrest of barbiturates, methotrexate,
bone marrow maturation. phenytoin, primidone, and
trimethoprim. Folate deficiency may
Absorption: readily absorbed from also result from renal dialysis.
proximal small intestine  Keep physician informed of patient's
response to therapy.
Distribution: distributed to all body  Monitor patients on phenytoin for
tissues; high concentrations in csf; subtherapeutic plasma levels.
crosses placenta; distributed into
breast milk DIAGNOSIS
Metabolism: metabolized in liver to  Imbalanced nutrition less than
active metabolites body requirements
Excretion: small amounts eliminated
in urine in folate-deficient patients; IMPLEMENTATION

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 Remain under close medical
supervision while taking folic acid
therapy. Adjustment of maintenance
dose should be made if there is
threat of relapse.
 Do not breast feed while taking this
drug without consulting physician.
EVALUATION
 Resolution of the symptoms of
vitamin B12 deficiency.
XVI. EMERGENCY AGENTS
CLASSIFICATION: SALICYLATE
GENERIC NAME: ASPIRIN
BRAND NAME: ECOTRIN
RECOMMENDED DOSAGE,
ROUTE, AND FREQUENCY:
PAIN/FEVER
PO, Rect (Adults): 325– 1000 mg q
4– 6 hr (not to exceed 4 g/day).
Extendedrelease tablets—650 mg q
8 hr or 800 mg q 12 hr.
PO, Rect (Children 2– 11 yr): 10–
15 mg/kg/dose q 4– 6 hr; maximum
dose: 4 g/ day.
INFLAMMATION
PO (Adults): 2.4 g/day initially;
increased to maintenance dose of
3.6– 5.4 g/day in divided doses (up
to 7.8 g/day for acute rheumatic
fever).
PO (Children): 60– 100 mg/kg/day
in divided doses (up to 130
mg/kg/day for acute rheumatic
fever). Prevention of Transient
Ischemic Attacks
PO (Adults): 50– 325 mg once daily.
Prevention of Myocardial
Infarction/Antiplatelet effects
PO (Adults): 80– 325 mgonce daily
Suspected acute MI-160 mg as soon
as MI is suspected.
PO (Children): 3– 10 mg/kg/day
given once daily (round dose to a
convenient amount).
Kawasaki Disease
PO (Children): 80– 100 mg/kg/day
in 4 divided doses until fever
resolves; may be followed by
maintenance dose of 3– 5 mg/kg/day
as a single dose for up to 8 wk.
DRUG ACTION: Produce analgesia
and reduce inflammation and fever
by inhibiting the production of
prostaglandins. Decreases platelet
aggregation.
THERAPEUTIC EFFECTS:
Analgesia. Reduction of
inflammation. Reduction of fever.
Decreased incidence of transient
ischemic attacks and MI.
ABSORPTION: Well absorbed from
the upper small intestine; absorption
from enteric-coated preparations
may be unreliable; rectal absorption
is slow and variable.
DISTRIBUTION: Rapidly and widely
distributed; crosses the placenta and
enters breast milk.
METABOLISM AND EXCRETION:
Extensively metabolized by the liver;
inactive metabolites excreted by the
kidneys. Amount excreted
unchanged by the kidneys depends
on urine pH; as pH increases,
amount excreted unchanged
increases from 2– 3% up to 80%.
Half-life: 2– 3 hr for low doses; up to
15– 30 hr with larger doses because
of saturation of liver metabolism.
Indications: Inflammatory disorders
including: Rheumatoid arthritis,
Osteoarthritis.Mild tomoderate pain.
Fever. Prophylaxis of transient
ischemic attacks and MI. Unlabeled
Use: Adjunctive treatment of
Kawasaki disease.
TIME/ACTION PROFILE
(analgesia/fever reduction†)
ROUTE ONSET PEAK DURATION
PO 5–30min 1–3 hr 3–6 hr
CONTRAINDICATIONS:
Hypersensitivity to aspirin or other

Page | 222
salicylates; Cross-sensitivity with location, and intensity before and at
other NSAIDs may exist (less with the peak (see Time/Action Profile)
nonaspirin salicylates); Bleeding after administration. ● Fever: Assess
disorders or thrombocytopenia; Pedi: fever and note associated signs
May increase risk of Reye’s (diaphoresis, tachycardia, malaise,
syndrome in children or adolescents chills).
with viral infections. Use Cautiously
in: History of GI bleeding or ulcer ● Lab Test Considerations:
disease; Chronic alcohol use/ abuse; Monitor hepatic function before
Severe hepatic or renal disease; OB: antirheumatic therapy and if
Salicylates may have adverse effects symptoms of hepatotoxicity occur;
on fetus and mother and should be more likely in patients, especially
avoided during pregnancy, especially children, with rheumatic fever,
during the 3rd trimester; systemic lupus erythematosus,
Lactation:Safety not established; juvenile arthritis, or pre-existing
Geri:qrisk of adverse reactions hepatic disease. May causeqserum
especially GI bleeding; more AST, ALT, and alkaline
sensitive to toxic levels. phosphatase, especially when
plasma concentrations exceed 25
SIDE EFFECTS: mg/100 mL. May return to normal
● constipation despite continued use or dose
●diarrhea reduction. If severe abnormalities or
●headache active liver disease occurs,
●heartburn discontinue and use with caution in
●indigestion future. ● Monitor serum salicylate
●irregular heartbeat levels periodically with prolonged
●nausea or vomiting high-dose therapy to determine
dose, safety, and efficacy, especially
●numbness in children with Kawasaki disease.
●seizures
●skin rash ● Toxicity and Overdose: Monitor
for the onset of tinnitus, headache,
ADVERSE REACTIONS: hyperventilation, agitation, mental
EENT: tinnitus. GI: GI BLEEDING, confusion, lethargy, diarrhea, and
dyspepsia, epigastric distress, sweating. If these symptoms appear,
nausea, abdominal pain, anorexia, withhold medication and notify health
hepatotoxicity, vomiting. Hemat: care professional immediately
anemia, hemolysis. Derm: rash, Diagnosis
urticaria. Misc: allergic reactions
including ANAPHYLAXISand Acute pain (Indications) Impaired
LARYNGEAL EDEMA. physical mobility (Indications)

NURSING RESPONSIBILITIES: Implementation

Assessment
Patients who have asthma, allergies,
and nasal polyps or who are allergic
to tartrazine are at an increased risk
for developing hypersensitivity
reactions. ● Pain: Assess pain and
limitation of movement; note type,
● Use lowest effective dose for
shortest period of time. ● PO:
Administer after meals or with food
or an antacid to minimize gastric
irritation. Food slows but does not
alter the total amount absorbed. ●
Do not crush or chew enteric-coated

Page | 223
tablets. Do not take antacids within DRUG ACTION: Increases coronary
1– 2 hr of enteric-coated tablets. blood flow by dilating coronary
Chewable tablets may be chewed, arteries and improving collateral flow
dissolved in liquid, or swallowed to ischemic regions. Produces
whole. Some extended-release vasodilation (venous greater than
tablets may be broken or crumbled arterial). Decreases left ventricular
but must not be ground up before end-diastolic pressure and left
swallowing. See manufacturer’s ventricular end-diastolic volume
prescribing information for individual (preload). Reduces myocardial
products. oxygen consumption. Therapeutic
Effects: Relief or prevention of
Evaluation anginal attacks. Increased cardiac
Relief of mild to moderate output. Reduction of BP.
discomfort. ● Increased ease of joint Absorption: Well absorbed after
movement. May take 2– 3 wk for oral, buccal, and sublingual
maximum effectiveness. ● Reduction administration. Also absorbed
of fever. ● Prevention of transient through skin. Orally administered
ischemic attacks. ● Prevention of MI. nitroglycerin is rapidly metabolized,
leading topbioavailability.
Distribution: Unknown.
BRAND NAME: NITROSTAT Metabolism and Excretion:
GENERIC NAME: Undergoes rapid and almost
NITROGLYCERIN complete metabolism by the liver;
CLASSIFICATION: NITRATE also metabolized by enzymes in
bloodstream.
RECOMMENDED DOSAGE,
ROUTE, AND FREQUENCY: INDICATIONS: Acute (translingual,
SL (Adults): 0.3– 0.6 mg; may SL, ointment) and long-term
repeat q 5 min for 2 additional doses prophylatic (oral, transdermal)
for acute attack. Translingual management of angina pectoris. PO:
Spray(Adults): 1– 2 sprays; may be Adjunct treatment of HF. IV: Adjunct
repeated q 5 min for 2 additional treatment of acute MI. Production of
doses for acute attack. Both may controlled hypotension during
also be used prophylactically 5– 10 surgical procedures. Treatment of
min before activities that may HF associated with acute MI.
precipitate an acute attack. CONTRAINDICATIONS:
PO (Adults): 2.5– 9 mg q 8– 12 hr. Hypersensitivity; Severe anemia;
IV (Adults): 5 mcg/min;qby 5 Pericardial tamponade; Constrictive
mcg/min q 3– 5 min to 20 mcg/min; if pericarditis; Alcohol intolerance
no response, qby 10– 20 mcg/min q (large IV doses only); Concurrent
3– 5 min (dosing determined by use of PDE-5 inhibitor (sildenafil,
hemodynamic parameters; max: 200 tadalafil, vardenafil). Use Cautiously
mcg/min). Transdermal (Adults): in: Head trauma or cerebral
Ointment—1– 2 in. q 6– 8 hr. hemorrhage; Glaucoma;
Transdermal patch— 0.2– 0.4 mg/hr Hypertrophic cardiomyopathy;
initially; may titrate up to 0.4– 0.8 Severe liver impairment;
mg/hr. Patch should be worn 12– 14 Malabsorption or hypermotility (PO);
hr/day and then taken off for 10– 12 Hypovolemia (IV); Normal
hr/day orppulmonary capillary wedge
pressure (IV); Cardioversion (remove

Page | 224
transdermal patch before water for faster absorption.
procedure); OB: May compromise Sustained-release preparations
maternal/fetal circulation; Lactation: should be swallowed whole; do not
Pedi: Safety not established. break, crush, or chew. ● SL: Tablet
should be held under tongue until
SIDE EFFECTS: dissolved. Avoid eating, drinking, or
Headache, dizziness, lightheadedne smoking until tablet is dissolved. ●
ss, nausea, and flushing may occur Translingual spray: Spray
as your body adjusts to Nitrolingual under tongue. Spray
this medication. If any of these Nitromist on or under tongue.
effects persist or worsen, tell your
doctor or pharmacist promptly. Evaluation

ADVERSE REACTIONS: CNS: ● Decrease in frequency and

dizziness, headache, apprehension,
restlessness, weakness. EENT:
blurred vision. CV: hypotension,
tachycardia, syncope. GI: abdominal
pain, nausea, vomiting. Derm:
contact dermatitis (transdermal).
Misc: alcohol intoxication (large IV
doses only), cross-tolerance,
flushing, tolerance.
severity of anginal attacks. ●
Increase in activity tolerance. During
long-term therapy, tolerance may be
minimized by intermittent
administration in 12– 14 hr or 10– 12
hr off intervals. ● Controlled
hypotension during surgical
procedures. ● Treatment of HF
associated with acute MI.

NURSING RESPONSIBILITIES:
Assessment
BRAND NAME: DURAMORPH
● Assess location, duration, GENERIC NAME: MORPHINE
intensity, and precipitating factors of SULFATE
patient’s anginal pain.
● Monitor BP and pulse before and CLASSIFICATION: OPIOID
after administration. Patients RECOMMENDED DOSAGE,
receiving IV nitroglycerin require ROUTE, AND FREQUENCY:
continuous ECG and BP monitoring.
Additional hemodynamic parameters Larger doses may be required during
may be monitored. chronic therapy.
● Lab Test Considerations: May PO, Rect (Adults 50 kg): Usual
causequrine catecholamine and starting dose for moderate to severe
urine vanillylmandelic acid pain in opioid-naive patients—30 mg
concentrations. ● Excessive doses q 3– 4 hr initially or once 24-hr opioid
may causeqmethemoglobin requirement is determined, convert
concentrations. ● May cause to controlled-, extended-, or
falselyqserum cholesterol levels. sustained-release morphine by
administering total daily oral
Diagnosis morphine dose every 24 hr (as
Acute pain (Indications) Ineffective Kadian or Avinza), 50% of the total
tissue perfusion (Indications) daily oral morphine dose every 12 hr
Implementation (as Kadian, MS Contin), or 33% of
the total daily oral morphine dose
● PO: Administer dose 1 hr before or every 8 hr (as MS Contin). See
2 hr after meals with a full glass of equianalgesic chart, Appendix B.

Page | 225
Avinza dose should not exceed 1600 and absorption into the intrathecal
mg/day because of fumaric acid in space via the meninges occurs.
formulation. Distribution: Widely distributed.
Crosses the placenta; enters breast
PO, Rect (Adults and Children 50 milk in small amounts. Protein
kg): Usual starting dosefor Binding: Premature infants: 20%;
moderateto severe pain in opioid- Adults: 35%.
naive patients—0.3 mg/kg q 3– 4 hr Metabolism and Excretion: Mostly
initially. metabolized by the liver. Active
PO (Children 1 mo): Prompt- metabolites
release tablets and solution—0.2– Half-life: Premature neonates: 10–
0.5 mg/kg/ dose q 4– 6 hr as 20 hr; Neonates: 7.6 hr; Infants 1– 3
needed. Controlled-release tablet— mo: 6.2 hr; Children 6 mo– 2.5 yr:
0.3– 0.6 mg/kg/dose q 12 hr. 2.9 hr; Children 3– 6 yr: 1– 2 hr;
IM, IV, Subcut (Adults 50 kg): Children 6– 19 yr with sickle cell
Usual starting dose for moderate to disease: 1.3 hr; Adults: 2– 4 hr
severe pain in opioid-naive patients ROUTE ONSET PEAK
—4– 10 mg q 3– 4 hr. MI—8– 15 DURATION
mg, for very severe pain additional PO unknown 60 min 4–5
smaller doses may be given every hr
3– 4 hr. IM, IV, Subcut (Adults and
Children 50 kg): Usual starting dose PO-ER unknown 3–4 hr 8–
for moderate to severe pain in 24 hr
opioid-naive patients—0.05– 0.2
mg/kg q 3– 4 hr, maximum: 15 IM 10–30 min 30–60min 4–
mg/dose. 5 hr

IM, IV, Subcut (Neonates): 0.05 Subcut 20 min 50–90min 4–

mg/kg q 4– 8 hr, maximum dose: 0.1 5 hr
mg/kg. Use preservative-free Rect unknown 20–60min 3–
formulation. 7 hr
DRUG ACTION: Binds to opiate IV rapid 20 min 4–5 hr
receptors in the CNS. Alters the
perception of and response to painful Epidural 6–30 min 1 hr up to 24 hr
stimuli while producing generalized
IT rapid (min) unknown up to 24 hr.
CNS depression. Therapeutic
Effects: Decrease in severity of pain. INDICATIONS: Severe pain (the 20
Addition of naltrexone in Embeda mg/mL oral solution concentration
product is designed to prevent abuse should only be used in opioid-
or misuse by altering the formulation. tolerant patients). Management of
Naltrexone has no effect unless the moderate to severe chronic pain in
capsule is crushed or chewed. patients requiring use of a
continuous around-the-clock opioid
Absorption: Variably absorbed
analgesic for an extended period of
(about 30%) following oral
time (extended/sustained-release).
administration. More reliably
Pulmonary edema. Pain associated
absorbed from rectal, subcut, and IM
with MI.
sites. Following epidural
administration, systemic absorption

Page | 226
CONTRAINDICATIONS: blood sugar (hypoglycemia) and
Hypersensitivity; Some products monitor your blood sugar carefully if
contain tartrazine, bisulfites, or you have diabetes and use
alcohol and should be avoided in hydrazine sulfate.
patients with known hypersensitivity; Liver disease: Hydrazine sulfate
Acute, mild, intermittent, or might damage the liver. It might be
postoperative pain unsafe for people with liver disease.
(extended/sustained-release); Surgery: Since hydrazine sulfate
Significant respiratory depression might affect blood glucose levels,
(extended/sustained-release); Acute there is a concern that it might
or severe bronchial asthma interfere with blood glucose control
(extended/sustained-release); during and after surgery. Stop using
Paralytic ileus (extended/sustained- hydrazine sulfate at least 2 weeks
release). Use Cautiously in: Head before a scheduled surgery.
trauma;qintracranial pressure;
Severe renal, hepatic, or pulmonary ADVERSE REACTIONS: CNS:
disease; Hypothyroidism; Seizure confusion, sedation, dizziness,
disorder; Adrenal insufficiency; dysphoria, euphoria, floating feeling,
History of substance abuse; hallucinations, headache, unusual
Undiagnosed abdominal pain; dreams. EENT: blurred vision,
Prostatic hyperplasia; Patients diplopia, miosis. Resp:
undergoing procedures that RESPIRATORY DEPRESSION. CV:
rapidlyppain (cordotomy, radiation); hypotension, bradycardia. GI:
long-acting agents should be constipation, nausea, vomiting. GU:
discontinued 24 hr before and urinary retention. Derm: flushing,
replaced with short-acting agents; itching, sweating. Misc: physical
Geri: Geriatric or debilitated patients dependence, psychological
(dosepsuggested); OB, Lactation: dependence, tolerance
Avoid chronic use; has been used NURSING RESPONSIBILITIES:
during labor but may cause Assessment
respiratory depression in the
newborn; Pedi: Neonates and infants ● Assess type, location, and intensity
3 mo (more susceptible to of pain prior to and 1 hr following
respiratory depression); Pedi: PO, subcut, IM, and 20 min (peak)
Neonates (oral solution contains following IV administration. When
sodium benzoate which can cause titrating opioid doses, increases of
potentially fatal gasping syndrome). 25– 50% should be administered
until there is either a 50% reduction
in the patient’s pain rating on a
SIDE EFFECTS: numerical or visual analogue scale
or the patient reports satisfactory
Pregnancy and breast-feeding: pain relief. When titrating doses of
Hydrazine sulfate is POSSIBLY short-acting morphine, a repeat dose
UNSAFE for anyone, including can be safely administered at the
pregnant and breast-feeding women. time of the peak if previous dose is
It has been linked to cases of liver ineffective and side effects are
damage, seizure, coma, and death. minimal. ● Patients on a continuous
Diabetes: Hydrazine sulfate might infusion should have additional bolus
lower blood sugar levels in people doses provided every 15– 30 min, as
with diabetes. Watch for signs of low needed, for breakthrough pain. The

Page | 227
bolus dose is usually set to the
amount of drug infused each hour by
continuous infusion.
● High Alert: Assess level of
consciousness, BP, pulse, and
respirations before and periodically
during administration. If respiratory
rate is 10/min, assess level of
sedation. Physical stimulation may
be sufficient to prevent significant
hypoventilation. Subsequent doses
may need to be decreased by 25–
50%. Initial drowsiness will diminish
with continued use.Geri: Assess
geriatric patients frequently; older
adults are more sensitive to the
effects of opioid analgesics and may
experience side effects and
respiratory complications more
frequently. Pedi: Assess pediatric
patient frequently; children are more
sensitive to the effects of opioid
analgesics and may experience
respiratory complications, excitability
and restlessness more frequently.
● Lab Test Considerations:
Mayqplasma amylase and lipase
levels. ● Toxicity and Overdose: If
an opioid antagonist is required to
reverse respiratory depression or
coma, naloxone is the antidote.
Dilute the 0.4-mg ampule of
naloxone in 10 mL of 0.9% NaCl and
administer 0.5 mL (0.02 mg) by
direct IV push every 2 min. For
children and adults weighing 40 kg,
dilute 0.1 mg of naloxone in 10 mL of
0.9% NaCl for a concentration of 10
mcg/mL and administer 0.5 mcg/kg
every 2 min. Titrate dose to avoid
withdrawal, seizures, and severe
pain.
Diagnosis
Acute pain (Indications)
Chronic pain(Indications)
Risk for injury (Side Effects)
Implementation
High Alert: Do not confuse Avinza
(morphine sulfate) with Invanz
(ertapenem) or Evista (raloxifene).
Do not confuse MS Contin (morphine
sulfate) with Oxycontin (oxycodone).
Do not confuse morphine (non-
concentrated oral liquid) with
morphine (concentrated oral liquid).
● High Alert: Do not confuse
morphine with hydromorphone—
errors have resulted in death. Other
errors associated with morphine
include overdose and infusion pump
miscalculations, especially in
children. Consider patients’ previous
analgesic use and current
requirements, but clarify doses that
greatly exceed normal range. Have
second practitioner independently
check original order, dose
calculations, and infusion pump
settings. Use only preservative-free
formulations for neonates, and for
epidural and intrathecal routes in all
patients.
● PO: Doses may be administered
with food or milk to minimize GI
irritation
● Rect:MS Contin and Oramorph SR
have been administered rectally. ●
IM, Subcut: Use IM route for
repeated doses, because morphine
is irritating to subcut tissues.
Evaluation
● Decrease in severity of pain
without a significant alteration in
level of consciousness or respiratory
status. ● Decrease in symptoms of
pulmonary edema.
Page | 228
BRAND NAME: IV: Reversal of adverse muscarinic
GENERIC NAME: Atropine Sulfate effects of anticholinesterase agents
(neostigmine, physostigmine, or
CLASSIFICATION: Anticholinergic pyridostigmine). IM, IV: Treatment of
RECOMMENDED DOSAGE, anticholinesterase (organophosphate
ROUTE, AND FREQUENCY: pesticide) poisoning. Inhaln:
Treatment of exercise-induced
DRUG ACTION: Inhibits the action bronchospasm.
of acetylcholine at postganglionic
sites located in: Smooth muscle, CONTRAINDICATIONS:
Secretory glands, CNS Hypersensitivity; Angle-closure
(antimuscarinic activity). Low doses glaucoma; Acute hemorrhage;
decrease: Sweating, Salivation, Tachycardia secondary to cardiac
Respiratory secretions. Intermediate insufficiency or thyrotoxicosis;
doses result in: Mydriasis (pupillary Obstructive disease of the GI tract.
dilation), Cycloplegia (loss of visual Use Cautiously in: Intra-abdominal
accommodation), Increased heart infections; Prostatic hyperplasia;
rate. GI and GU tract motility are Chronic renal, hepatic, pulmonary, or
decreased at larger doses. cardiac disease; OB,
Therapeutic Effects: Increased heart Lactation:Safety not established; IV
rate. Decreased GI and respiratory administration may produce fetal
secretions. Reversal of muscarinic tachycardia; Pedi: Infants with Down
effects. May have a spasmolytic syndrome have increased sensitivity
action on the biliary and to cardiac effects and mydriasis.
genitourinary tracts. Children may have increased
susceptibility to adverse reactions.
Absorption: Well absorbed Exercise care when prescribing to
following subcut or IM administration. children with spastic paralysis or
brain damage;Geri: Increased
Distribution: Readily crosses the
susceptibility to adverse reactions.
blood-brain barrier. Crosses the
SIDE EFFECTS: dry mouth, blurred
placenta and enters breast milk.
vision, sensitivity to light, lack of
Metabolism and Excretion: Mostly sweating, dizziness, nausea, loss of
metabolized by the liver; 30– 50% balance, hypersensitivity reactions
excreted unchanged by the kidneys. (such as skin rash), and rapid
Half-life: Children 2 yr: 4– 10 hr; heartbeat (tachycardia).
Children 2 yr: 1.5– 3.5 hr; Adults: 4–
5 hr
ADVERSE REACTIONS:
ROUTE ONSET PEAK
DURATION CNS: drowsiness, confusion,
hyperpyrexia. EENT: blurred vision,
IM, subcut rapid 15–50min 4–6
cycloplegia, photophobia, dry eyes,
hr
mydriasis. CV: tachycardia,
IV immediate 2–4min 4–6 hr palpitations, arrhythmias. GI: dry
mouth, constipation, impaired GI
INDICATIONS: IM: Given motility. GU: urinary hesitancy,
preoperatively to decrease oral and retention, impotency.Resp:
respiratory secretions. IV: Treatment tachypnea, pulmonary edema.Misc:
of sinus bradycardia and heart block. flushing, decreased sweating.

Page | 229
NURSING RESPONSIBILITIES: Antiarrhythmic—6 mg by rapid IV
Assessment bolus; if no results, repeat 1– 2 min
later as 12-mg rapid bolus. This dose
● Assess vital signs and ECG may be repeated (single dose not to
tracings frequently during IV drug exceed 12 mg). Diagnostic use—140
therapy. Report any significant mcg/kg/min for 6 min (0.84 mg/kg
changes in heart rate or BP, or total). I
increased ventricular ectopy or V (Children 50 kg): Antiarrhythmic
angina to health care professional —0.05– 0.1 mg/kg as a rapid bolus,
promptly. ● Monitor intake and may repeat in 1– 2 min; if response
output ratios in elderly or surgical is inadequate, may increase by
patients because atropine may 0.05– 0.1 mg/kg until sinus rhythm is
cause urinary retention.● Assess established or maximum dose of 0.3
patients routinely for abdominal mg/kg is used.
distention and auscultate for bowel
sounds. If constipation becomes a DRUG ACTION: Restores normal
problem, increasing fluids and sinus rhythm by interrupting re-
adding bulk to the diet may help entrant pathways in the AV node.
alleviate constipation. ● Toxicity Slows conduction time through the
and Overdose: If overdose occurs, AV node. Also produces coronary
physostigmine is the antidote. artery vasodilation. Therapeutic
Effects: Restoration of normal sinus
Diagnosis rhythm.
Decreased cardiac output Absorption: Following IV
(Indications) Impaired oral mucous administration, absorption is
membrane (Side Effects) complete.
Constipation (Side Effects) Distribution: Taken up by
Implementation erythrocytes and vascular
endothelium.
● IM: Intense flushing of the face Metabolism and Excretion: Rapidly
and trunk may occur 15– 20 min converted to inosine and adenosine
following IM administration. In monophosphate. Half-life: 10 sec
children, this response is called
“atropine flush” and is not harmful. TIME/ACTION PROFILE
(antiarrhythmic effect)
Evaluation ROUTE ONSET PEAK
DURATION
● Increase in heart rate. ● Dryness
of mouth. ● Reversal of muscarinic IV immediate unknown
effects 1–2 min

INDICATIONS: Conversion of
paroxysmal supraventricular
BRAND NAME: Adenocard
tachycardia (PSVT) to normal sinus
GENERIC NAME: Adenosine
rhythm when vagal maneuvers are
CLASSIFICATION: Antidysrhythmic unsuccessful. As a diagnostic agent
III: Drugs that prolong Repolarization (with noninvasive techniques) to
assess myocardial perfusion defects
RECOMMENDED DOSAGE, occurring as a consequence of
ROUTE, AND FREQUENCY: coronary artery disease.
IV (Adults and Children 50 kg):

Page | 230
CONTRAINDICATIONS: (premature ventricular contractions,
Hypersensitivity; 2nd- or 3rd-degree atrial premature contractions, sinus
AV block or sick sinus syndrome, tachycardia, sinus bradycardia,
unless a functional artificial skipped beats, AV nodal block) may
pacemaker is present. Use occur, but generally last a few
Cautiously in: Patients with a seconds. ● Monitor BP during
history of asthma (may induce therapy. ● Assess respiratory status
bronchospasm); Unstable angina; (breath sounds, rate) following
OB, Lactation: Safety not administration. Patients with history
established. of asthma may experience
SIDE EFFECTS: facial flushing, bronchospasm.
difficulty breathing, chest pain, heart
attack, lightheadedness, dizziness, Diagnosis
tingling in arms, numbness, nausea, Decreased cardiac output
low blood pressure (hypotension), (Indications)
irregular heartbeat (palpitations), Implementation
chest pain, blurred vision,
burning sensation, heaviness in IV Administration ● pH: 4.5– 7.5. ●
arms, neck and back pain, IV: Crystals may occur if adenosine
metallic taste, tightness in throat, is refrigerated. Warm to room
pressure in groin, sweating, temperature to dissolve crystals.
hyperventilation. Solution must be clear before use.
ADVERSE REACTIONS: CNS: Do not administer solutions that are
apprehension, dizziness, headache, discolored or contain particulate
head pressure, light-headedness. matter. Discard unused portions. ●
EENT: blurred vision, throat Direct IV: Diluent: Administer
tightness. Resp: shortness of breath, undiluted. Concentration: 3 mg/mL.
chest pressure, hyperventilation. CV: Rate: Administer over 1– 2 seconds
facial flushing, transient arrhythmias, via peripheral IV as proximal as
chest pain, hypotension, palpitations. possible to trunk. Slow
GI: metallic taste, nausea. Derm: administration may cause increased
burning sensation, facial flushing, heart rate in response to
sweating.MS: neck and back pain. vasodilation. Follow each dose with
Neuro: numbness, tingling. Misc: 20 mL rapid saline flush to ensure
heaviness in arms, pressure injection reaches systemic
sensation in groin. circulation. ● Intermittent Infusion(for
use in diagnostic testing): Diluent:
NURSING RESPONSIBILITIES: Administer 30- mL vial undiluted.
Assessment Concentration: 3 mg/mL. Rate:
● Monitor heart rate frequently Administer at a rate of 140
(every 15– 30 sec) and ECG mcg/kg/min over 6 min for a total
continuously during therapy. A short, dose of 0.84 mg/kg. Thallium-201
transient period of 1st-, 2nd-, or 3rd- should be injected as close to the
degree heart block or asystole may venous access as possible at the
occur following injection; usually midpoint (after 3 min) of the infusion.
resolves quickly due to short
duration of adenosine. Once
conversion to normal sinus rhythm is
achieved, transient arrhythmias
Evaluation

Page | 231
● Conversion of supraventricular enzyme system).
tachycardia to normal sinus rhythm. Half-life: 3.5– 9 hr
● Diagnosis of myocardial perfusion
defects TIMEACTION PROFILE
ROUTE ONSET
PEAK DURATION
PO 30min
BRAND NAME: Cardizem 2–3hr 6–8 hr PO–SR
GENERIC NAME: Diltiazem unknown unknown 12 hr
CLASSIFICATION: Antidysrhythmic PO–CD, XR, LA unknown 14 days†
IV: Calcium Channel Blocker up to 24 hr

RECOMMENDED DOSAGE, IV 2–5min 2–4 hr unknown

ROUTE, AND FREQUENCY:
PO (Adults): 30– 120 mg 3– 4 times
daily or 60– 120 mg twice daily as
SR capsules or 180– 240 mg once
daily as CD or XR capsules or LA
tablets (up to 360 mg/day);
Concurrent simvastatin therapy—
Diltiazem dose should not exceed
240 mg/day and simvastatin dose
should not exceed 10 mg/day.
IV (Adults): 0.25 mg/kg; may repeat
in 15 min with a dose of 0.35 mg/kg.
May follow with continuous infusion
at 10 mg/hr (range 5– 15 mg/hr) for
up to 24 hr.
DRUG ACTION: Inhibits transport of
calcium into myocardial and vascular
smooth muscle cells, resulting in
inhibition of excitation-contraction
coupling and subsequent
contraction. Therapeutic Effects:
Systemic vasodilation resulting in
decreased BP. Coronary
vasodilation resulting in decreased
frequency and severity of attacks of
angina. Reduction of ventricular rate
in atrial fibrillation or flutter.
Absorption:Well absorbed, but
rapidly metabolized after oral
administration. Distribution:
Unknown. Protein Binding: 70– 80%.
Metabolism and Excretion: Mostly
metabolized by the liver (CYP3A4
INDICATIONS: Hypertension.
Angina pectoris and vasospastic
(Prinzmetal’s) angina.
Supraventricular tachyarrhythmias
and rapid ventricular rates in atrial
flutter or fibrillation.
CONTRAINDICATIONS: :
Hypersensitivity; Sick sinus
syndrome; 2nd- or 3rd-degree AV
block (unless an artificial pacemaker
is in place); Systolic BP 90 mm Hg;
Recent MI or pulmonary congestion;
Concurrent use of rifampin. Use
Cautiously in: Severe hepatic
impairment (pdose recommended);
Geri:p dose; slower IV infusion rate
recommended;qrisk of hypotension;
consider age-related decrease in
body mass,phepatic/renal/cardiac
function, concurrent drug therapy
and other disease states); Severe
renal impairment; Serious ventricular
arrhythmias or HF;OB, Lactation,
Pedi: Safety not established.
SIDE EFFECTS: dizziness,
lightheadedness, weakness, tired
feeling, nausea, upset stomach,
flushing (warmth, redness, or tingly
feeling), sore throat, cough, stuffy
nose, and headache.
ADVERSE REACTIONS: CNS:
abnormal dreams, anxiety,
confusion, dizziness, drowsiness,
headache, nervousness, psychiatric
disturbances, weakness. EENT:

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blurred vision, disturbed equilibrium,
epistaxis, tinnitus. Resp: cough,
dyspnea. CV: ARRHYTHMIAS, HF,
peripheral edema, bradycardia,
chest pain, hypotension, palpitations,
syncope, tachycardia. GI:qliver
enzymes, anorexia, constipation,
diarrhea, dry mouth, dysgeusia,
dyspepsia, nausea, vomiting. GU:
dysuria, nocturia, polyuria, sexual
dysfunction, urinary frequency.
Derm: STEVENS-JOHNSON
SYNDROME, dermatitis, erythema
multiforme, flushing, sweating,
photosensitivity, pruritus/urticaria,
rash. Endo: gynecomastia,
hyperglycemia. Hemat: anemia,
leukopenia, thrombocytopenia.
Metab: weight gain. MS: joint
stiffness, muscle cramps. Neuro:
paresthesia, tremor. Misc:gingival
hyperplasia.
NURSING RESPONSIBILITIES:
Assessment
● Monitor BP and pulse prior to
therapy, during dose titration, and
periodically during therapy. Monitor
ECG periodically during prolonged
therapy. May cause prolonged PR
interval.
● Monitor intake and output ratios
and daily weight. Assess for signs of
HF (peripheral edema,
rales/crackles, dyspnea, weight
gain,jugular venous distention). ●
Monitor frequency of prescription
refills to determine adherence. ●
Patients receiving digoxin
concurrently with calcium channel
blockers should have routine serum
digoxin levels checked and be
monitored for signs and symptoms of
digoxin toxicity. ● Assess for rash
periodically during therapy. May
cause Stevens-Johnson syndrome.
Discontinue therapy if severe or if
accompanied with fever, general
malaise, fatigue, muscle or joint
aches, blisters, oral lesions,
conjunctivitis, hepatitis and/or
eosinophilia. ● Angina: Assess
location, duration, intensity, and
precipitating factors of patient’s
anginal pain. ● Arrhythmias: Monitor
ECG continuously during
administration. Report bradycardia or
prolonged hypotension promptly.
Emergency equipment and
medication should be available.
Monitor BP and pulse before and
frequently during administration. ●
Lab Test Considerations: Total
serum calcium concentrations are
not affected by calcium channel
blockers.
Diagnosis
Acute pain (Indications) Decreased
cardiac output (Adverse Reactions)
Implementation
● Do not confuse Tiazac (diltiazem)
with Ziac
(bisprolol/hydrochlorothiazide). ●
PO: May be administered without
regard to meals. May be
administered with meals if GI
irritation becomes a problem. ● Do
not open, crush, break, or chew
sustained-release capsules or
tablets. Empty tablets that appear in
stool are not significant. Crush and
mix diltiazem with food or fluids for
patients having difficulty swallowing
Evaluation
Decrease in BP. ● Decrease in
frequency and severity of anginal
attacks. ● Decrease in need for
nitrate therapy. ● Increase in activity
tolerance and sense of well-being. ●
Suppression and prevention of
tachyarrhythmias.
Page | 233

BRAND NAME: Adenocard
GENERIC NAME: Amiodarone
CLASSIFICATION: Antidysrhythmic
III: Drugs that prolong Repolarization
RECOMMENDED DOSAGE,
ROUTE, AND FREQUENCY:
DRUG ACTION: Prolongs action
potential and refractory period.
Inhibits adrenergic stimulation. Slows
the sinus rate, increases PR and QT
intervals, and decreases peripheral
vascular resistance (vasodilation).
Therapeutic Effects:Suppression of
arrhythmias.
Absorption:Slowly and variably
absorbed from the GI tract (35–
65%). IV administration results in
complete bioavailability.
Distribution: Distributed to and
accumulates slowly in body tissues.
Reaches high levels in fat, muscle,
liver, lungs, and spleen. Crosses the
placenta and enters breast milk.
Protein Binding: 96% bound to
plasma proteins. Metabolism and
Excretion: Metabolized by the liver,
excreted into bile. Minimal renal
excretion. One metabolite has
antiarrhythmic activity. Half-life: 13–
107 days.
TIME/ACTION PROFILE
(suppression of ventricular
arrhythmias)
ROUTE ONSET
PEAK DURATION
PO 2–3 days 3–7 hr
wk–mos
IV 2 hr 3–
7 hr unknown
INDICATIONS: Life-threatening
ventricular arrhythmias unresponsive
to less toxic agents. Unlabeled Use:
PO: Management of supraventricular
tachyarrhythmias. IV: As part of the
Advanced Cardiac Life Support
(ACLS) and Pediatric Advanced Life
Support (PALS) guidelines for the
management of ventricular fibrillation
(VF)/pulseless ventricular
tachycardia (VT) after
cardiopulmonary resuscitation and
defibrillation have failed; also for
other life-threatening
tachyrrhythmias
CONTRAINDICATIONS: : Patients
with cardiogenic shock; Severe sinus
node dysfunction; 2nd- and 3rd-
degree AV block; Bradycardia (has
caused syncope unless a pacemaker
is in place); Hypersensitivity to
amiodarone or iodine; OB: Can
cause fetal hypo- or hyperthyroidism;
Lactation: Enters breast milk and can
cause harm to the neonate; use an
alternative to breast milk;
Pedi:Safety not established;
products containing benzyl alcohol
should not be used in neonates. Use
Cautiously in: History of HF; Thyroid
disorders; Corneal refractive laser
surgery; Severe pulmonary or liver
disease; Geri: Initiate therapy at the
low end of the dosing range due
tophepatic, renal, or cardiac function;
comorbid disease; or other drug
therapy.
SIDE EFFECTS: nausea, vomiting,
fatigue, tremor, lack of coordination,
constipation, insomnia, headache,
stomach pain, decreased sex drive
or performance, uncontrollable or
unusual movements of the body.
ADVERSE REACTIONS: CNS:
confusional states, disorientation,
hallucinations, dizziness, fatigue,
malaise, headache, insomnia. EENT:
corneal microdeposits, abnormal
sense of smell, dry eyes, optic
neuritis, optic neuropathy,
photophobia. Resp: ADULT
RESPIRATORY DISTRESS
SYNDROME (ARDS), PULMONARY
FIBROSIS, PULMONARY
Page | 234
TOXICITY. CV: CHF, WORSENING (ataxia, proximal muscle weakness,
OF ARRHYTHMIAS, bradycardia, tingling or numbness in fingers or
hypotension. GI: anorexia, toes, uncontrolled movements,
constipation, nausea, vomiting, tremors); common during initial
abdominal pain, abnormal sense of therapy, but may occur within 1 wk to
taste,qliver enzymes. GU:p libido, several mo of initiation of therapy
epididymitis. Derm: TOXIC and may persist for more than 1 yr
EPIDERMAL NECROLYSIS (rare), after withdrawal. Dose reduction is
photosensitivity, blue discoloration. recommended. Assist patient during
Endo: hypothyroidism, ambulation to prevent falls.
hyperthyroidism. Neuro:ataxia, ● Lab Test Considerations: Monitor
involuntary movement, paresthesia, liver and thyroid functions before and
peripheral neuropathy, poor every 6 mo during therapy. Drug
coordination, tremor. effects persist long after
discontinuation Thyroid function
NURSING RESPONSIBILITIES: abnormalities are common, but
Assessment clinical thyroid dysfunction is
● Monitor ECG continuously during uncommon. ● Monitor AST, ALT,
IV therapy or initiation of oral and alkaline phosphatase at regular
therapy. Monitor heart rate and intervals during therapy, especially in
rhythm throughout therapy; PR patients receiving high maintenance
prolongation, slight QRS widening, dose. If liver function studies are 3
T-wave amplitude reduction with T- times normal or double in patients
wave widening and bifurcation, and with elevated baseline levels or if
U waves may occur. QT prolongation hepatomegaly occurs, dose should
may be associated with worsening of be reduced. ● May cause
arrhythmias and should be asymptomaticqin ANA titer
monitored closely during IV therapy. concentrations.
Report bradycardia or increase in Diagnosis
arrhythmias promptly; patients
receiving IV therapy may require Decreased cardiac output
slowing rate, discontinuing infusion, (Indications) Impaired gas exchange
or inserting a temporary pacemaker. (Side Effects)
● Assess pacing and defibrillation
threshold in patients with Implementation
pacemakers and implanted ● High Alert: IV vasoactive
defibrillators at beginning and medications are inherently
periodically during therapy. dangerous; fatalities have occurred
● IV: Assess for signs and symptoms from medication errors involving
of ARDS throughout therapy. Report amiodarone. Before administering,
dyspnea, tachypnea, or have second practitioner check
rales/crackles promptly. Bilateral, original order, dose calculations, and
diffuse pulmonary infiltrates are seen infusion pump settings. Patients
on chest x-ray. ● Monitor BP should be hospitalized and
frequently. Hypotension usually monitored closely during IV therapy
occurs during first several hours of and initiation of oral therapy. IV
therapy and is related to rate of therapy should be administered only
infusion. If hypotension occurs, slow by physicians experienced in treating
rate. ● PO: Assess for neurotoxicity life-threatening arrhythmias. ● Do

Page | 235
not confuse amiodarone with milk.
amantadine. ● Hypokalemia and Metabolism and Excretion: Mostly
hypomagnesemia may decrease metabolized by the liver; 10%
effectiveness or cause additional excreted in urine as unchanged
arrhythmias; correct before therapy. drug.
● Monitor closely when converting Half-life: Biphasic— initial phase, 7–
from IV to oral therapy, especially in 30 min; terminal phase, 90– 120
geriatric patients. ● PO: May be min;qin HF and liver impairment.
administered with meals and in
divided doses if GI intolerance INDICATIONS: IV: Ventricular
occurs or if daily dose exceeds 1000 arrhythmias. IM: Self-injected or
mg. when IV unavailable (during
transport to hospital facilities). Local:
Evaluation Infiltration/mucosal/topical
● Cessation of life-threatening anesthetic. Patch: Pain due to post-
ventricular arrhythmias. Adverse herpetic neuralgia.
effects may take up to 4 mo to
resolve. CONTRAINDICATIONS:
Hypersensitivity; cross-sensitivity
may occur; Third-degree heart block.
Use Cautiously in: Liver disease,
BRAND NAME: Xylocaine HF, patients weighing 50 kg, and
GENERIC NAME: Lidocaine geriatric patients (pbolus and/or
CLASSIFICATION: maintenance dose); Respiratory
ANTIDYSRHYTHMIC CLASS I: depression; Shock; Heart block; OB,
SODIUM CHANNEL BLOCKER IB Lactation:Safety not established;
Pedi:Safety not established for
RECOMMENDED DOSAGE, transdermal patch.
ROUTE, AND FREQUENCY: SIDE EFFECTS: Low blood
pressure (hypotension), Swelling
DRUG ACTION: IV, IM: Suppresses
(edema), Redness at injection site,
automaticity and spontaneous
Small red or purple spots on skin,
depolarization of the ventricles
Skin irritation, Constipation, Nausea,
during diastole by altering the flux of
Vomiting, Confusion, Dizziness,
sodium ions across cell membranes
Headache, Numbness and tingling,
with little or no effect on heart rate.
Drowsiness, Tremor, Irritation
Local: Produces local anesthesia by
symptoms (topical products).
inhibiting transport of ions across
neuronal membranes, thereby ADVERSE REACTIONS: Applies
preventing initiation and conduction mainly to systemic use CNS:
of normal nerve impulses. SEIZURES, confusion, drowsiness,
Therapeutic Effects: Control of blurred vision, dizziness,
ventricular arrhythmias. Local nervousness, slurred speech,
anesthesia. tremor. EENT: mucosal use—por
Absorption: Well absorbed after absent gag reflex. CV: CARDIAC
administration into the deltoid ARREST, arrhythmias, bradycardia,
muscle; some absorption follows heart block, hypotension. GI:
local use. Distribution: Widely nausea, vomiting. Resp:
distributed. Concentrates in adipose bronchospasm. Hemat:
tissue. Crosses the blood-brain methemoglobinemia. Local:
barrier and placenta; enters breast stinging, burning, contact dermatitis,

Page | 236
erythema.MS:chondrolysis.Misc:alle
rgic reactions, including
ANAPHYLAXIS.
NURSING RESPONSIBILITIES:
Assessment
● Antiarrhythmic: Monitor ECG
continuously and BP and respiratory
status frequently during
administration. ● Anesthetic: Assess
degree of numbness of affected part.
● Transdermal: Monitor for pain
intensity in affected area periodically
during therapy. ● Lab Test
Considerations: Serum electrolyte
levels should be monitored
periodically during prolonged
therapy. ● IM administration may
causeqCPK levels. ● Toxicity and
Overdose: Serum lidocaine levels
should be monitored periodically
during prolonged or high-dose IV
therapy. Therapeutic serum lidocaine
levels range from 1.5 to 5 mcg/mL. ●
Signs and symptoms of toxicity
include confusion, excitation, blurred
or double vision, nausea, vomiting,
ringing in ears, tremors, twitching,
seizures, difficulty breathing, severe
dizziness or fainting, and unusually
slow heart rate. ● If symptoms of
overdose occur, stop infusion and
monitor patient closely
Diagnosis
Decreased cardiac output
(Indications) Acute pain (Indications)
Implementation
● High Alert:Lidocaine is readily
absorbed through mucous
membranes.Inadvertent overdosage
of lidocaine jelly and spray has
resulted in patient harm or death
from neurologic and/or cardiac
toxicity. Do not exceed
recommended doses. ● Throat
Spray: Ensure that gag reflex is
intact before allowing patient to drink
or eat. ● IM: IM injections are
recommended only when ECG
monitoring is not available and
benefits outweigh risks. Administer
IM injections only into deltoid muscle
while frequently aspirating to prevent
IV injection. IV Administration ●
Direct IV: Only 1% and 2% solutions
are used for direct IV injection.
Diluent: Administer undiluted. Rate:
Administer loading dose over 2– 3
min. Follow by IV continuous
infusion.
● Continuous Infusion: Diluent:
Lidocaine vials need to be further
diluted. Dilute 2 g of lidocaine in 250
mL or 500 mL of D5W or 0.9% NaCl.
Admixed infusion stable for 24 hr at
room temperature. Premixed
infusions are already diluted and
ready to use. Concentration: 4– 8
mg/mL. Rate: See Route/Dosage
section. Administer via infusion
pump for accurate dose.
Evaluation
● Decrease in ventricular
arrhythmias.
● Local anesthesia
BRAND NAME: PRONESTYL
GENERIC NAME: PROCAINAMIDE
CLASSIFICATION:
ANTIDYSRHYTMIC CLASS I:
SODIUM CHANNEL BLOCKER IA
RECOMMENDED DOSAGE,
ROUTE, AND FREQUENCY: IM
(Adults): 50 mg/kg/day in divided
doses q 3– 6 hr. IV (Adults): 100 mg
q 5 min until arrhythmia is abolished
or 1000 mg have been given; wait at
least 10 min until further dosing or
loading infusion of 500– 600 mg over
30– 60 min followed by maintenance
infusion of 1– 4 mg/min.
Page | 237
DRUG ACTION: Decreases arrhythmias, including: Atrial
myocardial excitability. Slows premature contractions, Premature
conduction velocity. May depress ventricular contractions, Ventricular
myocardial contractility. Therapeutic tachycardia, Paroxysmal atrial
Effects: Suppression of arrhythmias. tachycardia. Maintenance of normal
sinus rhythm after conversion from
Absorption: Well absorbed (75– atrial fibrillation or flutter.
90%) following IM administration.
Distribution: Rapidly and widely CONTRAINDCIATIONS:
distributed. Hypersensitivity; AV block;
Metabolism and Excretion: Myasthenia gravis. Use Cautiously
Converted by the liver to N- in: MI or digoxin toxicity; HF, renal
acetylprocainamide (NAPA), an dysfunction, or hepatic dysfunction
active antiarrhythmic compound. (doseprecommended); Geri:
Remainder (40– 70%) excreted Doseprecommended); OB,
unchanged by the kidneys. Lactation, Pedi:Safety not
Half-life: 2.5– 4.7 hr (NAPA— 7 established.
hr);qin renal impairment
SIDE EFFECTS/ADVERSE
ROUTE ONSET PEAK EFFECTS: CNS: SEIZURES,
DURATION confusion, dizziness. CV:
IV immediate 25–60min 3– ASYSTOLE, HEART BLOCK,
4 hr VENTRICULAR ARRHYTHMIAS,
IM 10–30min 15–60min 3– hypotension. GI: diarrhea, anorexia,
4 hr bitter taste, nausea, vomiting. Derm:
rash. Hemat: AGRANULOCYTOSIS,
DRUG-DRUG AND DRUG-FOOD eosinophilia, leukopenia,
INTERACTIONS: Drug-Drug: May thrombocytopenia. Misc: chills, drug-
have additive or antagonistic effects induced systemic lupus syndrome,
with other antiarrhythmics. Additive fever.
neurologic toxicity (confusion,
seizures) with lidocaine. NURSING RESPONSIBILITIES:
Antihypertensives and nitrates may
potentiate hypotensive effect. Assessment
Potentiates neuromuscular blocking ● Monitor ECG, pulse, and BP
agents. May partially antagonize the continuously throughout IV
therapeutic effects of administration. Parameters should
anticholinesterase agents in be monitored periodically during oral
myasthenia gravis.qrisk of administration. IV administration is
arrhythmias with pimozide. Additive usually discontinued if any of the
anticholinergic effects with other following occur: arrhythmia is
drugs possessing anticholinergic resolved, QRS complex widens by
properties, including antihistamines, 50%, PR interval is prolonged, BP
antidepressants, atropine, drops 15 mm Hg, or toxic side
haloperidol, and phenothiazines. effects develop. Patient should
Effects of procainamide may beqby remain supine throughout IV
cimetidine, quinidine, or administration to minimize
trimethoprim. hypotension. ● Lab Test
INDICATIONS: Treatment of a wide Considerations: Monitor CBC every
variety of ventricular and atrial 2 wk during the first 3 mo of therapy.

Page | 238
May causepleukocyte, neutrophil, infusion at rate of 1– 4 mg/min to
and platelet counts. Therapy may be maintain control of arrhythmia.
discontinued if leukopenia occurs.
Blood counts usually return to Evaluation
normal within 1 mo of discontinuation ● Resolution of cardiac arrhythmias
of therapy. ● Monitor ANA without detrimental side effects.
periodically during prolonged therapy
or if symptoms of lupus-like reaction BRAND NAME:
occur. Therapy is discontinued if a
GENERIC NAME: EPINEPHRINE
steady increase in ANA titer occurs.
● May causeqAST, ALT, alkaline CLASSIFICATION:
phosphatase, LDH, bilirubin, and a SYMPATHOMIMETIC AGENT:
positive Coombs’ test result. ● ALPHA AND BETA 2 ADRENERGIC
Toxicity and Overdose:Serum AGENT
procainamide and N-
acetylprocainamide levels may be
monitored periodically during dosage RECOMMENDED DOSAGE,
adjustment. Therapeutic blood level ROUTE, AND FREQUENCY:
of procainamide is 4– 8 mcg/mL. ●
Subcut, IM (Adults): Anaphylactic
Toxicity may occur with
reactions/asthma—0.1– 0.5 mg
procainamide blood levels of 8– 16
(single dose not to exceed 1 mg);
mcg/mL or greater. ● Signs of
may repeat q 10– 15 min for
toxicity include confusion, dizziness,
anaphylactic shock or q 20 min– 4 hr
drowsiness, decreased urination,
for asthma.
nausea, vomiting, and
tachyarrhythmias. Subcut (Children 1 mo):
Anaphylactic reactions/asthma—
Diagnosis
0.01 mg/kg (not to exceed 0.5
Decreased cardiac output mg/dose) q 15 min for 2 doses, then
(Indications) q 4 hr. IV (Adults): Severe
anaphylaxis—0.1– 0.25 mg q 5– 15
Implementation min; may be followed by 1– 4
mcg/min continuous infusion;
● IM: Used only when IV route is not
cardiopulmonary resuscitation
feasible
(ACLS guidelines)—1 mg q 3– 5
● pH: 4.0– 6.0. ● Direct IV: (only to
min; bradycardia (ACLS guidelines)
be used for life-threatening
—2– 10 mcg/min). IV (Children):
arrhythmias).Diluent: Dilute each 100
Severe anaphylaxis—0.1 mg (less in
mg of procainamide with 10 mL of
younger children); may be followed
0.9% NaCl. Rate: Not to exceed 25
by 0.1 mcg/kg/min continuous
mg/min. Rapid administration may
infusion (may bequp to 1.5
cause ventricular fibrillation or
mcg/kg/min); symptomatic
asystole. ● Intermittent
bradycardia/pulseless arrest (PALS
Infusion(preferred route of
guidelines)—0.01 mg/kg, may be
administration): Diluent: Add 2 g of
repeated q 3– 5 min higher doses
procainamide to 250 mL of 0.9%
(up to 0.1– 0.2 mg/kg) may be
NaCl. Concentration: 8 mg/mL.
considered; may also be given by
Rate: Administer initial infusion over
the intraosseous route. May also be
30– 60 min. Administer maintenance
given by the endotracheal route in
doses of 0.1— 0.2 mg/kg diluted to a

Page | 239
volume of 3– 5 mL with normal Absorption: Well absorbed
saline followed by several positive following subcut administration;
pressure ventilations. Inhaln some absorption may occur following
(Adults): Inhalation solution—1 repeated inhalation of large doses.
inhalation of 1% solution; may be Distribution: Does not cross the
repeated after 1– 2 min; additional blood-brain barrier; crosses the
doses may be given q 3 hr; placenta and enters breast milk.
racepinephrine—Via hand nebulizer, Metabolism and Excretion: Action
2– 3 inhalations of 2.25% solution; is rapidly terminated by metabolism
may repeat in 5 min with 2– 3 more and uptake by nerve endings.
inhalations, up to 4– 6 times daily. Half-life: Unknown.
Inhaln (Children 1 mo): 0.25– 0.5
mL of 2.25% racemic epinephrine TIME/ACTION PROFILE
solution diluted in 3 mL normal (bronchodilation)
saline. IV, Intratracheal (Neonates): ROUTE ONSET
0.01– 0.03 mg/kg q 3– 5 min as PEAK
needed. IM (Children 1 mo 30 kg): DURATION
0.15 mg (EpiPen Jr); 30 kg: 0.3 mg Inhaln 1min
(EpiPen). Intracardiac (Adults): unknown 1–3hr
0.3– 0.5 mg. Endotracheal
(Adults): Cardiopulmonary Subcut 5–10min
resuscitation (ACLS guidelines)— 2– 20min 1–
2.5 mg. Topical (Adults and 4 hr
Children 6 yr): Nasal decongestant
IM 6–12min
—Apply 1% solution as drops, spray,
unknown 1–4 hr
or with a swab. Intraspinal (Adults
and Children): 0.2– 0.4 mL of IV rapid
1:1000 solution. With Local 20min
Anesthetics (Adults and Children): 20–30min
Use 1:200,000 solution with local
anesthetic. DRUG-DRUG AND DRUG-FOOD
INTERACTIONS:
DRUG ACTION: Results in the
accumulation of cyclic adenosine Drug-Drug: Concurrent use with
monophosphate (cAMP) at beta- other adrenergic agents will have
adrenergic receptors. Affects both additive adrenergic side effects.
beta1(cardiac)-adrenergic receptors Use with MAO inhibitors may lead
and beta2(pulmonary)-adrenergic to hypertensive crisis. Beta blockers
receptor sites. Produces may negate therapeutic effect.
bronchodilation. Also has alpha- Tricyclic antidepressantsenhance
adrenergic agonist properties, which pressor response to epinephrine.
result in vasoconstriction. Inhibits the Drug-Natural Products: Use with
release of mediators of immediate caffeine-containing herbs (cola nut,
hypersensitivity reactions from mast guarana, mate, tea,coffee)qstimulant
cells. Therapeutic Effects: effect.
Bronchodilation. Maintenance of
INDICATIONS: Subcut, IV, Inhaln:
heart rate and BP. Localization/
Management of reversible airway
prolongation of local/spinal
disease due to asthma or COPD.
anesthetic.
Subcut, IM, IV: Management of
severe allergic reactions.IV,

Page | 240
Intracardiac, Intratracheal,
Intraosseous (part of advanced
cardiac life support [ACLS] and
pediatric advanced life support
[PALS] guidelines): Management of
cardiac arrest (unlabeled). Inhaln:
Management of upper airway
obstruction and croup (racemic
epinephrine). Local/Spinal: Adjunct
in the localization/prolongation of
anesthesia.
CONTRAINDCIATIONS:
Hypersensitivity to adrenergic
amines; Some products may contain
bisulfites or fluorocarbons (in some
inhalers) and should be avoided in
patients with known hypersensitivity
or intolerance. Use Cautiously in:
Cardiac disease (angina,
tachycardia, MI); Hypertension;
Hyperthyroidism; Diabetes; Cerebral
arteriosclerosis; Glaucoma (except
for ophthalmic use); Excessive use
may lead to tolerance
paradoxical bronchospasm (inhaler);
OB: Use only if potential maternal
benefit outweighs potential risks to
fetus; Lactation: High intravenous
doses of epinephrine mightpmilk
production or letdown. Low-dose
epidural, topical, inhaled
ophthalmic epinephrine are unlikely
to interfere with breast feeding (NIH);
Geri: More susceptible to adverse
reactions; may requirepdose.
SIDE EFFECTS/ADVERSE
REACTIONS:
CNS: nervousness, restlessness,
tremor, headache, insomnia. Resp:
PARADOXICAL BRONCHOSPASM
(EXCESSIVE USE OF INHALERS).
CV: angina, arrhythmias,
hypertension, tachycardia.GI:
nausea, vomiting. Endo:
hyperglycemia.
NURSING RESPONSIBILITIES:
Assessment
● Bronchodilator: Assess lung
sounds, respiratory pattern, pulse,
and BP before administration and
during peak of medication. Note
amount, color, and character of
sputum produced, and notify health
care professional of abnormal
findings. ● Monitor pulmonary
function tests before and periodically
during therapy
● Bronchodilator: Assess lung
sounds, respiratory pattern, pulse,
and BP before administration and
during peak of medication. Note
amount, color, and character of
sputum produced, and notify health
care professional of abnormal
findings. ● Monitor pulmonary
function tests before and periodically
during therapy ● Vasopressor:
Monitor BP, pulse, ECG, and
and respiratory rate frequently during IV
administration. Continuous ECG,
hemodynamic parameters, and urine
output should be monitored
continuously during IV
administration. ● Monitor for chest
pain, arrhythmias, heart rate 110
or bpm, and hypertension. Consult
physician for parameters of pulse,
BP, and ECG changes for adjusting
dose or discontinuing medication. ●
Shock: Assess volume status.
Correct hypovolemia prior to
administering epinephrine IV. ●
Nasal Decongestant: Assess
patient for nasal and sinus
congestion prior to and periodically
during therapy. ● Lab Test
Considerations: May cause
transientpin serum potassium
concentrations with nebulization or at
higher than recommended doses. ●
May cause anqin blood glucose and
serum lactic acid concentrations. ●
Toxicity and Overdose: Symptoms
of overdose include persistent
Page | 241
agitation, chest pain or discomfort, Antihistamines and corticosteroids
decreased BP, dizziness, may be used in conjunction with
hyperglycemia, hypokalemia, epinephrine. ● IM, Subcut:
seizures, tachyarrhythmias, Medication can cause irritation of
persistent trembling, and vomiting. tissue. Rotate injection sites to
prevent tissue necrosis. Massage
Diagnosis injection sites well after
Ineffective airway clearance administration to enhance absorption
(Indications) I and to decrease local
neffective tissue perfusion vasoconstriction. Avoid IM
(Indications) administration in gluteal muscle.

Implementation IV Administration

● Do not confuse epinephrine with ● Direct IV: Diluent: The 1:10,000

ephedrine. ● High Alert: Patient solution can be administered
harm or fatalities have occurred from undiluted. Dilute 1 mg (1 mL) of a
medication errors with epinephrine. 1:1000 solution in 9 mL of 0.9%
Epinephrine is available in various NaCl to prepare a 1:10,000 solution.
concentrations, strengths, and Concentration: 0.1 mg/mL
percentages and used for different (1:10,000). Rate: Administer each 1
purposes. Packaging labels may be mg (10 mL) of a 1:10,000 solution
easily confused or products over at least 1 min; more rapid
incorrectly diluted. Dilutions should administration may be used during
be prepared by a pharmacist. IV cardiac resuscitation. Follow each
doses should be expressed in dose with 20 mL IV saline flush. ●
milligrams not ampules, Continuous Infusion: Diluent: Dilute 1
concentration or volume. Prior to mg (1 mL) of a 1:1000 solution in
administration, have second 250 mL of D5W or 0.9% NaCl.
practitioner independently check Protect from light. Infusion stable for
original order, dose calculations, 24 hr. Concentration: 4 mcg/mL.
concentration, route of Rate: See Route/Dosage section.
administration, and infusion pump Titrate to response (BP, heart rate,
settings. ● Medication should be respiratory rate). ● Y-Site
administered promptly at the onset of Incompatibility: acyclovir,
bronchospasm. ● Use a tuberculin alemtuzumab, aminophylline,
syringe with a 26-gauge -in. azathioprine, carmustine, dantrolene,
needle for subcut injec- 1⁄2 tion to diazepam, diazoxide, fluorouracil,
ensure that correct amount of ganciclovir, indomethacin,
medication is administered. ● micafungin, pentobarbital,
Tolerance may develop with phenobarbital, phenytoin, sodium
prolonged or excessive use. bicarbonate, thiopental,
Effectiveness may be restored by trimethoprim/sulfamethoxazole. ●
discontinuing for a few days and Inhaln: When using epinephrine
then readministering. ● Do not use inhalation solution, 10 drops of 1%
solutions that are pinkish or brownish base solution should be placed in the
or that contain a precipitate. ● For reservoir of the nebulizer. ● The
anaphylactic shock, volume 2.25% inhalation solution of
replacement should be administered racepinephrine must be diluted for
concurrently with epinephrine. use in the combination

Page | 242
nebulizer/respirator.● Endotracheal:
Epinephrine can be injected directly
into the bronchial tree via the
endotracheal tube if the patient has
been intubated. Perform 5 rapid
insufflations; forcefully administer 10
mL containing 2– 2.5 mg epinephrine
(1 mg/mL) directly into tube; follow
with 5 quick insufflations.
Evaluation
● Prevention or relief of
bronchospasm.
● Increase in ease of breathing.
● Prevention of bronchospasm or
reduction of frequency of acute
asthma attacks in patients with
chronic asthma.
● Prevention of exercise-induced
asthma. ● Reversal of signs and
symptoms of anaphylaxis.
● Increase in cardiac rate and
output, when used in cardiac
resuscitation.
● Increase in BP, when used as a
vasopressor.
● Localization of local anesthetic.
● Decrease in sinus and nasal
congestion.
BRAND NAME:
GENERIC NAME: VASOPRESSIN
CLASSIFICATION: ANTIDIURETIC
HORMONE
RECOMMENDED DOSAGE,
ROUTE, AND FREQUENCY:
Diabetes insipidus
IM, Subcut (Adults): 5– 10 units 2–
4 times daily. IM, Subcut
(Children): 2.5– 10 units 2– 4 times
daily. IV (Adults and Children):
0.0005 units/kg/hr, double dosage q
30 min as needed to a maximum of
0.01 units/kg/hr.
Pulseless VT/VF, Asystole, or PEA
(ACLS guidelines)
IV (Adults): 40 units as a single
dose (unlabeled).
IV (Children): 0.4 units/kg after
resuscitation and at least 2 doses of
epinephrine.
Vasodilatory shock
IV (Adults): 0.01– 0.1 units/min,
titrate to effect.
IV (Infants and Children): 0.0003–
0.002 units/kg/min, titrate to effect.
GI Hemorrhage
IV (Adults): 0.2– 0.4 units/min then
titrate to maximum dose of 0.9
units/min; if bleeding stops continue
same dose for 12 hr then taper off
over 24– 48 hr.
IV (Children): 0.002– 0.005
units/kg/min then titrate to maximum
dose of 0.01 units/kg/min; if bleeding
stops continue same dose for 12 hr
then taper off over 24– 48 hr.
DRUG ACTION: Alters the
permeability of the renal collecting
ducts, allowing reabsorption of
water. Directly stimulates
musculature of GI tract. In high
doses acts as a nonadrenergic
peripheral vasoconstrictor.
Therapeutic Effects: Decreased
urine output and increased urine
osmolality in diabetes insipidus.
Page | 243
Absorption: IM absorption may be sensitivity to vasopressin);
unpredictable. Distribution: Widely Comatose patients; Seizures;
distributed throughout extracellular Migraine headaches; Asthma; Heart
fluid. failure; Cardiovascular disease;
Metabolism and Excretion: Rapidly Renal impairment Pedi:
degraded by the liver and kidneys; Geri:qsensitivity to vasopressin
5% excreted unchanged by the effects.
kidneys.
Half-life: 10– 20 min. SIDE EFFECTS/ADVERSE
TIME/ACTION PROFILE REACTIONS: CNS: dizziness,
(antidiuretic effect) “pounding” sensation in head. CV:
MI, angina, chest pain. GI:
ROUTE ONSET abdominal cramps, belching,
PEAK DURATION diarrhea, flatulence, heartburn,
nausea, vomiting. Derm: paleness,
IM, subcut unknown unknown perioral blanching, sweating. Neuro:
2–8 hr trembling. Misc: allergic reactions,
IV unknown fever, water intoxication (higher
unknown 30–60min doses).

DRUG-DRUG AND DRUG-FOOD NURSING RESPONSIBILITIES:

INTERACTIONS: Assessment
Drug-Drug: Antidiuretic effect may ● Monitor BP, HR, and ECG
bepby concurrent administration of periodically throughout therapy and
alcohol, lithium, demeclocycline, continuously throughout
heparin, or norepinephrine. cardiopulmonary resuscitation. ●
Antidiuretic effect may be q by Diabetes Insipidus: Monitor urine
concurrent administration of osmolality and urine volume
carbamazepine, chlorpropamide, frequently to determine effects of
clofibrate, tricyclic antidepressants, medication. Assess patient for
or fludrocortisone. Vasopressor symptoms of dehydration (excessive
effect may beqby concurrent thirst, dry skin and mucous
administration of ganglionic blocking membranes, tachycardia, poor skin
agents. turgor). Weigh patient daily, monitor
INDICATIONS: Central diabetes intake and output, and assess for
insipidus due to deficient antidiuretic edema. ● Lab Test Considerations:
hormone. Unlabeled Use: Monitor urine specific gravity
Management of pulseless VT/VF throughout therapy. ● Monitor serum
unresponsive to initial shocks, electrolyte concentrations
asystole, or pulseless electrical periodically during therapy. ●
activity (PEA) (ACLS guidlines). Toxicity and Overdose: Signs and
Vasodilatory shock. Gastrointestinal symptoms of water intoxication
hemorrhage. include confusion, drowsiness,
headache, weight gain, difficulty
CONTRAINDCIATIONS: : Chronic urinating, seizures, and coma. ●
renal failure with increased BUN; Treatment of overdose includes
Hypersensitivity to beef or pork water restriction and temporary
proteins.Use Cautiously in: discontinuation of vasopressin until
Perioperative polyuria (increased polyuria occurs. If symptoms are

Page | 244
severe, administration of mannitol, RECOMMENDED DOSAGE,
hypertonic dextrose, urea, and/or ROUTE, AND FREQUENCY:
furosemide may be used.
DRUG ACTION: Increases the
Diagnosis osmotic pressure of the glomerular
filtrate, thereby inhibiting
Deficient fluid volume (Indications) reabsorption of water and
Excess fluid volume (Adverse electrolytes. Causes excretion of:
Reactions) Water, Sodium, Potassium, Chloride,
Implementation Calcium, Phosphorus, Magnesium,
Urea, Uric acid. Therapeutic
● Aqueous vasopressin injection Effects: Mobilization of excess fluid
may be administered subcut or IM in oliguric renal failure or edema.
for diabetes insipidus. ● Administer Reduction of intraocular or
1– 2 glasses of water at the time of intracranial pressure. Increased
administration to minimize side urinary excretion of toxic materials.
effects (blanching of skin, abdominal Decreased hemolysis when used as
cramps, nausea). an irrigant after transurethral
prostatic resection.
IV Administration
Absorption: IV administration
● pH: 2.5– 4.5. ● Direct IV: Diluent:
produces complete bioavailability.
Administer undiluted. Concentration:
Some absorption may follow use as
20 units/mL. Rate: Administer over
a GU irrigant.
1– 2 sec during pulseless VT/VF,
asystole, or PEA. ● Continuous Distribution: Confined to the
Infusion: Diluent: Dilute 100 units of extracellular space; does not usually
vasopressin in 250 mL of 0.9% NaCl cross the blood-brain barrier or eye.
or D5W. Concentration: 0.4 units/mL. Metabolism and Excretion:
Rate: See Route/Dosage section. Excreted by the kidneys; minimal
liver metabolism.
Evaluation
Half-life: 100 min.
● Decrease in urine volume.
TIME/ACTION PROFILE (diuretic
● Relief of polydipsia.
effect)
● Increased urine osmolality in
patients with central diabetes ROUTE ONSET
insipidus. PEAK
DURATION
● Resolution of VT/VF.
● Improvement in signs of septic IV 30–60 min
shock. 1hr 6–8 hr

DRUG-DRUG AND DRUG-FOOD

B. EMERGENCY DRUGS FOR
INTRACRANIAL HYPERTENSION INTERACTIONS: Drug-Drug:
Hypokalemia increase the risk of
BRAND NAME: OSMITROL digoxin toxicity
INDICATIONS: IV: Adjunct in the
GENERIC NAME: MANNITOL
treatment of: Acute oliguric renal
CLASSIFICATION: OSMOTIC failure, Edema, Increased
DIURETIC intracranial or intraocular pressure,
Toxic overdose. GU irrigant During

Page | 245
transurethral procedures (2.5– 5% ● Lab Test Considerations: Renal
solution only). function and serum electrolytes
should be monitored routinely
CONTRAINDCIATIONS: throughout course of therapy.
Hypersensitivity; Anuria;
Dehydration; Active intracranial Diagnosis
bleeding; Severe pulmonary edema
or congestion. Use Cautiously in: Excess fluid volume (Indications)
OB, Lactation,Safety not Risk for deficient fluid volume (Side
established). Effects)

SIDE EFFECTS/ADVERSE Implementation

REACTIONS: CNS:confusion, ● Observe infusion site frequently for
headache. EENT: blurred vision, infiltration. Extravasation may cause
rhinitis. CV: transient volume tissue irritation and necrosis. ● Do
expansion, chest pain, HF, not administer electrolyte-free
pulmonary edema, tachycardia.GI: mannitol solution with blood. If blood
nausea, thirst, vomiting. GU: renal must be administered simultaneously
failure, urinary retention. F and E: with mannitol, add at least 20 mEq
dehydration, hyperkalemia, NaCl to each liter of mannitol. ●
hypernatremia, hypokalemia, Confer with physician regarding
hyponatremia. Local: phlebitis at IV placement of an indwelling Foley
site. catheter (except when used to
NURSING RESPONSIBILITIES: decrease intraocular pressure). ● IV:
Administer by IV infusion undiluted. If
Assessment solution contains crystals, warm
bottle in hot water and shake
● Monitor vital signs, urine output, vigorously. Do not administer
CVP, and pulmonary artery solution in which crystals remain
pressures (PAP) before and hourly undissolved. Cool to body
throughout administration. Assess temperature. Use an in-line filter for
patient for signs and symptoms of 15%, 20%, and 25% infusions. ●
dehydration (decreased skin turgor, Test Dose: Administer over 3– 5 min
fever, dry skin and mucous to produce a urine output of 30– 50
membranes, thirst) or signs of fluid mL/hr. If urine flow does not
overload (increased CVP, dyspnea, increase, administer 2nd test dose. If
rales/crackles, edema). ● Assess urine output is not at least 30– 50
patient for anorexia, muscle mL/hr for 2– 3 hr after 2nd test dose,
weakness, numbness, tingling, patient should be re-evaluated. ●
paresthesia, confusion, and Oliguria: Administration rate should
excessive thirst. Report signs of be titrated to produce a urine output
electrolyte imbalance. of 30– 50 mL/hr. Administer child’s
● Increased Intracranial Pressure: dose over 2– 6 hr. ● Increased
Monitor neurologic status and Intracranial Pressure: Infuse dose
intracranial pressure readings in over 30– 60 min in adults and
patients receiving this medication to children. ● Intraocular Pressure:
decrease cerebral edema. ● Administer dose over 30 min. When
Increased Intraocular Pressure: used preoperatively, administer 60–
Monitor for persistent or increased 90 min before surgery. ● Y-Site
eye pain or decreased visual acuity. Compatibility:amifostine,

Page | 246
aztreonam, fludarabine, fluorouracil, response obtained. Additional doses
idarubicin, linezolid, melphalan, may be given q 1– 2 hr if needed.
ondansetron, paclitaxel,
piperacillin/tazobactam, IM, IV, Subcut (Neonates): 0.01
sargramostim, teniposide, thiotepa , mg/kg; may repeat q 2– 3 min until
vinorelbine. ● Y-Site response obtained. Additional doses
Incompatibility:cefepime, filgrastim. may be given q 1– 2 hr if needed.
● Irrigation: Add contents of two 50- POSTOPERATIVE OPIOID-
mL vials of 25% mannitol to 900 mL INDUCED RESPIRATORY
of sterile water for injection for a DEPRESSION
2.5% solution for irrigation. Use only
clear solutions. IV (Adults): 0.02– 0.2 mg q 2– 3 min
until response obtained; repeat q 1–
Evaluation 2 hr if needed.
● Urine output of at least 30– 50 IV (Children): 0.01 mg/kg; may
mL/hr or an increase in urine output repeat q 2– 3 min until response
in accordance with parameters set obtained. Additional doses may be
by physician. given q 1– 2 hr if needed.
● Reduction in intracranial pressure. IM, IV, Subcut (Neonates): 0.01
● Reduction of intraocular pressure. mg/kg; may repeat q 2– 3 min until
response obtained. Additional doses
● Excretion of certain toxic may be given q 1– 2 hr if needed.
substances.
OVERDOSE OF OPIOIDS
● Irrigation during transurethral
prostate resection. IV, IM, Subcut (Adults): Patients not
suspected of being opioid dependent
— 0.4 mg (10 mcg/kg); may repeat q
2– 3 min (IV route is preferred).
C. EMERGENCY DRUGS FOR
POISONING Some patients may require up to 2
mg. Patients suspected to be opioid
dependent—Initial dose should
CLASSIFICATION: OPIOID bepto 0.1– 0.2 mg q 2– 3 min. May
ANTAGONIST also be given by IV infusion at rate
GENERIC NAME: NALOXONE adjusted to patient’s response. IV,
IM, Subcut (Children 5 yr or 20 kg): 2
BRAND NAME: NARCAN mg/dose, may repeat q 2– 3 min. IV,
IM, Subcut (Infants up to 5 yr or 20
RECOMMENDED DOSAGE,
kg): 0.1 mg/kg, may repeat q 2– 3
ROUTE, AND FREQUENCY:
min.
POSTOPERATIVE OPIOID-
Opioid-Induced Pruritus
INDUCED RESPIRATORY
DEPRESSION IV (Children): 2 mcg/kg/hr
continuous infusion, mayqby 0.5
IV (Adults): 0.02–0.2 mg q 2– 3 min
mcg/kg/hr every few hours if pruritus
until response obtained; repeat q 1–
continues.
2 hr if needed. IV (Children): 0.01
mg/kg; may repeat q 2– 3 min until DRUG ACTION: Competitively
blocks the effects of opioids,

Page | 247
including CNS and respiratory NURSING RESPONSIBILITIES:
depression, without producing any
agonist (opioid-like) effects. Assessment
Therapeutic Effects: Reversal of ● Monitor respiratory rate, rhythm,
signs of opioid excess. and depth; pulse, ECG, BP; and
Absorption: Well absorbed after IM level of consciousness frequently for
or subcut administration. 3– 4 hr after the expected peak of
blood concentrations. After a
Distribution: Rapidly distributed to moderate overdose of a short half-
tissues. Crosses the placenta. life opioid, physical stimulation may
be enough to prevent significant
Metabolism and Excretion: hypoventilation. The effects of some
Metabolized by the liver. opioids may last longer than the
Half-life: 60– 90 min (up to 3 hr in effects of naloxone, and repeat
neonates). doses may be necessary. ● Patients
who have been receiving opioids for
TIME/ACTION PROFILE (reversal 1 wk are extremely sensitive to the
of opioid effects) effects of naloxone. Dilute and
administer carefully. ● Assess
ROUTE ONSET PEAK
patient for level of pain after
DURATION
administration when used to treat
IV 1–2min unknown 45min postoperative respiratory depression.
Naloxone decreases respiratory
IM, Subcut 2–5 min unknown 45 depression but also reverses
min analgesia. ● Assess patient for signs
and symptoms of opioid withdrawal
DRUG-DRUG AND DRUG-FOOD
(vomiting, restlessness, abdominal
INTERACTIONS: Drug-Drug: Can
cramps, increased BP, and
precipitate withdrawal in patients
temperature). Symptoms may occur
physically dependent on opioid
within a few minutes to 2 hr. Severity
analgesics. Larger doses may be
depends on dose of naloxone, the
required to reverse the effects of
opioid involved, and degree of
buprenorphine, butorphanol,
physical dependence. ● Lack of
nalbuphine, or pentazocine.
significant improvement indicates
Antagonizes postoperative opioid
that symptoms are caused by a
analgesics.
disease process or other non-opioid
INDICATIONS: Reversal of CNS CNS depressants not affected by
depression and respiratory naloxone. ● Toxicity and
depression because of suspected Overdose: Naloxone is a pure
opioid overdose. Unlabeled Use: antagonist with no agonist properties
Opioid-induced pruritus (low dose IV and minimal toxicity
infusion). Management of refractory
Diagnosis
circulatory shock.
Ineffective breathing pattern
CONTRAINDCIATIONS:
(Indications)
SIDE EFFECTS/ADVERSE
Ineffective coping (Indications)
REACTIONS: CV: VENTRICULAR
ARRHYTHMIAS, hypertension, Acute pain
hypotension.GI: nausea, vomiting.

Page | 248
Implementation consciousness is not obtained after
waiting an additional 45 sec, further
● Do not confuse naloxone with injections of 0.01 mg/kg (up to 0.2
Lanoxin (digoxin). Do not confuse mg) can be administered and
Narcan (naloxone) with Norcuron repeated at 60-sec intervals when
(vecuronium). necessary (up to a maximum of 4
● Larger doses of naloxone may be additional times) to a maximum total
necessary when used to antagonize dose of 0.05 mg/kg or 1 mg,
the effects of buprenorphine, whichever is lower. The dose should
butorphanol, nalbuphine, and be individualized based on the
pentazocine. patient’s response

● Resuscitation equipment, oxygen, Suspected Benzodiazepine

vasopressors, and mechanical
ventilation should be available to
supplement naloxone therapy as
needed.
● Doses should be titrated carefully
in postoperative patients to avoid
interference with control of
postoperative pain.
Evaluation
● Adequate ventilation.
● Alertness without significant pain
or withdrawal symptoms.
CLASSIFICATION:BENZODIAZEPI
NE
GENERIC NAME: FLUMAZENIL
BRAND NAME: ROMAZICON
RECOMMENDED DOSAGE,
ROUTE, AND FREQUENCY:
Reversal of Conscious
Sedation or General Anesthesia
IV (Adults): 0.2 mg. Additional
doses may be given at 1-min
intervals until desired results are
obtained, up to a total dose of 1 mg.
If resedation occurs, regimen may be
repeated at 20-min intervals, not to
exceed 3 mg/hr.
IV (Children): 0.01 mg/kg (up to 0.2
mg); if the desired level of
Overdose
IV (Adults): 0.2 mg. Additional 0.3
mg may be given 30 sec later.
Further doses of 0.5 mg may be
given at 1-min intervals, if necessary,
to a total dose of 3 mg. Usual dose
required is 1– 3 mg. If resedation
occurs, additional doses of 0.5
mg/min for 2 min may be given at
20-min intervals (given no more than
1 mg at a time, not to exceed 3 mg
per hr).
IV (Children): Unlabeled—0.01
mg/kg (maximum dose 0.2 mg) with
repeat doses every minute up to a
cumulative dose of 1 mg. As an
alternative to repeat doses,
continuous infusions of 0.005– 0.01
mg/kg/hr have been used.
DRUG ACTION: Flumazenil is a
benzodiazepine derivative that
antagonizes the CNS depressant
effects of benzodiazepine
compounds. It has no effect on CNS
depression from other causes,
including opioids, alcohol,
barbiturates, or general anesthetics.
Therapeutic Effects: Reversal of
benzodiazepine effects.
Absorption: IV administration
results in complete bioavailability.
Distribution: Unknown. Protein
Binding: 50% primarily to albumin.

Page | 249
Metabolism and Excretion: Pedi: Children 1 yr (safety not
Metabolism of flumazenil occurs established).
primarily in the liver. Half-life:
Children: 20– 75 min; Adults: 41– 79 SIDE EFFECTS/ADVERSE
min. REACTIONS: CNS: SEIZURES,
dizziness, agitation, confusion,
TIME/ACTION PROFILE (reversal drowsiness, emotional lability,
of benzodiazepine effects) fatigue, headache, sleep disorders.
EENT: abnormal hearing, abnormal
ROUTE ONSET PEAK vision, blurred vision.
DURATION CV:arrhythmias, chest pain,
IV 1–2min 6–10min 1–2 hr† hypertension.GI: nausea, vomiting,
hiccups. Derm: flushing, sweating.
DRUG-DRUG AND DRUG-FOOD Local: pain/injection-site reactions,
INTERACTIONS: Drug-Drug: None phlebitis. Neuro: paresthesia.
significant. Misc:rigors, shivering

INDICATIONS: Complete/partial NURSING RESPONSIBILITIES:

reversal of effects of
benzodiazepines used as general Assessment
anesthetics, or during diagnostic or ● Assess level of consciousness and
therapeutic procedures. respiratory status before and during
Management of intentional or therapy. Observe patient for at least
accidental overdose of 2 hr after administration for the
benzodiazepines. appearance of resedation.
CONTRAINDCIATIONS: Hypoventilation may occur. ●
Hypersensitivity to flumazenil or Overdose: Attempt to determine time
benzodiazepines; Patients receiving of ingestion and amount and type of
benzodiazepines for life-threatening benzodiazepine taken. Knowledge of
medical problems, including status agent ingested allows an estimate of
epilepticus orqintracranial pressure; duration of CNS depression.
Serious cyclic antidepressant Diagnosis
overdosage.
Risk for injury (Indications) Risk for
Use Cautiously in: Mixed CNS poisoning (Indications)
depressant overdose (effects of
other agents may emerge when Implementation
benzodiazepine effect is removed);
History of seizures (seizures are ● Do not confuse flumazenil with
more likely to occur in patients who influenza virus vaccine. ● Ensure
are experiencing sedative/hypnotic that patient has a patent airway
withdrawal, who have recently before administration of flumazenil. ●
received repeated doses of Observe IV site frequently for
benzodiazepines, or who have a redness or irritation. Administer
previous history of seizure activity); through a freeflowing IV infusion into
Head injury (mayqintracranial a large vein to minimize pain at the
pressure and risk of seizures); injection site. ● Optimal emergence
Severe hepatic impairment; OB, should be undertaken slowly to
Lactation: Safety not established; decrease undesirable effects
including confusion, agitation,

Page | 250
emotional lability, and perceptual IV (Children and Infants): 1– 20
distortion. mcg/kg/min, depending on desired
response (1– 5 mcg/kg/min has been
● Institute seizure precautions. used to improve renal blood flow).
Seizures are more likely to occur in
patients who are experiencing IV (Neonates): 1– 20 mcg/kg/min.
sedative/hypnotic withdrawal,
patients who have recently received DRUG ACTION: Small doses (0.5–
repeated doses of benzodiazepines, 3 mcg/kg/min) stimulate
or those who have a previous history dopaminergic receptors, producing
of seizure activity. Seizures may be renal vasodilation. Larger doses (2–
treated with benzodiazepines, 10 mcg/kg/min) stimulate
barbiturates, or phenytoin. Larger dopaminergic and beta1-adrenergic
than normal doses of receptors, producing cardiac
benzodiazepines may be required. stimulation and renal vasodilation.
Doses greater than 10 mcg/kg/min
● Suspected Benzodiazepine stimulate alpha-adrenergic receptors
Overdose: If no effects are seen and may cause renal
after administration of flumazenil, vasoconstriction. Therapeutic
consider other causes of decreased Effects: Increased cardiac output,
level of consciousness (alcohol, increased BP, and improved renal
barbiturates, opioid analgesics). blood flow.

Evaluation Absorption: Administered IV only,

● Improved level of consciousness. ●
Decrease in respiratory depression
caused by benzodiazepines.
resulting in complete bioavailability.
Distribution: Widely distributed but
does not cross the blood-brain
barrier.

Metabolism and Excretion:

D. EMERGENCY DRUGS FOR Metabolized in liver, kidneys, and
SHOCK plasma.
CLASSIFICATION: Half-life: 2 min.
CATHERCHOLAMINE
TIME/ACTION PROFILE
GENERIC NAME: DOPAMINE (hemodynamic effects)
BRAND NAME: ROUTE ONSET PEAK
RECOMMENDED DOSAGE, DURATION
ROUTE, AND FREQUENCY: IV 1–2min upto10 min 10 min
IV (Adults): Dopaminergic (renal DRUG-DRUG AND DRUG-FOOD
vasodilation) effects—1– 5 INTERACTIONS:
mcg/kg/min. Beta-adrenergic
(cardiac stimulation) effects—5– 15 Drug-Drug: Use with MAO inhi
mcg/kg/min. Alpha-adrenergic bitors, ergot
(increased peripheral vascular alkaloids(ergotamine), doxapram, or
resistance) effects—15 mcg/kg/min; some antidepressantsresults in
infusion rate may be increased as severe hypertension. Use with IV
needed. phenytoinmay cause hypotension
and bradycardia. Use with general

Page | 251
anestheticsmay result in administration. Notify physician if
arrhythmias. Beta blockersmay quality of pulse deteriorates or if
antagonize cardiac effects. extremities become cold or mottled.
● If hypotension occurs,
INDICATIONS: Adjunct to standard administration rate should be
measures to improve: BP, Cardiac increased. If hypotension continues,
output, Urine output in treatment of more potent vasoconstrictors
shock unresponsive to fluid (norepinephrine) may be
replacement. Increase renal administered. ● Toxicity and
perfusion (low doses). Overdose: If excessive hypertension
CONTRAINDCIATIONS: : occurs, rate of infusion should be
Tachyarrhythmias; decreased or temporarily
Pheochromocytoma; Hypersensitivity discontinued until BP is decreased.
to bisulfites (some products). Use Although additional measures are
Cautiously in: Hypovolemia; usually not necessary because of
Myocardial infarction; Occlusive short duration of dopamine,
vascular diseases; Geri: Older phentolamine may be administered if
patients may be more susceptible to hypertension continues.
adverse effects; OB: Pregnancy and Diagnosis
lactation (safety not established).
Decreased cardiac output
SIDE EFFECTS/ADVERSE (Indications) Ineffective tissue
REACTIONS: CNS: headache. perfusion (Indications)
EENT: mydriasis (high dose). Resp:
dyspnea. CV: arrhythmias, Implementation
hypotension, angina, ECG change,
palpitations, vasoconstriction. GI: ● High Alert: IV vasoactive
nausea, vomiting. Derm: medications are potentially
piloerection. Local: irritation at IV dangerous. Have second practitioner
site. independently check original order,
dose calculations, and infusion pump
NURSING RESPONSIBILITIES: settings. Do not confuse dopamine
with dobutamine. If both are
Assessment available as floor stock, store in
● Monitor BP, heart rate, pulse separate areas. ● Correct
pressure, ECG, pulmonary capillary hypovolemia with volume expanders
wedge pressure (PCWP), cardiac before initiating dopamine therapy.
output, CVP, and urinary output ● Extravasation may cause severe
continuously during administration. irritation, necrosis, and sloughing of
Report significant changes in vital tissue. Administer into a large vein
signs or arrhythmias. Consult and assess administration site
physician for parameters for pulse, frequently. If extravasation occurs,
BP, or ECG changes for adjusting affected area should be infiltrated
dose or discontinuing medication. ● liberally with 10– 15 mL of 0.9%
Monitor urine output frequently NaCl containing 5– 10 mg of
throughout administration. Report phentolamine. For pediatric patients,
decreases in urine output promptly. use 1 mL of phentolamine dilution to
● Palpate peripheral pulses and infiltrate (do not exceed 5 mg total).
assess appearance of extremities Infiltration within 12 hr of
routinely during dopamine

Page | 252
extravasation produces immediate increased BP, and improved renal
hyperemic changes. blood flow.

EVALUATION Absorption: Administered IV only,

● Increase in BP.
● Increase in peripheral circulation.
● Increase in urine output.
resulting in complete bioavailability.
Distribution: Widely distributed but
does not cross the blood-brain
barrier.

Metabolism and Excretion:

Metabolized in liver, kidneys, and
CLASSIFICATION: plasma.
CATHECHOLAMINE
Half-life: 2 min.
GENERIC NAME: DOPAMINE
PROFILE (hemodynamic effect
BRAND NAME: TIME/ACTIONs)

RECOMMENDED DOSAGE, ROUTE ONSET PEAK DURATION

ROUTE, AND FREQUENCY:
IV 1-2min up to 10min 10min
IV (Adults): Dopaminergic (renal
vasodilation) effects—1– 5 DRUG-DRUG AND DRUG-FOOD
mcg/kg/min. Beta-adrenergic INTERACTIONS: Drug-Drug: Use
(cardiac stimulation) effects—5– 15 with MAO inhibitors, ergot
mcg/kg/min. Alpha-adrenergic alkaloids(ergotamine), doxapram, or
(increased peripheral vascular some antidepressants results in
resistance) effects—15 mcg/kg/min; severe hypertension. Use with IV
infusion rate may be increased as phenyto in may cause hypotension
needed. and bradycardia. Use with general
anesthetics may result in
IV (Children and Infants): 1– 20 arrhythmias. Beta blockers may
mcg/kg/min, depending on desired antagonize cardiac effects.
response (1– 5 mcg/kg/min has been
used to improve renal blood flow). INDICATIONS: Adjunct to standard
measures to improve: BP, Cardiac
IV (Neonates): 1– 20 mcg/kg/min. output, Urine output in treatment of
shock unresponsive to fluid
DRUG ACTION: Small doses (0.5–
replacement. Increase renal
3 mcg/kg/min) stimulate
perfusion (low doses).
dopaminergic receptors, producing
renal vasodilation. Larger doses (2– CONTRAINDCIATIONS:
10 mcg/kg/min) stimulate Tachyarrhythmias;
dopaminergic and beta1-adrenergic Pheochromocytoma; Hypersensitivity
receptors, producing cardiac to bisulfites (some products). Use
stimulation and renal vasodilation. Cautiously in: Hypovolemia;
Doses greater than 10 mcg/kg/min Myocardial infarction; Occlusive
stimulate alpha-adrenergic receptors vascular diseases; Geri: Older
and may cause renal patients may be more susceptible to
vasoconstriction. Therapeutic adverse effects; OB: Pregnancy and
Effects: Increased cardiac output, lactation (safety not established).

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SIDE EFFECTS/ADVERSE Diagnosis
REACTIONS: CNS: headache.
EENT: mydriasis (high dose). Resp: Decreased cardiac output
dyspnea. CV: arrhythmias, (Indications)
hypotension, angina, ECG change, Ineffective tissue perfusion
palpitations, vasoconstriction. GI: (Indications)
nausea, vomiting.Derm: piloerection.
Local: irritation at IV site. Implementation

NURSING RESPONSIBILITIES: ● High Alert: IV vasoactive

Assessment
● Monitor BP, heart rate, pulse
pressure, ECG, pulmonary capillary
wedge pressure (PCWP), cardiac
output, CVP, and urinary output
continuously during administration.
Report significant changes in vital
signs or arrhythmias. Consult
physician for parameters for pulse,
BP, or ECG changes for adjusting
dose or discontinuing medication. ●
Monitor urine output frequently
throughout administration. Report
decreases in urine output promptly.
● Palpate peripheral pulses and
assess appearance of extremities
routinely during dopamine
administration. Notify physician if
quality of pulse deteriorates or if
extremities become cold or mottled.
● If hypotension occurs,
administration rate should be
increased. If hypotension continues,
more potent vasoconstrictors
(norepinephrine
medications are potentially
dangerous. Have second practitioner
independently check original order,
dose calculations, and infusion pump
settings. Do not confuse dopamine
with dobutamine. If both are
available as floor stock, store in
separate areas. ● Correct
hypovolemia with volume expanders
before initiating dopamine therapy. ●
Extravasation may cause severe
irritation, necrosis, and sloughing of
tissue. Administer into a large vein
and assess administration site
frequently. If extravasation occurs,
affected area should be infiltrated
liberally with 10– 15 mL of 0.9%
NaCl containing 5– 10 mg of
phentolamine. For pediatric patients,
use 1 mL of phentolamine dilution to
infiltrate (do not exceed 5 mg total).
Infiltration within 12 hr of
extravasation produces immediate
hyperemic changes.
Evaluation
● Increase in BP.

● Increase in peripheral circulation.

● Increase in urine output.

) may be administered. ● Toxicity
and Overdose: If excessive
hypertension occurs, rate of infusion
CLASSIFICATION: BETA1
should be decreased or temporarily
ADRENERGIC AGENT
discontinued until BP is decreased.
Although additional measures are GENERIC NAME: DOBUTAMINE
usually not necessary because of
short duration of dopamine, BRAND NAME: DOBUTEX
phentolamine may be administered if
hypertension continues.

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RECOMMENDED DOSAGE, CONTRAINDCIATIONS:
ROUTE, AND FREQUENCY: Hypersensitivity to dobutamine or
bisulfites; Idiopathic hypertrophic
IV (Adults and Children): 2.5– 15 subaortic stenosis.Use Cautiously
mcg/kg/min titrate to response (up to in: History of hypertension
40 mcg/ kg/min). (increased risk of exaggerated
IV (Neonates): 2– 15 mcg/kg/min. pressor response); MI; Atrial
fibrillation (pretreatment with digitalis
DRUG ACTION: Stimulates glycosides recommended); History of
beta1(myocardial)-adrenergic ventricular atopic activity (may be
receptors with relatively minor effect exacerbated); Hypovolemia (correct
on heart rate or peripheral blood before administration); Pregnancy or
vessels. Therapeutic Effects: lactation (safety not established).
Increased cardiac output without
significantly increased heart rate. SIDE EFFECTS/ADVERSE
REACTIONS: CNS: headache.
bsorption: Administered by IV Resp: shortness of breath. CV:
infusion only, resulting in complete hypertension, increased heart rate,
bioavailability. premature ventricular contractions,
angina pectoris, arrhythmias,
Distribution: Unknown.
hypotension, palpitations. GI:
Metabolism and Excretion: nausea, vomiting. Local: phlebitis.
Metabolized by the liver and other Misc: hypersensitivity reactions
tissues. including skin rash, fever,
bronchospasm or eosinophilia,
Half-life: 2 min. nonanginal chest pain.
TIME/ACTION PROFILE (inotropic NURSING RESPONSIBILITIES:
effects) Assessment
ROUTE ONSET PEAK ● Monitor BP, heart rate, ECG,
DURATION pulmonary capillary wedge pressure
(PCWP), cardiac output, CVP, and
IV 1–2min 10min brief(min)
urinary output continuously during
DRUG-DRUG AND DRUG-FOOD the administration. Report significant
INTERACTIONS: Drug-Drug: Use changes in vital signs or arrhythmias.
with nitroprusside may have a Consult physician for parameters for
synergistic effect onqcardiac output. pulse, BP, or ECG changes for
Beta blockers may negate the effect adjusting dose or discontinuing
of dobutamine.qrisk of arrhythmias medication. ● Palpate peripheral
or hypertension with some pulses and assess appearance of
anesthetics (cyclopropane, extremities routinely throughout
halothane), MAO inhibitors, dobutamine administration. Notify
oxytocics, ortricyclic antidepressants. physician if quality of pulse
deteriorates or if extremities become
INDICATIONS: Short-term (48 hr) cold or mottled. ● Lab Test
management of heart failure caused Considerations: Monitor potassium
by depressed contractility from concentrations during therapy; may
organic heart disease or surgical cause hypokalemia. ● Monitor
procedures. electrolytes, BUN, creatinine, and
prothrombin time weekly during

Page | 255
prolonged therapy. ● Toxicity and
Overdose: If overdose occurs,
reduction or discontinuation of
therapy is the only treatment
necessary because of the short
duration of dobutamine.
Diagnosis
Decreased cardiac output
(Indications)
Ineffective tissue perfusion
(Indications)
Implementation
● High Alert: IV vasoactive
medications are potentially
dangerous. Have second practitioner
independently check original order,
dosage calculations, and infusion
pump settings. Do not confuse
dobutamine with dopamine. If
available as floor stock, store in
separate areas. ● Correct
hypovolemia with volume expanders
before initiating dobutamine therapy.
● Administer into a large vein and
assess administration site frequently.
Extravasation may cause pain and
inflammation.
IV Administration
● pH: 2.5– 5.5. ● Continuous
Infusion: Diluent: Vials must be
diluted before use. Dilute 250– 1000
mg in 250– 500 mL of D5W, 0.9%
NaCl, 0.45% NaCl, D5/0.45% NaCl,
D5/ 0.9% NaCl, or LR. Admixed
infusions stable for 48 hr at room
temperature and 7 days if
refrigerated. Premixed infusions are
already diluted and ready to use.
Concentration: 0.25– 5 mg/mL.
Rate: Based on patient’s weight (see
Route/Dosage section). Administer
via infusion pump to ensure precise
amount delivered. Titrate to patient
response (heart rate, presence of
ectopic activity, BP, urine output,
CVP, PCWP, cardiac index). Dose
should be titrated so heart rate does
not increase by 10% of baseline.
Evaluation
● Increase in cardiac output.
● Improved hemodynamic
parameters.
● Increased urine output.
CLASSIFICATION:
SYMPATHOMIMETIC AGENT:
ALPHA ADRENERGIC AGENT
GENERIC NAME:
NOREPINEPHRINE
BRAND NAME:
RECOMMENDED DOSAGE,
ROUTE, AND FREQUENCY:
IV (Adults): 0.5– 1 mcg/min initially,
followed by maintenance infusion of
2– 12 mcg/min titrated by BP
response (average rate 2– 4
mcg/min, up to 30 mcg/min for
refractory shock have been used).
IV (Children): 0.1 mcg/kg/min
initially; may be followed by infusion
titrated to BP response, up to 1
mcg/kg/min.
DRUG ACTION: Stimulates alpha-
adrenergic receptors located mainly
in blood vessels, causing constriction
of both capacitance and resistance
vessels. Also has minor beta-
adrenergic activity (myocardial
stimulation). Therapeutic Effects:
Increased BP. Increased cardiac
output.
Absorption: IV administration
results in complete bioavailability.
Distribution: Concentrates in
sympathetic nervous tissue. Does

Page | 256
not cross the blood-brain barrier but Cautiously in: Hypertension;
readily crosses the placenta. Concurrent use of MAO inhibitors,
tricyclic antidepressants, or
Metabolism and Excretion: Taken cyclopropane or halothane
up and metabolized rapidly by anesthetics; Hyperthyroidism;
sympathetic nerve endings. Cardiovascular disease;
Half-life: Unknown. Lactation:Safety not established.

TIME/ACTION PROFILE (effects on SIDE EFFECTS/ADVERSE

BP)
ROUTE ONSET PEAK
DURATION
IV immediate rapid 1–2 min
DRUG-DRUG AND DRUG-FOOD
INTERACTIONS: Drug-Drug: Use
with cyclopropane or halothane
anesthesia,cardiac glycosides,
doxapram, or local use of cocaine
may result inqmyocardial irritability.
Use with MAO inhibitors,
methyldopa, doxapram, or tricyclic
antidepressants may result in severe
hypertension. Alpha-adrenergic
blockerscan prevent pressor
response. Beta blockers may
exaggerate hypertension or block
cardiac stimulation. Concurrent use
with ergot alkaloids (ergotamine,
ergonovine, methylergonovine, or
oxytocin may result in enhanced
vasoconstriction and hypertension.
INDICATIONS: Produces
vasoconstriction and myocardial
stimulation, which may be required
after adequate fluid replacement in
the treatment of severe hypotension
and shock.
CONTRAINDCIATIONS:
: Vascular, mesenteric, or peripheral
thrombosis;OB:puterine blood flow;
Hypoxia; Hypercarbia; Hypotension
secondary to hypovolemia (without
appropriate volume replacement);
Hypersensitivity to bisulfites. Use
REACTIONS: CNS: anxiety,
dizziness, headache, insomnia,
restlessness, tremor, weakness.
Resp: dyspnea. CV: arrhythmias,
bradycardia, chest pain,
hypertension. GU:p urine output,
renal failure. Endo: hyperglycemia.
F and E: metabolic acidosis. Local:
phlebitis at IV site.Misc: fever.
NURSING RESPONSIBILITIES:
Assessment
● Monitor BP every 2– 3 min until
stabilized and every 5 min thereafter.
Systolic BP is usually maintained at
80– 100 mm Hg or 30– 40 mm Hg
below the previously existing systolic
pressure in previously hypertensive
patients. Consult physician for
parameters. Continue to monitor BP
frequently for hypotension following
discontinuation of norepinephrine. ●
ECG should be monitored
continuously. CVP, intra-arterial
pressure, pulmonary artery diastolic
pressure, pulmonary capillary wedge
pressure (PCWP), and cardiac
output may also be monitored. ●
Monitor urine output and notify
health care professional if it
decreases to 30mL/ hr. ● Assess IV
site frequently throughout infusion. A
large vein should be used to
minimize risk of extravasation, which
may cause tissue necrosis.
Phentolamine 5– 10mg may be
added to each liter of solution to
prevent sloughing of tissue in
extravasation. If extravasation
occurs, the site should be infiltrated

Page | 257
promptly with 10– 15 mL of 0.9%
NaCl solution containing 5– 10 mg of
phentolamine to prevent necrosis
and sloughing. If prolonged therapy
is required or if blanching along the
course of the vein occurs, change
injection sites to provide relief from
vasoconstriction.
● Toxicity and Overdose: If
overdose occurs, discontinue
norepinephrine and administer fluid
and electrolyte replacement therapy.
An alpha-adrenergic blocking agent
(phentolamine 5– 10 mg) may be
administered intravenously to treat
hypertension.
Diagnosis
Decreased cardiac output
(Indications)
Ineffective tissue perfusion
(Indications)
Implementation
● High Alert: Vasoactive
medications are inherently
dangerous. Have second practitioner
independently check original order,
dose calculations, and infusion pump
programming. Establish maximum
dose limits. Norepinephrine
overdose can result in severe
peripheral vasoconstriction with
resultant ischemia and necrosis of
peripheral tissue. Assess peripheral
circulation frequently. ● Volume
depletion should be corrected, if
possible, prior to initiation of
norepinephrine. ● Heparin may be
added to each 500 mL of solution to
prevent thrombosis in the infused
vein, perivenous reactions, and
necrosis in patients with severe
hypotension following MI. ●
Norepinephrine may deplete plasma
volume and cause ischemia of vital
organs, resulting in hypotension
when discontinued, if used for
prolonged periods. Prolonged or
large doses may also decrease
cardiac output. ● Infusion should be
discontinued gradually, upon
adequate tissue perfusion and
maintenance of BP, to prevent
hypotension. Do not resume therapy
unless BP falls to 70– 80 mm Hg.
Evaluation
● Increase in BP to normal range. '
● Increased tissue perfusion.
CLASSIFICATION:
SYMPATHOMIMENTIC AGENT:
BETA ADREGENIC
GENERIC NAME: ALBUTEROL
BRAND NAME:
RECOMMENDED DOSAGE,
ROUTE, AND FREQUENCY:
PO (Adults and Children 12 yr): 2–
4 mg 3– 4 times daily (not to exceed
32 mg/ day) or 4– 8 mg of extended-
release tablets twice daily.
PO (Geriatric Patients): Initial dose
should not exceed 2 mg 3– 4 times
daily, may beqcarefully (up to 32
mg/day).
PO (Children 6–12 yr): 2 mg 3– 4
times daily or 0.3– 0.6 mg/kg/day as
extendedrelease tablets divided
twice daily; may be carefullyqas
needed (not to exceed 8 mg/ day).
PO (Children 2–6 yr): 0.1 mg/kg 3
times daily (not to exceed 2 mg 3
times daily initially); may be
carefullyqto 0.2 mg/kg 3 times daily
(not to exceed 4 mg 3 times daily).
Inhaln (Adults and Children 4 yr):
Via metered-dose inhaler—2
inhalations q 4– 6 hr or 2 inhalations
15 min before exercise (90
Page | 258
mcg/spray); some patients may Absorption: Well absorbed after
respond to 1 inhalation. NIH oral administration but rapidly
Guidelines for acute asthma undergoes extensive metabolism.
exacerbation: Children—4– 8 puffs q
20 min for 3 doses then q 1– 4 hr; Distribution: Small amounts appear
Adults—4– 8 puffs q 20 min for up to in breast milk.
4 hr then q 1– 4 hr prn. Metabolism and Excretion:
Inhaln (Adults and Children Extensively metabolized by the liver
_x0005_12 yr): NIH Guidelines for and other tissues. Half-life: Oral
acute asthma exacerbation via 2.7– 5 hr; Inhalation: 3.8 hr.
nebulization or IPPB—2.5– 5 mg q TIME/ACTION PROFILE
20 min for 3 doses then 2.5– 10 mg (bronchodilation)
q 1– 4 hr prn; Continuous ROUTE ONSET PEAK
nebulization—10– 15 mg/hr. DURATION
Inhaln (Children 2–12 yr): NIH PO 15–30min 2–3hr 4–6hr or
Guidelines for acute asthma more
exacerbation via nebulization or
IPPB—0.15 mg/kg/dose (minimum PO–ER 30min 2–3hr 12 hr
dose 2.5 mg) q 20 min for 3 doses
Inhaln 5–15min 60–90min 3–
then 0.15– 0.3 mg/kg (not to exceed
6hr
10 mg) q 1– 4 hr prn or 1.25 mg 3– 4
times daily for children 10– 15 kg or DRUG-DRUG AND DRUG-FOOD
2.5 mg 3– 4 times daily for children INTERACTIONS: Drug-Drug:
_x0005_15 k g; Continuous Concurrent use with other adrenergic
nebulization—0.5– 3 mg/kg/hr. agents will haveqadrenergic side
effects. Use with MAO inhibitors may
Inhaln (Neonates): 1.25 mg/dose q
lead to hypertensive crisis. Beta
8 hr via nebulization or 1– 2 puffs via
blockers may negate therapeutic
MDI into the ventilator circuit q 6 hrs.
effect. Maypserum digoxin levels.
DRUG ACTION: Binds to beta2- Cardiovascular effects are
adrenergic receptors in airway potentiated in patients receiving
smooth muscle, leading to activation tricyclic antidepressants. Risk of
of adenyl cyclase and increased hypokalemiaqconcurrent use of
levels of cyclic-3, 5-adenosine potassium-losing diuretics.
monophosphate (cAMP). Increases Hypokalemiaqthe risk of digoxin
in cAMP activate kinases, which toxicity.
inhibit the phosphorylation of myosin
Drug-Natural Products: Use with
and decrease intracellular calcium.
caffeine-containing herbs (cola nut,
Decreased intracellular calcium
guarana, tea,coffee)qstimulant
relaxes smooth muscle airways.
effect.
Relaxation of airway smooth muscle
with subsequent bronchodilation. INDICATIONS: Used as a
Relatively selective for beta2 bronchodilator to control and prevent
(pulmonary) receptors. Therapeutic reversible airway obstruction caused
Effects: Bronchodilation. by asthma or COPD. Inhaln: Used
as a quick-relief agent for acute
bronchospasm and for prevention of
exercise-induced bronchospasm.

Page | 259
PO: Used as a long-term control Diagnosis
agent in patients with
chronic/persistent bronchospasm. Ineffective airway clearance
(Indications)
CONTRAINDCIATIONS:
Hypersensitivity to adrenergic Implementation
amines. Use Cautiously in: Cardiac ● PO: Administer oral medication
disease; Hypertension; with meals to minimize gastric
Hyperthyroidism; Diabetes; irritation. ● Extended-release tablets
Glaucoma; Seizure disorders; should be swallowed whole; do not
Excess inhaler use may lead to break, crush, or chew. ● Inhaln:
tolerance and paradoxical Shake inhaler well, and allow at least
bronchospasm; OB, Lactation, Pedi: 1 min between inhalations of aerosol
Safety not established for pregnant medication. Prime the inhaler before
women near term, breast-feeding first use by releasing 4 test sprays
women, and children 2 yr; Geri:qrisk into the air away from the face.
of adverse reactions; may require Use spacer for children 8 yr of age.
dosep. ● For nebulization or IPPB, the 0.5-,
SIDE EFFECTS/ADVERSE 0.83-, 1-, and 2-mg/mL solutions do
REACTIONS: CNS: nervousness, not require dilution before
restlessness, tremor, headache, administration. The 5 mg/mL (0.5%)
insomnia (Pedi: occurs more solution must be diluted with 1– 2.5
frequently in young children than mL of 0.9% NaCl for inhalation.
adults), hyperactivity in children. Diluted solutions are stable for 24 hr
Resp: PARADOXICAL at room temperature or 48 hr if
BRONCHOSPASM (excessive use refrigerated. ● For nebulizer,
of inhalers). CV:chest pain, compressed air or oxygen flow
palpitations, angina, arrhythmias, should be 6– 10 L/min; a single
hypertension. GI: nausea, vomiting. treatment of 3 mL lasts about 10
Endo: hyperglycemia. F and E: min. ● IPPB usually lasts 5– 20 min.
hypokalemia.Neuro: tremor. Evaluation
NURSING RESPONSIBILITIES: ● Prevention or relief of
Assessment ● Assess lung sounds, bronchospasm.
pulse, and BP before administration CLASSIFICATION:
and during peak of medication. Note ANTIHISTAMINE: FIRST
amount, color, and character of GENERATION, ETHANOLAMINE
sputum produced. ● Monitor DERIVATIVE
pulmonary function tests before GENERIC NAME:
initiating therapy and periodically DIPHENHYDRAMINE
during therapy. ● Observe for HYDROCHLORIDE
paradoxical bronchospasm BRAND NAME:
(wheezing). If condition occurs,
withhold medication and notify health
care professional immediately. ● Lab RECOMMENDED DOSAGE,
Test Considerations: May cause ROUTE, AND FREQUENCY:
transientpin serum potassium PO (Adults and Children 12 yr):
concentrations with nebulization or Antihistaminic/antiemetic/antivertigini
higher-than-recommended doses. c—25– 50 mg q 4– 6 hr, not to

Page | 260
exceed 300 mg/day. Antitussive—25 Absorption: Well absorbed after
mg q 4 hr as needed, not to exceed oral or IM administration but 40–
150 mg/day. Antidyskinetic—25– 50 60% of an oral dose reaches
mg q 4 hr(not to exceed 400 systemic circulation due to first-pass
mg/day).Sedative/hypnotic—50 mg metabolism. Distribution: Widely
20– 30 min before bedtime. distributed. Crosses the placenta;
enters breast milk.
PO (Children 6– 12 yr): Metabolism and Excretion: 95%
Antihistaminic/antiemetic/antivertigini metabolized by the liver.
c—12.5– 25 mg q 4– 6 hr (not to Half-life: 2.4– 7 hr
exceed 150 mg/day). Antidyskinetic TIME/ACTION PROFILE
—1– 1.5 mg/kg q 6– 8 hr as needed (antihistaminic effects)
(not to exceed 300 mg/day). ROUTE ONSET PEAK
Antitussive—12.5 mg q 4 hr(not to DURATION
exceed 75 PO 15–60 min 2–4 hr
mg/day).Sedative/hypnotic—1 4–8 hr
mg/kg/dose 20– 30 min before IM 20–30 min 2–4 hr
bedtime (not to exceed 50 mg). 4–8 hr
PO (Children 2– 6 yr): IV rapid unknown
Antihistaminic/antiemetic/ 4–8 hr
antivertiginic—6.25– 12.5 mg q 4– 6 DRUG-DRUG AND DRUG-FOOD
hr (not to exceed 37.5 mg/day). INTERACTIONS: Drug-Drug: qrisk
Antidyskinetic—1– 1.5 mg/kg q 4– 6 of CNS depression with other
hr as needed (not to exceed 300 antihistamines, alcohol, opioid
mg/day). Antitussive—6.25 mg q 4 analgesics, and
hr(not to exceed 37.5 mg/24 hr). sedative/hypnotics.qanticholinergic
Sedative/hypnotic—1 mg/kg/dose effects with tricyclic antidepressants,
20– 30 min before bedtime (not to quinidine, or disopyramide. MAO
exceed 50 mg). inhibitorsintensify and prolong the
IM, IV (Adults): 25– 50 mg q 4 hr as anticholinergic effects of
needed (may need up to 100-mg antihistamines. Drug-Natural
dose, not to exceed 400 mg/day). Products: Concomitant use of kava-
IM, IV (Children): 1.25 mg/kg (37.5 kava,valerian, orchamomile
mg/m2 ) 4 times daily (not to exceed canqCNS depression.
300 mg/ day). Topical (Adults and INDICATIONS: Relief of allergic
Children 2 yr): Apply to affected area symptoms caused by histamine
up to 3– 4 times daily. release including: Anaphylaxis,
DRUG ACTION: Antagonizes the Seasonal and perennial allergic
effects of histamine at H1-receptor rhinitis, Allergic dermatoses.
sites; does not bind to or inactivate Parkinson’s disease and dystonic
histamine. Significant CNS reactions from medications. Mild
depressant and anticholinergic nighttime sedation. Prevention of
properties.Therapeutic Effects: motion sickness. Antitussive (syrup
Decreased symptoms of histamine only).
excess (sneezing, rhinorrhea, nasal CONTRAINDICATIONS:
and ocular pruritus, ocular tearing Hypersensitivity; Acute attacks of
and redness, urticaria). Relief of asthma; Lactation:Lactation; Known
acute dystonic reactions. Prevention alcohol intolerance (some liquid
of motion sickness. Suppression of products). Use Cautiously in:
cough. Severe liver disease; Angle-closure

Page | 261
glaucoma; Seizure disorders; administration. ● Insomnia: Assess
Prostatic hyperplasia; Peptic ulcer; sleep patterns. ● Motion Sickness:
May cause paradoxical excitation in Assess nausea, vomiting, bowel
young children; Hyperthyroidism; sounds, and abdominal pain. ●
OB: Safety not established; Geri: Cough Suppressant: Assess
Appears on Beers list. Geriatric frequency and nature of cough, lung
patients are more susceptible to sounds, and amount and type of
adverse drug reactions and sputum produced. Unless
anticholinergic effects (delirium, contraindicated, maintain fluid intake
acute confusion, dizziness, dry of 1500– 2000 mL daily to decrease
mouth, blurred vision, urinary viscosity of bronchial secretions. ●
retention, constipation, tachycardia); Pruritus: Assess degree of itching,
dosepor non-anticholinergic skin rash, and inflammation.
antihistamine recommended. ● Lab Test Considerations:
SIDE EFFECTS/ADVERSE Maypskin response to allergy tests.
REACTIONS: Discontinue 4 days before skin
CNS: drowsiness, dizziness, testing.
headache, paradoxical excitation Diagnosis
(increased in children). EENT: Insomnia (Indications)
blurred vision, tinnitus. CV: Risk for deficient fluid volume
hypotension, palpitations. GI: (Indications)
anorexia, dry mouth, constipation, Risk for injury (Side Effects)
nausea. GU: dysuria, frequency, Implementation
urinary retention. Derm: ● Do not confuse Benadryl with
photosensitivity. Resp: chest benazepril. ● When used for
tightness, thickened bronchial insomnia, administer 20 min before
secretions, wheezing. Local: pain at bedtime and schedule activities to
IM site. minimize interruption of sleep. ●
NURSING RESPONSIBILITIES: When used for prophylaxis of motion
Assessment sickness, administer at least 30 min
● Diphenhydramine has multiple and preferably 1– 2 hr before
uses. Determine why the medication exposure to conditions that may
was ordered and assess symptoms precipitate motion sickness. ● PO:
that apply to the individual patient. Administer with meals or milk to
Geri: Appears in the Beers list. May minimize GI irritation. Capsule may
cause sedation and confusion due to be emptied and contents taken with
increased sensitivity to water or food. ● Orally disintegrating
anticholinergic effects. Monitor tablets and strips should be left in
carefully, assess for confusion, the package until use. Remove from
delirium, other anticholinergic side the blister pouch. Do not push tablet
effects and fall risk. Institute through the blister; peel open the
measures to prevent falls. ● blister pack with dry hands and place
Prevention and Treatment of tablet on tongue. Tablet will dissolve
Anaphylaxis: Assess for urticaria rapidly and be swallowed with saliva.
and for patency of airway. ● Allergic No liquid is needed to take the orally
Rhinitis: Assess degree of nasal disintegrating tablet. ● IM:
stuffiness, rhinorrhea, and sneezing. Administer 50 mg/mL into well-
● Parkinsonism and developed muscle. Avoid subcut
Extrapyramidal Reactions: Assess injections.
movement disorder before and after Evaluation

Page | 262
● Prevention of, or decreased unchanged by the kidneys.
urticaria in, anaphylaxis or other Half-life: Unknown.
allergic reactions. TIME/ACTION PROFILE (effects on
● Decreased dyskinesia in blood sugar in diabetic patients)
parkinsonism and extrapyramidal ROUTE ONSET PEAK
reactions. DURATION
● Sedation when used as a PO rapid rapid
sedative/hypnotic. brief
● Prevention of or decrease in IV rapid rapid
nausea and vomiting caused by brief
motion sickness. DRUG-DRUG AND DRUG-FOOD
● Decrease in frequency and INTERACTIONS: Drug-Drug: Will
intensity of cough without eliminating alter requirements forinsulin or oral
cough reflex. hypoglycemic agentsin diabetic
patients.
CLASSIFICATION: HYPERTONIC INDICATIONS: IV: Lower-
SOLUTION FOR HYPOGLYCEMIA: concentration (2.5– 11.5%) injection
ANTIHYPOGLYCEMIC AGENTS provides hydration and calories.
GENERIC NAME: DEXTROSE 50% Higher concentrations (up to 70%)
BRAND NAME: treat hypoglycemia and in
combination with amino acids
provide calories for parenteral
RECOMMENDED DOSAGE,
nutrition. 50%— treatment of
ROUTE, AND FREQUENCY:
hypoglycemia (hyperinsulinemia or
Hydration (as 5% solution)
insulin shock). PO: Corrects
IV (Adults and Children): 0.5– 0.8
hypoglycemia in conscious patients.
g/kg/hr. Hypoglycemia
CONTRAINDICATIONS: Allergy to
PO (Adults and Children):
corn or corn products; Hypertonic
Conscious patients—10– 20 g, may
solution (5%) should not be given to
repeat in 10– 20 min.
patients with CNS bleeding or anuria
IV (Adults): 20– 50 mL of 50%
or who are at risk of dehydration.
solution infused slowly (3 mL/min).
Use Cautiously in: Known diabetic
IV (Infants 6 mo and Children):
patients (frequent lab assessment
0.5– 1 g/kg/dose (maximum of 25
necessary to quantitate appropriate
g/dose) (as 25% dextrose).
doses); Neonates (excess/rapid
IV (Infants 6 mo and Neonates):
infusion of solutions 10% mayqrisk of
0.25– 0.50 g/kg/dose (maximum of
intracerebral hemorrhage); Chronic
25 g/ dose) (as 25% dext rose).
alcoholics or severely malnourished
DRUG ACTION: Provides calories.
patients (administration requires
Therapeutic Effects: Provision of
initial pretreatment with thiamine).
calories. Prevention and treatment of
SIDE EFFECTS/ADVERSE
hypoglycemia.
REACTIONS: Endo: inappropriate
Absorption: Well absorbed
insulin secretion (long-term use). F
following oral administration.
and E: fluid overload, hypokalemia,
Distribution:Widely distributed and
hypomagnesemia,
rapidly utilized.
hypophosphatemia. Local: local
Metabolism and Excretion:
pain/irritation at IV site (hypertonic
Metabolized to carbon dioxide and
solution). Metab: glycosuria,
water. When renal threshold is
hyperglycemia.
exceeded, dextrose is excreted
NURSING RESPONSIBILITIES:

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Assessment
● Assess the hydration status of
patients receiving IV dextrose.
Monitor intake and output and
electrolyte concentrations. Assess
patient for dehydration or edema. ●
Assess nutritional status, function of
gastrointestinal tract, and caloric
needs of patient. ● Diabetic patients
and patients receiving hypertonic
dextrose solution (5%) should have
serum glucose, potassium, and
phosphate monitored regularly. ●
Monitor IV site frequently for phlebitis
and infection. ● Lab Test
Considerations: May cause
anqserum glucose level.
Diagnosis
Deficient fluid volume (Indications)
Imbalanced nutrition: less than body
requirements (Indications)
Excess fluid volume (Adverse
Reactions)
Implementation
● Dextrose solution alone does not
contain enough calories to sustain
an individual for a prolonged period.
Dextrose contains 3.4 kcal/g. D5W
contains 170 cal/liter and D10W
contains 340 cal/liter. ● PO:
Concentrated dextrose gels and
chewable tablets may be used in the
treatment of hypoglycemia in
conscious patients. The dose should
be repeated if symptoms persist and
serum glucose has not increased by
at least 20 mg/dL within 20 min. May
be followed by more complex
carbohydrates. ● IV: Hypertonic
dextrose solution (10%) should be
administered IV into a central vein.
For emergency treatment of
hypoglycemia, administer slowly into
a large peripheral vein to prevent
phlebitis or sclerosis of the vein.
Assess IV site frequently. Rapid
infusions may cause hyperglycemia
or fluid shifts. When hypertonic
solution is discontinued, taper
solution and administer D5W or
D10W to prevent rebound
hypoglycemia. ● Patients requiring
prolonged infusions of dextrose
should have electrolytes added to
the dextrose solution to prevent
water intoxication and maintain fluid
and electrolyte balance. ● Additive
Incompatibility: whole blood.
Evaluation
● Correction and maintenance of
adequate hydration status and
normal serum glucose levels.
● Maintenance of adequate caloric
intake.
CLASSIFICATION: AMINO ACID
HORMONE/GLUCOSE-ELEVATING
AGENT
GENERIC NAME: GLUCAGON
BRAND NAME:
RECOMMENDED DOSAGE,
ROUTE, AND FREQUENCY:
Hypoglycemia
IV, IM, Subcut (Adults and
Children 20 kg): 1 mg; may be
repeated in 15 min if necessary.
IV, IM, Subcut (Children 20 kg ):
0.5 mg or 0.02– 0.03 mg/kg; may be
repeated in 15 min if necessary.
Radiographic Examination of the
GI Tract
IM, IV (Adults): 0.25– 2 mg;
depending on location and duration
of examination (0.5 mg IV or 2 mg IM
for relaxation of stomach, for
examination of the colon 2 mg IM 10
min before procedure).
Antidote (unlabeled)
IV (Adults): To beta blockers—50–
150 mcg (0.05– 0.15 mg)/kg,
followed by 1– 5 mg/hr infusion. To
calcium channel blockers—2 mg;
additional doses determined by
response.
Page | 264
DRUG ACTION: Stimulates hepatic Prolonged fasting, starvation,
production of glucose from glycogen adrenal insufficiency or chronic
stores (glycogenolysis). Relaxes the hypoglycemia (low levels of
musculature of the GI tract (stomach, releasable glucose); When used to
duodenum, small bowel, and colon), inhibit GI motility, use cautiously in
temporarily inhibiting movement. Has geriatric patient with cardiac disease
positive inotropic and chronotropic or diabetics; OB:Should be used
effects. Therapeutic Effects: during pregnancy only if clearly
Increase in blood glucose. needed; Lactation:Safety not
Relaxation of GI musculature, established.
facilitating radiographic examination.
SIDE EFFECTS/ADVERSE
Absorption: Well absorbed REACTIONS: CV: hypotension. GI:
following IM and subcut nausea, vomiting. Misc:
administration. hypersensitivity reactions including
ANAPHYLAXIS.
Distribution: Unknown.
NURSING RESPONSIBILITIES:
Metabolism and Excretion:
Extensively metabolized by the liver, Assessment
plasma, and kidneys. Half-life: 8– 18
min. ● Assess for signs of hypoglycemia
(sweating, hunger, weakness,
DRUG-DRUG AND DRUG-FOOD headache, dizziness, tremor,
INTERACTIONS: Drug-Drug: Large irritability, tachycardia, anxiety) prior
doses may enhance the effect of to and periodically during therapy. ●
warfarin. Negates the response to Assess neurologic status throughout
insulin or oral hypoglycemic agents. therapy. Institute safety precautions
Phenytoin inhibits the stimulant to protect patient from injury caused
effect of glucagon on insulin release. by seizures, falling, or aspiration. For
Hyperglycemic effect is intensified insulin shock therapy, 0.5– 1 mg is
and prolonged by epinephrine. administered after 1 hr of coma;
Patients on concurrent beta blocker patient usually awakens in 10– 25
therapy may have a greater increase min. If no response occurs, repeat
in heart rate and BP. the dose. Feed patient supplemental
carbohydrates orally to replenish
INDICATIONS: Acute management liver glycogen and prevent
of severe hypoglycemia when secondary hypoglycemia as soon as
administration of glucose is not possible after awakening, especially
feasible. Facilitation of radiographic pediatric patients. ● Assess
examination of the GI tract. nutritional status. Patients who lack
Unlabeled Use: Antidote to: Beta liver glycogen stores (starvation,
blockers, Calcium channel blockers. chronic hypoglycemia, adrenal
CONTRAINDCIATIONS: : insufficiency) will require glucose
Hypersensitivity; instead of glucagon. ● Assess for
Pheochromocytoma; Some products nausea and vomiting after
contain glycerin and phenol— avoid administration of dose. Protect
use in patients with hypersensitivities patients with depressed level of
to these ingredients. Use consciousness from aspiration by
Cautiously in: History suggestive of positioning on side; ensure that a
insulinoma or pheochromocytoma; suction unit is available. Notify health

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care professional if vomiting occurs;
patient will require parenteral
glucose to prevent recurrent
hypoglycemia. ● Lab Test
Considerations: Monitor serum
glucose levels throughout episode,
during treatment, and for 3– 4 hr
after patient regains consciousness.
Use of bedside fingerstick blood
glucose determination methods is
recommended for rapid results.
Follow-up lab results may be ordered
to validate fingerstick values, but do
not delay treatment while awaiting
lab results, as this could result in
neurologic injury or death. ● Large
doses of glucagon may cause apin
serum potassium concentrations.
Diagnosis
Risk for injury (Indications)
Noncompliance (Patient/Family
Teaching)
Implementation
● May be given subcut, IM, or IV.
Reconstitute with diluent supplied in
kit by manufacturer. Inspect solution
prior to use; use only clear, water-
like solution. Solution is stable for 48
hr if refrigerated, 24 hr at room
temperature. Unmixed medication
should be stored at room
temperature. ● Administer
supplemental carbohydrates IV or
orally to facilitate increase of serum
glucose levels.
IV Administration
● pH: 2.5– 3.5. ● Direct IV: Diluent:
Reconstitute each vial with 1 mL of
an appropriate diluent. For doses 2
mg, use diluent provided by
manufacturer. For doses 2 mg, use
sterile water for injection instead of
diluent supplied by manufacturer to
minimize risk of thrombophlebitis,
CNS toxicity, and myocardial
depression from phenol preservative
in diluent supplied by manufacturer.
Reconstituted vials should be used
immediately. Concentration: Not
exceed 1 mg/mL. Rate: Administer at
a rate not exceeding 1 mg/min. May
be administered through IV line
containing D5W. ● Continuous
Infusion: Diluent: Reconstitute vials
as per directions above (use sterile
water for injection). Further dilute 10
mg of glucagon in 100 mL of D5W.
Concentration: 0.1 mg/mL. Rate:
See Route/Dosage section. ● Y-Site
Compatibility: No information
available.
Evaluation
● Increase of serum glucose to
normal levels with improved level of
consciousness.
● Smooth muscle relaxation of the
stomach, duodenum, and small and
large intestine in patients undergoing
radiologic examination of the GI
tract.
E. EMERGENCY DRUGS FOR
HYPERTENSIVE CRISIS AND
PULMONARY EDEMA
CLASSIFICATION: ALPHA 1 AND
BETA 1 BETA BLOCKER
GENERIC NAME: LABETALOL
BRAND NAME: TRANDATE
RECOMMENDED DOSAGE,
ROUTE, AND FREQUENCY: PO
(Adults): 100 mg twice daily initially,
may beqby 100 mg twice daily q 2– 3
days as needed (usual range 400–
800 mg/day in 2– 3 divided doses;
doses up to 1.2– 2.4 g/day have
been used). PO (Infants and
Children): 1– 3 mg/kg/day divided
BID (maximum dose: 10– 12
Page | 266
mg/kg/day, up to 1200 mg/day). IV adjustments may be necessary).
(Adults): 20 mg (0.25 mg/kg) Maypthe effectiveness of adrenergic
initially, additional doses of 40– 80 bronchodilatorsand theophylline.
mg may be given q 10 min as Maypbeneficial beta cardiovascular
needed (not to exceed 300 mg total effects ofdopamine or dobutamine.
dose) or 2 mg/min infusion (range Use cautiously within 14 days of
50– 300 mg total dose required). : MAO inhibitortherapy (may result in
0.2– 1 mg/kg/dose (maximum: 40 hypertension). Effects may beqby
mg/dose) propranolol orcimetidine. Concurrent
DRUG ACTION: Blocks stimulation NSAIDsmaypantihypertensive action
of beta1 (myocardial)- and beta2
(pulmonary, vascular, and uterine)- INDICATIONS:Management of
adrenergic receptor sites. Also has hypertension.
alpha1-adrenergic blocking activity,
CONTRAINDCIATIONS:
which may result in more orthostatic
Uncompensated HF; Pulmonary
hypotension. Therapeutic Effects:
edema; Cardiogenic shock;
Decreased BP
Bradycardia or heart block. Use
Absorption: Well absorbed but
Cautiously in: Renal impairment;
rapidly undergoes extensive first-
Hepatic impairment; Pulmonary
pass hepatic metabolism, resulting in
disease (including asthma); Diabetes
25% bioavailability.
mellitus (may mask signs of
Distribution: Some CNS
hypoglycemia); Thyrotoxicosis (may
penetration; crosses the placenta.
mask symptoms); Patients with a
Protein Binding: 50%.
history of severe allergic reactions
Metabolism and Excretion:
(intensity of reactions may beq); OB:
Undergoes extensive hepatic
May cause fetal/neonatal
metabolism.
bradycardia, hypotension,
Half-life: 3– 8 hr.
hypoglycemia, or respiratory
TIME/ACTION PROFILE
depression; Lactation: Usually
(cardiovascular effects)
compatible with breast feeding
ROUTE ONSET PEAK
(AAP); Pedi:Limited data available;
DURATION
Geri:qsensitivity to beta blockers
PO 20min–2 hr 1–4 hr
(qrisk of orthostatic hypotension);
8–12 hr
initial dosageprecommended.
IV 2–5min 5 min
SIDE EFFECTS/ADVERSE
16–18 hr
REACTIONS: CNS: fatigue,
DRUG-DRUG AND DRUG-FOOD weakness, anxiety, depression,
INTERACTIONS: Drug-Drug: dizziness, drowsiness, insomnia,
General anesthesia and verapamil memory loss, mental status
may cause additive myocardial changes, nightmares. EENT: blurred
depression. Additive bradycardia vision, dry eyes, intraoperative floppy
may occur with digoxin, verapamil, or iris syndrome, nasal stuffiness.
diltiazem. Additive hypotension may Resp: bronchospasm, wheezing.
occur with other antihypertensives, CV: ARRHYTHMIAS,
acute ingestion of alcohol, or BRADYCARDIA, CHF,
nitrates. Concurrent thyroid PULMONARY EDEMA, orthostatic
administration maypeffectiveness. hypotension. GI: constipation,
May alter the effectiveness of insulin diarrhea, nausea. GU: erectile
or oral hypoglycemic agents (dose dysfunction,plibido. Derm: itching,

Page | 267
rashes. Endo: hyperglycemia, Implementation
hypoglycemia. MS: arthralgia, back ● High Alert: IV vasoactive
pain, muscle cramps.Neuro: medications are inherently
paresthesia. dangerous. Before administering
NURSING RESPONSIBILITIES: intravenously, have second
Assessment practitioner independently check
● Monitor BP and pulse frequently original order, dosage calculations,
during dose adjustment and and infusion pump settings. ● Do
periodically during therapy. Assess not confuse labetalol with
for orthostatic hypotension when Lamictal. ● Discontinuation of
assisting patient up from supine concurrent clonidine should take
position. ● Check frequency of refills place gradually, with beta blocker
to determine compliance. ● Patients discontinued first. Then, after several
receiving labetalol IV must be supine days, discontinue clonidine. ● PO:
during and for 3 hr after Take apical pulse prior to
administration. Vital signs should be administering. If 50 bpm or if
monitored every 5– 15 min during arrhythmia occurs, withhold
and for several hours after medication and notify health care
administration. ● Monitor intake and professional. ● Administer with
output ratios and daily weight. meals or directly after eating to
Assess patient routinely for evidence enhance absorption.
of fluid overload (peripheral edema, Evaluation
dyspnea, rales/ crackles, fatigue, ●Decrease in BP.
weight gain, jugular venous
distention). ● Lab Test
Considerations: May causeqBUN,
CLASSIFICATION: DIRECT-
serum lipoprotein, potassium,
ACTING ARTERIORIAL
triglyceride, and uric acid levels. ●
VASODILATOR
May causeqANA titers. ● May
GENERIC NAME:
causeqin blood glucose levels. ●
NITROPRUSSIDE SODIUM
May causeqserum alkaline
BRAND NAME: NITROPRESS
phosphatase, LDH, AST, and ALT
levels. Discontinue if jaundice or
laboratory signs of hepatic function RECOMMENDED DOSAGE,
impairment occur. ● Toxicity and ROUTE, AND FREQUENCY: IV
Overdose: Monitor patients receiving (Adults and Children): 0.3
beta blockers for signs of overdose mcg/kg/min initially; may beqas
(bradycardia, severe dizziness or needed up to 10 mcg/kg/min (usual
fainting, severe drowsiness, dose is 3 mcg/kg/min; not to exceed
dyspnea, bluish fingernails or palms, 10 min of therapy at 10 mcg/ kg/min
seizures). Notify health care infusion rate).
professional immediately if these DRUG ACTION: Produces
signs occur. ● Glucagon has been peripheral vasodilation by a direct
used to treat bradycardia and action on venous and arteriolar
hypotension. smooth muscle. Therapeutic
Effects: Rapid lowering of BP.
Diagnosis
Decreased cardiac preload and
Decreased cardiac output (Side
afterload.
Effects) Noncompliance
Absorption: IV administration
(Patient/Family Teaching)

Page | 268
results in complete bioavailability. continuous monitoring is preferred.
Distribution: Unknown. Consult physician for parameters.
Metabolism and Excretion: Rapidly Monitor for rebound hypertension
metabolized in RBCs and tissues to following discontinuation of
cyanide and subsequently by the nitroprusside. ● Pulmonary capillary
liver to thiocyanate. wedge pressure (PCWP) may be
Half-life: 2 min. monitored in patients with MI or HF.
TIME/ACTION PROFILE ● Lab Test Considerations: May
(hypotensive effect) causepbicarbonate concentrations,
ROUTE ONSET PEAK PCO2, and p H. ● May
DURATION causeqlactate concentrations. ● May
IV immediate rapid causeqserum cyanide and
1–10 min thiocyanate concentrations. ●
DRUG-DRUG AND DRUG-FOOD Monitor serum methemoglobin
INTERACTIONS: Drug- concentrations in patients receiving
Drug:qhypotensive effect with 10 mg/kg and exhibiting signs of
ganglionic blocking agents, impaired oxygen delivery despite
general anesthetics, and other adequate cardiac output and arterial
antihypertensives. Estrogens and PCO2 (blood is chocolate brown
sympathomimetics may pthe without change on exposure to air).
response to nitroprusside. Treatment of methemoglobinemia is
INDICATIONS: Hypertensive crises. 1– 2 mg/kg of methylene blue IV
Controlled hypotension during administered over several minutes. ●
anesthesia. Cardiac pump failure or Toxicity and Overdose: If severe
cardiogenic shock (alone or with hypotension occurs, drug effects are
dopamine). quickly reversed, within 1– 10 min,
CONTRAINDICATIONS: by decreasing rate or temporarily
Hypersensitivity; pcerebral perfusion. discontinuing infusion. May place
Use Cautiously in: Renal disease patient in Trendelenburg position to
(qrisk of thiocyanate accumulation); maximize venous return. ● Monitor
Hepatic disease (qrisk of cyanide plasma thiocyanate levels daily in
accumulation); Hypothyroidism; patients receiving prolonged
Hyponatremia; Vitamin B deficiency; infusions at a rate 3 mcg/kg/min or 1
OB, Lactation: Safety not mcg/kg/min in patients with anuria.
established; Geri: May Thiocyanate levels should not
haveqsensitivity to drug effects. exceed 1 millimole/L.
SIDE EFFECTS/ADVERSE Diagnosis
REACTIONS: Ineffective tissue perfusion
CNS: dizziness, headache, (Indications)
restlessness. EENT: blurred vision, Implementation
tinnitus. CV: dyspnea, hypotension, ● If infusion of 10 mcg/kg/min for 10
palpitations. GI:abdominal pain, min does not produce adequate
nausea, vomiting. F and E: acidosis. reduction in BP, manufacturer
Local: phlebitis at IV site. Misc: recommends nitroprusside be
CYANIDE TOXICITY, thiocyanate discontinued.
toxicity. ● May be administered in left
NURSING RESPONSIBILITIES: ventricular HF concurrently with an
Assessment inotropic agent (dopamine,
● Monitor BP, heart rate, and ECG dobutamine) when effective doses of
frequently throughout therapy; nitroprusside restore pump function

Page | 269
and cause excessive hypotension. response.
Evaluation DRUG ACTION:Inhibits the
● Decrease in BP without the reabsorption of sodium and chloride
appearance of side effects. from the loop of Henle and distal
● Treatment of cardiac pump failure renal tubule. Increases renal
or cardiogenic shock. excretion of water, sodium, chloride,
magnesium, potassium, and calcium.
CLASSIFICATION: LOOP/HIGH Effectiveness persists in impaired
CEILING DIURETIC renal function. Therapeutic Effects:
GENERIC NAME: FUROSEMIDE Diuresis and subsequent
BRAND NAME: LASIX mobilization of excess fluid (edema,
pleural effusions). Decreased BP.
Absorption: 60– 67% absorbed
RECOMMENDED DOSAGE,
after oral administration (pin acute
ROUTE, AND FREQUENCY:
HF and in renal failure); also
Edema PO (Adults): 20– 80 mg/day
absorbed from IM sites.
as a single dose initially, may repeat
Distribution: Crosses placenta,
in 6– 8 hr; mayq dose by 20– 40 mg
enters breast milk. Protein Binding:
q 6– 8 hr until desired response.
91– 99%.
Maintenance doses may be given
Metabolism and Excretion:
once or twice daily (doses up to 2.5
Minimally metabolized by liver, some
g/day have been used in patients
non hepatic metabolism, some renal
with HF or renal disease).
excretion as unchanged drug.
Hypertension—40 twice daily initially
Half-life: 30– 60 min (qin renal
(when added to regimen,pdose of
impairment). TIME/ACTION
other antihypertensives by 50%);
PROFILE (diuretic effect)
adjust further dosing based on
ROUTE ONSET PEAK
response;Hypercalcemia—120
DURATION PO 30–60 min
mg/day in 1– 3 doses.
1–2 hr 6–8 hr
PO (Children 1 mo): 2 mg/kg as a
IM 10–30 min unknown
single dose; may beqby 1– 2 mg/kg
4–8 hr
q 6– 8 hr (maximum dose 6 mg/kg).
IV 5 min 30 min
PO (Neonates): 1– 4 mg/kg/dose 1–
2 hr
2 times/day. IM, IV (Adults): 20– 40
DRUG-DRUG AND DRUG-FOOD
mg, may repeat in 1– 2 hr andqby 20
INTERACTIONS: :qrisk of
mg every 1– 2 hr until response is
hypotension with
obtained, maintenance dose may be
antihypertensives, nitrates, or
given q 6– 12 hr; Continuous
acute ingestion of alcohol.qrisk of
infusion—Bolus 0.1 mg/kg followed
hypokalemia with other diuretics,
by 0.1 mg/kg/hr, double q 2 hr to a
amphotericin B, stimulant
maximum of 0.4 mg/kg/hr.
laxatives, and corticosteroids.
IM, IV (Children): 1– 2 mg/kg/dose q
Hypokalemia mayqrisk of digoxin
6– 12 hr Continuous infusion—0.05
toxicity andqrisk of arrhythmia in
mg/ kg/hr, titrate to clinical effect.
patients taking drugs that prolong the
IM, IV (Neonates): 1– 2 mg/kg/dose
QT interval. plithium excretion, may
q 12– 24 hr. Hypertension
cause lithium toxicity.qrisk of
PO (Adults): 40 twice daily initially
ototoxicity with aminoglycosides or
(when added to regimen,pdose of
cisplatin.qrisk of nephrotoxicity with
other antihypertensives by 50%);
cisplatin. NSAIDSpeffects of
adjust further dosing based on
furosemide. Mayqrisk of

Page | 270
methotrexate toxicity.peffects of hyperuricemia. F and E:
furosemide when given at same time dehydration, hypocalcemia,
assucralfate,cholestyramine,orcolesti hypochloremia, hypokalemia,
pol.qrisk ofsalicylate toxicity (with hypomagnesemia, hyponatremia,
use of high-dose salicylate therapy). hypovolemia, metabolic alkalosis.
Concurrent use with Hemat: APLASTIC ANEMIA,
cyclosporinemayqrisk of gouty AGRANULOCYTOSIS, hemolytic
arthritis. anemia, leukopenia,
INDICATIONS:Edema due to heart thrombocytopenia. MS: muscle
failure, hepatic impairment or renal cramps. Neuro: paresthesia. Misc:
disease. Hypertension. fever.
CONTRAINDICATIONS: NURSING RESPONSIBILITIES:
Contraindicated in: Assessment
Hypersensitivity; Cross-sensitivity ● Assess fluid status. Monitor daily
with thiazides and sulfonamides may weight, intake and output ratios,
occur; Hepatic coma or anuria; amount and location of edema, lung
Some liquid products may contain sounds, skin turgor, and mucous
alcohol, avoid in patients with alcohol membranes. Notify health care
intolerance. Use Cautiously in: professional if thirst, dry mouth,
Severe liver disease (may precipitate lethargy, weakness, hypotension, or
hepatic coma; concurrent use with oliguria occurs. ● Monitor BP and
potassium-sparing diuretics may be pulse before and during
necessary); Electrolyte depletion; administration. Monitor frequency of
Diabetes mellitus; Hypoproteinemia prescription refills to determine
(qrisk of ototoxicity); Severe renal compliance in patients treated for
impairment (qrisk of ototoxicity); OB, hypertension.
Lactation:Safety not established; ● Geri: Diuretic use is associated
Pedi:qrisk for renal calculi and patent with increased risk for falls in older
ductus arteriosis in premature adults. Assess falls risk and
neonates; Geri: May haveqrisk of implement fall prevention strategies.
side effects, especially hypotension ● Assess patients receiving digoxin
and electrolyte imbalance, at usual for anorexia, nausea, vomiting,
doses. muscle cramps, paresthesia, and
SIDE EFFECTS/ADVERSE confusion. Patients taking digoxin
REACTIONS: are at increased risk of digoxin
CNS: blurred vision, dizziness, toxicity because of the potassium-
headache, vertigo. EENT: hearing depleting effect of the diuretic.
loss, tinnitus. CV: hypotension. GI: Potassium supplements or
anorexia, constipation, diarrhea, dry potassium-sparing diuretics may be
mouth, dyspepsia,qliver enzymes, used concurrently to prevent
nausea, pancreatitis, vomiting. hypokalemia.
GU:qBUN, excessive urination, ● Assess patient for tinnitus and
nephrocalcinosis.Derm: ERYTHEMA hearing loss. Audiometry is
MULTIFORME, STEVENS- recommended for patients receiving
JOHNSON SYNDROME, TOXIC prolonged high-dose IV therapy.
EPIDERMAL NECROLYSIS, Hearing loss is most common after
photosensitivity, pruritis, rash, rapid or high-dose IV administration
urticaria. Endo: in patients with decreased renal
hypercholesterolemia, function or those taking other
hyperglycemia, hypertriglyceridemia, ototoxic drugs.

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Diagnosis
Excess fluid volume (Indications)
Deficient fluid volume (Side Effects)
Implementation
● Do not confuse Lasix with Luvox.
● If administering twice daily, give
last dose no later than 5 pm to
minimize disruption of sleep cycle.
● IV route is preferred over IM route
for parenteral administration.
● PO: May be taken with food or milk
to minimize gastric irritation. Tablets
may be crushed if patient has
difficulty swallowing.
● Do not administer discolored
solution or tablets.
Evaluation
● Decrease in edema.
● Decrease in abdominal girth and
weight.
● Increase in urinary output.
● Decrease in BP.

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