NLN Pharmacology Study Guide

NLN Pharmacology Study Guide There is no official study guide for the NLN Pharmacology Exam. This guide is not meant to be all-inclusive of the information you will need to know to successfully pass the NLN Pharmacology exam. You should utilize other resources as necessary to prepare for the exam. Please note that after taking the exam, NLN provides access to review resources on-line. The test is composed of 100 scored questions plus some trial questions (about 25). You will not know which are which. All are multiple choice questions, including calculations. Content is divided in three areas on the exam: calculations, principles of medication administration and medication effects. They are pretty evenly divided. The questions are very similar to the NCLEX questions. You should also use traditional NCLEX testtaking tips to prepare for this exam also. Calculations Please remember this is about 1/3 of the pharmacology exam. It may be beneficial for you to practice calculations and/or review a nursing math book to help prep. You may not have used all the calculation methods recently. Questions may include one or more type of calculation. Tips: 1. READ CAREFULLY. Always be sure you know what the end result should be (mg, pills, ml, etc.). This can help you select the correct formula and eliminate unnecessary information. 2. Double (and triple) check actual math. Did you clear the calculator correctly? 3. Does the answer make sense? 4. There are both adult and pediatric calculations. 5. Watch ‘per dose’, ‘per day’. 6. How you calculate the answer does not matter (desired over have, ratio : proportion, etc.); accuracy does. 1 2Common calculations include (but are not limited to): 1. Kg to mg to mcg conversion (any which way) L K H D M D C M mcg G liter (kilo – hecto – deca – meter – deci – centi – milli – skip – skip – micro) gram 2. Dosage calculations a. Tablets b. mg. to tablets c. mg. to ml d. units to ml e. kg to ml f. Half-life calculation g. IV rate calculation (hourly infusion rate) AND adjustment h. IV rate dosage calculation (based on units per ml, etc.) i. Macro- vs. micro-drop tubing j. Calculating drops/minute (gtts/min) Examples: (abbreviated to type of question; exam will add extra information) 1. Have 5 mg tablets; ordered dose 2.5 mg. How many tablets will the nurse administer? 2. Have 2 mg/2 ml; order is 1 mg. How many milliliters will the nurse administer? 3. Prepare a 20 mEq dose of a medication. Available solution is 40 mEq/10 ml. How many ml will be administered? Note: calculation method is not different in examples 1 - 3, just the unit of measure (mg, units, mEq, etc.). BE SURE AVAILABLE AND HAVE ARE THE SAME UNIT OF MEASURE. 4. Half-life conversion: Half-life is known to be 2 hours. What percentage will be left in the body after six hours? 5. A person weighs 165 lbs. How many kg does the person weigh? 2 6. The available medication has been reconstituted to 250 mg/5 ml. The order is 5 mg/kg/daily in two evenly divided doses. Child weight 44 pounds. How many milliliters will be administered per dose? NOTE: More than one calculation method must be used to answer this question. 7. IV was ordered at 1000 ml over 8 hour period. After two hours, only 900 ml has infused. Calculate the new infusion rate for the medication to be administered within the original 8 hour period. 8. Order is for 3000 cc over a 24-hour period. What is the hourly flow rate? OR: What will the pump be set at per hour? 9. Order is for antibiotic to be mixed in 50 ml NS and administered over 45 minutes. What is the hourly flow rate? OR: What will the pump be set at per hour? 10. Volume is 1000 ml. Ordered infusion time is 8 hours. Have tubing of 15 drops/ml. How many drops need to be counted to deliver the identified milliliters per minute? 11. Available solution = 25,000 units in 250 ml NS. Order is to administer at 22 ml/hour. How many units will be given per hour? 12. Available solution = 25,000 units in 250 ml NS. Administer at 2000 units/hour. How many ml will be given be hour? OR: What will the pump be set at per hour? Principles of Pharmacology These include the basics! Review: 1. Routes of administration – benefits and problems 2. Sizes of needles and syringes for injections 3. Six Rights of Medication Administration; Three Checks 4. Side effects; adverse effects; paradoxical reactions; toxicity; antagonists 5. Half-life calculation 6. Allergic or hypersensitivity reactions 7. Absorption, metabolism, distribution and excretion 8. There may be questions on lab values as relevant. 9. There are pediatric and adult questions. 10. Immunosuppression precautions (due to meds for cancer, HIV/AIDS, etc.) 3 Administration routes: some key points Sublingual administration □ absorbed in mucosa of oral cavities □ rapid onset of action □ Place tablet on floor of mouth, close mouth. Do not swallow, hold under tongue until dissolve. □ Use spray on floor of mouth under tongue and close mouth. Buccal □ place tablet between gum and cheek near back of mouth, close mouth and keep in place until dissolve □ slower to dissolve and absorb than sublingual Intramuscular injections □ Given in the vastus lateralis in children up to 3 □ Spread skin taught to bring muscle near surface of skin, with dart-like motion insert needle at 90 degrees □ Aspirate to determine if needle enter a blood vessel. If there is blood return discard the needle and meds and start procedure over. NGtube / Gtube □ NG usually temporary; G-tube for longer term □ Follow instructions re crushing, dissolving medication – no sustained release meds Eye drop administration □ Clean exudates from eye; (2) tilt head toward side of affected eye; (3) pull lower eyelid down; (4) have pt. look up; (5) instill drops in conjunctival sac formed by lower lid (not onto the eye); (6) Apply gentle pressure for 30 sec to 1 min over inner cantus next to nose (this prevents absorption through the tear duct and drainage of the medication). Close eyes gently massage the eyes to distribute the meds. □ Slow absorption except in infants where they readily absorb EYE OINTMENT □ Same as eye drop except it is expressed directly into the conjunctival sac from the inner canthus to the outer canthus. Close eyes and gently massage to distribute the medication 4 Definitions: Agranulocytosis / Neutropenia / agranulocytopenia □ Definition: Acute decrease in the number of granulocytes/leukopenia (WBC) in peripheral blood □ Causes include: treatment with broad spectrum PCN, sulfonamides or cephalosporin (piperacillin, tazobactam, cetazidime, ticarcillin, gentamycin), bone marrow transplant, chemotherapy, radiation. □ Generally is impaired resulting from bone marrow depression by drugs and chemicals or replacement by a neoplasm(oral lesion, ulcer necrotic, gingivitis, buccal mucosa □ Lymphadenopathy, lymphadenitis may be prevalent. □ Could lead to respiratory infection, ulceration of mouth colon, high fever, UTI. But may be asymptomatic Chelating agents □ A form of detoxification □ Chelating therapy involves an injection or oral administration of ethylene diamine Tetra acetic avide (a synthetic amino acid which attaches to toxic substance such as lead, cadmium, aluminum and other metal in the blood to facilitate their removal from the body.) □ May be used to treat hardening of the arteries, heart attack, stroke, arthritis and gangrene because of its ability to remove excess calcium from the body. EDTA: Ethylenediaminetetraacetic acid □ Use in children with lead level between 45&70 micron/dl. □ EDTA binds to lead in blood and excreted by the bowel and kidney. EDTA may be toxic to kidney. Monitor urine output. □ Give this by IV. Dose depends on weight of child, severity of the poison. Agent is given every 4 hours for 5 days. A second course may be needed if there is a rebound in the blood level. Give oral and IV fluid to enhance excretion □ Do not use EDTA with hypocalcemia or hypokalemia. OTHER AGENTS □ British antiLewisite (BAL) does not give with iron supplement and avoid in pt. with plant allergy. Give this by IM □ Succimer (Chemer) □ Chemet – oral medication - Do not give in pt. with encephalopathy Epistaxis □ Nose bleed. Can be anterior or posterior. Posterior is more serious. □ due to rupture of blood vessels within richly perfuse nasal mucosa spontaneous or initiated by trauma □ blood can come up through the eye, can also flow down the stomach causing nausea, vomiting 5 Treat epistaxis □ cauterization with silver nitrate, calcium alginate mesh, nasal cavity packed with sterile dressing ribbon gauze, absorbent dressing or saline sprayed into the nose □ Ice pack to forehead or back of the neck □ pinch septum of nose for 5 minutes □ Do not pack nose with tissue or gauze Half-life □ The time it takes for a medication to lose half of its pharmacologic or physiologic effect □ To calculate half-life: There is a formula but the easiest way to decrease count. □ Example: half- life is 1 hour. Start 100% 1 hr. 50% 2 hrs. 25% 3 hrs. 12.5% 4 hrs. 6.25% Question – Half-life of ‘xyz’ medication is 1 hour. After 3 hours, what percentage of the medication will be left? A = 12.5% Osmotic agent - see entry under Mannitol Paradoxical reaction □ A response to a drug (or medical treatment) that is the opposite to the usual response, such as agitation produced in an individual patient by a drug which is ordered to sedate or calm a person. Sustained release / time released / extended release / controlled release □ Pills or capsule formulated to dissolve slowly and release drug over time. □ They can often be taken less frequently, keep steadier levels of the drug in the bloodstream □ Contain in a matrix of insoluble substance (e.g. Acrylics) the drug swells up to form a gel so that the drug has first to dissolve in matrix then exit through the outer surface. □ Cannot be crushed, dissolved or opened 6 Medication Effects There is a bit of an overlap here with Principles of Pharmacology. These questions tend to be medication (or classification) specific. There are many medications on the test and many could be. As applicable, both brand and generic names are used. We recognize the attached grid is very lengthy, but have included some of the key components as identified below. Most medications addressed are either high usage or high risk. Please note that auto-corrections will change generic names to starting with caps. In the grid, we have tried to list generic first, then brand names. Areas to know: 1. Use, dose, side effects, contraindications 2. Since there are a limited number of questions, not all medications are addressed. You may be asked to select which medication would be given for a particular diagnosis. When studying, focus on the classifications – this may enable you to answer without knowing the actual medication. 3. Focus on what are the major side effects of a medication or class? What makes it high risk? Why might one particular med be used other than another? 4. Patient teaching is a major focus. What would you tell the patient about the medication? What would indicate understanding? What would indicate need for further teaching? Common classification of medications Note letters in medication name and look for those letters that identify a particular classification: ◊ Androgens: end with –terone: testosterone (Testoderm) ◊ ACE Inhibitors: end with –pril: enalapril (Vasotec) ◊ Antidiuretic hormones: end with –pressin: desmopressin (DDAVP) ◊ Antilipidemic: end with –statin: atorvastatin (Lipitor) ◊ Antiviral: contain -vir: ritonavir (Norvir) 7 ◊ Benzodiazepines: include alprazolam (Xanax), chlordiazepoxide (Librium), clorazepate (Tranxene), ◊ Beta Blockers: end with –lol: atenolol (Tenormin) ◊ CCB: end with –pine: amlodipine (Norvasc); some exceptions include diltiazem (Cardizem), verapamil estazolam (ProSom), and triazolam (Halcion). Most others end with –pam: diazepam (Valium) (Isoptin) ◊ Carbonic anhydrase inhibitors: end with –mide: acetazolamide (Diamox) ◊ Estrogens: contain est: conjugated estrogen (Premarin) ◊ Glucocorticoids and corticosteroids: end with –sone: prednisone (Deltasone) ◊ Histamine H2 receptor antagonists: end with –dine: cimetidine (Tagamet) ◊ Nitrates: contain nitr: nitroglycerin (Nitrostat) ◊ Pancreatic enzyme replacements: contain pancre: pancrelipase (Pancrease) ◊ Phenothiazines: end with –zine: chlorpromazine (Thorazine) ◊ Proton Pump Inhibitors: end with –zole: lansoprazole (Prevacid) ◊ Sulfonamides: include –sulf: sulfasalazine (Azulfidine) ◊ Thiazide diuretics: end with –zide: hydrochlorothiazide (HydroDIURIL) ◊ Thrombolytics: end with -ase: alteplase (Activase) ◊ Thyroid hormones: contain –thy: levothyroxine (Synthroid) ◊ Xanthine bronchodialators: end with –line: theophylline 8 Specific Diseases or treatments: Aminoglycoside □ antibiotics - Treats serious life threatening gram negative (and some positive) infections All aminoglycoside ends Mycin but not all drugs that ends in Mycin are aminoglycosides such as (Erythromycin and azithromycin) Examples: □ Gentamycin □ Tobramycin □ Vancomycin □ Neomycin □ Generally IM or IV. □ Oral route is not recommended. It is only use for bowel prep prior to surgery (see Neomycin) Adverse effects/toxicity: Two most common MAJOR adverse effects: Nephrotoxicity and ototoxicity. Also: □ Photosensitivity □ risk for superinfections □ Pseudomembranous colitis (c-diff): stop med and treat with PO Flagyl Peak level: □ Drawn 15-30 min after the infusion is completed. □ Peak concentration determines that toxic level does not occur. □ If peak is too high, may reduce dose. Trough level: □ Drawn immediately (within 30 minutes) before next IV dose □ Assures that therapeutic level of drug is maintained. Trough level is 1-2 g/ml between doses. □ Dose will be adjusted if level is not sustained □ 9 Blood administration □ Start blood transfusion slow 2 ml/min. Remain with pt. for the first 15-30 min. if there is no sign of side effect, increase rate to the desired rate □ Administer using largest gauge IV access as possible. □ Observe for acute reaction such as: allergic s/s – rash, itching, localized edema; febrile (even low grade); septic; air embolism; circulatory overload. □ Observe for delayed reaction: Graft vs. host; hepatitis; hemolysis Crack abuse effect on newborns □ Crack crosses the placenta and enters the fetus. □ Common presentation: Infant may appear normal or develop neurological problem. Child may develop depression or excitability, they may be lethargy, have poor suck; weak cry and difficulty in arousing, hypotonicity, rigidity, irritability, inability to console and intolerance to change, small head, decreased birth length □ Late symptoms: Some infant showed late symptoms 2-8 wks. There may be growth retardation - head growth is one of the best indication Diabetes treatment in children □ Hypoglycemic reaction takes place most time before meals or when insulin effect is peaking. □ First teaching: (1) let child wear bracelet or tag; (2) Teach how to give injection. Inject at 90 degree angle. □ Teach only the essentials on the first few visits and intense later. Keep session for children to 14-20 min and adult may go up to 45-60 □ Have same meal as normal child time intake of food. Eat at the same time each day. □ Children can start learn to assume responsibility for self-management as soon as age 4-5. At age 9, they can start giving their own insulin with supervision. □ Exercise: do not restrict exercise. Have extra snack before and after exercise. Exercise very regularly as it decreases the need for insulin □ Carry a source of glucose at all times (hard candy, sugar cubes glucose tablets, insta glucose). The rapid releasing sugar is followed by complex CHO and protein such as slice of bread or cracker spread with peanut butter □ After glucagon injection, vomiting may occur. Place child on the side to prevent aspiration. □ Preferred way of treating ketoacidosis is by insulin IV of low dosing. Note. Run a mixture of insulin through the tubing before starting the drip because the insulin can chemically bind to plastic. Replace fluid over 24-48 hrs. 10 Diabetes – Intravenous insulin administration □ Can only be done with regular insulin in management of DKA, HHNK. □ Premature discontinuation can cause prolongation of DKA. □ Begin SQ insulin therapy before stopping the infusion. If not, there might be prolonged hyperglycemia. Hepatitis – see below HIV treatment – antiretinoviral therapy Side effects: START therapy: Common meds: (1) all symptomatic HIV people □ Assess for opportunistic infection (presenting with a AIDS-defining illness) □ abacavir (ziagen) (cancer, neurological disease); HA, or fatigue, nausea, vomiting, diarrhea, □ stavudine (Zerit) (2) with a CD4 count less than 350 mm3. abdominal discomfort, anemia, taste □ zidovudine (AZT) perversion, asthenia, circumoral (3) also start pregnant women (AZT is used to prevent maternal transmission paresthesia with ritonivair, Antiviral protease inhibitor. End in AVIR of HIV) Adverse/toxicity □ Use prophylactically. STOP if severe rash or other □ Hepatoxicity, Hepatotoxicity: AST, □ Use in combination to decrease viral hypersensitivity reaction occurs. ALT, bilirubin; observe for nausea, load and increase CD4. Excluding reaction to medications vomiting jaundice upper right Reverse transcriptase inhibitors: Ends in and/or ineffectiveness of medication, abdominal quad enlargement and INE treatment will be long-term. tenderness. Reduce dose in liver □ Stop replication/growth. Reduces dysfunction. viral load. TEACH □ Nephrotoxicity; creatinine, BUN, □ One major advantage is that they do □ Use neutropenic precautions creatinine clearance, urinalysis, keep not affect adversely affect □ Eat small frequent meals with accurate I& O, monitor for SE of development of blood cells. complete or complementary proteins neutropenic, observe occult signs of □ Use in combination with other meds infection. (lower back, flank or because resistant strains may rapidly suprapubic pain, normal temp or low evolve if used as single agent grade fever related to UTI therapy. □ Inhibit cell protein synthesis that interfere with viral replication; block protease activity in HIV. □ Treat AIDS and AIDS-related complex to decrease viral load 11 Inotropic medications: Positive inotropic meds increase cardiac contractility – examples: epinephrine, norepinephrine, dopamine Negative inotropic meds decrease cardiac contractility, lower BP: examples – quinidine; betablockers (most end in ‘olol”) Sulfonamides Side effects: CAUTION: do not use: □ Rash common; most are urticaria and □ known allergies to sulfa drugs maculopapular. □ Anti-infective. □ In polyuria, advanced renal or hepatic dysfunction □ Bacteriostatic which action on □ GI symptoms bacteria results from interference □ Bone marrow depression □ with intestinal and urinary blockage, with the functioning of enzyme □ Headache, dizziness, vertigo, ataxia, □ asthma systems necessary for normal convulsion, depression metabolism, growth and Adverse effects/toxicity: □ Take adequate amount to fluid 3000multiplication □ Hepatotoxicity 4000ml/day to promote urinary □ Treat: UTI, Chlamydia causing output, at least 1500ml/d to prevent □ Nephrotoxicity blindness, pneumonia, brain abscess, crystalluria/stone formation □ Stevens Johnson syndrome (an ulcerative colitis, active Crohn’s □ May be taken after meals to prolong adverse reaction of skin that disease, rheumatoid arthritis resembles appearance of partial time in intestine. Examples: thickness burns) □ Collect C&S prior to beginning □ Bactrim therapy Thiazide diuretics: Side effects: □ Take early in the day to avoid Examples: nocturia □ Dizziness, vertigo, HA, weakness, chlorothiazide (Hydrodiuril), dehydration, orthostatic hypotension □ Take with food to avoid GI upset. hydrochlorothiazide (HCTZ, Diuril) □ N/V, abdominal pain, diarrhea, □ Thiazide is ineffective if creatinine Name ends in ZIDE constipation, frequent urination clearance is < 30ml/min □ non-potassium sparing diuretic. □ dermatitis and rash □ Eat foods high in potassium, restrict □ Acts on distal tubes, blocks □ Electrolyte imbalance sodium, do not use salt substitute if reabsorption of sodium, chloride and taking potassium supplement □ impaired glucose tolerance water. Leads to increased loss of Adverse effects/toxicity: □ weigh self daily, report sudden Potassium. weight gains or losses □ Renal failure, □ Use for edema and mild to moderate Avoid use with: □ aplastic anemia, agranulocytosis, hypertension □ Children thrombocytopenia □ will see effect of within 1-4 wks. □ anaphylactic reaction □ anuria 12 Tricyclic Antidepressants □ Initial mechanism of TCA takes 1-3 weeks to develop. □ Maximum response is achieved in 6-8 wks. □ Has long half-life. Most Tricyclics ends in INE □ nortriptyline (Pamelor) □ amitriptyline (Elavil) □ doxepin (sinequan) □ imipramine (tofranil) □ Block the reuptake of norepinephrine or serotonins or both, leaving more available in the CNS. It intensifies the effect of norepinephrine and serotonin which can elevate mood, increase activity and alertness, decrease preoccupation with morbidity, improve appetite and regulate sleep pattern. □ It is used to treat insomnia, attention deficit/hyperactivity and panic disorder. Side effects: □ orthostatic hypotension, □ sedation and anticholinergic effects. Adverse effects/toxicity: □ Most serious adverse effect is cardiac toxicity; in the absence of overdose or preexisting cardiac impairment, serious cardiotoxicity is rare. □ URINARY RETENTION IS URGENT □ Overdose may cause convulsions □ Take at nights, it causes sedation. □ Do not take with MAO it will cause hypertensive crisis from excessive adrenergic stimulation of the heart and blood vessels, □ monitor orthostatic BP of pt. in hospital Use with caution: □ Glaucoma □ Elderly □ constipation, prostatic hyperplasia, as they are more sensitive to anticholinergic effect Avoid use with: □ hypersensitivity, □ MI, Cardiovascular disease Vesicant – Chemotherapy □ See precautions under “Vincristine” Hepatitis: inflammation of liver caused by virus, bacteria or exposure to meds or hepatotoxins Stages of viral hepatitis: (1) Pre-icteric – precedes appearance of jaundice, may have flulike symptoms (2) Icteric – appearance of jaundice, elevated bilirubin, dark or tea colored urine, clay-colored stools (3) Post-icteric – convalescent stage; jaundice improves; color of urine and stool returns to normal 13 Hepatitis A (formerly “infectious hepatitis”) Cause: enterovirus At risk: □ Young children □ Institutionalized people □ Health care personnel Transmission: □ fecal-oral □ ingestion of food or liquids contaminated with the virus. □ person by person contact Incubation: 3-5 wks. Infectious: usually 2 wks. before the onset of jaundice and 1 wk. after onset of jaundice. s/s: May have no symptoms initially. Complications: □ Fulminant hepatitis Hepatitis B. Hepatitis C Hepatitis D Hepatitis E At risk: □ IV drug users □ People on Hemodialysis □ Health care personnel At risk: □ IV drug users □ People receiving frequent transfusions □ Healthcare personnel Cause: Occurs only with Hepatitis B and only causes problems with an acute HepB infection. Cause: waterborne virus Transmission: □ blood and body fluids □ contaminated needles, parenteral □ sexual activity Incubation: 6-24 weeks s/s: □ progression of symptoms is more insidious and prolonged than Hep A virus. □ Initially may be asymptomatic. □ 1 week -2 months of Prodromal symptoms: fatigue, anorexia, transient fever, abdominal Transmission: □ Same as Hep B □ Blood and body fluids Incubation period: 5-10 weeks s/s: similar to HBV but often less severe. Complications: □ chronic liver disease □ Cirrhosis. At risk: □ common in Middle east, south Africa and Mediterranean □ same as HepB Transmission: □ same as Hepatitis B. Incubation period: 7-8 weeks HepD along with HepB causes superinfection and worsening of condition and rapid progression of cirrhosis Complications: As per Hep B At risk: □ Travel to areas where sewage disposal is inadequate and/or people bathe in contaminated rivers □ At higher risk with higher mortality: women in third trimester of pregnancy Transmission: □ Same as HepA Incubation: 2-9 weeks Complications: □ Maternal and fetal demise 14 □ death discomfort N/V, HA. □ Then expanding to: Hepatic S/S, photophobia, angioedema, rash, vasculitis, jaundice in Icteric phase Complication: □ Cirrhosis □ Fulminant hepatitis A grid follows with a listing of medications that may be on the exam. 15 Drug Acetylsalicylic acid (Aspirin) □ Non-narcotic analgesic □ Antipyretic □ Antiplatelets Use and dosage □ Blocks pain impulse in peripheral and some CNS; □ antipyretic result; □ inhibit platelets aggregation □ Treat TIA, Post MI, Stroke, angina Activated charcoal (Actidose) □ Antidote □ Adsorbent □ Treat poison and overdose following oral ingestion. □ Binds to poison and prevent its absorption by the GI tract and then eliminates in the feces. □ Administer within 60 minutes of ingestion. □ Give once or twice depending on the level of toxin. □ May come premixed with water 12.5-25 grams Side effect □ Increases coagulation times □ Reye’s syndrome (encephalopathy and fatty liver), □ GI bleed, □ tinnitus, □ liver toxicity (dark urine, clay stool, itching, yellowing sclera and skin), □ visual changes □ Vomiting with rapid administration □ pulmonary aspiration Teaching and labs □ Monitor coagulation studies □ Take with full glass of water, milk for food to prevent stomach upset □ Do not crush enteric coated □ given daily (81-325 mg) for cardiac prophylaxis post MI, stents, strokes, etc. □ Binding is irreversible so cathartic such as sorbitol may be added as well. □ It allows certain drugs/toxins to be drawn out of the blood and bind to charcoal in the intestine a kind of “gut dialysis” □ Stools will be black □ Charcoal does not change the stomach PH. contraindication Do not use with: □ children under 12 and/or children or teenagers with chicken pox or flu like symptoms (because of risk of Reye’s syndrome); □ pregnancy in 3rd trimester; and □ vitamin K deficiency Do not administer with Ingestion of: □ caustic alkali agent, □ high viscosity petroleum products OR when: □ convulsions are occurring, □ cardiac dysrhythmias are present, or □ there is emesis of blood Implement antidote supportive care and prevent aspiration are if gastric lavage is not to be performed. 16 Drug Acyclovir (Zovirax) □ Antiviral - Herpes simplex virus – HSV - Herpes zoster - varicella Alteplase recombinant (Activase) Streptokinase is similar. Urokinase is given mostly in emergency situation. □ Thrombolytic agent Cath-flo Activase – is for occluded catheters Use and dosage □ Used for herpes simplex. Does not eradicate latent herpes. It reduces viral shedding and formation of new lesions and speeds healing time. (oral, IV and topical) □ To decrease symptoms with varicella zoster (chicken pox/ shingles). □ Dissolves or break down clots to reestablish perfusion. □ Indicated for clients at risk for developing thrombus with resultant ischemia such as MI, ischemic stroke, arterial thrombosis, DVT, PE □ occlusion of IV catheters. Side effect Side effects: □ Headache, dizziness □ seizure □ nausea, vomiting, diarrhea □ acute renal failure □ thrombocytopenia □ purpura hemolytic □ uremia syndrome Adverse effects/toxicity: □ nephrotoxicity □ □ □ □ Hemorrhage, N/V, hypotension cardiac dysrhythmias. □ Dose related is the highest problem Teaching and labs □ Even after HSV infection is controlled, latent virus can be activated by stress, trauma, fever exposure to sunlight, sexual intercourse. □ Refrain from sex if S/S of herpes. contraindication □ Watch for s/s bleeding; VS changes, s/s of impending shock □ If bleeding is occurring stop treatment and notify doctor. May start on FFP and PRBC. □ Aminocaprionic acid (Amicar) may be ordered for overdose or excessive bleeding. Do not give with: □ pregnancy, □ active bleeding, □ recent Hx of CVA, □ Uncontrolled HTN, IM medication route is contraindicated when using thrombolytics. □ Do not take NSAIDs or Aspirin because of enhanced bleeding. 17 Drug Aluminum hydroxide (Amphogel) □ Antacid Ampicillin (Ampicin) IV, PO, IM. □ Antibiotic □ Aminopenicillin Similar side effects, allergic reaction, etc. for all Penicillins (PCN) Use and dosage □ Neutralizes gastric acid, □ antflatulent to alleviate symptoms of gas and bloating Treat bacterial infection Commonly used with: □ Shigella, □ salmonella, Escherichia coli, □ haemophilus influenza, □ Neisseria gonorrhea, □ Neisseria meningitis, □ gram positive organism Side effect □ Increases gastric pH, □ Decreases absorption of other drugs such as dig, antibiotic, iron supplement. □ Toxicity causes dementia, Hypercalcemia, metabolic alkalosis, worsening of HTN, heart failure from increased intake. □ allergic reaction: Skin rash, urticaria, swelling, pruritus, angioedema. □ Severe allergy: hives, wheezing, anaphylactic reaction. Medical emergency requires immediate tx or can lead to death. □ side effects: GI, N/V, diarrhea, abdominal pain. □ Pruritic rash like measles is not a true allergic reaction Teaching and labs Given 2 hrs. apart from other drugs where interaction may occur. Observe for signs and symptoms of altered phosphate levels; anorexia, muscle weakness and malaise. Increase fluid, exercise and fiber to prevent constipation. contraindication Do not use: □ abdominal pain, N/V, diarrhea, □ severe renal dysfunction, □ fecal impaction, rectal bleeding, □ colostomy, ileostomy □ dehydration □ hypercalcemia and hypercalciuria □ Do not give with fruit juice, milk or carbonated beverages because of poor absorption. □ Watch for hypokalemia □ Take on empty stomach. □ May not be necessary to stop treatment if mild diarrhea develops. □ Give yogurt or buttermilk to restore normal flora (or probiotics) Avoid with: □ Hypersensitivity to any penicillins; use cautiously if history of hypersensitivity to cephalosporins; □ Exfoliated dermatitis □ Loop diuretic may exacerbate hypokalemia and rash. □ Potassium-sparing diuretic may contribute to hyperkalemia 18 Drug Atropine Sulfate. Two different uses: □ Anticholinergic (such as for Parkinson’s disease) □ For ophthalmic use Systemic effect is more pronounced in infant and children with blue eyes and blond hair. Also increased risk of toxicity with Down syndrome Use and dosage □ Use to increase heart rate (not necessarily first drug of choice). □ Decreases involuntary movement and rigidity in Parkinson’s disease □ Pre-op to decrease secretions and prevent aspiration of secretions while under anesthesia □ Use for inflammation of the iris and uveal tract. Side effect □ Dry mouth, constipation, urinary retention or hesitancy headache, dizziness Adverse effects/toxicity: □ Paralytic ileus. □ Treat overdose (resp. depression and circulatory collapse) symptomatically. Adverse effect when used for the eye □ Transient stinging, □ increase IOP, photophobia, Teaching and labs □ Monitor dosage of meds carefully, even slight overdose can lead to toxicity. □ Assess for constipation and urinary retention; increase fluids, bulk and exercise, assess bowel sound to rule out paralytic ileus, □ Avoid driving or other hazardous activities, drowsiness may occur. For the Eye □ Acute glaucoma can be precipitated by papillary dilation; if not recognized and treat, acute glaucoma can result in blindness. □ Wear dark sunglass and avoid bright light for photophobia, □ Monitor intraocular pressure and vision contraindication □ Increased anticholinergic effect with phenothiazine, antidepressant, MAO’s amantadine. □ Contraindicated in pt. with narrow angle glaucoma, myasthenia gravis, or GI obstruction. 19 Drug Beclomethasone diproprionate (Beclovent) □ inhaled corticosteroid medication note: also nasal inhalant as Beconase Use and dosage □ Used in bronchial asthma, allergic rhinitis Side effect Side Effects: □ Pharyngeal irritation and sore throat, coughing, dry mouth, oral fungal infections, and sinusitis. □ Increased susceptibility to infection, dermatologic effects and osteoporosis, diarrhea, N/V, HA, fever, dizziness angioedema rash urticaria and paradoxical bronchospasm Adverse effects/toxicity □ Adrenocortical insufficiency □ fluid and electrolyte disturbances, □ nervous system effects and endocrine effects if absorbed systemically. Teaching and labs □ Decrease dose if pt. is on systematic corticosteroid. □ Assess for impaired bone growth in children receiving inhaled corticosteroid Considerations: □ Monitor for hyperglycemia □ Rinse mouth after use for medication; oropharyngeal candidiasis and/or hoarseness can occur. □ Use bronchodilator inhalant before corticosteroid when both are ordered. □ Do not abruptly stop meds taper over 2 weeks. □ Be aware of steroids symptoms - Moon face, acne, edema, increased fat pads - notify doctor. □ Report weight gain contraindication Do not use with: □ children under □ Clients with known allergy □ May require adjustment of antidiabetic agent as there is a potential for elevated blood glucose levels with corticosteroids are administered orally. □ Not use in bronchospasm or status asthmaticus. 20 Drug Benztropine mesylate (Cogentin) Use and dosage □ Treat Parkinson symptoms: Suppresses tremors and rigidity, not tardive dyskinesia □ Decreases hypersalivation and irregular movement related to Parkinson disease. □ Reduces extrapyramidal side effects Side effect Side effects: □ dry mouth, □ urinary retention/hesitancy, □ HA, □ dizziness. Buspirone (Buspar) □ Anxiety □ anxiolytic □ Desired response 710 days; Make take 3-4 weeks for full effect Side effects: □ Dizziness □ headache □ drowsiness □ Anticholinergic (cholinergic receptor antagonist) □ Anti-Parkinson Adverse effects/toxicity: □ paralytic ileus Teaching and labs □ Monitor dose carefully; even slight overdose can lead to toxicity. contraindication Avoid use with: □ narrow-angle glaucoma, □ myasthenia gravis, □ GI obstruction Nursing considerations: □ Monitor I&O’s, Education: □ Avoid driving, or other hazardous activities; drowsiness may occur. □ Avoid cough OTC medication unless prescribed. □ When switching to Buspar, taper off benzodiazepines □ Less likely to have cognitive impairment than other CNS meds □ Does not cause withdrawal s/s and thus does not need to be tapered off when stopping Avoid use with: □ MAO Inhibitors □ Lactation □ Caution with: moderate to severe renal impairment 21 Drug Chlordiazepoxide hydrochloride (Librium) □ Anxiolytic □ Sedative-hypnotic benzodiazepine IM & tablet form Peak: □ 1-4 hours PO, □ 15-30 min IM. Half-life 5-30hr Use and dosage □ To relieve tension and/or anxiety □ To manage alcohol withdrawal Side effect Adverse effect: □ respiratory distress, drowsy, dizziness, lethargy, orthostatic hypotension □ photosensitivity □ do not to stop taking drug abruptly – will have withdrawal symptoms (usually in 5-7 days) Suicidal tendencies may be present and protective measures may be necessary. □ Monitor closely for paradoxical reactions – excitement, stimulation, acute rage – usually early in tx – withhold drug and notify dr. Teaching and labs □ Give with milk or food to prevent GI upset. □ Check BP and pulse early in tx. If BP falls delay medication and notify dr. □ Labs: Monitor CBC, renal and hepatic enzyme levels □ watch for dependency Education: □ Avoid alcohol □ no OTC meds unless prescribed □ Avoid driving and other hazardous activities until effects known. contraindication Avoid use with: □ Narrow angle glaucoma, □ under 12 year old □ lactation Use cautiously with: □ impending depression, □ impaired hepatic or renal function, □ COPD 22 Drug Chloramphenicol (Chloromycetin) Oral, injection, ophthalmic drops and ointment Use and dosage □ severe infection for susceptible organisms when other anti-infective are ineffective. □ Sty, conjunctivitis, uveitis Side effect Side effects: dermatitis, itching, stinging, swelling Adverse effects/toxicity (oral and injection) □ edema □ super infection, □ aplastic anemia. □ Stevens-Johnson syndrome Teaching and labs □ obtain culture specimen from eye before initiation of treatment □ remove exudates. □ Monitor for pain, drainage, redness, swelling. □ Monitor for bleeding or bruising contraindication Avoid use with: □ hypersensitivity □ Increases urinary excretion sodium and water by inhibiting sodium reabsorption. □ Use for edema and HTN, HF, cirrhosis, corticosteroid and estrogen therapy, diabetes insipidus, Side effects: □ Dizziness, vertigo, frequent urination, electrolyte imbalance, impaired glucose tolerance, hyperuricemia, photosensitivity Adverse effects/toxicity: □ Renal failure, aplastic anemia, and anaphylaxis □ Take early in the morning to avoid nocturia. □ Give with food, □ allow for 3-4 weeks for maximum effect, □ Will not be effective if creatinine clearance Is less than 30ml/min Avoid use: □ Client with anuria. □ Use cautiously with impaired renal or hepatic function. □ If pregnant. □ Will increase serum lithium level □ Anti-bacterial Chlorothiazide (Diuril) □ Thiazide diuretic, non-Potassium sparing □ Anti-hypertensive 23 Drug Chlorpromazine hydrochloride (Thorazine) □ phenothiazine □ Antipsychotic medication □ Anti-emetic □ Give bromocripitine (Parlodel) and dantrolene (Dantrium) for NMS. Use and dosage □ Block dopamine receptor in CNS to □ Use: treat psychotic disorder (schizophrenia, bipolar, and other mental illnesses); prevent acute exacerbation and maintain highest possible level of function □ Use to control manic phase (bipolar) □ intractable hiccups □ nausea/vomiting □ Low potency antipsychotic which can reduce the risk of EPSE (extrapyramidal side effects) Side effect Side effects: □ Sedation, orthostatic hypotension, □ anticholinergic effect (dry mouth, blurred vision, urinary retention, photophobia, constipation, tachycardia) □ liver damage, tremor are two major side effects. □ photosensitivity Adverse effects/toxicity: □ Neuroleptic malignant syndrome (NMS), catatonia, rigidity, stupor, unstable blood pressure profuse sweating, dyspnea. Can be toxic effect and MAY last for 5-10 days after discontinuation of the med. Teaching and labs □ get baseline ECG, thorough baseline evaluation lab tests before treatment. □ Give bromocripitine (Parlodel) and dantrolene (Dantrium) for NMS. □ Withdrawal of drug is necessary □ Take measures to protect eyes exposed to sunlight contraindication □ Monitor diabetics closely for glucose intolerance 24 Drug Cimetidine (Tagamet) □ GI meds, □ H2 receptor antagonist Cisplatin (Platinol) Half-life 20-30 minutes □ Antineoplastic medication □ Alkylating agent ** Major allergic reaction can occur within first 15 mins. of administration. Anaphylaxis may occur within minutes of drug initiation. Use and dosage □ Works against histamine receptors, decreases gastric secretion. □ Use short term for duodenal ulcer, benign gastric ulcer, acute upper GI bleed □ Treat ovarian and testicular cancer by interfering with DNA replication Side effect Side effects: □ Cardiac dysrhythmia, diarrhea, dry mouth, constipation Adverse effects/toxicity: □ Rare but may include agranulocytosis neutropenia , thrombocytopenia aplastic anemia, anaphylaxis Side effects: □ anorexia, uncontrolled N/V, fluid retention, weight gain Adverse effects/toxicity: □ Major toxicities occur in the blood, GI, and reproductive system. □ Watch urine output and specific gravitynephrotoxicity may occur within 2 wks. □ ototoxicity (tinnitus or difficulty hearing in the high frequency range) Teaching and labs □ May be given with meals and at bedtime □ Avoid smoking which cause gastric stimulation □ Avoid antacid use within one hour of dose contraindication Avoid use: □ hypersensitivity Use caution: □ impaired renal or hepatic function □ maintain fluid at least 3000 ml in 24 hr. ; report reduced urine output □ Avoid food high in thiamine (beer, wine cheese, brewer’s yeast, chicken liver & banana) - may lead to hypertension & intracranial hemorrhage Avoid use: □ Hx of sensitivity to platinum-containing compounds, □ impaired renal function and hearing, □ Hx of gout, renal stones. Incompatible with □ dextrose and Reglan, Vanco □ Lasix may increase otoxicity □ other nephrotoxic drugs may increase nephrotoxicity and renal failure. 25 Drug Codeine sulfate □ Opioid analgesic (agonist) □ Antitussive (cough suppressant) Use and dosage □ To treat mild to severe pain □ most oral preparations combined with ASA or acetaminophen □ Rapid onset if IM or IV. Peak 1-2 hrs., Duration up to 7 hours. Cyanocobalamin (Vitamin B12) □ Half- life: 6 days □ □ Side effect Side effects: □ Constipation, urinary retention, dizziness, lightheadedness. Adverse effects/toxicity: □ Respiratory depression, respiratory arrest, hyperactive cough circulatory depression, ICP. □ Long term use may cause withdrawal symptoms when stopped Vitamin B12 helps in Adverse effects/toxicity: the formation of □ Anaphylactic shock, red blood cells sudden death, essential for the □ severe optic nerve proper production atrophy (may of blood platelets develop after years and red and white of use or with blood cells and the Leber’s disease) nervous system Malabsorption syndrome Pernicious anemia □ water-soluble vitamin that is stored in the liver. Teaching and labs Assess for: □ respiration and usually hold <12 breaths per minute, □ CNS changes (LOC), □ allergic reaction TEACH: □ no alcohol □ no OTC pain meds unless ordered □ Avoid driving until drug response is known. contraindication Do not use: □ Hypersensitivity □ Increased ICP, head injury □ Acute alcoholism □ labor Teach: Do not use: □ Injection is once per □ Hypersensitivity month for life with □ Lactation pernicious anemia . □ Oral preps may be mixed with fruit juice but give immediately since ascorbic acid (Vit. C) affects stability of B12. □ Dietary B12: best are organ meats, egg yolk, clams, oysters, crabs, sardines, salmon 26 Drug Cyclosporine (Sandimmune) □ Immunosuppressant medication Metabolized in the liver. Peak 4-5hr, Duration 20-54 hrs. Half-life 19-27 hrs. Use and dosage □ Inhibit T helper and T suppressor cells. □ Prevent rejection of kidney, liver and heart transplants. □ Treat chronic rejection in people who have received immunosuppressive agent, rheumatoid arthritis, recalcitrant plaque psoriasis Side effect Side effects: □ Hypertension, □ increased risk of infection □ Tremor is an expected side effect Adverse effects/toxicity: □ Renal toxicity, □ hepatotoxicity Teaching and labs □ Monitor labs: AST, ALT, BUN, creat, platelet count, K, TEACH: □ Take with food to reduce GI upset □ mix with milk, chocolate milk or orange juice but not with Grapefruit juice □ Mix in glass, not plastic □ Avoid use of live vaccine □ Prevention of infection and report signs of infections contraindication □ Do not use: Pregnant/lactating mom, □ Use cautiously in renal and hepatic impairment □ Antiepileptic medications decrease cyclosporine levels □ oral contraceptive increase levels □ Immunosuppressed precautions 27 Drug Debrox drops □ Ear drops to dewax Use and dosage □ used to soften and loosen ear wax, making it easier to remove. Side effect Side effects: □ temporary decrease in hearing after using the ear drops □ mild feeling of fullness in the ear □ mild itching inside the ear. Adverse effects/toxicity: □ Get emergency medical help if you have any of these signs of an allergic reaction: hives; difficulty breathing; swelling of your face, lips, tongue, or throat Teaching and labs Use: □ Tilt head with ear facing upward. Pull back on ear to open up the ear canal. Drop the correct number of ear drops into the ear. □ After using the ear drops, stay lying down or with your head tilted for at least 5 minutes. You may use a small piece of cotton ball to plug the ear and keep the medicine from draining out. □ A bubbling sound inside may be heard after putting in the drops. This is caused by the foaming action of carbamide peroxide, which helps break up the wax □ May come with bulb syringe. contraindication Do not use: □ With a ruptured ear drum. □ any signs of ear infection or injury □ Do not use this medication in a child younger than 12 years old without the advice of a doctor. □ Do not use for longer than 4 days in a row. 28 Drug Diazepam (Valium) □ Benzodiazepine (have zep and zap in them) □ minor tranquilizers, □ anticonvulsant, □ anxiolytic □ Absorbed from GI, metabolize in liver Onset 30 min IM, 60 PO, 15 IV. Works quickly. Peak 1-2hr PO, Duration 15 min to 1hr IV; up to 3 hrs. PO. Half-life 20-50 min Use and dosage □ Relieve pain and discomfort from musculoskeletal disorders, □ manage anxiety, □ Manage acute alcohol withdrawal Maximum effect will be seen in 1-2 weeks. Can take 2-4 wks. It has addictive effect. Side effect Side effects: ABCD. □ Anticholinergic (dry mouth), □ Blurred vision, □ Constipation, & □ Drowsiness, □ cardiovascular collapse, laryngospasm, dizzy, weakness, nausea Adverse effects/toxicity: □ Erythema multiforme, □ angioedema, □ anaphylaxis, □ dysrhythmia □ seizure Teaching and labs □ Watch for CNS effect. □ Monitor CBC WBC with diff. □ notify dr. if drop in BP of 20 mm Hg □ Assess for allergic reaction including idiosyncratic reaction, anaphylaxis, rash fever resp distress Teach □ Do not stop abruptly – withdrawal symptoms will occur (insomnia, nausea HA, spasticity, tachycardia). □ No alcohol (will increase CNS depression) contraindication Do not use: □ compromised pulmonary function, □ hepatic disease, □ impaired myocardial function, □ acute alcohol intoxication □ infant < 6 months □ narrow angle glaucoma, open angle glaucoma □ Suicide prevention precautions 29 Drug Digoxin (Lanoxin) □ Cardiac glycoside, antiarrhythmic drug. □ Therapeutic range: 0.5-2.0ng/ml □ Toxic level > 2 Antidote: digibind (digoxin immune fab) Use and dosage □ Positive inotropic effect □ In heart failure it Increase contraction of the heart muscle. □ In atrial fib, it slows the heart rate Side effect Side effects: □ Nausea, HA, loss of usual appetite. Adverse effects/toxicity: □ Toxicity may go unrecognized since it presents with same symptoms as flu (N/V, anorexia, diarrhea, vomiting visual disturbance). □ Blurred green or yellow vision or halo effect** □ In HF, early sign of toxicity includes dysrhythmias. □ Children rarely show signs of N/V, diarrhea, visual problem, anorexia (could become dig toxic without showing usual s/s) Teaching and labs □ may give without regard for food □ IVP over 5 min, do not give IM, it will cause tissue irritation. □ Monitor apical pulse, if <60/min., usually hold meds and notify doctor. □ Monitor labs (K, calcium, magnesium, creatinine clearance), □ Monitor Dig level every 6 months. □ weigh daily and report weight greater than 2 lbs. per day contraindication Avoid use with: □ hypersensitivity to dig □ Caution with kidney failure Interaction: □ IV calcium with dig may increase risk of cardiac dysrhythmias, □ erythromycin will increase dig level, □ quinidine, verapamil and amiodarone will increase dig levels and dig dose should be decreased by 50% □ Cyclophosphamide combined with dig cause dig toxicity 30 Drug Disulfiram (Antabuse) The only alcohol antagonist in use. □ Enzyme inhibitor □ Anti-alcohol agent. Half-life 24-36 hour Onset up to 12 hrs. Duration up to 2 wks. Absorbed from the GI excreted in feces or in the breath as carbon disulfide Use and dosage □ Adjunct treatment of patient with chronic alcoholism who sincerely wants to maintain sobriety. □ At least 12 hours should elapse from the time of last alcohol intake and the initial dose □ Use only in people with high physical health. □ Use for 1-2 wks. INTENDED Reaction with alcohol ingestion: □ flushing face, chest, arms □ pulsating HA □ Nausea □ violent vomiting □ thirst □ sweating □ marked uneasiness Side effect Side effects: □ Rare in the absence of alcohol Adverse effects/toxicity: ** Acetaldehyde syndrome □ hypotension to shock level arrhythmias, □ acute congestive failure, □ marked respiratory depression, □ unconsciousness, □ convulsions □ sudden death Teaching and labs □ The effects of disulfiram may persist for 2 weeks after last dose is taken; alcohol must not be consumed until this interval is over. □ Give in the morning when the resolve not to drink is the strongest. Give at bedtime to minimize the effect of drug □ avoid alcohol of all forms include those found in sauces, cough mixture and after shave lotions, colognes and liniments contraindication Do not use: □ In people who do not want to stop drinking. □ Severe cardiac disease, □ psychoses, □ pregnancy, □ multiple drug dependence. 31 Drug Epinephrine (Adrenalin) □ alpha and beta adrenergic agonist □ vasopressor □ bronchodilator □ If given IM, SQ result seen in 5 min & lasts up to 4 hrs., □ Also available eye drops and intranasal Use and dosage □ Reverses anaphylactic reaction □ Restores cardiac rhythm in cardiac arrest □ Acute asthmatic attack Side effect Side effects: □ nervousness, □ tremors, □ increased HR, BP, □ insomnia, □ anorexia □ cardiac stimulation □ vascular HA. □ Also use in ophthalmic decongestant, manage open angle glaucoma Adverse effects/toxicity: □ Tachyarrhythmias, □ chest pain, □ restlessness, □ agitation, □ nervousness and □ insomnia. □ Nasal burning stinging, □ eye burning D/C if hypersensitivity develops (develops of lids, itching, discharge, crusting eyelid). Notify doctor Teaching and labs Teach □ Report nervousness and sleeplessness dose should be reduced. □ Administer eye drops at bedtime. May experience headache and stinging but subside with continued use. Report if continues. contraindication □ Monitor VS especially HR and BP because of cardio effect. CAUTION in: □ older adults, □ HTN □ TB, long standing bronchial asthma and emphysema □ children < 6 If use with MOA inhibitors may lead to hypertensive crisis. □ Narrow angle glaucoma, □ hemorrhagic traumatic or cardiogenic shock, □ arrhythmias, □ organic heart or brain disease. □ No breastfeeding 32 Drug Famotidine (Pepcid) □ Histamine □ H2 antagonist. Onset 1 hr. Peak 1-3hr Duration 10-12 hrs. Half-life 2.5-4hr Fluoxetine hydrochloride (Prozac) □ psych med. □ Tricyclic antidepressant. □ Selective Serotonin Reuptake inhibitors (SSRI) □ Half-life 1-6 days. Onset 2-3 weeks to be effective. Peak 4-8hrs. Metabolized in liver, absorbed from GI tract, excreted in urine and face. Use and dosage □ Decreases output of gastric acid □ Short term treatment in duodenal ulcer or benign gastric ulcer. □ Metabolized in liver, excreted in urine □ Major depressive disorder □ Obsessive compulsive disorder, □ bulimia, □ panic disorder □ obesity □ alcoholism □ chronic pain. Such as rash. Wait 4-6 weeks before switch to MAO Inhibitor Side effect Side effects: □ diarrhea, constipation, dry mouth Adverse effects/toxicity: □ thrombocytopenia Teaching and labs □ May be taken with food. □ pain relief may not be experienced for several days Common side effects: □ Orthostatic hypotension □ sedation □ Anticholinergic □ Hypomania □ Sexual dysfunction Adverse effects/toxicity: □ Cardiac toxicity Selective Serotonin syndrome (early s/s: diaphoresis, agitation, low grade temp.) Then increase in BP, muscle rigidity, temp, resp, pulse. Mental status changes, tremors, hyperthermia, sweating hypersalivation. Notify dr ASAP. □ DO NOT stop abruptly. □ Give meds once a day at about noon because it causes insomnia. If prescribed 2 times daily give dose in the morning early and 12 noon to prevent insomnia □ Teach side effects of drugs □ Therapeutic response takes some weeks to be established. contraindication □ Use cautiously with impaired renal or hepatic function. □ Do not breastfeed □ avoid antacid use within 1 hour of dose □ MI, cerebrovascular disease. □ If suicide risk, should not have access to a large quantity. □ Do not take while pregnant □ ** The combination of TCA and MAOI can lead to hypertensive crisis from excessive adrenergic stimulation of the heart and blood vessels. 33 Drug Fluphenazine (Prolixin) □ phenothiazine; Ends with azine □ antipsychotic Half-life > 24 hours Onset: 1 hr., peak 0. 5 hr. meds effect can be seen 1-2 days but full effect several weeks Use and dosage □ Potent medication for treatment of antipsychotic symptoms, including schizophrenia. □ Treatment is not curative. □ Adjust dose to symptoms. □ Use injectable form for long term maintenance - the rate of relapse is usually reduced and is more favorable Side effect □ Produces EPS which are reversible. ** Treat EPS with Cogentin, Artane, Benadryl, Symmetrel Side effects: ABCDE □ Anticholingergic (dry mouth), Blurred vision, Constipation, Drowsiness, EPS □ Photosensitivity □ may increase risk of agranulocytosis □ gynecomastia, □ amenorrhea □ weight gain Adverse effects/toxicity: Neuroleptic malignant syndrome (NMS) a fatal side effect. Presents with catatonia, rigidity, stupor, unstable blood pressure, hyperthermia profuse sweating, dyspnea, incontinence. Stop drug. Tx with Dantrium and Parlodel. Condition lasts for 5-10 days after stopping med. Teaching and labs Monitor LFTs TEACH □ Avoid alcohol use and other CNS depressants □ Do not alter dose or stop abruptly □ Avoid sun exposure □ With oral concentrate, avoid spills. Rinse skin with warm water immediately if there is contact contraindication Avoid with: □ Caution with narrow angle glaucoma, hepatic or renal dysfunction and seizure disorder. □ Do not breastfeed □ Dose should be reduced in the elderly. □ Dilute liquid drug with fruit juice water, carbonated beverage, milk, soup – avoid mixing with caffeine, tea, apple juice. 34 Drug Furosemide (Lasix) □ Loop diuretics, □ Anti-hypertensive Peak 60-70 min PO, 2060 min IV. Onset 30-60 min PO, 5 min IV, Duration 2 hrs., Half-life 30 min Use and dosage □ Rapid acting loop diuretic □ Inhibits reabsorption of sodium and water (in Loop of Henle) □ Lowers BP by decreasing edema and intravascular fluid Treat □ acute pulmonary edema, edema, □ heart failure, □ chronic renal impairment, □ hypertension, □ hypercalcemia Side effect Side effects: □ Ototoxicity □ headache □ Dizziness □ Orthostatic hypotension □ weakness Adverse effects/toxicity: □ s/s hypokalemia – □ Hyponatremia, □ hypochloremia, □ hypomagnesaemia □ hypocalcemia IV form: □ Administer slowly; hearing loss can occur if injected rapidly (ototoxicity). □ Give over 1-2 minutes to prevent hypotension. Teaching and labs TEACH □ change position slowly to avoid dizziness and orthostatic hypotension □ report ringing in the ear immediately □ Take with food or milk □ Give early in day to avoid nocturia □ Replace potassium (dietary or meds) □ Monitor labs, especially electrolytes. Also hgb, hct, platelet as these increase d/t hemoconcentration contraindication Avoid with: □ anuria, electrolyte depletion, increasing oliguria, anuria □ hepatic coma, □ pregnancy, lactation □ Interaction with digitalis can increase arrhythmias. □ Interaction with aminoglycosides increases risk of ototoxicity. □ Monitor body weight and I&O. 35 Drug Gentamicin (Garamycin) □ Aminoglycosides. □ Antibiotic Peak level: □ Drawn 15-30 min after the infusion is completed. □ Peak concentration determines that toxic level does not occur. □ If peak is too high, may reduce dose. Trough level: □ Drawn immediately (within 30 minutes) before next IV dose □ Assures that therapeutic level of drug is maintained. Trough level is 1-2 g/ml between doses. □ Dose will be adjusted if level is not sustained Peak 30-90 min Half-life 2-4 hr. Use and dosage □ Broad-spectrum antibiotic □ Parenteral use limited to severe infections, unresponsive to other antibiotics. Ophthalmic: □ treat superficial infection of the eye. □ Have pt. keep eyes closed for 1-2 min after instillation. □ Vision will be blurred initially Side effect Side effects: □ HA, parenthesia, skin rash fever Teaching and labs □ Maintain hydration to protect kidney damage. Fluid Adverse effects/toxicity: intake should be 2,500-3000 ml/day □ Nephrotoxicity □ Ototoxicity. □ give high protein This may cause foods irreversible auditory LABS impairment and □ WBC to monitor the vestibular damage effectiveness of Signs of ototoxicity therapy include HA, NV unsteady □ Watch kidney gait, tinnitus, vertigo, function tests (BUN, high frequency, hearing Creat) closely due to loss and dizziness toxicity risk □ Hypersensitivity reactions □ Report sore throat, watery stools □ Superinfection: a secondary infection greater than 4-6 per caused by day, severe nausea eradication of or vomiting, normal flora: indicating possible Candidiasis, skin and super infection mucous membrane contraindication Avoid with: □ Pre-existing renal disease □ Use caution with pre-existing hearing loss □ Pregnancy, lactation □ Increased risk with nephrotoxic drugs, prolonged treatment with aminoglycosides, impaired renal function and other ototoxic drug such as Lasix, Vanco. 36 Drug Glipizide (Glucotrol) □ oral antidiabetic □ Sulfonylurea duration: 12-24 hours Onset: 15-30 min Peak: 1-2hr Metabolized by the liver Glucagon □ Anti-hypoglycemic Onset 5-20 min, Peak 30 min Duration 1-1.5 hr., Half-Life; 3-10 minutes Metabolizes in liver, plasma and kidneys Use and dosage □ Stimulates pancreatic beta cells to secrete insulin. □ Type 2 diabetes mellitus Side effect Side effects: □ GI distress □ dizziness □ drowsiness □ headache □ Give dose 1-3 time daily Adverse effects/toxicity: □ Severe skin rash, pruritus □ Hypoglycemia □ may use alone or in combination with insulin □ Emergency treatment of severe hypoglycemia in unconscious client or those unable to swallow □ Comes in powder form. Reconstitute with provided diluent. □ Give IV, IM or SQ immediately □ Give IV through D5W only, not NS Side effects: □ Nausea/ vomiting Adverse effects/toxicity: □ Hypersensitivity reaction, □ hyperglycemia □ Hypokalemia Teaching and labs □ Monitor labs including glucose, Hgb A1C TEACH □ Take with first daily meal. □ Take any missed dose as soon as remembered. □ Report s/s of hypoglycemia if they occur □ Avoid alcohol □ Should awaken within 5-20 min after giving. □ Give 50% glucose if no response to glucagon Teach □ test blood sugar, □ teach family how to administer SQ or IM contraindication Avoid with: □ Pregnancy, lactation □ Allergy to sulfa or urea □ Diabetic ketoacidosis Caution with: □ impaired renal and hepatic function □ Adrenal or pituitary insufficiency. □ Incompatible with sodium chloride solution. 37 Drug Glyburide (Micronase, DiaBeta) □ Oral antidiabetic, □ more potent drug □ Sulfonylurea Onset 15-60 min Peak 1-2 hrs. Duration up to 24 hrs. Half-life 10 hours Metabolized in the liver, excreted in urine and feces. Haloperidol (Haldol) High potency drug □ Antipsychotic □ Butyrophenone □ Antiemetic Onset: 30-45 min IM Effects can be seen in 12 days. Substantial improvement 2-4 wks. Full effect several months. Use and dosage □ Lowers blood sugar concentration in diabetics and nondiabetics by sensitizing pancreatic beta cells to release insulin in the presence of serum glucose. □ Type 2 diabetes □ Use as adjunct to diet and exercise to lower blood sugar Side effect Side effects: □ Hypoglycemia, □ epigastric fullness □ heartburn □ pruritus □ Psychotic disorders □ Long acting drug for maintenance – to control symptoms □ Tourette’s syndrome Side effects: ABCDE: □ Anticholinergic (dry mouth) □ Blurred vision □ Constipation □ Drowsiness □ Extrapyramidal syndrome (such as Parkinson’s s/s) □ Photosensitivity Adverse effects/toxicity: □ Elderly patient may develop Neuroleptic Malignant Syndrome (NLMS) Adverse effects/toxicity: □ hypoglycemia Teaching and labs □ Give once in the morning with breakfast or with first main meal □ Monitor labs including glucose, HgbA1c Teach □ Report reaction □ Loss of control of blood glucose level may be due to fever, surgery, trauma, stress, infection. □ EPSE: usually first few days of tx, dose related, controlled by dose or antiParkinson’s drugs □ Oral: Give with milk or food. □ Taper dose slowly when stopping. □ Injection: deep IM – risk for orthostatic hypotension □ no alcohol or driving until response known contraindication Avoid use with: □ diabetic ketoacidosis □ Type I diabetes Caution with: □ renal or hepatic insufficiency □ older adult □ malnourished pt. □ adrenal or pituitary insufficiency Avoid with: □ Parkinson’s disease □ seizure disorder □ severe mental depression Use caution: □ older adults, □ lithium therapy □ HTN □ Lactation 38 Drug Heparin □ Anticoagulant Antidote = Protamine sulfate (see separate listing) Hydrochlorothiazide hydrochloride (Hydrodiuril, HCTZ) □ Electrolyte and water balance □ Thiazide diuretic □ Effects noted 3-4 days; max effect takes 3-4 weeks □ Most widely prescribed diuretic for HTN Use and dosage □ As anticoagulant – given IV or SQ □ Use as continuous IV infusion for DVT, Pulmonary embolus, angina, acute MI □ SQ for prevention □ Hep-lock (flush) is to maintain patency of IV catheters; not for anticoagulant therapy □ Act on distal tubules of nephron and increases urinary excretion of sodium, chloride, potassium, water, bicarbonate □ Decreases edema and lowers blood pressure Side effect Side effects: □ Bleeding □ Heparin-induced Thrombocytopenia (HIT) – may appear up to several weeks later. Teaching and labs □ Does not dissolve clots – prevents enlargement and development of new clots. □ Use bleeding precautions □ Monitor labs: aPTT Normal = 25-40 Coagulated = 1.5-2 times normal = 60-80 contraindication Avoid use with: □ Hemorrhage, active bleeding □ Do not give IM. □ Adjust IV dose based on labs. Side effects: □ Glucose intolerance, hyperglycemia □ Hypokalemia (low K+ ) □ Give with food or mild to reduce GI upset. □ Give dose(s) early in the day to avoid nocturia □ Limit Sodium intake □ Eat foods high in K+. – replacement med usually not needed □ photosensitivity reaction occur 10-14 days after initial sun exposure Avoid with: □ Anuria □ Hypersensitivity to thiazide Use caution: □ Bronchial asthma □ hepatic cirrhosis □ renal dysfunction □ history of gout □ diabetes □ SLE □ Lactation 39 Drug Hydroxyzine HCl (Atarax, Vistaril) □ Anti-emetics □ Anti-histamine (H1 receptor antagonist) □ antipruritic Onset 15-30 min PO Peak 4-6 hrs. Duration Absorbed form GI. Metabolized in the liver Ibuprofen (Advil, Motrin) □ Analgesic □ Non-steroidal antiinflammatory (NSAID) □ For high dose therapy: therapeutic effect may take up to one month Use and dosage □ Treat N/V (use anticipatorily) □ Relieve anxiety □ Reduce narcotic requirement before and after surgery. □ Treat acute or chronic alcoholism with withdrawal symptom or DTs □ Pruritus Side effect Side effects: □ CNS depression, □ Drowsiness □ Dizziness □ dry mouth, anticholinergic effect □ constipation □ visual changes □ photosensitivity Teaching and labs IM: □ Administer deep IM, Z-track – gluteus maximum or vastus lateralis in adults; vastus lateralis in children Side effects: □ CNS, renal system, eyes □ Nephrotoxicity □ dysuria, hematuria, oliguria, azotemia, □ Blurred vision. □ Ototoxicity Children toxicity: □ Rash, StevensJohnson syndrome □ Increases toxicity of anticoagulant, lithium Usually PO for maintenance □ Treat mild to moderate pain □ absorbed in GI; metabolized in liver □ monitor mouth daily □ no alcohol □ hard candy, ice chips or rinse mouth with warm water frequently to relieve dry mouth □ Avoid alcohol, ASA, other NSAIDs contraindication Avoid with: □ CNS depression and coma. □ Other CNS meds Use caution with: □ glaucoma □ seizure □ intestinal obstruction □ prostatic hyperplasia □ asthma □ cardiac, pulmonary or hepatic disease Avoid with: □ GI bleed □ Reaction to other NSAIDs □ Children under 6 months 40 Drug INSULINS - quick acting: short acting intermediate acting long acting Insulin is also available in a premixed form of Regular and NPH (example: 70/30 = 30% regular, 70% NPH). Use and dosage □ Diabetes mellitus, type 1 or type 2 □ Could be made of: pork/beef, pork or human insulin type. □ Short acting and intermediate acting insulin may be given more than once per day. Side effect Side effects: □ Hypoglycemia (anxiety, confusion, nervousness, hunger, diaphoresis, cool, clammy skin) □ Lipodystrophy (abnormal deposits of subcutaneous fat at injection sites), □ local allergic reaction Adverse effects/toxicity: □ Somogyi phenomenon: a rebound response with high blood sugar in response to low level at night. □ Coma □ Hyperosmolar hyperglycemic state (HHS) □ Diabetic ketoacidosis (DKA) Teaching and labs contraindication □ obtain med alert □ Do not use bracelets beef/pork insulin if sensitivity □ Open vial can be stored at room temp for up to one month. □ Rotate sites □ Alcohol will increase blood sugar □ Requires long-term monitoring of blood sugar control and potential complications. 41 Drug Insulin – Regular (Humulin R) **THIS IS THE ONLY TYPE OF INSULIN WHICH CAN BE GIVEN IV. ** Isophane (NPH) insulin (Humulin N) Insulin – Glargine (Lantus) ** LANTUS CANNOT BE MIXED IN SAME SYRINGE Use and dosage □ Short acting insulin □ Given IV or SQ □ type 1 and type 2 diabetes mellitus and ketoacidosis. □ given before meals according to blood levels □ Intermediate acting insulin □ Give 30 min before first meal of the day. If necessary, a second smaller dose may be prescribed 30 min before bedtime. □ Long acting insulin □ Type 1 children & adults; Type 2 adults □ SQ injection Side effect □ hypoglycemia Teaching and labs □ Regular insulin is clear and colorless. □ If given before breakfast, hypoglycemic episode is most likely to occur between midafternoon and dinner, when it peaks. Eat snack in midafternoon and carry sugar candy. □ NPH Insulin is a cloudy suspension. □ Roll the bottle to mix; do not shake. □ NOTE: NPH may be mixed with Regular insulin injection without altering either solution. contraindication □ With Type 2 diabetes, may or may not be given concurrently with oral agents. WITH ANY OTHER INSULIN.** □ Usually given one per day at bedtime. May be given two times per day. 42 Drug Iron Use and dosage □ Mineral replacement Side effect Side effects: □ Nausea/vomiting □ Staining of teeth □ Constipation □ Black stools (normal) Teaching and labs □ Taking on empty stomach preferred with full glass of water or citrus juice □ Calcium inhibits iron absorption – do not take with milk. □ Vitamin C increases iron absorption □ Liquid form can stain teeth contraindication Ipecac Syrup □ For overdose on certain drug or poison □ stimulates vomiting within 20-30 min Adverse effects/toxicity: □ Cardiotoxicity is most serious if vomiting does not occur and the substance is retained. □ Use of this medication is not automatic – verify appropriateness with Poison control center Do not use: □ With reduced level of consciousness or convulsions □ poison by Petroleum distillates, strong alkaline, acid or strychnine □ Emetic □ Antidote Alternate: Activated Charcoal (see separate listing) 43 Drug Lidocaine HCl (Xylocaine) □ Antiarrhythmic □ Topical Anesthetic Bolus dose – may repeat – then start continuous infusion – stop when stable. Therapeutic level: 1.56mcg/ml Use and dosage □ Treat VENTRICULAR arrhythmias, PVC’s, V-Tach. □ Use for rapid control of ventricular dysrhythmias during acute MI or Cardiac cath □ Use microdrip tubing and infusion pump. Side effect Side effects: □ Drowsiness, headache, dizziness, mild hypotension. Adverse effects/toxicity: □ convulsions, respiratory depression □ CV: hypotension, bradycardia, heart block CV collapse, and arrest □ Stop infusion with EKG changes such as prolonged PR, widened QRS, heart block. Teaching and labs LAB □ Monitor Lidocaine levels assess, therapeutic level is 1.5 -6mcg/ml □ Assess electrolyte, check baseline liver and renal blood studies. Report: □ lightheadedness, □ dizziness, confusion, □ numbness or tingling of lips, tongue or fingers □ visual changes or □ ringing in ears □ Correct hypokalemia before giving Lidocaine contraindication Avoid with: □ Sinus bradycardia □ Severe degrees of SA, AV and intraventricular heart block. Use caution: □ hepatic or renal disease □ CHF □ Hypovolemia □ shock □ hyperthermia □ elderly □ BETA BLOCKERS increase the effect of lidocaine 44 Drug Lithium carbonate (Eskalith) □ Mood stabilizer □ Antipsychotic □ Therapeutic level 0.8-1.5meq/L. □ Toxic level >2. □ Lithium has short half-life (about 1 day) and high toxicity. Lorazepam (Ativan) □ Anxiolytic □ Sedative-hypnotic □ Benzodiazepines. Onset 1-5 min IV, 15-30 IM, Peak 60-90 min IM, 2 hrs. PO Duration 12-24 hrs. Use and dosage □ Drug of choice to control manic episodes in bipolar disorder □ Anti manic effects are usually seen in 5-7 days after initial doses, but full effect does not occur for 2-3 wks. □ Lithium is a salt; exact action uncertain □ anxiety disorder □ short term for relief of symptoms of anxiety □ Pre-anesthetic medication to produce sedation and reduce anxiety. □ Status epilepticus Side effect □ This med does not cause sedation. Mild Side effects: □ fine tremor, nausea, thirst, polyuria, Adverse effects/toxicity: □ Vomiting, diarrhea, slurred speech, lack of coordination, drowsiness, muscle weakness, or twitching) – withhold dose and notify provider but DO NOT stop abruptly. Side effects: □ Drowsiness □ sedation □ Mild medication with limited toxic potential □ respiratory depression is rate Paradoxical reactions (nightmares, mania, etc.) may occur in children, psych patients and the elderly. Teaching and labs □ Give with meals □ Hydration is essential – dehydration will increase levels □ Watch for weight gain (fluid retention) □ Avoid NSAIDs and diuretics. □ Essential to monitor mood and behaviors □ Labs: Lithium level every 3 months initially, then every 6 months. □ Avoid alcohol □ Taper dose when stopping to avoid withdrawal symptoms □ Watch for suicidal risk contraindication Do not use with: □ Dehydration, severe debilitating, severe cardiovascular. Use caution: □ elderly, □ pt. with cardiac, renal, thyroid or diabetes □ pregnancy Do not use with: □ Acute narrow-angle glaucoma, □ Primary depression □ acute alcohol intoxication. □ Pregnancy and Lactation Use caution: □ renal or hepatic impairment □ myasthenia gravis □ suicidal tendencies 45 Drug Magnesium Sulfate iron(Epsom salt – oral form) Onset 1-2 hrs. PO; 1 hr. IM. Duration 30 min IV, 3-4 hr. PO Eliminated by kidneys Use and dosage □ Oral: laxative (by osmotic retention of fluid which distend the colon, increase content of feces and cause bowel stimulation) □ Parenteral: CNS depressant; used in seizures of toxemia; for hypomagnesemia Normal Magnesium level: 1.8-3 mEq/L □ 4 gm. loading dose is give over 20-20 min via pump. Side effect Side effects: □ Flushed warm feeling □ fluid and electrolyte imbalance □ hyponatremia □ N/V Adverse effects/toxicity: Early indication of magnesium toxicity □ Respiratory depression □ Cathartic effect □ profound thirst □ feeling of warmth □ sedation □ confusion □ depressed deep tendon reflexes □ muscle weakness □ can lead to cardiac arrest Teaching and labs s/s hypomagnesemia: □ irritability □ tremors, tetany □ tachycardia □ hypertension □ psychotic behavior □ Monitor urinary output and hydrate adequately with parenteral administration. contraindication Avoid with: □ MI, heart block, cardiac arrest except for certain arrhythmias. Use caution: □ impaired kidney function □ other cardiac glycosides □ Lactating moms and children 46 Drug Mannitol (Osmitrol) Use and dosage □ Use in oliguria and acute renal failure. Help to prevent □ Electrolyte and water balance renal failure and agent reduce increased intracranial or □ osmotic diuretic intraocular pressure Onset 1-3 hr. diuresis; 30 to 60 □ It acts by increasing min IOP, 15 min. for ICP the osmolality of Duration plasma, glomerular 4-6 hr. IOP, filtrate, and tubular 3-8 hr. ICP fluid. This decreases the Serum osmolality is 275reabsorption of 300 mmol/kg. fluid and electrolytes, which increases excretion of water, chloride Give IV. and sodium and Usually give test dose slightly increase the which should result in excretion of Output of 30 to 50 Potassium. ml/hr. and is produced □ In intraocular (IOP) 2-3 hrs. after and CSF (ICP), it administration. pulls the fluid and sends it to the plasma and extravascular systems Side effect Side effects: □ HA, confusion, syncope □ fluid and electrolyte imbalance, esp. hyponatremia □ pulmonary congestion, rhinitis □ Water intoxication Adverse effects/toxicity: □ Seizure, □ thrombophlebitis, □ CHF, Cardiovascular collapse □ Hyponatremia Warning: There may be a rebound increase in ICP about 12 hours after administration of med. Pt may complain of HA, or confusion. Teaching and labs □ Use filter needle and/or filter in infusion tubing because crystals may form in the solution. □ Mannitol is held if serum osmolality exceeds 310 -320. □ Daily weights Teach □ Non-narcotics such as Tylenol if there is headache □ Therapy is based on urine flow rate. □ Reassure pt. that excessive thirst, blurred vision, rhinitis should subside when Mannitol is discontinued contraindication Do not use: □ severely impaired renal function □ marked dehydration □ breast feeding □ hepatic failure, □ active ICP □ anuria □ Intracranial bleed shock □ Question the administration of mannitol if the patient has cor pulmonae (right sided heart failure) because Mannitol pulls fluid and it may lead to circulatory overload which the heart could not handle. This client would need loop diuretic to prevent serious complications 47 Drug Meperidine HCl (Demerol) Use and dosage □ Given for moderate to severe pain. □ Potent, long acting Side effect Side effects: □ N/V, Anorexia □ Sedation, dizziness □ elevated BP □ rash, urticaria □ tremors □ hyperventilation Adverse effects/toxicity: □ Resp depression, □ respiratory arrest, □ circulatory depression, □ increased intracranial pressure Teaching and labs Assess: □ LOC □ rash, urticaria □ respiratory rate. If respirations < 12 per minute – withhold meds. contraindication Avoid use with: □ acute bronchial asthma, upper airway obstruction □ increased intracranial pressure □ convulsive disorder □ pancreatitis, acute ulcerative colitis □ severe liver or kidney insufficiency Caution with: □ children and elderly □ Decreases heart rate and cardiac output □ Lowers BP Side effects: □ Usually well tolerated □ Nausea, vomiting □ Weight gain □ worsening CHF □ insomnia Adverse effects/toxicity: □ profound bradycardia □ heart block □ acute CHF, □ bronchospasm □ laryngospasm □ Give with or w/o food, but consistent □ Do not stop abruptly; may cause rebound effect. Gradually decrease over 1-2 wks. □ Hold meds if BP < 90 or pulse < 60 □ Watch for s/s heart failure □ Can lead to elevated BUN, creat. □ May mask hypoglycemia Avoid use with: □ Heart block greater than 1st degree □ Sinus brady, □ cardiogenic shock Use caution: □ hyperactive airway syndrome ( asthma or bronchospasm) □ Narcotic analgesic (opioid agonist) Give Narcan for toxicity - It is use to reverse respiratory depression induced by overdose Onset: 15 mins. PO, 10 mins. IM, 5 mins IV duration 2-4 hours Metoprolol tartrate (Lopressor, Toprol) □ Beta adrenergic antagonist (beta blocker) □ Antihypertensive □ Antianginal = same action as with propanolol □ Mild to severe HTN □ angina pectoris □ **Post - acute MI** □ Max effect may take 1 week □ Increases chance of both Dig and Lithium toxicity 48 Drug Morphine Sulfate (MS Contin = sustained release form) □ Narcotic analgesic (Opioid agonist) Give Narcan for toxicity. Use and dosage □ Produces effect by binding to opioid receptors throughout the CNS. □ Schedule II drug, major drug abuse. □ For severe, chronic or acute pain. □ Most commonly use in postoperative setting. □ mild bronchodilator to improve breathing Onset, Peak, Duration depend on route of medication. Onset: Immediate IV, rapid if given IM or oral, except MS Contin □ MS Contin is sustained release; it will not control break-through pain because it is time release. Side effect Side effects: □ Nausea vomiting anorexia, GI, □ pruritus, □ light headedness □ constipation Adverse effects/toxicity: □ Classic triad of symptoms: respiratory depression, coma, pinpoint pupils. □ Withdrawal begins 6-8 hrs. After the last dose, reach peak intensity within 48-72 hrs. S/S include craving, chills, sweating piloerection (goose flesh), abdominal pain and cramps, diarrhea, runny nose, irritability. □ Morphine induced CNS stimulation – paradoxical reaction common in women and older adults. Teaching and labs contraindication Avoid use with: □ Avoid alcohol use □ Hypersensitivity to opiates) □ Hold medication if □ acute bronchial respirations < 12/min asthma or upper airway obstruction, □ Hydrate adequately □ ICP to prevent □ convulsive constipation disorders □ pancreatitis, acute ulcerative colitis □ severe liver or kidney disease □ Do not give morphine to children 49 Drug Naloxone HCl (Narcan) □ Opioid antagonist. Onset 1-2 min IV; 2-5 mins. SQ or IM Duration 1 hr. IV; up to 4 hrs. IM but start to diminish after 20 mins. Nedocromil (Tilade) □ Inhaled nonsteroidal medication □ anti-inflammatory and antiasthmatic. Use and dosage □ Competes with opioids at the opiate receptor sites, blocking the effects of the opioids □ Reverses effects of opiates, including respiratory depression, sedation and hypotension. □ May need given every few hours until the opioids has dropped to a nontoxic level □ asthma prophylaxis NOT for acute asthma attacks □ up to a week for full effectiveness □ Must be taken regularly to be effective Side effect Side effects: □ Increased BP, HR, hyperpnea □ tremors, □ hyperventilation, □ drowsiness, □ nervousness □ N/V Adverse effects/toxicity: □ Hypotension, □ V-tach and V-fib □ convulsion, □ hepatitis □ pulmonary edema, Adverse effect: □ abnormal bitter taste □ N/V, HA, dizziness, sore throat. Teaching and labs □ Watch vital signs and respiratory function closely with administration of medication □ Titrate dose slowly if too much is given the client will swing from a state of intoxication to one of withdrawal □ Rinse mouth after taking medication to avoid dry mouth □ Do not use for acute attack □ Non-compliance is a concern due to bitter taste contraindication Avoid use with: □ Known allergy □ Respiratory depression d/t nonopioids □ Substance abuse (may lead to withdrawal symptoms) Avoid use with: □ acute bronchospasm or status asthmaticus. □ Hypersensitivity Use with caution: □ hepatic or renal function (also available as optic form – for ocular allergic conjunctivitis) 50 Drug Neomycin sulfate (Mycifradin) □ ORAL aminoglycoside □ antibiotic Nifedipine (Procardia) □ Calcium Channel Blocker □ Antianginal □ Antihypertensive □ Negative inotropic Use and dosage Antibacterial – ORAL □ GI tract □ Hepatic coma Main form is topical for eye, ear and skin infection. Side effect Side effects: skin rash (esp. topical) Teaching and labs □ Poorly tolerated GI so it is usually for bowel cleansing. contraindication □ Do not give 1-2 wks. after an acute MI. □ Do not give with grapefruit juice (could lead to toxicity) □ Report gradual weight gain and evidence of edema; may indicate onset of CHF. □ Do not stop suddenly (will have rebound symptoms) □ Smoking decreases efficacy of med □ Monitor pulse rate – report irregular or slower than normal rate. Hold for BP below 90/60. Avoid use with: □ Known hypersensitivity □ Unstable angina □ Lactation Adverse effects/toxicity: □ Nephrotoxicity □ Ototoxicity. NEOMYCIN IS NOT GIVEN IV Side effects: □ angina □ mild to moderate □ Usually well tolerated HTN (sustained □ Headache release form) □ fatigue □ Dilates coronary □ Dizziness arteries and relaxes □ Postural coronary spasm hypotension □ Increases cardiac □ peripheral edema output; decreases peripheral vascular Adverse effects/toxicity: resistance. □ Gingival hyperplasia □ Blocks calcium ion flow into cells of myocardial and arterial smooth muscle (cardiac and peripheral blood vessels) □ Slows HR; decreases O2 need 51 Drug Oxytocin (Pitocin) □ Oxytocic Labor and delivery. Onset is immediate. After stopping med, contractions should stop in 2-3 minutes Half-life 3-5 min Pancrelipase (Creon, Pancrease) □ Pancreatic enzyme replacement therapy Use and dosage □ To initiate or improve uterine contractions at term □ Induce labor □ Management of incomplete or missed abortion (miscarriage) □ reduce postpartum bleeding Side effect Side effects: □ subarachnoid bleed □ fetal trauma □ seizure, coma Adverse effects/toxicity: Hypertensive crisis. □ Help to breakdown fat, proteins and carbs for better absorption. Side effects: □ Nausea, diarrhea, and cramps □ cystic fibrosis □ chronic pancreatitis, post pancretectomy □ steatorrhea □ malabsorption syndrome For fetal anoxia: □ stop infusion, turn mom on left side, oxygen prn Stop infusion for: □ Contractions which occur more often than every 2 mins. or last over 90 sec. Adverse effects/toxicity: Hyperuricemia. □ Report joint or swelling pain (high uric acid level) Teaching and labs □ Careful monitoring of uterine contraction pattern, fetal heart rate and maternal BP. □ Postpartum; monitor lochia and BP. □ Do not increase dose after desired contraction pattern is achieved (contraction frequency of 2-3 min lasting 60 sec). □ Take with or just prior to eating □ Do not mix brand names; there is a variance in concentration of enzymes □ Swallow tablet or capsule whole; do not crush or chew. □ Can mix powder or open capsule with food. contraindication Avoid use with: □ Hypersensitivity □ Cepahalopelvic disproportion □ Obstetric emergencies Drug interaction: □ Allergy to med or pork □ Do not give with magnesiumcontaining antacid. May be ordered with H2 blockers or with proton pump inhibitors. □ Iron will decrease effectiveness of med. 52 Drug Phenobartial (Phenobarbital Sodium = Luminal) – this is the short-acting form. For status epilepticus: Administer slow IV □ Anticonvulsant □ Sedative-hypnotic Pilocarpine hydrochloride (Pilocar) □ Eye preparation. □ Miotic (Antiglaucoma agent). □ Direct acting cholinergic agent for ophthalmic use. □ It is an antidote to Atropine Use and dosage □ Long-term management of grand mal, partial seizure and status epilepticus. □ Sedative effect to decrease anxiety and tension. □ No analgesic effect □ For acute or chronic Glaucoma – decreases intraocular pressure □ Will reverse the effects of Atropine (and Atropine will reverse the effects of Pilocarpine). Side effect Side effects: □ Somnolence, hangover effect Adverse effects/toxicity: □ CNS depression, □ Stevens-Johnson □ Blood dyscrasias □ Paradoxical reactions may occur in children, older adults and debilitated people Teaching and labs □ Okay to crush and mix with food or fluids □ Monitor IV infusion closely. □ Do not stop abruptly □ Avoid alcohol and other CNS depressants contraindication Avoid use with: □ Hypersensitivity □ Resp or kidney failure □ Pregnancy and lactation Side effects: □ Visual blurring, myopia, irritation, brow pain and HA. (with ophthalmic) □ Normal: Increased pigmentation of iris and eyelids; long eyelashes. Adverse effects/toxicity: □ Retinal detachment □ Ataxia □ Confusion □ seizure □ Apply gentle pressure for 1-2 mins. to nasolacrimal drainage area after administering eye gtts □ Eye therapy will continue long term Avoid use with: □ Asthma, COPD □ HTN □ Acute eye infections, retinal detachment, contact lens use 53 Drug Prazosin hydrochloride (Minipress) □ Antihypertensive □ Alpha-adrenergic receptor antagonist □ vasodilator □ Treat benign prosthetic hyperplasia (BPH) Use and dosage □ Mild to moderate HTN – mainly diastolic □ little effect on cardiac output and HR □ BPH (due to vasodilator effects) Optimal effects may take 4-6 weeks Prochlorperazine (Compazine) □ Antiemetic □ Antipsychotic □ Phenothiazine □ Severe nausea and vomiting □ Management of psychotic disorders, excessive anxiety and agitation □ Take 30-60 min before any activity that causes nausea for best effect. □ Start doses low and increase slowly Side effect Side effects: □ Dizziness, drowsiness □ Fatigue, weakness. □ Priapism, impotence □ Orthostatic hypotension Adverse effects/toxicity: □ First-dose phenomenon: syncope within 30 min to 1 hr. Effect is transient, may diminish by giving at bedtime. Side effects: □ drowsiness, dizziness, □ EPSE Adverse effects/toxicity: □ Persistent tardive dyskinesia □ Tremor, twitching □ Agranulocytosis, □ thrombocytopenia □ After 1-2 months: Akathisia (inner restless, inability to sit still) – may tx with propranolol. Teaching and labs □ monitor for decreased BP, especially with initial administration □ Monitor urine vol. □ change position slowly to prevent orthostatic hypotension □ stop smoking and avoid alcohol intake □ avoid driving and hazardous tasks until effect of med is known □ Avoid excessive sunlight – may turn skin gray-blue □ Urine may turn reddish brown □ Use sugarless hard candy or ice chips to avoid dry mouth. □ Avoid skin contact with concentrate □ Do not crush or chew – swallow whole □ Deep IM, not SQ injection contraindication Avoid use with: □ Prior sensitivity □ hypotension Use caution with: □ impaired hepatic function □ older adults Avoid use with: □ Hypersensitivity □ Blood dyscrasias □ Dementia related psychosis in elderly □ Young children □ Seizures □ Lactation 54 Drug Promethazine (Phenergan) □ Antiemetic □ Antihistamine □ Anti-vertigo Protamine sulfate □ Antidote for Heparin toxicity. □ Heparin antagonist Onset = 5 minutes Duration = 2 hours Longer half-life than heparin Ranitidine hydrochloride (Zantac) □ H2-receptor antagonist. □ Higher potency than cimetidine (Tagamet) Use and dosage □ Long-acting med □ motion sickness □ nausea □ IM route: Give deep IM; not SQ (can cause necrosis) □ Avoid intra-arterial injection – can cause necrosis. □ Antidote for Heparin overdose □ Given IV; maximum dose of 50 mg in 10 min time period; should be titrated according to the time and length of time the heparin was administered □ Reduce gastric secretion. □ Active duodenal ulcer, maintenance after healing □ GERD □ benign gastric ulcer (short-term) Side effect Side effects: □ Resp depression, □ drowsiness, confusion □ agranulocytosis □ blurred vision □ dry mouth □ EPSE Teaching and labs □ Decrease GI distress by giving oral dose with milk or food. □ May crush and mix with food. □ Avoid sunlight exposure □ Avoid alcohol and other CNS depressants contraindication Avoid use with: □ Acute MI, angina, atrial fib Use caution with: □ Narrow angle glaucoma □ peptic ulcer □ duodenal obstruction Side effect: □ Abrupt drop in BP if administered too rapidly. □ Monitor vital signs and labs closely (aPTT) Avoid use with: □ Hemorrhage not induced by heparin overdose. See listing for HEPARIN Side effects: □ headache □ taste disorder, diarrhea, constipation □ dry mouth Adverse effects/toxicity: □ hepatotoxicity □ thrombocytopenia □ Give without regard to meals □ Usually give 1 x day □ reduce dose in renal patient □ avoid smoking to □ avoid antacid within 1 hour of dose Avoid use with: □ Hypersensitivity Use caution with: □ Impaired renal of hepatic function. □ May increase effects of alcohol, aspirin, Coumadin and sulfonylureas 55 Drug Rh0(D) immune globulin (RhoGAM) □ Biological response modifier □ Immunoglobulin (IgG) Peak 2 hour Half-life 25 days Use and dosage □ Given to Rhnegative moms with RH positive babies. □ Provides passive immunity by suppressing active antibody response and formation of anti-RHo when (1) positive fetal RBC enters maternal circulation during the third stage of labor; (2) there is fetal maternal hemorrhage or other trauma during pregnancy; (3) termination of pregnancy or miscarriage; or (4) following a Rh+ transfusion. Side effect Side effects: □ Injection site irritation □ slight fever □ myalgia □ lethargy Teaching and labs □ Send sample of newborn cord blood to lab for cross match and typing immediately after delivery before administer RHo (D) □ Give to mom IM via deltoid. (Only a few forms can be given IV). □ Give immediately after reconstitution □ Recommended at 28 weeks gestation and then within 72 hours after delivery or 3 hrs. of termination of pregnancy or miscarriage. □ Keep epinephrine available; systemic allergic reactions sometimes occur. □ TEACH it will prevent hemolytic disease in a subsequent pregnancy contraindication Avoid use with: □ Known sensitivity to human immunoglobulins. 56 Drug Setraline hydrochloride (Zoloft) □ Antidepressant □ SSRI (selective serotonin reuptake inhibitor) Spironolactone (Aldactone) □ Fluid & electrolyte balance □ antihypertensive □ Potassium sparing diuretic Use and dosage □ panic disorders □ Anxiety disorders □ OCD □ PTSD □ 2-3 wks. to be effective □ Increases sodium excretion; does not decrease potassium □ treatment of primary aldosteronism □ Use for edema and HTN associated with heart failure. Side effect Side effects: □ Cause fewer disorders than other antidepressants □ fewer side effects on HR and HTN □ Sexual dysfunction □ Weight gain Major complication □ (Selective Serotonin Syndrome): Pt. can die from it. Elevated temp up to 105. Every speed up. BP, HR, Temp. May progress to coma. Side effects: □ Headache □ dizziness, weakness □ orthostatic hypotension Adverse effects/toxicity: □ Hyperkalemia (nausea, vomiting, diarrhea, cramps, tachycardia then bradycardia) □ aplastic anemia □ thrombocytopenia Teaching and labs □ Give with food in the morning to prevent insomnia □ Watch for suicide risk □ Increases effect of Coumadin □ Avoid grapefruit juice contraindication Avoid use: □ Within 14 days of using MAO inhibitor □ Seizure disorder □ Take with food □ avoid salt substitute high in K+ □ Avoid excessive ingestion of foods high in potassium. □ no potassium supplement needed □ Monitor VS and urine output □ Avoid direct sunlight Avoid use with: □ Serum K+ level > 5.5 □ anuria, acute and chronic renal insufficiency □ diabetic nephropathy □ hypersensitivity □ impaired hepatic function □ Decreases effect of Dig; □ increases chance of lithium toxicity 57 Drug Sucralfate (Carafate) □ Antiulcer □ Gastro-protective agent Theophylline (Theo-dur) □ Bronchodilator (resp. smooth muscle relaxant) □ xanthines □ Normal level 10-20. toxic level (> 20) may develop quickly Use and dosage □ Protects the ulcer from gastric acid by forming an adherent coating; it absorbs pepsin decreasing its activity. □ Duodenal ulcer □ Short term with gastric ulcer □ esophageal ulcer related to radiation or chemotherapy □ bronchospasms □ asthma □ bronchitis □ emphysema Side effect Side effects: □ constipation □ nausea Side effects: □ Tachycardia □ Seizures □ N/V, anorexia, Adverse effects/toxicity: □ restlessness, agitation, HA, and insomnia □ note: restlessness could be due to toxicity or hypoxia so close assessment is required Teaching and labs □ No antacid use within ½ hour of this medication contraindication Avoid use with: □ Chronic kidney failure □ Avoid gastric irritants such as caffeine, alcohol, smoking and spicy foods. □ Decreases absorption of Cipro, Dig, Dilantin, Tetracycline (so take these med 2 hours apart from Sucralfate) □ PO: take with water and after meals. □ Wait 4-6 hours after IV to start PO. □ Take same time each day Avoid use with: □ CAD, angina □ Renal or liver disease □ Pregnancy, lactation □ children □ CHF and acute viral □ can cause seizure (with high doses/levels) so avoid with seizure disorder unless bronchospasm is unresponsive to other treatments □ Limit caffeine □ Smoking decreases effect of med □ Increases lithium excretion 58 Drug Tobramycin sulfate □ Aminoglycoside □ Antibiotic IV/IM Inhalation (TOBI) Ophthalmic (Tobrex) Tolbutamide (Orinase) □ Antidiabetic □ Sulfonylureas Peak: 3-5 hours Duration: 6-12 hours Use and dosage □ broad spectrum antibiotic □ Kills bacteria cell by affecting protein synthesis. Kill Gram negative infection. □ Inhalation – preventative with cystic fibrosis (28 days on, 28 days off) □ Eye – external eye infections □ Mild to moderately severe, stable Type 2 Diabetes □ May be used as adjunct therapy for Type 1 Diabetes but not sole medication □ Give 1-2 x day after meals □ 1-2 weeks of medication may be required for full therapeutic effect Side effect Side effects: □ HA, paresthesia, skin rash, fevers. Adverse effects/toxicity: □ Nephrotoxicity and ototoxicity are two common toxicities associated with aminoglycosides. Eye – itching, swelling REFER to sections on aminoglycosides (Gentamycin) Side effects: □ GI distress □ Pruritus, rash (may stop on own) □ Photosensitivity Adverse effects/toxicity: □ Alcohol may cause disulfiram like reaction (flushing, palpation and nausea, flushing of skin). □ Hypoglycemia due to too much med, drug interactions, N/V, inadequate food intake. Teaching and labs □ Doses are based on weight □ Do not other meds In the same IV LAB □ Peak and Trough □ serum creatinine, BUN to monitor renal function contraindication Do not use with: □ Known sensitivity to other aminoglycosides □ Preexisting renal disease. □ Monitor blood sugars including fasting and HgbA1C Teach □ Signs and symptoms of hypoglycemia and notify prescriber if they occur. □ Wear medic alert bracelet or tag □ Avoid alcohol Avoid use with: □ Allergy to sulfa or urea □ Beta adrenergic blocking agents (betablockers) can suppress insulin release and delay response to hypoglycemia □ Consult dr. when pregnant 59 Drug Triazolam (Halcion) □ sedative hypnotic □ Anxiolytic □ Benzodiazepine Has rapid onset (15-30 mins.) Peak 1-2 hours Duration 6-8 hours Trihexyphenidyl HCl (Artane) □ Anticholinergic □ Antispasmodic Use and dosage □ short term management of insomnia (4 weeks) characterized by difficulty falling asleep, frequent wakeful periods Side effect □ Drowsiness, lethargy, confusion □ sleepwalking Adverse effects/toxicity: □ Physical dependence □ Seizures (with rapid withdrawal) □ With overdose: coma, respiratory depression, paradoxical anxiety Teaching and labs □ Do not use in addictive prone pt. □ Monitor symptoms of overdose (slurred speech, confusion, somnolence, impaired coordination and coma). □ following long term use, tolerance may develop so do not stop taking abruptly contraindication Avoid use with: □ Known sensitivity □ Alcohol intoxication □ Suicidal ideas □ Pregnancy, lactation □ Treat Parkinson’s disease. □ Diminishes hypersalivation; rigidity and irregular movements in Parkinson’s. □ Use to control drug-induced extrapyramidal side effects Side effects: □ Drowsiness □ Decrease urine output, retention or hesitancy □ Dry mouth □ Constipation Adverse effects/toxicity: □ Paralytic ileus □ Monitor I& O □ increase fluids, bulk and exercise □ void before taking to reduce urinary retention □ Avoid driving or other hazardous activities as drowsiness may occur. □ Avoid OTC such as cough medicine with alcohol. □ Very dose sensitive Avoid use with: □ narrow angle glaucoma, □ myasthenia gravis □ GI obstruction 60 Drug Vincristine sulfate (Oncovin) □ Antineoplastic □ Vinca alkaloids (from plant) □ mitotic inhibitor □ IS a vesicant; administer into the side arm portal of a freely flowing IV. □ Hyaluronidase is given if this vesicant should infiltrate. May apply heat to site to disperse drug and minimize sloughing. Use and dosage □ Acute lymphoblastic and other leukemias □ lymphosarcoma, □ Hodgkin’s disease □ breast and lung cancers Side effect □ Major toxicities occur in the hematopoietic, integumentary, neurologic and reproductive, system. □ Peripheral neuropathy □ Paralytic ileus (more common in young children) □ Alopecia Adverse effects/toxicity: □ Neurotoxicity - loss of sensation of the soles of feet and fingertips □ Depression of the Achilles reflex is the earliest sign of neuropathy □ Children are especially likely to develop neuro changes Teaching and labs □ Neutropenic precautions prn □ Assess hand grasp and deep tendon reflexes □ Maintain a regimen against constipation and paralytic ileus; report a change in bowel habits. Vesicant safety precautions: □ Good vein, prefer central line access or fresh butterfly stick □ chemo-trained nurse □ remain during infusion □ have antidote handy contraindication Avoid use with: □ Obstructive jaundice □ Pre-existing neuromuscular disease □ Active infection □ Pregnancy, lactation □ Bronchospasm may occur in pt previously treated with mitomycin 61 Drug Vitamin B6 (Pyridoxine HCl) □ Water-soluble vitamin Absorbed by GI tract s/s of deficiency: □ Lack of energy □ Decreased brain functioning □ skin lesions, □ conjunctivitis Vitamin B12 Vitamin C (Ascorbic acid) □ Water soluble vitamin s/s of Deficiency which is called Scurvy □ Malaise, lethargy □ pinpoint hemorrhages □ bleeding gums, rough skin and blotchy spots especially legs Use and dosage □ Prevention and treatment of pyridoxine deficiency (see causes) □ Co-enzyme in amino acid metabolism and red blood cell production □ Treats acute toxicity of INH, hydralazine. (see entry under Cyanocobalamin) □ Protects connective tissue, strengthens blood vessel walls, forms scar tissue, provides matrix for bone growth □ Supports immune system □ helps in absorption of iron and to metabolize amino acid □ acidifies urine Side effect Teaching and labs Causes of deficiency: □ Alcoholism □ Malabsorption disorders □ Oral contraceptives Dietary sources: □ green leafy veg. □ organ meats, fish, poultry □ legumes, chickpeas □ bananas □ whole grains, □ potatoes contraindication Use with caution: □ Renal disease □ Cardiac disease Side effects: Rare at normal doses □ Mix oral solutions with food Avoid use with: □ Prone to kidney stones Adverse effects/toxicity: □ crystalluria Causes of deficiency: □ Normal aging □ Alcohol □ Other meds Side effects: □ Pain at injection site Adverse effects/toxicity: □ Neuropathy □ Ataxia □ seizures □ Increases absorption of Iron Dietary Sources: □ citrus fruits, cantaloupe, strawberries, □ broccoli, cabbage, cauliflower □ tomatoes Common drug interactions: □ INH, hydralazine, oral contraceptives □ Reverses or antagonizes effects of levodopa. □ Megadoses of Vit. C can interfere with absorption of Vitamin B12. 62 Drug Vitamin D2 (Ergocalciferol) □ Fat-soluble vitamin s/s deficiency which is called rickets □ bones fail to calcify □ bowed legs □ osteomalacia □ muscle spasm Use and dosage □ Calcium and phosphate metabolism Remember calcium and phosphorus are inverse (high one, lower other) □ Necessary to develop and maintain strong bones □ osteomalacia and osteoporosis □ hypoparathyroidism □ Treat and prevent rickets Side effect Side effects: □ Uncommon at normal doses □ Metallic taste Teaching and labs Causes of deficiency: □ Inadequate sunlight □ Dietary intake □ hypoparathyroid Adverse effects/toxicity: □ n/v, □ fatigue, headache, □ hallucinations □ dysrhythmias □ Hypercalcemia □ Stones Dietary Sources: □ Egg yolks □ fortified cereals and milk □ Cod liver oil □ some fish contraindication Avoid use with: □ Hypersensitivity to Vit. D □ Hypercalcemia □ Hyperphosphatemia □ Also obtained from sunlight 63 Drug Vitamin E (alpha-tocopherol) Use and dosage □ Dietary supplement □ Hemolytic anemia in neonates □ Topical to chapped skin □ Prevents cell membrane damage protects against blood clot development Side effect Side effects: □ Uncommon at normal doses Vitamin K1 (Aquamephyton) (Phytonadione) □ Promotes liver synthesis of clotting factors Side effects: □ Swelling and pain at injection site □ Fat soluble vitamin □ Given to newborns to prevent bleeding □ Given as antidote for coumadin toxicity. □ Also reverses hypoprothrombinemia from various causes Adverse effects/toxicity: □ Hypersensitivity or anaphylaxis – like reaction □ Bronchospasm, Cardiac arrest □ Fat-soluble vitamin s/s deficiency: □ Hemolytic anemia s/s deficiency: □ Deficiency causes hemorrhage. Given as antidote for Coumadin (warfarin) overdose. Onset IV = 6 hours Adverse effects/toxicity: □ N/V □ fatigue, □ headache □ blurred vision Toxic: □ jaundice □ brain damage Teaching and labs Causes of deficiency: □ normal aging □ Prematurity □ Malabsorption diseases Dietary Sources: □ Wheat germ □ Vegetable oils □ Green leafy vegetables □ Nuts □ Dairy, eggs contraindication Use with caution: □ Bleeding disorders □ Pregnancy □ SQ administration preferred over IM. □ Labs: Monitor PT/INR (see note under ‘warfarin’) Causes of deficiency: □ fat malabsorption □ medication Dietary Sources: □ Asparagus, broccoli, cabbage, Green leafy vegetables □ Green tea □ Tomatoes Avoid use with: □ Known hypersensitivity to med □ Avoid mineral oil See entry under Warfarin (Coumadin) 64 Drug Warfarin sodium (Coumadin) □ ORAL anticoagulant To reserve hyperanticoagulation – (1) Hold and/or skip doses of Coumadin (2) Antidote which is Vitamin K1 (Aquamephyton) Use and dosage □ Coumadin interferes with synthesis of clotting factor(s) that require Vit. K. Side effect Side effects: □ Ecchymotic skin □ GI & skin problem □ Hypotension □ thrombocytopenia □ Given PO. Adverse effects/toxicity: □ Bleeding is the major adverse effect. □ Has narrow therapeutic range. Can take 1 week for Therapeutic effect □ PT level will be maintained at 1.5 – 2.5 the times the control value (which is 12-15 sec.) □ INR range from 2.03.0 (control 1.0) □ Labs need monitored often (sometimes 2-3 x week) initially, then are decreased over time Teaching and labs □ Coumadin may be started while pt is still on continuous IV heparin therapy). Heparin is tapered off slowly over 2-3 days. Pt. remains on oral Coumadin. □ Often given in the evening with lab draws in the morning – it must be taken same time each day □ Avoid or use consistently foods high in Vit. K □ May be long-term medication depending on reason for medication □ Teach bleeding precautions □ Observe closely and report s/s bleeding contraindication Avoid use with: □ hemorrhaging or bleeding tendencies □ malignant hypertension □ past history of allergic reaction to Coumadin □ Many, many meds have drug interactions with Coumadin 65