Sodium Bicarbonate Classification: antiulcer agents, alkalinizing agent Indications 1. Management of metabolic acidosis 2.

Used to alkalinize urine and promote excretion of certain drugs in over dosage situations 3. Used as an antacid Action Sodium Bicarbonate acts as an alkalinizing agent by releasing bicarbonate ions. Following oral administration of this medication, it releases bicarbonate which is capable of neutralizing gastric acid. Contraindication 1. 2. 3. 4. 5. 6. 7. Metabolic or respiratory alkalosis Hypocalcemia Excessive chloride loss It is not recommended as an antidote following ingestion of strong mineral acids Patients on sodium restricted diet Renal failure Severe abdominal pain of unknown cause especially if associated with fever

Used cautiously in patients with: 1. Congenital heart failure 2. Concurrent corticosteroid therapy 3. Children with diabetic ketoacidosis because taking sodium bicarbonate may increase the risk of cerebral edema 4. Chronis use as an antacid because it may result to metabolic alkalosis and possible sodium overload Side effects 1. 2. 3. 4. 5. 6. 7. 8. 9. Edema Flatulence Gastric distention Metabolic alkalosis Hypernatremia Hypocalcemia Hypokalemia Sodium and water retention Irritation at IV site

10. Tetany Nursing Responsibilities 1. Assess the clients fluid balance throughout the therapy. This assessment includes intake and output, daily weight, edema and lung sounds. 2. Symptoms of fluid overload should be reported such as hypertension, edema, difficulty breathing or dyspnea, rales or crackles and frothy sputum. 3. Sigs of acidosis should be assessed such as disorientation, headache, weakness, dyspnea and hyperventilation. 4. Assess for alkalosis by monitoring the client for confusion, irritability, paresthesia, tetany and altered breathing pattern. 5. Hypernatremia clinical manifestations should be assessed and monitored which includes: edema, weight gain, hypertension, tachycardia, fever, flushed skin and mental irritability. 6. Hypokalemia should also be assessed by monitoring signs and symptoms such as: weakness, fatigue, U wave on ECG, arrhythmias, polyuria and polydipsia. 7. IV sites should be observed closely. Extravasation should be avoided as tissue irritation or cellulitis may occur when taking sodium bicarbonate. 8. If infiltration occurs, the physician should be notified immediately. Confer with the doctor or other health care staff regarding warm compresses and infiltration site with lidocaine or hyaluronidase. 9. Monitor the clients serum calcium, sodium, potassium, bicarbonate concentrations, serum osmolarity, acid-base balance and renal function before and throughout the therapy. 10. Tablets must be taken with a full glass of water. 11. For clients taking the medication as a treatment for peptic ulcers it may be administered 1 and 3 hours after meals and at bedtime.

Epinephrine

Action: Naturally occurring catecholamine obtained from animal adrenal glands; also prepared synthetically. Acts directly on both alpha and beta receptors; the most potent activator of alpha receptors. Strengthens myocardial contraction; increases systolic but may decrease diastolic blood pressure; increases cardiac rate and cardiac output. Classifications: AUTONOMIC NERVOUS SYSTEM AGENT; ALPHA- AND BETA-ADRENERGIC AGONIST; BRONCHODILATOR Indication:

Temporary relief of bronchospasm,acute asthmaticattack, mucosalcongestion,hypersensitivity andanaphylacticreactions, syncopedue to heart block or carotid sinushypersensitivity, andto restore cardiacrhythm in cardiacarrest. Ophthalmicpreparation is usedin management of simple (open-angle)glaucoma, generallyas an adjunct totopical miotics andoral carbonicanhydrase inhibitors;also used asophthalmicdecongestant. Relaxesmyometrium andinhibits uterinecontractions

Contraindications: Special Senses: y Nasal burning or stinging, dryness of nasal mucosa, sneezing,rebound congestion.Transient stinging or burning of eyes,lacrimation, browache,headache, reboundconjunctival hyperemia,allergy, iritis; withprolonged use: melanin-like deposits on lids,conjunctiva, and cornea;corneal edema; loss of lashes (reversible);maculopathy withcentral scotoma inaphakic patients(reversible). Body as a Whole: y Nervousness,restlessness,sleeplessness, fear,anxiety, tremors, severeheadache,cerebrovascular accident, weakness,dizziness, syncope,pallor, sweating,

Contraindications:

NURSING IMPLICATIONS Assessment & Drug Effects

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Monitor BP, pulse, respirations, and urinary output and observe patient closely following IV administration. Epinephrine may widen pulse pressure. If disturbances in cardiac rhythm occur, withhold epinephrine and notify physician immediately. Keep physician informed of any changes in intake-output ratio. Use cardiac monitor with patients receiving epinephrine IV. Have full crash cart immediately available. Check BP repeatedly when epinephrine is administered IV during first 5 min, then q3 5min until stabilized. Advise patient to report to physician if symptoms are not relieved in 20 min or if they become worse following inhalation. Advise patient to report bronchial irritation, nervousness, or sleeplessness. Dosage should be reduced.

Monitor blood glucose & HbA1c for loss of glycemic control if diabetic.

Patient & Family Education

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Be aware intranasal application may sting slightly. Administer ophthalmic drug at bedtime or following prescribed miotic to minimize mydriasis, with blurred vision and sensitivity to light (possible in some patients being treated for glaucoma). Transitory stinging may follow initial ophthalmic administration and that headache and browache occur frequently at first but usually subside with continued use. Notify physician if symptoms persist. Discontinue epinephrine eye drops and consult a physician if signs of hypersensitivity develop (edema of lids, itching, discharge, crusting eyelids). Learn how to administer epinephrine subcutaneously. Keep medication and equipment available for home emergency. Confer with physician. Note: Inhalation epinephrine reduces bronchial secretions and thus may make mucous plugs more difficult to dislodge. Report tolerance to physician; may occur with repeated or prolonged use. Continued use of epinephrine in the presence of tolerance can be dangerous. Take medication only as prescribed and immediately notify physician of onset of systemic effects of epinephrine. Discard discolored or precipitated solutions. Do not breast feed while taking this drug without consulting physician.

Lidocaine Classification: Anesthetic topical or local, Antiarrythmics Indications:

y y y y

Intravenous ventricular arrhythmias Intramuscular self-injected or when IV is unavailable during transport to local facilities Local infiltration or mucosal or topical anesthetic Patch used when pain is present due to post-herpetic neuralgia

Mechanism of action When administered intramuscularly or intravenously, Lidocaine suppresses the automaticity and spontaneous depolarization of the ventricles during diastole by altering the flux of sodium ions across the cell membrane with little or no effect on the heart. Locally, it produces local anesthesia effect by inhibiting the transport of ions across the neural membranes. Thus, initiation and conduction of normal nerve impulses is prevented. Contraindications

y y

Hypersensitivity Advanced AV block

Used cautiously in patients with:

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Liver diseases Congenital heart failure Patient weighing less than 50 kilograms Geriatric patients Respiratory depression Shock Heart block Pregnancy and lactation

Adverse reactions
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Drowsiness Dizziness Nervousness (mucosal use) decreased or absent gag reflex Bradycardia Hypotension Burning sensation

Signs and symptoms of toxicity and overdose of Lidocaine:

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Confusion Excitation Blurred or double vision Nausea and vomiting Ringing in the ears Tremors Twitching Seizures Difficulty breathing Severe dizziness and fainting Unusually low heart rate

Nursing Responsibilities
y

When Lidocaine is administered as an antiarrhythmic the nurse should monitor the ECG continuously. Blood pressure and respiratory status should be monitored frequently during the drug administration. When administered as an anesthetic, the numbness of the affected part should be assessed.

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Serum Lidocaine levels should be monitored frequently during prolonged use. Therapeutic serum lidocaine levels range from 1.5 to 5 mcg/ml. If signs of overdose occur (listed above), stop the infusion immediately and monitor the patient closely. For throat sprays, make sure that the patients gag reflex is intact before allowing the patient to eat or drink. When IM injections are used, the medication should be administered in the deltoid muscle only while frequently aspirating to prevent IV injection. For direct IV injection only 1% and 2% solutions are used. Undiluted IV loading dose of Lidocaine is administered at 1 mg/kg at a rate of 25 to 50 mg over 1 minute. The dose may be repeated after 5 minutes.

Furosemide Action: Rapid-acting potent sulfonamide loop diuretic and antihypertensive with pharmacologic effects and uses almost identical to those of ethacrynic acid. Exact mode of action not clearly defined; decreases renal vascular resistance and may increase renal blood flow. Classification: ELECTROLYTIC AND WATER BALANCE AGENT; LOOP DIURETIC Indication: Treatment of edema associated with CHF, cirrhosis of liver, and kidney disease, including nephrotic syndrome. May be used for management of hypertension, alone or in combination with other antihypertensive agents, and for treatment of hypercalcemia. Has been used concomitantly with mannitol for treatment of severe cerebral edema, particularly in meningitis. NURSING IMPLICATIONS Assessment & Drug Effects
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Observe patients receiving parenteral drug carefully; closely monitor BP and vital signs. Sudden death from cardiac arrest has been reported. Monitor BP during periods of diuresis and through period of dosage adjustment. Observe older adults closely during period of brisk diuresis. Sudden alteration in fluid and electrolyte balance may precipitate significant adverse reactions. Report symptoms to physician. Lab tests: Obtain frequent blood count, serum and urine electrolytes, CO2, BUN, blood sugar, and uric acid values during first few months of therapy and periodically thereafter. Monitor for S&S of hypokalemia (see Appendix F).

y y

Monitor I&O ratio and pattern. Report decrease or unusual increase in output. Excessive diuresis can result in dehydration and hypovolemia, circulatory collapse, and hypotension. Weigh patient daily under standard conditions. Monitor urine and blood glucose & HbA1C closely in diabetics and patients with decompensated hepatic cirrhosis. Drug may cause hyperglycemia. Note: Excessive dehydration is most likely to occur in older adults, those with chronic cardiac disease on prolonged salt restriction, or those receiving sympatholytic agents.

Patient & Family Education

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Consult physician regarding allowable salt and fluid intake. Ingest potassium-rich foods daily (e.g., bananas, oranges, peaches, dried dates) to reduce or prevent potassium depletion. Learn S&S of hypokalemia (see Appendix F). Report muscle cramps or weakness to physician. Make position changes slowly because high doses of antihypertensive drugs taken concurrently may produce episodes of dizziness or imbalance. Avoid replacing fluid losses with large amounts of water. Avoid prolonged exposure to direct sun. Do not breast feed while taking this drug.

Digoxin

Classifications: cardiovascular agent; cardiac glycoside; antiarrhythmic Pregnancy Category: A NURSING IMPLICATIONS Assessment & Drug Effects
y

y y

Be familiar with patients baseline data (e.g., quality of peripheral pulses, blood pressure, clinical symptoms, serum electrolytes, creatinine clearance) as a foundation for making assessments. Lab tests: Baseline and periodic serum digoxin, potassium, magnesium, and calcium. Notify physician of abnormal values. Draw blood samples for determining plasma digoxin levels at least 6 h after daily dose and preferably just before next scheduled daily dose. Therapeutic range of serum digoxin is 0.82 ng/mL; toxic levels are >2 ng/mL. Take apical pulse for 1 full min noting rate, rhythm, and quality before administering. If changes are noted, withhold digoxin, take rhythm strip if patient is on ECG monitor, notify physician promptly. Withhold medication and notify physician if apical pulse falls below ordered parameters (e.g., >50 or 60/min in adults and >60 or 70/min in children). Monitor for S&S of drug toxicity: In children, cardiac arrhythmias are usually reliable signs of early toxicity. Early indicators in adults (anorexia, nausea, vomiting, diarrhea, visual disturbances) are rarely initial signs in children.

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Monitor I&O ratio during digitalization, particularly in patients with impaired renal function. Also monitor for edema daily and auscultate chest for rales. Monitor serum digoxin levels closely during concurrent antibioticdigoxin therapy, which can precipitate toxicity because of altered intestinal flora. Observe patients closely when being transferred from one preparation (tablet, elixir, or parenteral) to another; when tablet is replaced by elixir potential for toxicity increases since 30% of drug is absorbed.

Patient & Family Education

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Report to physician if pulse falls below 60 or rises above 110 or if you detect skipped beats or other changes in rhythm, when digoxin is prescribed for atrial fibrillation. Suspect toxicity and report to physician if any of the following occur: Anorexia, nausea, vomiting, diarrhea, or visual disturbances. Weigh each day under standard conditions. Report weight gain >1 kg (2 lb)/d. Take digoxin PRECISELY as prescribed, do not skip or double a dose or change dose intervals, and take it at same time each day. Do not to take OTC medications, especially those for coughs, colds, allergy, GI upset, or obesity, without prior approval of physician. Continue with brand originally prescribed unless otherwise directed by physician. Do not breast feed while taking this drug without consulting physician.