Lab Values

Hematocrit (packed cell Blood Urea Nitrogen(BUN)

5-23 mg/ 100mL volume PCV) Female= 38%-47% Male= 40%-54%

Creatinine
0.6-1.5 mg / 100mL 24-32 mEq/L

Carbon dioxide content PCO2

35-43 mmHg

Hemoglobin
Female= 12-16g / 100mL Male=13-18g/100 mL Newborn 14-20g/ 100mL

PO2 PH

75-100 mmHg (breathing room air) 7.35-7.45

Iron
50-150 mcg/100mL

Platelet count

150,000-400,000/mm3

Red blood cell count

Female 4.2-5.4 million/mm3 Male 4.5-6.2 million/mm3

White blood cell count

4500-11,000/mm3

60%-70% of total

Neutrophills

Lab Values (cont)

Albumin
3.5-5g/100mL

Potassium
3.8-5.1mEq/L

Creatinine
0.6-1.5mg/100mL

Specific Gravity
1.058

Glucose

Calcium
8.4-10.5mg/100mL

70-110mg/1oomL(fasting)

Coagulation time (glass tube)

5-15 Min.

Cholesterol total
120-220mg/100mL >40mg/100mL

High-density cholesterol Low-density cholesterol

<80mg/100mL

Sodium

136-145 mEq/L

Chloride
96-107 meq/L

Drug Therapy: Insulin Preparation, Time Course of Action

INSULIN TYPE APPEARAN CE ONSET PEAK DURATION

RAPIDACTING Humalog NovoLog SHORTACTING Humulin R, Novolin R

Clear Clear

< 15 minutes <15 minutes 30 mins 1 hour

1-2 hours 1-2 hours 2-3 hours

3-4 hours 3-4 hours

Clear

3-6 hours

INTERMEDIAT E-ACTING

NPH insulin LONGACTING Lantus

Cloudy

2-4 hours

4-10 hours Does not peak

10-16 hours 20-24 hours

Cloudy

1-2 hours

Effect of Breakfast InsulinLunch on Blood 150 Glucose Levels Dinner Bedtime 130 90 Short-acting insulin 70 CBG Intermediate-acting insulin Mg/gL Long-acting insulin ANTIINFECTIVES
*Fight infection -Bacteriostatic: retard (limit, slow) growth of microorganism

-Bacteriocidal: kill microorganisms *Bacteria, viruses, fungi, protozoa *Spectrum: the number of organism that medication is effective against -Broad Spectrum: will kill everything -Narrow Spectrum: is used for specific infections, effective against only a few organisms *Bacterial Resistance: after multiple exposure to a medication, the bacteria will mutate and become infective against the drug. For example: MRSA, VRE *Super-infections: when other organisms that are not sensitive to prescribed antibiotic (for example, yeast) are able to multiply, overgrow and get out of control because the antibiotic also killed the organisms that would have kept them under control *Culture & Sensitivity: diagnostic test to find out the specific bacteria and what drug will be effective against it

Sulfonamides Pg. 1205 &

1331
(Silver Sulfadiazine, Bactrim, Sulfasalazin) ACTION Antibacterial USES -Acute & chronic UTI caused by E. coli -Cystitis, pyelitis & pyelonephritis ADVERSE REACTION -N/V/D, pruititis, urticara *urine & skin take on orange-yellow color *crystalluria: crystals in urine (increase fluid) *photosensitivity

*Toxic-Epidermal Necrolysis (TEN) *Stevens-Johnson Syndrome (SJS) -lesions, fever, cough, aches/pains, headache. Lesions appear as red wheals or blisters often starting on face, mouth, lips -Leukopenia, thrombocytopenia INTERACTIONS Drug: anticoagulantsincrease bleeding Food: Taken on empty stomach Herbal: encourage cranberry juice to prevent & relieve UTI symptoms NURSING PRECAUTIONS

*Any allergies to sulfa drugs, aspirin, thiazides & sulfonylurea *Discontinue if pts urinary output is decreased or rash develops *Have patients avoid the sun *Encourage adequate fluid intake to avoid crystalluria *Empty stomach=hour before, 2

hours after with a full glass of water *watch for signs/symptoms of blood dyscrasias, jaundice, renal/hepatic failure in high-risk patients

Penicillins Pg. 958

(Penicillin, Amoxicillin, Ampicillin, Augmentin, Unasyn, Dixloacillin, Nafcillin) ACTION

infections *Can be used as a prophylaxis (prevention) for rheumatic fever & chronic ear infections ADVERSE REACTIONS -N/V/D, neuropathy, rash, utricara, angioedema (swelling of skin/mucous membranes), anaphylaxis -anemia, thrombocytopenia, leucopenia, bone marrow depression,

Antibacterial

USES *UTIs, Septicemia, Meningitis, STDs, Pneumonia & other respiratory

phlebitis *Super-infection & pseudomembranous colitis

INTERACTIONS Drug: oral contraceptivesdecrease

effectiveness of contraceptive Tetracyclinesdecreases effect of PCN Anticoagulantsincreased bleeding risk Beta-adrenergic blockersmay increase risk of anaphylactic shock Antacidsdecrease absorption of PCNs

*PCN may change results of some lab tests*

Food: affects absorption of most PCNs NURSING PRECAUTIONS *Prior PCN allergy, asthma, hypersensitivity to procaine or tartrazine *Give on EMPTY stomach *Frequent skin care-avoid harsh soap/lotions *After administering PCN IM in outpatient setting, ask patient to wait 30 minutes to assess for anaphylactic reactions *Watch for severe diarrhea and sign/symptoms of super-infection *Recommend soft-bristled toothbrush and frequent mouth care

282, 286

Cephalosporins Pg. 279,

(Ancef, Keflex, Rocephin, Maxipime)

ACTION Antibacterial USES *Treatment of infections caused by bacteria -Respiratory -Otitis media -Bone/joint -Genitourinary *May be used as a prophylaxis (prevention) after surgery ADVERSE REACTIONS *N/V/D, malaise, fever, dizziness, heartburn *Pruritus, urticara, TEN & SJS (death of epidermal layer of skin), nephrotoxicity *phletbitis, thrombophletbitis with IV use INTERACTIONS Drugs: Aminoglycosides (anti-

infective)will increase risk of nephrotoxicity Anticoagulants increase risk for bleeding Loop diureticsincrease cephalosporin blood level Food: Alcohol consumed within 72 hours after administration will produce an Antabuse-like reaction (vomiting, dyspnea, sweating and hypotension) NURSING PRECAUTIONS *10% of PCN allergy patients will be allergic to cephalosporins *May be TAKEN WITH FOOD reduce GI upset **Cedax should NOT be taken with food**

*Inpatients should be assessed Q4 hours for skin redness, rash, lesion, blister/red wheals *Risk of nephrotoxicity, early sign=decrease urine output (daily output < 500 mL call MD)

*Watch sign/symptoms of superinfection *Should be taken around the clock to keep an adequate amount of drug in the body *Finish full course of drug regimen

Tetracyclines Pg. 1155

(Declormycin, Doryx, Sumycin, Tygacil) ACTION Antibacterial when PCN is contraindicated USES Treats infections caused by: -Rocky Mnt Spotted Fever, typhus fever

-Intestinal amebiasis -Skin/soft tissue infections, severe acne -Cervical/rectal infections -Infection caused by helicobacter pylori (bacterium in stomach causes peptic ulcers) ADVERSE REACTIONS *N/V/D, epigastic distress, stomatitis *photosensitivity (demeclocycline most severe reaction, minocycline least likely to produce a reaction) INTERACTIONS Drug: Digoxin increase risk digitalis

toxicity

Antacids decrease effectiveness of tetracycline Anticoagulantsincrease risk for bleeding Oral contraceptivesdecrease effectiveness of contraceptives Food: Calcium-rich foodsimpairs tetracycline absorption NURSING PRECAUTIONS Children younger than 9 tetracyclines should NOT be

given, may cause permanent teeth discoloration & prolonged/repeated-use may result in resistance Blood glucose levels should be monitored frequently with diabetic during tetracycline therapy *on an empty stomach with a full glass of water (exceptions: Minocin and Terramycin) *Avoid calcium-rich foods: cheese, milk, cream, yogurt, ice cream

Aminoglycosides Pg. 140

(Amikin, gentamicin, Kantrex,

neomycin, streptomycin & tobramycin) ACTION

Antibacetial

USES May be used to reduce normal flora in bowel prior to abdominal surgery (bowel preparation) ADVERSE REACTION *N/V, anorexia, rash, utritcaria *Nephrotoxicityproteinuria, hematuria, increase in blood urea nitrogen (BUN) level, Decrease in urine ouput *Ototoxicity: damage to hearing organs, sign/symptoms=tinnitus, dizziness, vertigo *Neurotoxicity: numbness, tingling, tremors INTERACTIONS

Drug: Cephalosporinsincrease risk nephrotoxicity Loop Diureticsincrease risk ototoxicity Pavulon or Anectine (Anesthesia)increase risk of neuromuscular blockade NURSING PRECATIONS *Hypersensitivity to patients with preexisting hearing loss, myasthenia gravis (condition characterized by weakness & muscle fatigue) & Parkinsonism *Oral administration of Amingolycosides: enteric-coated erythromycin given with neomycin *Drug delivery timing is critical for optimal response of suppression of intestinal

bacteria when preparing a patient for surgery with kanamycin or neomycin*

Macrolides Pg. 49
(Zithromax, Z pack, erythromycin, Ketex)

ACTION Antibacterial USES *Used as prophylaxis before dental or other procedures in patients allergic to PCN *Acne vulgaris, skin infections - Hemophilus influenza Upper Respiratory infections ADVERSE REACTIONS

*N/V/D, Pseudomembranous colitis, abdominal cramping or pain *visual disturbances: changes in eyes accommodation to light INTERACTIONS Drug: Antacidsdecease absorption
and effectiveness of macrolides Digoxinincrease serum levels of cardiac medication Anticoagulants risk for bleeding Clindamyclin, lincomysi, chloramphenicol decreased therapeutic activity of macrolides Theophyline (asthma medication) increased serum theophyline level

NURSING PRECAUTIONS

*Hypersensitivity in patients with pre-existing liver disease *Telithromycin (Ketek) should NOT be ordered if a patient is taking cisapride (Proulsid) or pimozide (Orap)

*Oral administration for Macrolides: -Administered without regard to meals and with milk *Exceptions: Azithromycin, Dirthromycin, Erythromycin*

Lincosamides Pg. 317

(clindamycin, lincomycin)

ACTION Antibacteral USES Treating serious infections in which PCN or erythromycin is NOT effective

ADVERSE REACTION *N/V/D, abdominal pain, *Pseudomembranous colitis *Blood dyscrasias (an abnormality of the blood cell structure or function)

INTERACTIONS Drug: Kaolin (Al based antacid) decreases absorption of lincosamides Neuromuscular Blocking drugs increased action of neuromuscular blocking drug that can lead to severe respiratory depression NURSING PRECAUTIONS Contraindicated in infants younger than 1 month of age

*Patients taking cisapride (Propulsid) or antipsychotic drug pimozide (Orap) *Oral administration for Lincosamides: -Food impairs absorption -Patient should NOT take anything by mouth for 1 to 2 hours before/after meals -Give clindamycin with food or a full glass of water

Fluoroquinolones Pg. 557

(Cipro, Tequin, Maxaquin, Avelox & Floxin, Vacomycin)

ACTION Antibacterial USES Lower respiratory infections Bone/Joint infections UTIs, STDs Infections of the skin ADVERSE REACTIONS *N/V/D, headache, dizziness *abdominal pain/discomfort *Photosensitivity: more serious with lomefloxacin & sparfloxacin

INTERACTIONS

Drug: Theophyllineincrease theophylline levels Cimetidine interferes with eliminations of the antibiotic Oral Anticoagulants increased risk of bleeding Antacids (Fe, salts, Zn) decreases absorption of the antibiotic Nonsteroidal Anti-Inflammatory Drug (NSAIDs) risk of seizure activity NURSING PRECAUTIONS *Monitor VS for adverse reactions during first 48 hours *Patients with a history of hypersensitivity, children younger than 18 years old, during pregnancy, who cannot follow precautions regarding photosensitivity

*Used cautiously in patient with: renal impairment, history of seizures, geriatric patients and patients on dialysis

Carbapenems Pg. 49, 496

(Merrum, Primaxin, Ertapenem)

Ertapenem used to treat serious infections; bacterial community-acquired pneumonia

ACTION Antibacterial USES Meropenem (Merrem) used for intra-abdominal infections, bacterial meningitis Imipenem-cilastatin (Primaxin) used to treat serious infections, endocarditis, septicemia

ADVERSE REACTIONS * N/V/D, rash, abscess, tissue sloughing or phletitis at the injection site INTERACTIONS Drug: The excretion of

carbapenems is inhibited when the drug is administered to a patient also taking probenecid (Benemid) NURSING PRECAUTIONS *Contraindicated in patients who are: - allergic to cephalosporins & penicillin -have renal failure -children younger than 3 years old

Vancomycin Pg. 1215

(Vacocin) ACTION Antibacterial USES Serious gram-positive infections that do not response to treatment with other anti-infectives Anti-infective associated pseudomembranous colitis caused by Clostridium difficile (C. Diff) ADVERSE REACTIONS *Nausea, chills, fever, urtiicaria, sudden fall in BP with parenteral administration, rash *Nephrotoxicity, ototoxicity CONTRINDICATIONS *Contraindicated in patient who have known sensitivity to the drug *Used cautiously in patients with renal or hearing impairment, during pregnancy/lactation Interaction *Should NOT be used with other drugs that can cause ototoxicity and nephrotoxicity

NURSING PRECAUTIONS The nurse should administer each IV dose of Vancomycin over 60 minutestoo rapid an infusion may result in a sudden and profound fall in blood pressure and shock. Signs/symptoms include decrease BP, throbbing neck, fever, chills, back pain or red neck, known as red-man syndrome.

Linezolid Pg. 752

(Zyvox) ACTION Antibacterial USES Vancomycin-resistant enterococcus (VRE) Health care and communityacquired pneumonias Skin and skin structure infections

ADVERSE REACTIONS *N/V/D, headache and dizziness, insomnia, rash -Less common: fatigue, depression, nervousness, photosensitivity *Pseudomembranous colitis and Thrombocytopenia

CONTRAINDICATIONS *Contraindications in patients who are

allergic to the drug, pregnant (Category C) or lactating, or patients who phenylnetonuria *Used cautiously in patients with: *Bone marrow depression *hepatic dysfunction*Renal impairment *Hypertension/hyperthryroidism INTERACTIONS Drug: Anti-platelet drugs (Aspirin, NSAIDs, Plavix) Increased risk of bleeding & low platelets

MAOI Antidepressants Decreased effectiveness Food: Large amounts of food containing tyramine risk of severe hypertension **Tyramine foods: aged cheese, caffeinated beverages, yogurt, chocolate, red wine, beer, pepperoni)

Spectinomycin
(Trobicin)

ACTION *Antibacterial USES

*Used for treating gonorrhea in patients who are allergic to penicillins, cephalosporins or probenecid (Benemid) ADVERSE REACTIONS *Soreness at injection site, urticaria, dizziness, rash, chills, fever & hypersensitivity reactions INTERACTIONS/NURSING PRECAUTIONS
*Contraindicated in patients with known hypersensitivity to the drug **No known safe use with pregnancy/lactating women and infants/children** ***Interaction: No significant drug or food interactions are known***

Aztronam
(Azactam) ACTION

Differs structurally from penicillin and cephalosporins in having a monocyclic rather than a bicyclic nucels. Acts by inhibiting synthesis of bacterial wall, primarily in aerobic gram-negative bacteria USES Gram-negative bacteria infections such as: -urinary tract -lower respiratory tract -skin/skin structures -intraabdominal -septicemia ADVERSE REACTIONS *N/V/D, hypotension, rash, headache, pseudomembranous colitis INTERACTIONS Drug: patients sensitive to penicillins, cephalosporins or carbapenemcross sensitivity NURSING PRECUATIONS *Contraindicated in patients with known hypersensitivity, during pregnancy/lactation (Category B) *Used cautiously in patients with patients with renal or hepatic impairment

Daptomycin Pg. 376

(Cubicin) ACTION Antibacterial

USES Complicated skin and skin structure infections ADVERSE REACTIONS *N/V/D, hypotension, rash, headache, pseudomembranous colitis INTERACTIONS Drug: potential increased risk of myopathy with statin drugs NURSING PRECAUTIONS *Contraindicated in patients with known hypersensitivity to the drug and during pregnancy/lactation (Category B) *Used cautiously in patients taking warfarin (Coumadin)

Quinupristin/Dalfopristin Pg. 1049

(Synercid)

ACTION Antibacterial against gram-positive pathogens including VREF USES Serious and life-threatening infections associated with vancomycinresistant Enterococcus faecium (VREF) Complicated skin/skin structure infections caused by staphylococcus aureus ADVERSE REACTIONS Irritation in the vein; incompatibility with saline or heparin flush solutions; N/V/D INTERACTION Drug: serum levels of the following drugs may increase: -Antiretrovirals -Anti-neoplastic -Immunosuppressants -Calcuim channel blockers -Benzodiazepines -Cisapride

CONTRAINIDCATIONS/NURSING PRECAUTIONS *Contraindicated in patients with known sensitivity to the drug; pregnancy/lactation (Category B)

Isoniazid Pg. 705

(INH, Nydrazid) ACTION Antibacterial USES Used to treat Active Tuberculosis ADVERSE REACTIONS *N/D, skin eruptions, jaundice Toxicity = peripheral neuropathy and severe & sometimes fatal hepatitis) INTERACTIONS Drug: Aluminum salts reduced absorption of isoniazid Anticoagulants increased risk for bleeding

Phenytoin (Dilantin) increased serum level of Dilantin Food: Alcohol higher incidence of drugrelated hepatitis

NURSING PRECAUTIONS *Give on empty stomach, if GI upset may take with meals *Isoniazid solution tends to crystallize at low temperatures, let it warm to room temperature before injecting *Rotate injection sites *Monitor BP during dosage adjustment: some experience orthostatic

hypotension *Monitor diabetics for abnormal blood sugar results *Avoid tyramine & histaminecontaining foods causes hypertension

*N/V, heartburn, vertigo, reddishorange discoloration of body fluids (urine, tears, saliva, sweat, sputum) *Call the MD immediately if patient becomes jaundice of skin & eyes = ABNORMAL INTERACTIONS Drug: Digoxin decreases digoxin serum levels Oral contraceptives decreases contraceptives effectiveness Antiretroviral for HIV (efavirenz, nevirapine) decreases level of antiretroviral Isoniazid (INH for TB) higher risk of hepatotoxicity

Rifampin Pg. 1066

(Rifadin, Rimactant) ACTION Antibacterial USES Used to treat Active Tuberculosis ADVERSE REACTIONS

Anticoagulants increased risk for bleeding Hypoglycemics decreases effectiveness of hypoglycemia, patients become hyperglycemic NURSING PRECAUTIONS FOR ANTITUBERCULAR DRUGS *Rotate injection sites *Monitor for gastric upset, given with/ or without food *Explain coloration of bodily fluids (soft contact lenses may be permanently stained). *REPORT JAUNDICE immediately *Do NOT interrupt dosage regimen

ANTIVIRALS
Pg.59
Acyclovir (Zovirax) for Herpes Simplex 1 & 2, Zoster (Shingles), Varicella zoster (Chicken pox) Oseltamivir (Tamiflu) for prevention and treatment of Influenza A &B Valacyclovir (Valtrex) for Herpes ACTION *Combats viral infections does NOT kill viruses *Can be toxic to human cells *Herbal alert: Lemon Balm USES CMV in transplant patients Herpes simplex virsus 1, 2 (genital) and Herpes Zoster (Shingles) HIV

Influenza A & B Hepatitis B & C

ADVERSE REACTIONS *N/V/D, headache, rash, fever *Cidofovir (Vistide) contraindicated for patients on other nephrotoxic meds, like aminoglycosides *Ribavirin contraindicated for patients with unstable cardiac disease INTERACTIONS Drug: Probenecid (for gout) increase levels of the antivirals Cimetidine (for peptic ulcers) increases levels of antiviral valacyclovir Ibruprofen increases level of antiviral devoir

NURSING PRECAUTIONS *Monitor I/Os & hydration status *Refrain from sex if signs/symptoms of herpes persists *Do not breast feed while taking this drug

ANTIRETROVIRALS
Pg. 1349-1351
ACTION Retrovirsus: attack host cells, just like a virus -To control the disease effectively, a number of drugs are used (a cocktail) *highly active antiretroviral therapy (HAART): multidrug therapy USES Used in the treatment of HIV/AIDs

ADVERSE REACTIONS *N/V/D, altered taste *numbness &tingling around the mouth or peripherally CONTRAINDICATIONS *Patients who are lactating *Patients also taking cisapride, primozide, triazolam, midazolam or ergot derivative INTERACTIONS Drug: Antifungals increases levels of antiretroviral Clarithromycin increases levels of BOTH drugs Sildenafil (Viagra) increase levels of sildenafil Opiod analgesics risk of toxicity with ritonavir Anticoagulants/anticonvulsant/antiparas itics

decrease effectiveness of antiretroviral if taking ritonavir Interleukins risk of antiretroviral toxicity Fentantyl increases level of fentanyl Oral contraceptives decreases effectiveness of contraceptive NURSING PRECAUTIONS *Observe patients on Amantadine for adverse effects *Ribavirin: Pregnancy Category X, monitor respiratory function *Help reduce effects of nausea, odorfree environment *Monitor for skin lesions

Fleets
(Magnesium/Saline enema) ACTION Enema, Hyperosmotic Laxative

USES Relief of constipation Stimulates peristalsis by acting as an irritant ADVERSE REACTIONS *N/V/D, bloating, flatulence, cramping, perianal irritation, fainting CONTRINDICATIONS *Safe use during pregnancy or lactation is not established (Category C) *DO NOT use in presence of abdominal pain/N/V *Consult physician regarding fluid intake in patients receiving drug for elevated intraocular pressure INTERATIONS Drug: other laxatives effectiveness of laxatives NURSING PRECAUTIONS *May cause hyperglycemia in diabetics *Evacuation usually comes 15-30 min after administration of enema *Do not breast feed while taking this drug without consulting physician *Place patient in Sims position *Lubricate tip of bottle *Instruct patient to retain enema for 5-10 minutes prior to expelling fluid

*Used cautiously in diabetic patients *Pregnancy Category B INTERACTIONS Drug: Antacids & metoclopramide (GI

Ranitidine
(Zantac, Zantac 75) Pg.623 ACTION Anti-ulcer drug USES Gastric/duodenal ulcers GERD, heartburn GI Bleeding ADVERSE RACTIONS *Headache, somnolence, diarrhea CONTRAINICATIONS *Hypersensitivity to the drug *Cautiously used in patients with renal/hepatic impairment, severely ill, elderly or debilitated patients.

distress) decreased absorption of the H2 antagonists Carmustine (anticancer) decreases WBC Opioid Analgesics increased risk of respiratory depression Anticoagulants increased risk of bleeding digoxin may decrease digoxin levels

NURSING PRECAUTIONS *BIG risk of potential toxicity from decreased elimination in older adults or patients with hepatic or renal dysfunction *Monitor liver function tests & early signs of hepatoxicity -jaundice, dark urine, pruritius, yellow sclera and skin

*Long-term therapy may lead to vitamin B12 deficiency *Remember to provide pain relief through the night *Do NOT supplement with OTC gastric distress remedies (Mylanta, Pepto reduces Zantac absorption) *Do NOT SMOKE *Do NOT breast feed without consulting MD

Intermediate-acting insulin hormone that decreases blood glucose levels

USES To control hyperglycemia in diabetic patients ADVERSE REACTIONS *Hypoglycemia: sudden onset, fatigue,
weakness, nervousness, agitation, convulsions, dizziness, unconsciousness. Normal to shallow respirations, hunger/nausea, pale/moist/cool/diaphoretic skin, numbness, tingling of lips/tongue *Hyperglycemia: gradual onset, drowsiness, dim vision, deep rapid respirations, thirst/nausea/vomiting, dry/flushed warm skin, rapid & weak pulse

NPH (Isophane Insulin)

(Humulin 70/30, Novolin 70/30, Novolin N)

Pg. 683
ACTION

CONTRAINICATIONS

*Pregnancy Category B, renal/hepatic impairment and older adults *Hypersensitivity to animal products (beef or pork) INTERACTIONS Drug:
Drugs that decrease the effect (more insulin may be required) Albuterol, contraceptives, corticosteroids, diltiazem, diuretics, epinephrine, estrogens, glucagon, HIV antivirals, isoniazid, lithium, morphine Drugs that increased the effect (less insulin may be required) ACE inhibitors, alcohol, anabolic steroids, oral anti-diabetic, calcium, MAOIs, salicylates, sulfonamides, tetracyclines

weakness, sweating, tremor or nervousness occur *Advise mid-afternoon, after dinner snack

Regular Insulin
(Humulin R, Novolin R) Pg.681 ACTION Short-acting insulin hormone that decreases blood glucose levels USES To control hyperglycemia in diabetic patients ADVERSE REACTIONS *Hypoglycemia: sudden onset, fatigue,
weakness, nervousness, agitation, convulsions, dizziness, unconsciousness. Normal to shallow respirations,

NURSING PRECAUTIONS *Learn signs/symptoms of hypo & hyperglycemia *Suspect hypoglycemia if fatigue,

hunger/nausea, pale/moist/cool/diaphoretic skin, numbness, tingling of lips/tongue *Hyperglycemia: gradual onset, drowsiness, dim vision, deep rapid respirations, thirst/nausea/vomiting, dry/flushed warm skin, rapid & weak pulse

be required) ACE inhibitors, alcohol, anabolic steroids, oral anti-diabetic, calcium, MAOIs, salicylates, sulfonamides, tetracyclines

CONTRAINICATIONS *Pregnancy Category B, renal/hepatic impairment and older adults *Hypersensitivity to animal products (beef or pork) INTERACTIONS Drug:
Drugs that decrease the effect (more insulin may be required) Albuterol, contraceptives, corticosteroids, diltiazem, diuretics, epinephrine, estrogens, glucagon, HIV antivirals, isoniazid, lithium, morphine Drugs that increased the effect (less insulin may

NURSING PRECAUTIONS *Learn signs/symptoms of hypo & hyperglycemia *Suspect hypoglycemia if fatigue, weakness, sweating, tremor or nervousness occur *Advise mid-afternoon, after dinner snack

Nitroglycerin
(Paste, patch or sublingual) Pg. 892 ACTION Cardiovascular ; Nitrate Vasodilator USES

Angina, Preventative of MI

ADVERSE REACTIONS *headache, weakness, vertigo, dizziness, faintness, hypotension *circulatory collapse CONTRAINDICATIONS *Patients with severe anemia, cerebral hemorrhage *Used cautiously in the following patients: severe hepatic/renal disease, severe head trauma and hypothyroidism INTERACTIONS Drug: Aspirin increases nitrate concentration Calcium Channel Blockers increases symptomatic orthostatic hypotension

Dihydroergotamine (migrate medicine) Increases risk of hypertension heparin decreased effect of heparin Erectile dysfunction meds severe hypotension & cardiovascular collapse may occur Alcohol severe hypotension & cardiovascular collapse because of its a vasodilator NURSING PRECAUTIONS *Nurse should NOT rub nitro ointment into patients skin, it will be absorbed into their skin & causes a severe headache *Sublingual nitro may be repeated Q 5 mins until pain is relieved or patient has received 3 doses in a 15-minute period. *Heart rate MUST be above 60 Keep in a dark,cool,airtight container.

Albuterol
(Ventolin, Volmax, Proventil, Provenil)

Pg. 120
ACTION Bronchodilator USES Bronchospasm, bronchitis, emphysema Acute & Chronic bronchial asthma ADVERSE REACTIONS *Headache, palpitations, tachycardia, tremor, dizziness, shakiness, nervousness, hyperactivity, vertigo CONTRAINIDATIONS *Contraindicated in patients with cardiac arrhythmias associated with

tachycardia, organic brain damage & cerebral arteriosclerosis, patients with history of seizures and patients who are pregnant (Category C) INTERACTIONS Drug:
Adrenergic drugs possible additive adrenergic effects Tricyclics (anti-depressives) possible hypotension Beta-adrenergic blockers (hypertension) inhibits the cardiac, bronchodilating & vasodilating effects of the adrenergic methyldopa (hypertensive med) possible hypotension oxytocic drugs possible severe hypotension theophylline (asthma/COPD med) increased risk for cardiotoxicity

NURSING PRECAUTIONS

*Monitor for signs/symptoms of fine

tremor in fingers, CNS stimulation (particularly in children 2-6 y), excitement, nervousness, insomnia, tachycardia, GI symptoms *Lab tests: periodic ABGs, pulse oximetry and pulmonary function *Avoid contact of inhalation drug with eyes *Do not use OTC drugs without physician approval, including cold medicine

USES Edema due to heart failure, cirrhosis of the liver, renal disease, acute pulmonary edema and hypertension ADVERSE REACTIONS *Electrolyte and hematologic imbalances, anorexia, N/V, dizziness, rash, photosensitivity, orthostatic hypotension CONTRAINIDCATIONS *Patients with electrolyte imbalances, severe kidney or liver dysfunction and anuria (cessation of urine production).

Furosemide
(Lasix) Pg. 587 ACTION Antihypertensive Loop Diuretics

INTERACTIONS Drug: Cisplatin (cancer med) AND

aminoglycosides increased risk of ototoxicity anticoagulants or thrombolytic (increases risk of bleeding) digitalis increased risk of arrhythmias lithium increased risk of Li toxicity hydantoins (seizure med) decreases effectiveness of diuretic NSAIDs decreases effectiveness of diuretic NURSING PRECAUTIONS *Closely monitor BP and vital signs *Monitor potassium levels, watch for hypokalemia (K+ between 3.5 -5) *Be careful of electrolyte imbalance *Monitor I/Os & voiding pattern *Lasix may cause hyperglycemia *Excessive dehydration occurs in older adults

*Hold if BP if less 100/60

Epinephrine
(EpiPen) Pg.480 ACTION Autonomic Nervous System Agent Central Nervous System (wakefulness, quick reaction to stimuli, quicken reflexes, increases heart rate) USES Treatment & prophylaxis of cardiac arrest, heart block; mucosal congestion and acute sinusitis Prolonged anesthetics and anaphylactic reactions ADVERSE REACTIONS

*Anxiety, sweating, flushing, headache, lightheadedness, dizziness, nausea, vomiting, tachycardia CONTRAINDICATIONS *Patients with narrow-angle glaucoma, and as a local anesthetic adjunct in fingers and toes INTERACTIONS Drug: Antidepressants increased sympathomimetic effect Oxytocin increased risk of hypertension Bretylium (severe cardiac med) increased risk of arrhythmias NURSING PRECAUTIONS

*Monitor BP, pulse and respirations *Call MD if any change in input/output ratio *Use cardiac monitor with patients receiving epinephrine IV. Have full crash cart immediately available *Check BP first 5 mins then every 3-5 mins until stabilized *Advise patient to report bronchial irritation, nervousness or sleeplessness

TB/Mantoux
A negative reaction (no induration) or a size of hard swelling that falls below the cutoff for each risk group may mean that you have not been infected with the bacteria that cause TB. The results of the test depend on the size of the skin reaction and on the person being tested. A small reaction (5 mm of firm swelling at the site) is considered to be positive in people: Who have HIV Who are taking steroid therapy Who have been in close contact with a person who has active TB

Larger reactions (greater than or equal to 10 mm) are considered positive in: People with diabetes or kidney failure Health care workers Injection drug users

There is a very small risk of severe redness and swelling of the arm in people who have had a previous positive PPD test and who have the test again. There also have been a few cases of this reaction in people who have not been tested before. A positive skin test does not necessarily mean that a person has

active tuberculosis. More tests must be done to check whether there is active disease.

surgery or removal of a foreign body. ADVERSE REACTIONS None known

Artificial Tears
(Ocular Lubricants) Pg. 1351 ACTION Utilizes isotonic solutions & wetting agents in the management of dry eyes due to the lack of tears USES Keeps the eye moist Lubrication for artificial eyes, provide lubrication & protection in a variety of conditions, including exposure keratitis, decreased corneal sensitivity, corneal erosions, during/following ocular

CONTRAINIDCATIONS May alter effects of other concurrently administered ophthalmic medications Photophobia, lid edema, stinging, temporary blurred vision, & eye discomfort NURSING PRECAUTIONS Adults & children 1-2 drops 3-4 times per day instilled into the conjunctiva

*Diarrhea, nausea, vomiting, bloating, flatulence, cramping, perianal irritation CONTRATINDIATIONS *Not advised for patients with persistent abdominal pain, nausea, or vomiting of unknown causes or signs of acute appendicitis *Used cautiously in patients with rectal bleeding, pregnant woman and during lactation (Pregnancy Category C), used only during pregnancy when the benefits outweigh risks INTERACTIONS Drugs: Mineral Oil impairs GI absorption of fat-soluble vitamin (A, D, E and K) *Laxatives reduce absorption of other drugs present in GI tract

Bisacodyl
(Dulcolax) Pg. 223 ACTION Laxatives USES Relief of constipation ADVERSE REACTIONS

*Milk, antacid, histamine H2 antagonists & proton pump inhibitors should NOT be administered 1 to 2 hours before bisacodyl Tablets because enteric coating may dissolve early, resulting in gastric lining irritation NURSING PRECAUTIONS *Evaluate patients need to continue; dulcolax usually produces 1 or 2 soft formed stools daily *Monitor patients receiving anticoagulants, may result in decreased absorption of vitamin K. *Add high-fiber foods slowly to avoid

gas and diarrhea

Nystatin
(Cream, powder, oral swish/swallow or swish/spit) Pg. 181-184 ACTION Antifungal USES Fungal infections Most likely to occur in groin area, under breasts, folds of stomach in obese patients ADERVSE REACTIONS *D/N/V, rash, headache, abdominal/joint/muscle pain, anorexia and malaise CONTRAINDICATIONS

*Contraindicated during pregnancy & lactation & ONLY used when situation is life-threatening and outweigh the risk to the fetus *Patients renal dysfunction/hepatic impairment INTERACTIONS No known interactions NURSING PRECAUTIONS *This drug may cause dermatitis, if it does it should be stopped and call MD *It taken for treatment of trush, take after meals and at bedtime *If taking orally, dissolve troche in mouth (about 30 mins), do NOT chew or swallow. Avoid food and drink during period of

dissolving and for 30 mins after treatment *If powder, dust shoes and stockings as well as feet *Wash skin before topical use *Do not breast feed while taking this drug without consulting MD *If sublingual, bottle must be air-tight away from sunlight

Hydrocortisone Cream
(Cortisol) Pg.350 ACTION Glucocorticoid Anti-inflammatory Drug USES Allergic reactions Dermatologic conditions ADVERSE REACTIONS *Buffalo hump, moon face, oily skin and acne, osteoporosis, purple striae on the abdomen and hips, altered skin pigmentation and weight gain CONTRAINDICATIONS

*Patients with serious infections (such as TB, fungal and antibiotic resistant infections) *Used cautiously in patients with renal/hepatic disease, hypothyroidism, ulcers/diverticulitis INTERACTIONS Drug: Barbiturates decrease effect of steroid Oral contraceptives steroid concentration may be increased and clearance decreased Estrogen steroid clearance decreased Digitalis possibility of digitalis toxicity Loop Diuretics hypokalemia Antiinfectives decrease effectiveness of antiinfective

NURSING PRECAUTIONS *Monitor electrolytes and blood glucose level *Monitor for persistent backache or chest pain or fractures of long bones *Monitor change in mood or behavior in longterm therapy *Be alert to possible masked infections and delayed healing *One time or short term use do NOT produce withdrawal symptoms when discontinued

Carbamide Peroxicde
(Debrox) ACTION Otic preparation USES Aids in removing cerumen by softening and breaking up the wax ADVERSE REACTIONS *Ear irritation, itching, burning CONTRAINDICATIONS *Used cautiously during pregnancy and lactation *Otic drugs available in dropper bottles may be dangerous if ingested

*Stored safety out of reach of children and pets *DO NOT USE if ear drainage, discharge, pain or irritation is present, if eardrum is perforated or after ear surgery INTERACTIONS *No known drug interactions NURSING PRECAUTIONS *When assessing an infant, look for the infant to pull, grab or tug on ears. W *When administering in a childs ear, pull the pinna down and back, in adult- up & back *Cerumen is thicker in the elderly *Allow solution to stay in ear canal for 5

minutes *Do use for more than 4 days

Digoxin
(Digitek, Lanoxin) Pg.412 ACTION Cardiovascular medication USES Heart Failure Atrial Fibrillation

ADVERSE REACTIONS *Headache, weakness, drowsiness, visual disturbances, nausea, vomiting, anorexia, arrhythmias CONTRAINDIATIONS *Contraindicated in the presence of digitalis toxicity, patients with ventricular failure, tachycardia, cardiac tamponade or AV block *Given cautiously in patients with electrolyte imbalance (especially hypokalemia), thyroid disorders, severe pulmonary disease, impaired renal/hepatic function. *Pregnancy Category C, used cautiously INTERACTIONS Drug: Increase levels leading to digitalis

toxicity: amiodarone, benzodiazepines, indomethacin, itraconazole, macrolides, propafenone, quinidine, spironolactone, tetracyclines, verapamil, aminoglycoside, Antacids

*Hold if BP is less than 100/60 OR greater than 140/90, OR HR less than 60

Decrease levels of digitalis: anticancer agents,

Metoprolol
(Lopressor, Toprol-XL) Pg.814
ACTION -Adrenergic Blocking Drug (Beta Blocker) Decreases stimulation of sympathetic nervous system by: Decreasing excitability of heart Decreasing cardiac workload and oxygen consumption Provides membrane-stabilizing effects USES Hypertension Angina Myocardial Infraction Heart Failure

activated charcoal, cholestyramine, colestipol, Neomycin and rifampin

NURSING PRECAUTIONS *Labs need to be drawn to monitor drug level *Hypokalemia makes muscles more sensitive to digitalis, leading to toxicity *Signs/symptoms of toxicity: levels above 2.0 nanograms/ML, anorexia, nausea, vomiting, abdominal pain, visual disturbance, and arrhythmias

ADVERSE REACTIONS *Dizziness, hypotension, heart failure, cardiac arrhythmia, nausea, vomiting, diarrhea CONTRAINIDICATIONS *Contraindicated in patients with sinus bradycardia, second or third degree heart block, heart failure and in those with asthma, emphysema or hypotension. *Used cautiously in patients with diabetes, thyrotoxicosis or peptic ulcer. *B-blockers are recommended for pregnant woman over other hypertensive because of the risk to the fetus is less with these drugs INTERACTIONS Drug: Antidepressants increased effect of Beta blocker, bradycardia NSAIDs decreased effect of beta blocker Loop Diuretic increased risk of hypotension

Clonidine increased risk of paradoxical hypertensive effect Cimetidine higher risk of B-blocker toxicity Iidocaine higher risk of B-blocker toxicity NURSING PRECAUTIONS *Take apical pulse and BP before administration *Hold if BP is less than 100/60 OR greater than 140/90, OR HR less than 60 *Monitor BP, HR and ECG carefully during IV administration

Heparin
Pg. 616
ACTION Anticoagulant USES

Thrombosis/embolism Preventative of DVT Clotting prevention

ADVERSE REACTIONS *Bleeding, chills, fever, urticaria, local irritation, erythema, mild pain, hematoma or bruising at the injection site (SubQ injection) CONTRAINDICATIONS *If patient has an active bleed, hemophilia, open wound, advanced kidney or liver disease, severe hypertension or recent surgery or eye, brain, spinal cord or spinal tap or shock INTERACTIONS Drug: Aspirin & anticoagulants increased bleeding

Nitroglycerin decrease anticoagulant Protamine antagonizes effect of heparin Herbal: Feverfew, ginkgo, ginger, valerian may potentiate bleeding NURSING PRECAUTIONS *Lab tests: PT/INR, baseline blood coagulation tests, H/H *Monitor APTT levels closely *In general, dosage is adjusted to keep APTT between 1.5-2.5 times normal control level *Monitor vital signs *Observe all needle sites daily for hematoma and signs of inflammation

*Antidote: have on hand Protamine sulfate, Specific heparin antagonist

Cefotetan Disodium Pg.

282
(Cefotan) ACTION Antibacterial USES *Treatment of moderate to severe infections *May be used as a prophylaxis (prevention) after surgery ADVERSE REACTIONS *N/V/D, malaise, fever, dizziness, heartburn *Pruritus, urticara, TEN & SJS (death

of epidermal layer of skin), nephrotoxicity *phletbitis, thrombophletbitis with IV use INTERACTIONS Drugs: Aminoglycosides (antiinfective)will increase risk of nephrotoxicity Anticoagulants increase risk for bleeding Loop diureticsincrease cephalosporin blood level

Food: Alcohol consumed within 72 hours after administration will produce an Antabuse-like reaction (vomiting, dyspnea, sweating and hypotension) NURSING PRECAUTIONS

*10% of PCN allergy patients will be allergic to cephalosporins *May be TAKEN WITH FOOD reduce GI upset *Inpatients should be assessed Q4 hours for skin redness, rash, lesion, blister/red wheals *Risk of nephrotoxicity, early sign=decrease urine output (daily output < 500 mL call MD) *Watch sign/symptoms of superinfection *Should be taken around the clock to keep an adequate amount of drug in the body *Finish full course of drug regimen

Warfarin Sodium
(Coumadin) Pg. 1245 ACTION Oral anticoagulant, blood thinner USES Prophylaxis & treatment of DVTs, pulmonary embolisms and atria fibrillation with embolization Coronary occlusion Cerebral Transient Ischemic Attacks (TIA ADVERSE REACTIONS *Bleeding, fatigue, dizziness, abdominal cramping CONTRATINDICATIONS *Patients with an active bleed (except when caused by DIC), hemorrhagic disease, tuberculosis, leukemia, uncontrolled

hypertension, GI ulcers, recent surgery of eye or central nervous system.

barbiturates decreased effectiveness of anticoagulant

NURSING PRECAUTIONS

*Use during pregnancy CAN CAUSE fetal death (pregnancy category X) INTERACTIONS Drug:
Aspirin, acetaminophen, NSAIDs, chloral hydrate increase risk of bleeding Penicillin, aminoglycodies, isoniazid, tetracyclines & cephalosporins increased risk for bleeding Beta blockers/loop diuretics increased risk for bleeding disulfiram & cimetidine increased risk for bleeding oral contraceptives, vitamin K,

*Lab tests: PT/INR, periodic urinalyses, stool guaiac & liver function tests *Monitor older adults, psychotic or alcoholic patients may present serious noncompliance problems *Avoid straight-edge razor use *Risk bleeding up to 1 month if received flu vaccine

Enoxaparin
(Lovenox) Pg. 619 ACTION Parenteral (SubQ) Anticoagulant, blood thinner USES

DVTS, presurgical prophylaxis, Pulmonary embolism treatment, unstable angina/non-Q-wave MI

Garlic, ginger, gingko, feverfew, horse chestnut increased risk of bleeding NURSING PRECAUTIONS *Lab tests: periodic CBC, platelet count, urine and stool for occult blood *Monitor platelet count closely *Renal sufficient patients are at higher risk for thrombocytopenia *Monitor for signs/symptoms of unexplained bleeding *Consult MD before taking any OTC meds *Do not breast feed while taking medication without consulting MD

ADVERSE REACTIONS *Bleeding, bruising, rash, fever, erythema and irritation at site of injection CONTRAINDICATIONS *Patients with an active bleed, hemophilia, heparin sensitivity, heparin-induced thrombocytopenia *Pregnancy category B INTERACTIONS Drug: Aspirin, NSAIDs, warfarin increased risk of bleeding Herbal:

Calcium Carbonate
Pg. 256

Hypercalcemia; Renal calculi; ventricular fibrillation. Use cautiously in pt.s receiving digitalis glycosides, severe respiratory insufficiency, renal disease INTERACTIONS
Drug: Hypercalcemia increases the risk of digoxin toxicity, PO ingestion decreases absorption of tetracyclines, fluoroquinolones, phenytoin, & iron salts. Excessive amounts may decrease effectiveness of calcium channel blockers, concurrent use with diuretics may result in hypercalcemia. Drug/Food: Cereals, spinach, or rhubarb may decrease absorption of calcium supplements

ACTION

Mineral & electrolyte replacements/supplements Replacement of calcium in deficiency End-stage renal disease/ control hyperphosphatemia Antacid CNS- syncope(IV only), tingling CV- arrhythmias, bradycardia GI- Constipation, N,V GU-Calculi, hypercalciuria

USES

ADVERSE REACTIONS

CONTRAINIDICATIONS

NURSING PRECAUTIONS Monitor blood pressure, pulse, frequently.

May cause vasodilation & hypotension, bradycardia, arrhythmias, & cardiac arrest. Especially in elderly pt.s and pt.s with hypertension. When use with an antacid assess for heartburn, indigestion, & abdominal pain. Labs: monitor serum calcium, sodium,
potassium, magnesium, albumin, & parathyroid hormone(PTH)

Prevention of constipation by incorporating water into the stool, resulting in a softer fecal mass.

ADVERSE REACTIONS EENT- throat irritation GI- mild cramps Derm- rashes CONTRAINDICATIONS Hypersensitivity, abdominal pain, N,V, especially when associated with fever or other signs of an acute abdomen

Docusate
(Colace) Pg. 442 ACTION Stool softener USES INTERACTIONS Drug: None significant NURSING PRECAUTIONS

Assess for abdominal pain, distension, bowel sounds, and usual pattern for bowel function. Assess the color, consistency, and amount of stool produced. Advise pt.s that laxatives should be used for short-term therapy. Longterm use may cause an electrolyte imbalance & dependence. In courage pt. to increase intake of fluids and mobility. Pt.s with cardiac issues should be informed not to strain during a bowel movement (Vasovagal Syncope), they should also avoid using laxatives when abdominal pain, N,V, or fever is present.

Ferrous Sulfate

(Iron supplements) Pg. 700 ACTION Essential mineral found in hemoglobin, it is sent into the bloodstream into the liver, spleen, & bone marrow where it is separated out & becomes part of iron stores. USES Prevention/Treatment of iron deficiency ADVERSE REACTIONS CNS- dizziness, headache, syncope CV- hypotension, hypertension, tachycardia GI- N,V,D constipation, dark stools, epigastric pain, GI bleeding CONTRAINDICATIONS

Hypersensitivity, Anemias not due to iron deficiency

Assess nutritional status & dietary history, Assess bowel function Labs: hemoglobin, hematocrit, reticulocyte, transferring, ferritin & plasma iron values periodically

INTERACTIONS Drug: Decrease absorption of tetracyclines, fluoroquinolones, & penicillamine, chloramphenicol & vitamin E may decrease hematologic response to iron therapy. **Etc. NURSING PRECAUTIONS Assess Pt. for signs and symptoms of anaphylaxis (rash, purities, laryngeal edema, wheezing) notify physician if these occur.

Phenadoz
(Promethazine) Pg. 1017 ACTION Gastrointestinal Agent Antiemetic Antivertigo USES Treatment of various allergic conditions & motion sickness.

Preoperative sedation, treatment and prevention of N,V. adjunct to anesthesia and analgesia

INTERACTIONS Drug: Additive CNS depression when used with other CNS depressants, including alcohol, other antihistamines, opioid analgesics, sedatives, antidepressants, haloperidol, may cause seizures when used with seizure medications, MAO inhibitors may cause increased sedation NURSING PRECAUTIONS Monitor blood pressure, pulse & respirations, for IV monitor site frequently. PO may be given with food, water, milk to minimize GI upset. Watch for signs & symptoms of an allergic reaction (rhinitis, hives)

ADVERSE REACTIONS CNS- Neuroleptic malignant syndrome(confusion, disorientation, sedation, dizziness, extrapyramidal reactions), fatigue, insomnia, nervousness EENT-blurred vision, diplopia, tinnitus CV- bradycardia, hypertension, hypotension, tachycardia GI- constipation, drug induced hepatitis, dry mouth Derm.- photosensitivity, & severe tissue necrosis upon infiltration at IV site, rashes Hemat.- blood dyscrasias

Gabapentin
(Neurontin) Pg. 591 ACTION Central Nervous System Agent USES Partial seizures, post-herpetic neuralgia, UNLABELED USESchronic pain, prevention of migraines, bi-polar disorder, anxiety ADVERSE REACTIONS CNS-confusion, depression, drowsiness, sedation, anxiety, concentration difficulties, dizziness, hostility, malaise, vertigo, weakness EENT- abnormal vision CV- hypertension/ GI- weight gain, anorexia, flatulence, gingivitis

Neuro- ataxia, altered reflexes, paresthesia, hyperkinesia/ MISC. facial edema INTERACTIONS Drug: Antacids may decrease absorption, increased risk of CNS depression when used with other CNS depressants, including alcohol, antihistamines, opioids, & sedatives, morphine may increase serum levels and cause toxicity Drug/Food: kava kava; valerian; chamomile may increase CNS depression NURSING PRECAUTIONS Monitor for seizures, pain, dizziness, confusion, or anxiety. Recommend

that the patient not drive or operate machinery until response to the medication is known. Advise female PT.s to notify the physician if she plans to become pregnant or is pregnant or is breastfeeding an infant.

ANALGESICS

Acute v. Chronic Pain *Acute pain: is brief and lasts less than 3 to 6 months. Causes: range from sunburn to postoperative, procedural or traumatic pain -Usually subsides when the injury is healed *Chronic pain: lasts more than 6 months and is often associated with specific disease, such as cancer, sickle cell anemia, and end-stage organ or system failure. Causes: Various neuropathic and musculoskeletal disorders such as headache, fibromyalgia, rheumatoid arthritis and osteoarthritis, are also causes of chronic pain.

Analgesics and Pain Relief *Analgesics: drugs used to relieve pain Salicylates: Aspirin, Bayer, Alka-Seltzer with Aspirin Nonsalicylates: Acetaminophen (Tylenol) Nonsteroidal Anti-Inflammatory Drugs (NSAIDs): Advil, Aleve, Celebrex

Opioids: general term used for the opium-derived or synthetic analgesic used in pain control Narcotic: term referring to the properties of a drug to produce numbness or stupor-like state Opioid and narcotic were once interchangeable, law enforcement agencies have generalized the term narcotic to mean a drug that is addictive and abusive or used illegally Health care providers use the term opioid to describe the drugs used in pain relief

Aspirin (ASA) Pg. 1087

(Aspirin, Bayer, Alka-Seltzer with Aspirin)
ACTION

Lowers body temperature, anti-inflammatory effects, prolongs bleeding time Salicylates

*N/V, epigastic distress, GI bleeding, tinnitus, allergic/anaphylactic reactions; salicylism with overuse CONTRAINDICATIONS *Patients with bleeding disorders or GI bleed: children with chickenpox or influenza Reyes syndrome (a lifethreatening condition characterized by vomiting & lethargy progressing to coma) *Pregnancy Category D (aspirin) and C and should be used cautiously during pregnancy/lactation INTERACTIONS Drug: Anticoagulant increased risk of bleeding NSAIDs increased serum of levels of NSAIDs Activated charcoal decreases absorption of salicylates Antacids decreases effects of salicylates Carbonic anhydrase inhibitors increased risk for salicylism Herbal:

USES

pain

Mild moderate

Antipyretic Decreases risk of MI Reduces risk of TIA stroke by inhibiting clotting (particularly in men) ADVERSE REACTIONS

Feverfew, garlic, ginger, ginkgomay increase bleeding risk NURSING PRECAUTIONS

*Adult no more than 4,000 mg or 3 g/day *Child no more than 3,600 mg or 3.6 g/day
*Lab tests: PT/INR, liver function tests, urine ketones, pregnancy tests, more frequent CBGs with diabetes *Monitor children for salicylate toxicity dehydration, fever, hyperventilation, agitation *Discontinue use if ringing or buzzing in ears, impaired hearing, dizziness, GI discomfort of bleeding *Avoid other aspirin containing medications without consulting MD *Do not breast feed while taking medication

Analgesic, Antipyretic USES Mild to moderate pain Reducing elevated body temperature (fever) ADVERSE REACTIONS *Skin eruptions, urticaria (hives), anemia *Pancytopenia (a reduction in all blood components) *Hypoglycemia *Jaundice, hepatoxicity & hepatic failure CONTRAINDICIATIONS *Habitual alcohol user at risk for hepatotoxicity *Safe for short-term use ONLY *Pregnancy Category B INTERACTIONS Drug:
Barbituratesincreases possibility of toxicity and decreases effect of Tylenol hydantoins (anticonvulsants) increases possibility of toxicity and decreases effect of Tylenol & Rifampin increases possibility of toxicity

Acetaminophen
(Tylenol) Pg. 107
ACTION

and decreases effect of Tylenol Loop Diuretics decreases effectiveness of diuretics

NURSING PRECAUTIONS *Asses alcohol use *Long-term use can lead to serious GI toxicity can cause bleeding, ulceration & perforation *Do NOT take other cold medications that contain acetaminophen without MD advice *Adult < 4,000 mg or 4 g/day *Child < 2,600 mg or 2.6 g/day
*Overdose treat with activated charcoal & N-acetylcysteine (Mucomyst), follow-up treatment sulfa based to continue through GI system and absorb residual Tylenol *Avoid use of 1 week before/after surgery Observe signs of salicylism (overdose) Levels greater than 400 mcg: result in respiratory alkalosis; hemorrhage

*Tinnitus/impaired hearing hold next dose; first sign of internal bleeding

Ibuprofen
(Advil, Motrin) Pg. 654
ACTION Non-steroidal Anti-Inflammatory Drugs (NSAIDs) USES Mild moderate pain Rheumatoid disorders Fever ADVERSE REACTIONS *Nausea, dizziness, dyspepsia, gastric or duodenal ulcer, GI bleeding, headache, lightheadedness, vertigo, stroke (most common in elderly), decrease/increase in blood pressure, polyuria, dysuria, oliguria, hematuria, cystitis, reduction in blood cell components, prolonged bleeding, rash, erythema, irritation, skin eruptions, SJS CONTRAINIDICATIONS *Hypersensitivity to aspirin, during ALL

trimesters of pregnancy & lactation, patients with hypertension (lowers effects of antihypertensive), peptic ulceration/GI bleed INTERACTIONS Drug: Anticoagulants increased risk of bleeding
Lithium (mood stabilizer) increased effectiveness & possible toxicity of lithium

Cyclosporine (immunosuppressive) increased effectiveness of cyclosporine Hydantoins (anticonvulsant) increased effectiveness of anticonvulsant Diuretics decreased effectiveness of diuretic Antihypertensives decreased effectiveness of antihypertensive Acetaminophen (in long-term use) increased risk of renal impairment Herbal: Capsicum (hot pepper) used to dilate blood vessels and increase supply of nutrients to injured joints; should be avoided with ulcers (no spicy foods). NURSING PRECAUTIONS

*Take with food, enteric coding GI upset *Elderly are more vulnerable to GI bleed due to higher incidence of rheumatoid arthritis and osteoarthritis, NSAID use on long-term basis *Report any changes in vision; blurred, diminished vision or change in color vision **caution when driving or task requiring alertness** *Lab tests: Hemoglobin levels, renal/hepatic function *Symptoms of acute toxicity in children: apnea, cyanosis, response only to painful stimuli, dizziness *Do not give to children younger than 3 months or for longer than 2 days without calling MD *Do not take aspirin concurrently with ibuprofen

Naproxen Pg. 864

(Aleve)

ACTION

Non-steroidal Anti-Inflammatory Drugs (NSAIDs) USES Rheumatoid, juvenile and osteoarthritis Mild moderate pain Dysmenorrhea General aches and fever ADVERSE REACTIONS *Dizziness, headache, nausea, vomiting, gastric or duodenal ulcer, GI bleeding CONTRAINDICATIONS *Hypersensitivity to NSAIDs, during ALL trimesters of pregnancy & lactation, patients with hypertension (lowers effects of antihypertensive), peptic ulceration/GI bleed INTERACTIONS Drug: Anticoagulants increased risk of bleeding
Lithium (mood stabilizer) increased effectiveness & possible toxicity of lithium

increased effectiveness of cyclosporine Hydantoins (anticonvulsant) increased effectiveness of anticonvulsant Diuretics decreased effectiveness of diuretic Antihypertensives decreased effectiveness of antihypertensive Acetaminophen (in long-term use) increased risk of renal impairment Herbal: Capsicum (hot pepper) used to dilate blood vessels and increase supply of nutrients to injured joints; should be avoided with ulcers (no spicy foods). NURSING PRECAUTIONS *Take with food, enteric coding GI upset *Elderly are more vulnerable to GI bleed due to higher incidence of rheumatoid arthritis and osteoarthritis, NSAID use on long-term basis *Report any changes in vision; blurred, diminished vision or change in color vision **caution when driving or task requiring alertness**

Cyclosporine (immunosuppressive)

*Lab tests: Hemoglobin levels, renal/hepatic function *Symptoms of acute toxicity in children: apnea, cyanosis, response only to painful stimuli, dizziness *Do not give to children younger than 3 months or for longer than 2 days without calling MD *Do not take Aleve concurrently with ibuprofen

Celecoxib Pg. 278 & 1326

(Celebrex)
ACTION Non-steroidal Anti-Inflammatory Drugs (NSAIDs) USES Acute pain Rheumatoid arthritis & osteoartithris ADVERSE REACTIONS *Headache, dyspepsia, rash and change in BP, GI distress, prolong bleeding CONTRAINIDICATIONS *Contraindicated in patients allergic to sulfonamides or history of cardiac disease or stroke; should NOT be used to relieve postoperative pain from coronary bypass graft NTERACTIONS Drug; Anticoagulants increased risk of bleeding

Lithium (mood stabilizer) increased effectiveness & possible toxicity of lithium Cyclosporine (immunosuppressive) increased effectiveness of cyclosporine Hydantoins (anticonvulsant) increased effectiveness of anticonvulsant Diuretics decreased effectiveness of diuretic Antihypertensives decreased effectiveness of antihypertensive Acetaminophen (in long-term use) increased risk of renal impairment Herbal: Capsicum (hot pepper) used to dilate blood vessels and increase supply of nutrients to injured joints; should be avoided in patients with ulcers (no spicy foods). NURSING PRECAUTIONS *Administered with: food (tastes bad) *Elderly are more vulnerable to GI bleed due to

higher incidence of rheumatoid arthritis and osteoarthritis, NSAID use on long-term basis *Report any changes in vision; blurred, diminished vision or change in color vision **caution when driving or task requiring alertness** *Lab tests: Hemoglobin levels, renal and hepatic function *Do not take concurrently with aspirin

Codeine Pg. 330

ACTION Attach to the many different receptor sites to produce the analgesic, sedative and euphoric effect USES Moderate severe pain Persistent cough ADVERSE REACTIONS *Constipation

*CNS sedation, sweating, headache, dizziness, lethargy, confusion, lightheadedness CONTRAINIDICATIONS *Patients with acute bronchial asthma, emphysema, or upper airway obstruction; patients with head injury or increased intracranial pressure. Not recommended in pregnancy or labor travels through to placenta to baby *Cautiously used in elderly, patients who are opioid nave, lactating woman, patients with undiagnosed abdominal pain INTERACTIONS
Drug: Alcohol, antihistamines, antidepressants, sedatives, phenothiazines increased risk CNS depression Opioid agonist-antagonist opioid withdrawal symptoms, inhibits all receptors causing withdrawal Barbiturates resp. depression, hypotension, sedation Herbal:

Passion flower (sometimes mixed in teas with chamomile & hops) used for relaxation, rest & sleep; in large doses may cause CNS depression

(30 mg Codeine / 300mg Acetaminophen)

ACTION Attach to the many different receptor sites to produce the analgesic, sedative and euphoric effect USES Moderate severe pain ADVERSE REACTIONS *Constipation *lightheadedness, CNS sedation, dizziness, nausea, vomiting, sweating, respiratory depression CONTRAINIDICATIONS *Patients with acute bronchial asthma, emphysema, or upper airway obstruction; patients with head injury or increased intracranial pressure. Not recommended in pregnancy or labor travels through to placenta to baby *Cautiously used in elderly, patients who are opioid

NURSING PRECAUTIONS

*Drink plenty of non-caffeinated beverages *May be habit-forming with long term use *> 65 years old could have more side effects *Impairs alertness, DO NOT drink until you know how medicine affects you *Avoid ETOH & other meds that slows your actions/reactions *Obtain: BP, HR, respiratory rate, pain rating *Reassess pain: oral 30-60 minutes IM/IV check every 1520 minutes *Hold: if respiratory rate less than 10, significant change in HR, significant drop in BP (systolic < 100) *Monitor bowel movements, watch for constipation

Tylenol #3 Pg. 1347

nave, lactating woman, patients with undiagnosed abdominal pain INTERACTIONS

Drug: Alcohol, antihistamines, antidepressants, sedatives, phenothiazines increased risk CNS depression Opioid agonist-antagonist opioid withdrawal symptoms, inhibits all receptors causing withdrawal Barbiturates resp. depression, hypotension, sedation Herbal: Passion flower (sometimes mixed in teas with chamomile & hops) used for relaxation, rest & sleep; in large doses may cause CNS depression

*Obtain: BP, HR, respiratory rate, pain rating *Reassess pain: oral 30-60 minutes IM/IV check every 15-20 minutes *Hold: if respiratory rate less than 10, significant change in HR, significant drop in BP (systolic < 100) *Monitor bowel movements, watch for constipation *Monitor daily Tylenol levels and PRN Tylenol usage

Fentanyl Pg. 540 & 542

(Patch , IV, IM, Buccal & Lozenge)
ACTION Attach to the many different receptor sites to produce the analgesic, sedative and euphoric effect USES Severe pain, management of cancer pain

NURSING PRECAUTIONS
*Geriatric: drug should be titrated to appropriate analgesic effect *May be taken with food *Excess ETOH may increase risk of acetaminophen-induced hepatoxicity, avoid/limit <3 drinks/day *Be careful if G6PD deficiency, anemia may occur *Take good care of teeth

ADVERSE REACTIONS *Constipation *CNS sedation, sweating, headache, vertigo, lethargy, confusion, lightheadedness, nausea, vomiting CONTRAINIDICATIONS *Patients with acute bronchial asthma, emphysema, or upper airway obstruction; patients with head injury or increased intracranial pressure. Not recommended in pregnancy or labor travels through to placenta to baby *Cautiously used in elderly, patients who are opioid nave, lactating woman, patients with undiagnosed abdominal pain
INTERACTIONS
Drug: Alcohol, antihistamines, antidepressants, sedatives, phenothiazines increased risk CNS depression Opioid agonist-antagonist opioid withdrawal symptoms, inhibits all receptors causing withdrawal Barbiturates respiratory depression, hypotension, sedation Herbal:

Passion flower (sometimes mixed in teas with chamomile & hops) used for relaxation, rest & sleep; in large doses may cause CNS depression

NURSING PRECAUTIONS *Avoid drinking large quantities of grapefruit juice *Maintain good oral hygiene risk dental carries *Patch: avoid heating pads/blankets, hot tubs *Report dizziness, chest pain, slow or rapid HR, headache, confusion or change in mental status *Patch: clean & dry area, hold for 30 seconds. DO NOT cut, use damaged/leaking patches, if leaking wash area DO NOT USE SOAP *If MRI scan: remove patch causes burns *Reassess pain: oral 30-60 minutes IM/IV check every 1520 minutes *Hold: if respiratory rate less than 10, significant change in HR, significant drop in BP (systolic < 100)

Hydomorphone Pg.640,
1372, 1374
(Dilaudid)
Rectal Oral, IV, PCA, Epidural, IM, SubQ,

in pregnancy or labor travels through to placenta to baby *Cautiously used in elderly, patients who are opioid nave, lactating woman, patients with undiagnosed abdominal pain INTERACTIONS Drug: Alcohol, antihistamines, antidepressants, sedatives, phenothiazines increased risk CNS depression Opioid agonist-antagonist opioid withdrawal symptoms, inhibits all receptors causing withdrawal Barbiturates respiratory depression, hypotension, sedation Herbal: Passion flower (sometimes mixed in teas with chamomile & hops) used for relaxation, rest & sleep; in large doses may cause CNS depression NURSING PRECAUTIONS
*Parenteral doses are up to 5x more potent *Obtain: BP, HR, respiratory rate, pain rating *Assess pts physical/psychological dependency

ACTION Attach to the many different receptor sites to produce the analgesic, sedative and euphoric effect USES Moderate severe pain ADVERSE REACTIONS *Constipation *CNS sedation, vertigo, lethargy, confusion, lightheadedness, nausea, vomiting CONTRAINIDICATIONS *Patients with acute bronchial asthma, emphysema, or upper airway obstruction; patients with head injury or increased intracranial pressure. Not recommended

*Inpatient: implement safety measures to prevent fall *DO NOT crush, break, chew or dissolve *Discontinue slowly after prolong use *Teratogenic in some animal studies crosses placenta *In opioid nave patients risk for respiratory depression AND in elderly *Reassess pain: oral 30-60 minutes IM/IV check every 15-20 minutes *Hold: if respiratory rate less than 10, significant change in HR, significant drop in BP (systolic < 100)

USES Acute Moderate severe pain Preoperative sedation, anesthetics adjunct ADVERSE REACTIONS *Constipation *Lightheadedness, dizziness, nausea, vomiting, respiratory depression CONTRAINIDICATIONS *Patients with acute bronchial asthma, emphysema, or upper airway obstruction; patients with head injury or increased intracranial pressure. Not recommended in pregnancy or labor travels through to placenta to baby *Cautiously used in elderly, patients who are opioid nave, lactating woman, patients with undiagnosed abdominal pain INTERACTIONS Drug: Alcohol, antihistamines, antidepressants, sedatives, phenothiazines increased risk CNS depression

Meperodome Pg. 784 &

1373
(Demerol)
IV, oral, IM

ACTION Attach to the many different receptor sites to produce the analgesic, sedative and euphoric effect

Opioid agonist-antagonist opioid withdrawal symptoms, inhibits all receptors causing withdrawal Barbiturates respiratory depression, hypotension, sedation Herbal: Passion flower (sometimes mixed in teas with chamomile & hops) used for relaxation, rest & sleep; in large doses may cause CNS depression NURSING PRECAUTIONS

IM/IV check every 15-20 minutes *Hold: if respiratory rate less than 10, significant change in HR, significant drop in BP (systolic < 100)

Methadone 795 & 1372

(Dolophine)
ACTION Attach to the many different receptor sites to produce the analgesic, sedative and euphoric effect USES Severe pain Treatment of opioid dependence ADVERSE REACTIONS *Constipation *Lightheadedness, dizziness, nausea, vomiting, CONTRAINIDICATIONS

*Debilitated patients: potential for critical respiratory depression, even at therapeutic changes *Avoid use in elderly: may cause confusion, other opioids are preferred *NOT recommended for management of chronic pain *Discontinue slowly after prolong use to avoid withdrawals *Inpatient: implement safety measures to prevent fall *Obtain: BP, HR, respiratory rate, pain rating *Reassess pain: oral 30-60 minutes

*Patients with acute bronchial asthma, emphysema, or upper airway obstruction; patients with head injury or increased intracranial pressure. Not recommended in pregnancy or labor travels through to placenta to baby *Cautiously used in elderly, patients who are opioid nave, lactating woman, patients with undiagnosed abdominal pain INTERACTIONS Drug: Alcohol, antihistamines, antidepressants, sedatives, phenothiazines increased risk CNS depression Opioid agonist-antagonist opioid withdrawal symptoms, inhibits all receptors causing withdrawal Barbiturates respiratory depression, hypotension and sedation Herbal: Passion flower (sometimes mixed in teas with chamomile & hops) used for relaxation, rest &

sleep; in large doses may cause CNS depression NURSING PRECAUTIONS *Because long half-life, it is difficult to titrate *NOT considered first drug of choice in elderly *Teratogenic effects in animal studies *Appears in breast milk 4-5 hours after oral dose *Obtain baseline ECG, then annually or more often if syncope or seizure occurs (evaluate QT interval) *Obtain: BP, HR, respiratory rate, pain rating *Hold: if respiratory rate less than 10, significant change in HR, significant drop in BP (systolic < 100) *Wait 48 hours after last dose of levomthadyl before administering first dose of methadone

Roxanol
(Morphine) Pg. 843 ACTION Analgesic-Narcotic USES Severe pain Pulmonary edema Pain associated with MI ADVERSE REACTIONS
CNS- Confusion, sedation, dizziness, dysphoria, euphoria, hallucinations, headache, unusual dreams EENT- blurred vision, diplopia, miosis Resp-RESPIRATORY DEPRESSION CV- hypotension, bradycardia GI- constipation, N,V GU- urinary retention Derm- flushing, itching, sweating Misc.- physical dependence, psychological dependence, tolerance

INTERACTIONS Drug: USE WITH EXTREME CAUTION FOR PTs WITH MAO INHIBITOR. Increased CNS depression with alcohol, sedatives, clomipramine, barbiturates, antidepressants, antihistamines, ANTAGONIST OPIOIDS!(can cause sudden withdrawal), May increase the effects of warfarin, cimetidine may decrease metabolism & may increase effects. Drug/Food: kava kava; valerian; chamomile may increase CNS depression NURSING PRECAUTIONS Assess levels of consciousness, blood pressure, pulse (apical) & respirations

before/during administration, if resp. rate is <10 per min. notify physician! Monitor VS every 15-30 min. *If an antagonist is needed to reverse adverse effects (narcan) is the antidote

*CNS sedation, hypotension, increased sweating, dizziness, drowsiness, nausea, vomiting, dry mouth, respiratory depression, itching CONTRAINIDICATIONS *Patients with acute bronchial asthma, emphysema, or upper airway obstruction; patients with head injury or increased intracranial pressure. Not recommended in pregnancy or labor travels through to placenta to baby *Cautiously used in elderly, patients who are opioid nave, lactating woman, patients with undiagnosed abdominal pain

Morphine Pg. 843, 13721374

(timed release, MS Contin)
ACTION Attach to the many different receptor sites to produce the analgesic, sedative and euphoric effect USES Acute/chronic pain, preoperative sedatives Dyspnea ADVERSE REACTIONS *Constipation

INTERACTIONS

Drug: Alcohol, antihistamines, antidepressants, sedatives, phenothiazines increased risk CNS depression Opioid agonist-antagonist opioid withdrawal symptoms, inhibits all receptors causing withdrawal Barbiturates resp. depression, hypotension & sedation

Herbal: Passion flower (sometimes mixed in teas with chamomile & hops) used for relaxation, rest & sleep; in large doses may cause CNS depression

Oxycodone Pg. 926 & 1372

(timed release, OxyContin)
ACTION Attach to the many different receptor sites to produce the analgesic, sedative and euphoric effect USES Moderate severe pain ADVERSE REACTIONS *Constipation *lightheadedness, CNS sedation, dizziness, nausea, vomiting, sweating, respiratory depression CONTRAINIDICATIONS *Patients with: CNS depression, hypotension and phenanthrene hypersensitivity *Cautiously used in elderly, patients who are opioid nave, lactating woman, patients with undiagnosed abdominal pain

NURSING PRECAUTIONS

*Be consistent when taking with or without meals *Elderly more sensitive to adverse effects *ETOH disrupts extended-release characteristics *Growth & behavioral abnormalities in offspring crosses placenta *Some quinolones produce false positive urine screening results for opiates *DO NOT crush or chew controlled releases tablets or caps. *Obtain: BP, HR, respiratory rate, pain rating *Call MD if analgesic is ineffective *Reassess pain: oral 30-60 minutes IM/IV check every 15-20 minutes *Hold: if respiratory rate less than 10, significant change in HR, significant drop in BP (systolic < 100) *Monitor bowel movements, watch for constipation

INTERACTIONS Drug: Alcohol, antihistamines, antidepressants, sedatives, phenothiazines increased risk CNS depression Opioid agonist-antagonist opioid withdrawal symptoms, inhibits all receptors causing withdrawal Barbiturates respiratory depression, hypotension, sedation Herbal: Passion flower (sometimes mixed in teas with chamomile & hops) used for relaxation, rest & sleep; in large doses may cause CNS depression NURSING PRECAUTIONS *Blood level of 5 mg/L associated with
fatality *Wax matrix from controlled release tablets may appear in stool

*Obtain: BP, HR, respiratory rate, pain rating *Call MD if analgesic is ineffective *Reassess pain: oral 30-60 minutes IM/IV check every 1520 minutes *Hold: if respiratory rate less than 10, significant change in HR, significant drop in BP (systolic < 100) *Monitor bowel movements, watch for constipation; prophylactic use of laxative to be considered

Percocet Pg. 926

(5 mg Oxycodone / 325mg Acetaminophen)
ACTION Attach to the many different receptor sites to produce the analgesic, sedative and euphoric effect USES Moderate severe pain

ADVERSE REACTIONS *Constipation *lightheadedness, CNS sedation, dizziness, nausea, vomiting, sweating, respiratory depression CONTRAINIDICATIONS *Patients with acute bronchial asthma, emphysema, or upper airway obstruction; patients with head injury or increased intracranial pressure. Not recommended in pregnancy or labor travels through to placenta to baby *Cautiously used in elderly, patients who are opioid nave, lactating woman, patients with undiagnosed abdominal pain INTERACTIONS
Drug: Alcohol, antihistamines, antidepressants, sedatives, phenothiazines increased risk CNS depression Opioid agonist-antagonist opioid withdrawal symptoms, inhibits all receptors causing withdrawal

Barbiturates resp. depression, hypotension & sedation Herbal: Passion flower (sometimes mixed in teas with chamomile & hops) used for relaxation, rest & sleep; in large doses may cause CNS depression

NURSING PRECAUTIONS *Obtain: BP, HR, respiratory rate, pain rating *Reassess pain: oral 30-60 minutes IM/IV check every 15-20 minutes *Hold: if respiratory rate less than 10, significant change in HR, significant drop in BP (systolic < 100) *Monitor bowel movements, watch for constipation *Monitor daily Tylenol levels and PRN Tylenol usage, <4 g/day acetaminophen *Avoid OTCs containing Tylenol *Initial dose based on oxycodone content, maximum daily based on acetaminophen *Duration of action maybe increased in elderly *Avoid ETOH, limit <3 days/day

Vicodin Pg. 637 & 1348

Vicodin
(5 mg Hydrocodone / 500 Acetaminophen) Vicodin ES (7.5 mg Hydrocodone / 750 Acetaminophen)

placenta to baby *Cautiously used in elderly, patients who are opioid nave, lactating woman, patients with undiagnosed abdominal pain INTERACTIONS
Drug: Alcohol, antihistamines, antidepressants, sedatives, phenothiazines increased risk CNS depression Opioid agonist-antagonist opioid withdrawal symptoms, inhibits all receptors causing withdrawal Barbiturates resp. depression, hypotension & sedation Herbal: Passion flower (sometimes mixed in teas with chamomile & hops) used for relaxation, rest & sleep; in large doses may cause CNS depression

ACTION Attach to the many different receptor sites to produce the analgesic, sedative and euphoric effect USES Moderate severe pain ADVERSE REACTIONS *Constipation *lightheadedness, CNS sedation, dizziness, nausea, vomiting, sweating, respiratory depression CONTRAINIDICATIONS *Patients with acute bronchial asthma, emphysema, or upper airway obstruction; patients with head injury or increased intracranial pressure. Not recommended in pregnancy or labor travels through to

NURSING PRECAUTIONS *Obtain: BP, HR, respiratory rate, pain rating *Reassess pain: oral 30-60 minutes IM/IV check every 15-20 minutes

*Hold: if respiratory rate less than 10, significant change in HR, significant drop in BP (systolic < 100) *Monitor bowel movements, watch for constipation *Monitor daily Tylenol levels and PRN Tylenol usage, <4 g/day acetaminophen *Avoid OTCs containing Tylenol *Duration of action maybe increased in elderly *Avoid ETOH, limit <3 days/day

Oxymorphone Pg. 929 &

1372
(Opana)
ACTION Attach to the many different receptor sites to produce the analgesic, sedative and euphoric effect

USES Moderate severe pain, preoperative sedation, obstetric analgesia ADVERSE REACTIONS *Constipation *lightheadedness, CNS sedation, dizziness, nausea, vomiting, sweating, respiratory depression CONTRAINIDICATIONS *Patients with acute bronchial asthma, emphysema, or upper airway obstruction; patients with head injury or increased intracranial pressure. Not recommended in pregnancy or labor travels through to placenta to baby *Cautiously used in elderly, patients who are opioid nave, lactating woman, patients with undiagnosed abdominal pain INTERACTIONS
Drug: Alcohol, antihistamines, antidepressants, sedatives, phenothiazines increased risk CNS depression

Opioid agonist-antagonist opioid withdrawal symptoms, inhibits all receptors causing withdrawal Barbiturates resp. depression, hypotension & sedation Herbal: Passion flower (sometimes mixed in teas with chamomile & hops) used for relaxation, rest & sleep; in large doses may cause CNS depression

*High risk of withdrawal, if missed dose *Plasma levels 40% higher in elderly

Tramadol Pg. 1196

(Ultram)
ACTION Synthetic Opioids; manufactured analgesic with properties & actions similar to natural opioids USES Moderate severe chronic pain Patients with a sensitivity to natural opioids ADVERSE REACTIONS *Constipation *lightheadedness, CNS sedation, dizziness, nausea, vomiting, sweating, respiratory depression CONTRAINIDICATIONS *Patients with acute bronchial asthma, emphysema, or upper airway obstruction;

NURSING PRECAUTIONS *Obtain: BP, HR, respiratory rate, pain rating *Call MD if analgesic is ineffective *Reassess pain: oral 30-60 minutes IM/IV check every 15-20 minutes *Hold: if respiratory rate less than 10, significant change in HR, significant drop in BP (systolic < 100) *Monitor bowel movements, watch for constipation *Immediate & extended release, take 1 hour before or 2 hours after eating *Not suitable as PRN analgesic

patients with head injury or increased intracranial pressure. Not recommended in pregnancy or labor travels through to placenta to baby *Cautiously used in elderly, patients who are opioid nave, lactating woman, patients with undiagnosed abdominal pain INTERACTIONS
Drug: Alcohol, antihistamines, antidepressants, sedatives, phenothiazines increased risk CNS depression Opioid agonist-antagonist opioid withdrawal symptoms, inhibits all receptors causing withdrawal Barbiturates resp. depression, hypotension & sedation Herbal: Passion flower (sometimes mixed in teas with chamomile & hops) used for relaxation, rest & sleep; in large doses may cause CNS depression

*Avoid use with MAO inhibits, SSRIs/serotonergic agents *Patients age >75 years old may be more sensitive to adverse effects *Ultram stays in breast milk for 16 hours following a single dose of 100 mg/ via IV *May interfere with urine detection of PCP and gives a false positive *Reassess pain: oral 30-60 minutes IM/IV check every 15-20 minutes *Hold: if respiratory rate less than 10, significant change in HR, significant drop in BP (systolic < 100)

Naloxone Pg. 862

(Narcan) ACTION
IM, IV, intranasal (adults only), SubQ

NURSING PRECAUTIONS
*Obtain: BP, HR, respiratory rate, pain rating *Increased suicide risk in patients taking tranquilizers and/or antidepressants

Opioid antagonists displaces narcotic at receptor sites Complete/partial reversal of opioid drug effects (pain will return)

*Pregnancy category B, infants of opioid-

USES Postoperative acute respiratory depression Opioid adverse effects, suspected acute opioid over-dosage ADVERSE REACTION *Nausea, vomiting, sweating, tachycardia, increased blood pressure, tremors (increased CNS effects), seizures, PAIN CONTRAINDICATIONS

dependent mothers, patients with opioid dependency, cardiovascular disease and lactation *Withdrawal symptoms: opioid dependent NURSING PRECAUTIONS *Monitor vital signs every 5-15 minutes after patient responsive and is stable -continue until effects of opioid wears off *Short duration of action: narcotic symptoms start to diminish 20-40 minutes after administration and

usually disappear within 90 minutes *Repeated dose needed if results from initial dose unsatisfactory *Cardiac monitoring, artificial ventilation, suction equipment made available *Assess pain & monitor I/Os *Excessive doses of Narcan in preoperative period may cause an increased BP and reversal of anesthesia

ANESTHESIA
*Induced by various drugs to bring about partial or complete loss of sensation Types of Anesthesia Loss anesthesia General anesthesia LOCAL ANESTHESIA Topical Anesthesia

Application of the anesthesia to surface of skin, open area & mucous membrane Example: Emalcreme Local Infiltration Anesthesia Injection of anesthesia into tissue Dental procedures, suturing small wounds, making an incision into a small area Regional anesthesia Injection of anesthesia around nerves to prevent sending pain signals Spinal anesthesia: injection of anesthesia into the subarachnoid space of the spinal cord Conduction blocks: injection of anesthesia into or nerve trunk (block) Nursing Precautions *Take patients allergy history

*Prepare area too be anesthetized: -cleaning area antiseptically then shave Administering Local Anesthesia -Mixed with epinephrine to cause local vasoconstriction Pre-Anesthetic Drugs (Anti-Anxiety) *Given before administration of anesthesia *May consist of one drug or a combination of drugs *Diazepam (Valium) used for preoperative sedation GENERAL ANETHESIA The choice of anesthetic drug depends on:

General physical condition of the patient Area, organ, system being operated on Anticipated length of the surgical procedure Stages of General Anesthesia Stage 1- analgesia (pain relief) Stage 2- delirium Stage 3- surgical analgesia Stage 4- respiratory paralysis (need to be intubated) After general anesthesia: takes 1-2 hours to recover fully

Misazolam Pg. 822

(Versed) ACTION Anesthetic CNS depressant

USES Local anesthetic procedures: cataract surgery or colonoscopy

ADVERSE REACTIONS *Some experience amnesia (general unaware their memory is impaired), long-term use of Benzos associated with long-lasting deficits of memory.

Children & elderly or pts with history of ETOH abuse and/or aggressive behavior/anger are at increased risk of paradoxical effects. *Hungover effects, sleepiness, impaired psychomotor, cognitive functions *Sedation, depression, increase HR & hypotension INTERACTIONS Drug:
Fluvoxamine increased effects of midazolam Itraconazole increased effects of midazolam and the elimination half-life 2-fold Ketoconazole ) increased effects of midazolam Nefazodone increased effects of midazolam Rifampicin significantly increased the

systemic and oral clearance of midazolam Saquinavir decreased the clearance of IV midazolam and increased its elimination half-life from 4.1 to 9.5 hours

Food: Grapefruit juice NURSING PRECAUTIONS *If given too quickly hypotension occurs, increase length of ventilator support needed *May impair gait, potential fall *Check airway for patency, BP, HR Q 5-15 mins

CENTRAL NERVOUS SYSTEM STIMULANTS Analeptics: drugs that stimulate the resp. center of the brain &
cardiovascular system Caffeine, Modafinil Amphetamines: used to treat children with ADHD Adderall, Ritalin Anorexiants: drugs used to suppress appetite Meridia

Amphetamines & Anorexiants have abuse and addiction potential. These

drugs are recommended only for short-term use in selected patients for treatment of obesity. Long-term use of amphetamines for obesity may result in tolerance to the drug and a tendency to increase the dose. Extreme psychological dependency may also occur. Pediatric: an increase risk of suicidal ideation in children & adolescents have been found when using the drug Strattera. Patients with ADHD started on Strattera should be monitored carefully for changes in behavior. Gerontology: older adults are especially sensitive to the effects of the CNS stimulants and may exhibit excessive anxiety, nervousness,

insomnia and mental confusion. Cardiovascular disorders, common in the older adult, may be worsened by the CNS stimulant.

Modafinil Pg. 837

(Provigil) ACTION Cardiac stimulate: dilates coronary and peripheral blood vessels Constriction of cerebral blood vessels Skeletal muscle stimulation USES Narcolepsy Obstructive Sleep Apnea

ADVERSE REACTIONS *Excessive CNS stimulation, headache, nausea, dizziness, apprehension, disorientation, hyperactivity, tachycardia, palpitation CONTRAINIDCATIONS *Patients with convulsive disorders, ventilation mechanism disorders *Nurses should NOT administer CNS stimulants to patients with cardiac problems, severe hypertension & hyperthyroidism INTERACTIONS Drug:
Anesthetics increased risk of cardiac arrhythmias

Theophyline increased risk of hyperactive behaviors Oral contraceptives decreases effectiveness of contraceptives

NURSING PRECAUTIONS *Avoid coffee, tea, carbonated beverages containing caffeine *Avoid/limit ETOH+ *Food delays absorption but does not affect bioavailability

*Monitor levels of sleepiness, BP (especially patients with hypertension) *If used for ADHD, evaluate cardiovascular risk monitor HR, BP, ECG *Potential for abuse

Diuretic Seizure Induction during ECT

Caffeine
ACTION CNS Stimulant USES Fatigue, drowsiness Respiratory Depression

ADVERSE REACTIONS *Palpations, nausea, vomiting, insomnia, tachycardia, restlessness CONTRAINDICATIONS *Hypersensitivity to caffeine, patients with anxiety, cardiovascular disease, GI disease/peptic ulcer/GERD, seizure disorders

INTERACTIONS Drug: Adenosine may diminish the therapeutic effect of Adenosine Cannabinoids may enhance tachycardic effect Formoterol may enhance the adverse/toxic effect of Formoterol, Caffeine may enhance the hypokalemic effect of Formoterol Sympathomimetics may enhance the adverse/toxic effect of other s ympathomimetics NURSING PRECAUTIONS *Assess potential for interactions with other prescriptions, OTC meds or herbal products

*Assess knowledge/teach patient appropriate use, side effects & symptoms to report *Maintain adequate hydration

Amphetamine/Dextoamp hetamine
(Adderall) Pg.158
ACTION Amphetamine CNS Stimulant USES Narcolepsy ADHD ADVERSE REACTIONS

*Insomnia, nervousness, headache, tachycardia, anorexia, dizziness, excitement CONTRAINDICATIONS *Hypersensitivity to amphetamine, advanced arteriosclerosis, symptomatic cardiovascular disease, moderatesevere hypertension, hyperthyroidism, glaucoma, agitated states and patients with a history of drug abuse INTERACTIONS
Drug: Opioid Analgesics enhances the analgesic effect Antacida may decrease the excretion of amphetamines Antihistamines may diminish the sedative effect of antihistamines Antipsychotics may diminish stimulatory effect of amphetamines Cannabinoids may enhance tachycardic effect of sympathomimetics

MAO Inhibitors with or within 14 days following MAO inhibitors (hypertensive crisis) Food: Acidic foods, juices, Vit. C adderall serum levels may be altered Caffeine should be avoided Alcohol should be avoided, may increase CNS depression

NURSING PRECAUTIONS *Monitor CNS activity, BP, pulse, appetite and signs/symptoms of tolerance or dependence *When used for treatment of ADHD, thoroughly evaluate for cardiovascular risk

*Monitor HR, BP and consider obtaining ECG prior to initiation

Methylphenidate Pg. 808

(Ritalin) Immediate & Extended release
ACTION

CNS Stimulant Amphetamine

adverse/toxic effect of

USES ADHD Narcolepsy Depression ADVERSE REACTIONS *Insomnia, anorexia, dizziness, headache, abdominal pain CONTRAINDICATIONS *Idiosyncratic reactions to sympathomimetics , marked anxiety, tension & agitation, glaucoma, use during or within 14 days following MAO inhibitor therapy, family history or diagnoses of Tourettes syndrome or tics INTERACTIONS
Drug:Antacids may increase absorption of Methylphenidate, specifically extended-release capsules Antihypertensives may diminish the antihypertensive effect Antipsychotics may enhance the adverse/toxic effects of Methylphenidate, as well as

antipsychotic Cannabinoids may enhance tachycardic effect of Sympthomimetics MAO Inhibitors may enhance hypertensive effect Proton Pump Inhibitors may increase the absorption of Methylphenidate Vitamin K Antagonists (ex. Warfarin) may increase the serum concentration of Vitamin K Antagonists Food: Food may increase oral absorption, food and high-fat meals delays early peak Alcohol should be avoided, may cause CNS depression Herbal: Ephedra may cause hypertension or arrhythmias Yohimbe CNS stimulatory activity

NURSING PRECAUTIONS *May cause false-positive amphetamine in urine test

*Monitor BP, HR, signs/symptoms of depression, aggression or hostility *Monitor CBC, differential and platelet counts *Liver function tests, growth rate in children & signs of CNS stimulation

*Assess history of addiction, long-term use can result in dependence, abuse or tolerance *Taper off slowly when discontinuing

ANTI-ANXIETY OR ANXIOLYTICS Benzodiazepines: long term use can result in physical dependence or physiological addiction Symptoms of benzodiazepine withdrawal include: anxiety, concentration difficulties, tremor and sensory disturbances (such as parasthesias, photophobia, hypersomnia and metaliic taste) Benzos are excreted more slowly in older adults causing a prolonged drug effect. The drug may accumulate in the blood, resulting in an increase in adverse reactions or toxicity

Lorazepam & oxazepam are relatively safe for older adults when given in normal dosages Non-benzodiazepines: useful anti-anxiety medication without addictive quality
ADVERSE REACTION *Transient mild drowsiness, lightheadedness, headache, depression, constipation, diarrhea, dry mouth CONTRAINIDCATIONS *Hypersensitivity to benzodiazepines, patients with narrow-angle glaucoma, pregnant, has been associated with anterograde amnesia, CNS depression, paradoxical reactions (hyperactivity or aggressive behavior particularly in adolescent/pediatric or psychiatric patients).

Alprazolam Pg. 131

(Xanax)
ACTION Benzodiazepine USES Anxiety disorders (short-term relief of anxiety) Panic Attacks

*Drug abuse or acute alcoholism *Use caution in patients with respiratory disease INTERACTIONS

Drug: Analgesis increased risk for CNS depression Tricyclic antidepressants increased risk for sedation and respiratory depression Antipsychotics increased risk for sedation and respiratory depression Digoxin increased risk for digitalis toxicity Food: Alcohol increased risk for CNS depression or convulsions Cigarette smoking may decrease aplrozolam concentration up to 50% Herbal: St. Johns Wort, valerian, kava kava, gotu kola increases CNS depression Yohimbine may diminish the therapeutic effect of anti-anxiety agent

*If inpatient: institute safety measures and monitor for adverse reactions *Taper slowly when discontinuing *Avoid ETOH, OTC meds such as pain medication, sedatives, antihistamines or hypnotics *Do NOT stop medication abruptly

Chlordiazepoxide Pg. 298

(Librium)
ACTION Benzodiazepine USES Anxiety disorders (short-term relief of anxiety) Acute Alcohol Withdrawal ADVERSE REACTION *Transient mild drowsiness, lightheadedness, headache, depression, constipation, diarrhea, dry mouth CONTRAINIDCATIONS *Hypersensitivity to benzodiazepines, patients with narrow-angle glaucoma, pregnant

NURSING PRECAUTIONS

*Assess for signs of CNS depression *Assess for history of addiction, long-term use dependence, abuse, tolerance

*Use caution in patients with depression, particularly if suicidal ideation is present *Drug abuse or alcoholism: risk for drug dependency *Use caution in patients with respiratory disease INTERACTIONS
Drug: Analgesis increased risk for CNS depression Oral contraceptives (Progestins) may increase concentration of benzo Oral contraceptives (Estrogens) may decrease the metabolism of benzo MAO Inhibitors may enhance orthostatic hypotensive effect Tricyclic antidepressants increased risk for sedation and respiratory depression Antipsychotics increased risk for sedation and respiratory depression Digoxin increased risk for digitalis toxicity Food: Alcohol increased risk for CNS depression or convulsions Cigarette smoking may decrease aplrozolam concentration up to 50% Herbal:

St. Johns Wort, valerian, kava kava, gotu kola increases CNS depression Yohimbine may diminish the therapeutic effect of anti-anxiety agent

NURSING PRECAUTIONS

*Assess for signs of CNS depression *Assess for history of addiction, long-term use dependence, abuse, tolerance *If inpatient: institute safety measures and monitor for adverse reactions *Maintain adequate hydration *If preventative ETOH withdrawal: monitor for tremors, seizures, withdrawal symptoms *Taper slowly when discontinuing *Avoid ETOH, OTC meds such as pain medication, sedatives, antihistamines or hypnotics *Do NOT stop medication abruptly

Lorazepam Pg. 762

(Ativan)

ACTION Benzodiazepines Sedative USES Anxiety disorders (short term relief of anxiety) Pre-anesthetic ADVERSE REACTIONS *Transient mild drowsiness, lightheadedness, headache, depression, constipation, diarrhea, dry mouth CONTRAINICATIONS *Hypersensitivity to benzos, patients with sleep apnea, severe respiratory insuifficency, CNS depression, anterograde amnesia, patients who are a fall risk INTERACTIONS Drug: CNS depressants enhances adverse/toxic effect of other CNS depressants

Analgesis increased risk for CNS depression Tricyclic antidepressants increased risk for sedation and respiratory depression Antipsychotics increased risk for sedation and respiratory depression Digoxin increased risk for digitalis toxicity Food: Alcohol increased risk for CNS depression or convulsions Herbal: St. Johns Wort, valerian, kava kava, gotu kola increases CNS depression Yohimbine may diminish the therapeutic effect of anti-anxiety agent NURSING PRECAUTIONS *Oral: assess history of addiction, longterm use can result in dependence, abuse or tolerance

*Avoid alcohol, OTC medications (especially pain medication, sedatives, antihistamines and hypnotics) *Maintain adequate hydration *IM/IV: monitor vital signs and CNS status (possible retrograde amnesia with I.V.) and ability to void

Clonazepam Pg. 320

(Klonopin)
ACTION Benzodiazepines Sedative USES Panic disorders Anticonvulsant ADVERSE REACTIONS *Transient mild drowsiness, lightheadedness, headache, depression, constipation, diarrhea, dry mouth

CONTRAINICATIONS *Hypersensitivity to benzos, patients with significant liver disease, narrow-angle glaucoma, pregnancy *Patients with active suicidal ideation show increase risk of suicidal thoughts/behaviors INTERACTIONS Drug: CNS depressants enhances adverse/toxic effect of other CNS depressants Analgesis increased risk for CNS depression Tricyclic antidepressants increased risk for sedation and respiratory depression Antipsychotics increased risk for sedation and respiratory depression Digoxin increased risk for digitalis toxicity Food:

Alcohol increased risk for CNS depression or convulsions Herbal: St. Johns Wort, valerian, kava kava, gotu kola increases CNS depression Yohimbine may diminish the therapeutic effect of anti-anxiety agent NURING PRECAUTIONS *Monitor CBC, liver function tests *Observe patient for excess sedation, respiratory depression, suicidality (example: suicidal thoughts, depression, behavioral changes) *Risk of addiction *Taper dosage slowly when discontinuing *Take exactly as direction; do NOT increase dose or frequency

Benzodiazepines Sedative

Diazepam Pg. 404

(Valium)
ACTION

USES Anxiety disorders (short term relief of anxiety) Acute alcohol withdrawal Anticovulsant Preoperative muscle relaxant ADVERSE REACTIONS *Transient mild drowsiness, lightheadedness, headache, depression, constipation, diarrhea, dry mouth CONTRAINICATIONS *Hypersensitivity to benzos, myasthenia gravis, severe respiratory insufficiency, severe hepatic insufficiency, sleep apnea syndrome, acute narrow-angle glaucoma, not for use in children under 6 months of age *Narcotic dosages should be reduced by approximately 1/3 when valium is added *Fall risk: use extreme caution in patients

who are at risk of falls INTERACTIONS

Drug: CNS depressants enhances adverse/toxic effect of other CNS depressants Analgesis increased risk for CNS depression Tricyclic antidepressants increased risk for sedation and respiratory depression Antipsychotics increased risk for sedation and respiratory depression Digoxin increased risk for digitalis toxicity Food: Alcohol increased risk for CNS depression or convulsions Herbal: St. Johns Wort, valerian, kava kava, gotu kola increases CNS depression Yohimbine may diminish the therapeutic effect of anti-anxiety agent

depression, behavioral changes) *Risk of addiction *Taper dosage slowly when discontinuing *Take exactly as direction; do NOT increase dose/frequency

Hydroxyzine Pg. 644

(Vistaril, Atarax)
ACTION Nonbenzodiazepines Antimetic Antihistamine USES Anxiety and tension associated with psychoneurosis Pruritus Preanesthetiic sedative ADVERSE REACTIONS *Dry mouth, transitory drowsiness, involuntary motor activity

NURING PRECAUTIONS
*Monitor CBC, liver function tests *Observe patient for excess sedation, respiratory depression, suicidality (example: suicidal thoughts,

CONTRAINICATIONS *Early pregnancy, patients with CNS depression, glaucoma, respiratory disease, the elderly (may be inappropriate in this age group due to potent anticholinergic effects,) INTERACTIONS
Drug: Amphetamines may enhance the sedative effect of antihistamine Anti-cholinergics may enhance the adverse/toxic effect of other anticholinergic Food: Alcohol CNS depressants may enhance the CNS depressant effect of alcohol Herbal: St. Johns Wort, valerian, kava kava, gotu kola increases CNS depression Yohimbine may diminish the therapeutic effect of anti-anxiety agent

NURING PRECAUTIONS *Monitor relief of symptoms, mental status and blood pressure *Ensure patient safety precautions *Will cause drowsiness (do not use other sedative, tranquilizers, antihistamines or pain meds) *Report hallucinations, seizure activity, tremors, involuntary movements or loss of sensation

Buspirone Pg. 243

(BuSpar)
ACTION Nonbenzodiazepines USES Anxiety disorders (short-term relief of anxiety) Generalized Anxiety Disorder (GAD)

ADVERSE REACTIONS *Dizziness, drowsiness CONTRAINICATIONS *Patients with cognitive/motor impairments, restlessness syndrome INTERACTIONS Drug: SSRI antidepressants may enhance the serotonergic effect of antidepressants CNS depressants may enhance the adverse/toxic effects of other CNS depressants Macrolide antibiotics may decrease the metabolism of Buspirone Food: Alcohol CNS depressants may enhance the CNS depressant effect of alcohol Grapefruit juice may cause increased buspirone concentrations Herbal:

St. Johns Wort, valerian, kava kava, gotu kola increases CNS depression Yohimbine may diminish the therapeutic effect of anti-anxiety agent NURING PRECAUTIONS *Monitor mental status, symptoms of anxiety *May take 2-3 weeks to see full effect *Avoid large quantities of grapefruit juice *Maintain adequate hydration *Has little potential for abuse *Needs continuous use because of slow onset, not appropriate for PRN

Doxepin Pg. 452

(Sinequan)
ACTION Nonbenzodiazepines

USES Anxiety disorders Depression ADVERSE REACTIONS *Dizziness, drowsiness, orthostatic hypotension CONTRAINICATIONS *Patients with hypersensitivity to drugs similar chemical class, narrow-angle glaucoma, urinary retention, use of MAO inhibitors within 14 days, patients with active suicidal thinking/behavior *May worsen psychosis in some patients or precipitate a shift to mania in bipolar patients INTERACTIONS

Barbiturates may increase the metabolism of tricyclic antidepressants Lithium may enhance the neurotoxic effect MAO inhibitors enhances serotonergic effect and orthostatic hypotensive effect NSAIDs increase risk of bleeding SSRI antidepressants may enhance adverse/toxic effect of tricyclic antidepressant Food: Alcohol CNS depressants may enhance the CNS depressant effect of alcohol Grapefruit juice may cause increased buspirone concentrations Herbal: St. Johns Wort, valerian, kava kava, gotu kola increases CNS depression & sedation Kava kava, SAMe may diminish the therapeutic effect of anti-anxiety agent

Drug: Amphetamines may enhance the stimulatory effect of amphetamines and cardiovascular effects Anticholingerics may enhance the adverse/toxic effect of other anticholinergics Aspirin may enhance the anti-platelet effect of aspirin

NURING PRECAUTIONS *Monitor BP, HR, mental status, suicidal ideation, weight, ECG in older adults *Assess for insomnia (re-evaluate diagnosis if insomnia does not remit within 7-10 days of treatment) *Taper dosage slowly when discontinuing

SEDATIVE AND HYPNOTICS Benzaodiazepines, Nonbenzodiazepines (Lunesta and Ambien) and Barbiturates Childbearing Women: women taking barbiturates or benzos should be
warned of the potential risk to the fetus so that contraceptive methods may be instituted, if necessary. A child born to a mother taking benzos may experience withdrawal symptoms during the postnatal period. Gerontology: the older adult is at greatest risk for oversedation, dizziness, confusion or ataxia (unsteady gait) when taking a sedative or hypnotic. The nurse checks elderly and debilitated patients for a paradoxical reaction, such as marked excitement or confusion. If excitement or confusion occurs, the nurse observes the patient at frequent intervals (as often as every 5-10 minutes may be necessary) for the duration of the occurrence and institutes safety measures to prevent injury. If over sedation, extreme dizziness or ataxia occurs, the nurse notified the primary health care provider Barbiturates: have little to no analgesic action, so the nurse does not give these drugs if the patient has pain and cannot sleep. Barbiturates when given in the presence of pain, may cause restlessness, excitement and delirium. HOLD medication if respiration rate is 10 breaths/min or below or if patient is lethargic

Sedative: a drug that produces a relaxing, calming effect. Sedatives are usually given during daytime hours, and although they may make the patient drowsy, they usually do NOT produce sleep Hypnotic: a drug for short-term use to promote sleep. It induces drowsiness or sleep, it allows the patient to fall asleep and stay sleep. Hypnotics are given at night or bedtime Gerontology: elderly patients may require smaller hypnotic dose and in some instances, a sedative dose produced sleep.

Eszopiclone Pg. 514

(Lunesta)
ACTION Nonbenzodiazepine USES Chronic insomnia ADVERSE REACTIONS

*Headache, somnolence, taste changes, chest pain, migraine, edema CONTRAINIDCATIONS *Patients with hypersensitivity to sedative or hypnotics. *DO NOT administer to comatose patients, those with severe respiratory problem, those with history of drug/alcohol habitual use or pregnant/lactating women. *Used cautiously in patients who are lactation, patients with hepatic/renal impairment and mental health problems

INTERACTIONS

Drug: Antidepressants increased sedative effect Opioid Analgesics/Antihistamines increased sedative Phenothiazines (Thorazine) increased sedative effect Cimtidine (gastric upset med) increased sedative effect Alcohol increased sedative effect Herbal: Melatonin (released by pineal gland, can be added in teas/supplements) increased drowsiness, depression, some allergic reactions Valerian, lemon balm & chamomile (used for sedative effects, anxiety & restlessness) increases drowsiness, alters mood & sleep patterns and may experience withdrawal symptoms is stopped abruptly.

*When taking as a sedative, be aware that the drug can impair the mental/physical abilities required for performing potentially dangerous tasks, such as driving car or operating machinery. *Observe caution with getting out of bed at night, never drive or perform hazardous tasks *DO NOT use with OTC cold, cough, allergy or sleep medication

Zolpidem Pg. 1262

(Ambien, Ambien Controlled Release)
ACTION Nonbenzodiazepine USES Transient insomnia ADVERSE REACTIONS *Drowsiness, headache, myalgia, nausea CONTRAINIDCATIONS

NURSING PRECAUTIONS *Avoid alcohol 2 hour before or 8 hours after taking medication

*Patients with hypersensitivity to sedative or hypnotics. *DO NOT administer to comatose patients, those with severe respiratory problem, those with history of drug/alcohol habitual use or pregnant/lactating women. *Used cautiously in patients who are lactation, patients with hepatic/renal impairment and mental health problems

drowsiness, alters mood & sleep patterns and may experience withdrawal symptoms is stopped abruptly.

NURSING PRECAUTIONS

INTERACTIONS
Drug: Antidepressants increased sedative effect Opioid Analgesics/Antihistamines increased sedative effect Phenothiazines (Thorazine) increased sedative effect Cimtidine (gastric upset med) increased sedative effect Alcohol increased sedative effect Herbal: Melatonin (released by pineal gland, can be added in teas/supplements) increased drowsiness, depression, some allergic reactions Valerian, lemon balm & chamomile (used for sedative effects, anxiety & restlessness) increases

*Avoid alcohol 2 hour before or 8 hours after taking medication *When taking as a sedative, be aware that the drug can impair the mental/physical abilities required for performing potentially dangerous tasks, such as driving car or operating machinery. *May cause memory loss or amnesia. A person may not remember getting up out of bed, driving, or eating. These drugs should be taken when a person plans for 78 hours of sleep. *Observe caution with getting out of bed at night, never drive or perform hazardous tasks *DO NOT use with OTC cold, cough, allergy or sleep medication

ANTIDEPRESSANTS
Depression: A major depressive episode or a depressed or dysphoric (extreme or exaggerated sadness, anxiety or unhappiness) mood that interferes with daily function. For a classification of clinical depression, five or more of the symptoms need to occur daily or nearly every day for a period of 2 weeks or more. The symptoms of clinical depression are not the result of normal bereavement, such as a loss of a loved one or another disease. -Hopeless -Significant weight loss/gain -Insomnia or hypersomnia -Decrease in interested/engagement -Fatigue or loss of energy -Agitation/restlessness/irritability -Feelings of worthlessness -Excessive/inappropriate guilt -Changes in concentration -Recurrent thoughts of death/suicide (or suicide attempt) Tricyclic antidepressants (TCAs) *Sinequan, amitriptyline, nortiptylein Selective serotonin reuptake inhibitors (SSRIs) *Celexa, Lexapro, Prozac, Paxil, Zoloft

Monoamine oxidase inhibitors (MAOIs) *Nardil, Parnate, Marplan Atypical antidepressants *Wellbutrin, Cymbalta, Effexor

Tricyclic Antidepressants
Doxepine (Sinequan) Amitriptyline Nortiptylein (Aventyl, Pamelor)
ACTION Antidepressant USES Depressive episodes Bipolar disorder, depression accompanied by anxiety disorders Obsessive-compulsive disorders Chronic neuropathic pain Enuresis ADVERSE REACTIONS *Sedation, anticholinergic effects (dry mouth, dry eyes, urinary retention), constipation

CONTRAINICATIONS *Patients with hypersensitivity to drugs similar chemical class, use of MAO inhibitors within 14 days, patients with recent MI, to children or lactating mothers. *Doxepin is contraindicated in patients with glaucoma or in those with a tendency for urinary retention *TCAs should be used cautiously in patients with cardiac disease, hepatic or renal impairment, hyperthyroid disease, history of seizure activity, narrow-angle glaucoma or increased intraocular pressure, urinary retention and risk of suicidal ideation behavior INTERACTIONS Drug:

Adrengeric agents increased risk for arrhythmias and hypertension Sedatives/hypnotics/analgesics increased risk for respiratory & nervous system depression MAO inhibitors increased risk for hypertensive episodes, severe convulsions & hyperpyretic episodes NURING PRECAUTIONS *Although the TCAs are not considered antipsychotic agents, the drug amoxapine has been associated with tardive dyskinesia and neuroleptic malignant syndrome (NMS). Tardive dyskinesia is a syndrome of involuntary movements that may be irreversible. Symptoms of NMS are similar and include muscle rigidity, altered

mental status and autonomic system problems (such as tachycardia or sweating). These syndromes tend to occur more readily in elderly women; the drug should be discontinued, the primary health care provider notified immediately & treatment of adverse effects begun quickly. *TCAs can cause cardiac-related adverse reactions, such as tachycardia and heart block. The nurse therefore gives these drugs with caution to the person with preexisting cardiac disease, and to the elderly.

Selective Serotonin Reuptake Inhibitors (SSRIs)

Citalopram (Celexa) Escitalopram (Lexapro) Fluxetine (Prozac) Paroxetine (Paxil) Sertraline (Zoloft) ACTION

Antidepressant

USES Depressive episodes Obsessive-compulsive disorders Bulimia nervous ADVERSE REACTIONS *Nausea, dry mouth, sweating, insomnia, anorexia, diarrhea, anxiety, nervousness,

tremor, headache, constipation, sexual dysfunction, ejaculatory disturbances CONTRAINDICATIONS

*Patients with hypersensitivity to antidepressants, during pregnancy, patients taking cisapride (Propulsid), pimozide (Orap) or carbamazepine (Tegretol) should not take with Prozac.

*Used cautiously in patients with diabetes mellitus, cardiac disease, impaired liver/kidney function and risk for suicidal ideation or behavior. Patients should NOT be switched to an SSRI within 2 weeks of stopping an MAOI antidepressant INTERACTION
Drug: Other antidepressants increased risk of toxic effects Cimetidine increased anticholingeric symptoms (dry mouth, urinary retention, blurred vision) NSAIDs increased risk for GI bleeding Lithium increased risk of Li toxicity Herbal: St. Johns wort increased risk for a severe sedative effect

NURSING PRECAUTIONS *Watch closely for worsening of depression or suicidal ideation *Monitor therapeutic levels: 1-4 weeks may be needed before improvement is noted *Monitor HR and BP and cardiac status in known or suspect cardiac disease *Monitor adverse effect especially with doses>20mg *Avoid alcohol *Do not breast feed while taking medication

Monoamine Oxidase Inhibitors (MAOIs)

Phenelzine (Nardil) Tranylcypromine (Parnate) Isocarboxazid (Marplan)
ACTION Antidepressant

USES Depressive episodes used in conjunction with psychotherapy in severe cases Seasonal affective disorder ADVERSE REACTIONS *Orthostatic hypotension, vertigo, dizziness, nausea, constipation, dry mouth, diarrhea, headache, restlessness, blurred vision, hypertensive crisis CONTRAINICATIONS
*In the elderly, patients with liver/kidney disease, cerebrovascular disease, hypertension, history of headaches or CHF. *Used cautiously in patients with impaired liver function, history of seizures, parkinsonian symptoms, diabetes, hyperthyroidism or risk of suicidal or behavior.

Thiazide diuretic increased hypotensive effects of MAOI Adrenergic agents increased risk for cardiac arrhythmias and hypertension Antitussives (relieve cough) hypotension, fever, nausea, jerking motions to leg, coma

Food:

Tyamine or tryptophan hypertensive crisis, which may occur up to 2 weeks after the MAOI is discontinued

NURSING PRECAUTIONS

INTERACTIONS Drug:
Sedatives/hypnotics/analgesics increased risk for adverse reactions during surgery

*One of the earliest symptoms of hypertensive crisis is headache (usually occipital), followed by a stiff or sore neck, nausea, vomiting, sweating, fever, chest pain, dilated pupils and bradycardia or tachycardia. If a hypertensive crisis occurs, immediate intervention is necessary to reduce the blood pressure. Stroked and death have been reported. *Avoid drug-food interactions with MAOIs -aged cheese, sour cream, yogurt, beef/chicken livers, pickled herring, fermented meats (pepperoni, salami, Slim-Jims), alcoholic beverages, caffeinated beverage, chocolate, certain fruits & vegetables (avocado, bananas, fava beans, figs, raisins, sauerkraut), yeast extracts, soy sauce

Atypical Antidepressants
Bupropion (Wellbutrin) Duloxetine (Cymbalta) Venlafaxine (Effexor)
ACTION Antidepressant USES Depressive episodes Depression accompanied by anxiety disorders Diabetic peripheral neuropathic pain Smoking cessation ADVERSE REACTION
*Somnolence, migraine headache, hypotension, dizziness, lightheadedness, vertigo, blurred vision, photosensitivity, insomnia, nervousness, agitation, tremor, dry mouth, thirst, bitter taste, tachycardia, palpitations

*Should not be used with patients who have a seizure disorder or during the acute phase of a MI *Used cautiously in patient with cardiac disease, renal/hepatic impairment, hyperthyroid disease, or risk of suicidal ideation or behavior.

INTERACTION

Drug: Sedative/hypnotics/analgesics increased risk of respiratory and nervous system depression Warfarin increased risk of bleeding Antihypertensive agents increased risk for hypotension MAOIs increased risk for hypertensive episode, severe convulsions & hyperpyretic episodes Herbal: St. Johns Wort potential for adverse reaction when taken with antidepressants

NURSING PRECAUTIONS

CONTRAINIDCATIONS

*Safe use during pregnancy has NOT been established

*Monitor for therapeutic effectiveness: may take four or more week, close observe for worsening depression *Use extreme caution when administering drug to patient with seizures or cranial trauma

*Report significant restlessness, agitation, anxiety, insomnia *Monitor & report delusions, hallucinations, psychotic episodes, confusion and paranoia *Take at the same time each day *Monitor weight weekly *Avoid alcohol *Do NOT breast feed *The smoking cessation product Zyban is a form of

Wellbutrin. Smokers should NOT use Zyban if they are currently taking Wellbutrin for management of depression, because of the possibility of overdose.

Hydrochlorothiazide (HCTZ)
(Microzide) Pg 434 ACTION Diuretic, Thiazide USES Hypertension Edema (dieresis) ADVERSE REACTIONS

*Orthostatic hypotension, photosensitivity, hypokalemia, epigastric distress CONTRAINDICATIONS *Hypersensitivity to diuretics, thiazides, patients with Sulfa allergies, electrolyte disturbances, photosensitivity, anuria, renal decomposition or pregnancy

INTERACTIONS Drug:

Ace Inhibitors, Alcohol, Opioid Analgesics, Antidiabetic agents, Antihypertensive, Barbiturates, MAO Inhibitors enhance hypotensive effect Corticosteroids enhance hypokalemic effect Lithium decrease Li excretion NSAIDs diminish diuretic effect NURSING PRECAUTIONS *Assess weight, I/Os, BP, serum electrolytes, BUN & creatinine *May be administered with food *Take early in day to avoid nocturia *Take last dose of multiple doses no later than 6PM unless instructed otherwise *May need to increase intake of high K+ foods (bananas and/or OJ) *If diabetic: monitor CBG closely

Levodopa Pg.743
(Carbidopa, Entacapone, Stalevo) ACTION Anti-Parkinsons Agent USES Dopamine Precursor ADVERSE REACTIONS *Diarrhea, hallucinations, melanoma, somnolence, body fluid discoloration (urine, saliva, sweat red, brown, black in color) CONTRAINIDCATIONS *Hypersensitivity to Anti-Parkinsons, use of MAO inhibitor therapy with/in prior 14 days, narrow-angle

glaucoma, undiagnosed skin lesions or history of melanoma

*Monitor CBC, liver & renal function tests, BP, mental status, S/S neuroleptic malignant syndrome *Monitor iron levels in anemic patients *Monitor IOP in patients with glaucoma

INTERACTIONS Drug: Alcohol enhance CNS depressant effect Antipsychotics diminish antiParkinsons agent CNS depressants MAO inhibitors enhance toxic/adverse effects NURSING PRECAUTIONS *Swallow tablet whole: do NOT crush, break or chew *May result in false-negative for glucsouria

Venlafaxine Pg. 1222

(Effexor, Effexor XR) ACTION Antidepressant SSRI USES General Anxiety Disorder (GAD) Panic or Social Anxiety Disorder

Obsessive-Compulsive Disorder Post-traumatic Stress Disorder (PTSD)

MAO inhibitors enhance serotonin reuptake & orthostatic hypotensive effects, NURSING PRECAUTIONS *Swallow capsule or tablet whole: do NOT crush or chew. Contents of capsule may be sprinkled on a spoonful of applesauce & swallowed immediately without chewing: followed with a glass of water *May produce a false-positive of PCP in urine *BP should be monitored regularly, especially in patients with high baseline BP *May cause mean increase in HR of 49 bpm *Monitor mental status chance, suicidal thinking, anxiety & panic attacks

ADVERSE REACTIONS *Bleeding risk, CNS depression, hypertension, headache, somnolence, dizziness, insomnia, nervousness, abnormal ejaculation/orgasm CONTRAINIDICATIONS *Hypersensitivity to SSRIs, use of MAO inhibitors within 14 days; should not initiate MAO inhibitor within 7 days of discontinuing Effexor I NTERACTIONS Drug: Alcohol, CNS depressants enhance CNS depressant effect

*Avoid alcohol, caffeine, aspirin or other NSAIDs that increase risk of bleeding

*Events have generally been noted within the first 3 months of therapy & may occur with initial dose CONTRAINDICATIONS *Patients with pancreatitis, heart failure, hepatic/renal impairment INTERACTIONS Drug: ACE inhibitors enhance adverse effects of ACE inhibitors Corticosteroids diminish hypoglycemic effect Digoxin increase digoxin concentration Thiazide diuretics diminish effect of anti-diabetic medication NURSING PRECAUTIONS

Sitagliptin Pg. 1112

(Januvia) ACTION Oral Antidiabetic Agent USES Type 2 Diabetes ADVERSE REACTIONS *Hypersensitivity to oral hypoglycemic, angioedema, SJS, peripheral edema, hypoglycemia, diarrhea, constipation, nausea, osteosrthritis

*Do not chew or crush tablet *Follow dietary & lifestyle recommendations *Monitor HbA1C serum glucose, renal function prior to initiation and periodically during treatment *If uses insulin: added risk of hypoglycemia

Type 2 Diabetes

ADVERSE REACTIONS *Edema, headache, hypoglycemia, diarrhea, anemia, fractures, upper respiratory infections CONTRAINDICATIONS *Patients with fractures, heart failure/cardiac effects *Higher risk for hypoglycemia in patients with combination therapies

Rosiglitazone Pg. 1082

(Avandia) ACTION Oral Antidiabetic Agent USES INTERACTIONS
Drug: Corticosteroids diminish hypoglycemic effect Insulin may enhance fluid-retaining effect of anti-diabetic agent

Rifampin may increase metabolism of anti-diabetic agent Thiazide diuretics diminish effect of antidiabetic medication Vasodilators may enhance adverse/toxic effects of Avandia Food: Aloe, bitter melon, celery, garlic, ginger, ginseng, marshmallow

(Prinivil, Zestril) ACTION Angiotension-Converting Enzyme (ACE) Inhibitor USES Hypertension Heart Failure ADVERSE REACTIONS *Cough, hyperkalemia, Orthostatic hypotension, headache, dizziness, D/N/V, upper respiratory infection CONTRAINDICATIONS *Used cautiously in patients with chloestatic jaundice, hyperkalemia, hypotension/syncope, neutropenia, renal function deterioration

NURSING PRECAUTIONS
*Protect from light *May be administered with/out food *Do not chew or crush tablet *Follow dietary & lifestyle recommendations *Monitor HbA1C serum glucose, renal function prior to initiation and periodically during treatment *Monitor weight & fluid retention

Lisinopril Pg. 170

INTERACTIONS
Drug: Antacids decrease ACE inhibitors concentration Lithium increase concentration of Li Loop Diuretics, MAO inhibitors, antihypertensives, thiazide diuretics enhance hypotensive effect NSAIDs & Salicylates diminish antihypertensive effect K+ salts: enhance hyperkalemic effect

with renal dysfunction or those maintained on K+ supplements or K+ sparing diuretics *Take first dose at bedtime

Glipizide Pg.648
(Glucotrol) ACTION Oral Anti-diabetic Agent USES Type 2 Diabetes ADVERSE REACTIONS *Edema, anxiety, depression, eczema, anorexia, N/V/D, blurred vision, diaphoresis CONTRAINDICATIONS

NURSING PRECAUTIONS *Medication & herbals that may impact fluid balance or cardiac status *Patients taking diuretics should have them discontinued 2-3 days prior to initiating lisinopril if possible. *Use K+ containing salt substitutes cautiously in patients with diabetes, patients

*Patients with cardiovascular issues, hypoglycemia, sulfonamide allergies INTERACTIONS Drug: Alcohola flushing reaction may occur Corticosteroids & Thiazide Diuretics diminish hypoglycemic effect Cyclic Antidepressants, Salicylates, Beta-Blockers enhance hypoglycemic effect NURSING PRECAUTIONS *Administer immediate release tablets 30 minutes before a meal to achieve greatest reduction in postprandial hyperglycemia *Extended release tablets should be given with breakfast

*Patients that are NPO or require decreased caloric intake may need doses held to avoid hypoglycemia *Monitor CBG & HbA1C *Take medication at the same times everyday *Avoid alcohol while taking medication *You may experience more sensitivity to sunlight, headache or nausea.

Simvastatin Pg. 629

(Zocor) ACTION Antilipemic Agent USES To lower LDL-cholesterol levels

ADVERSE REACTIONS *Atrial fibrillation, edema, headache, vertigo, abdominal pain, eczema CONTRAINICATIONS *Patients with acute liver disease, pregnancy, breast-feeding or patients with myopathy *Should not be used on patients who hepatic impairment and/or ethanol use INTERACTIONS Drug:
Antacids decrease antilipemic concentration Diltiazem increase concentration of diltiazem Niacin enhance adverse/toxic effect of antilipemic agent Vitamin K Antagonist (ex. Warfarin) may enhance anticoagulant effect

Food: Grapefruit juice & Green Tea decrease antilipemic metabolism Herbal: St. Johns Wort increase metabolism of antilipemic agent

NURSING PRECAUTIONS *Red yeast rice contains an estimated 2.4 mg lovastatin per 600 mg rice *Avoid alcohol consumption &closely monitor Liver function *Teach proper diet/exercise regimen *Take same time/each day in evening with/without food *Report unusual muscle cramping/weakness, yellow of skin/eyes, easy bruising/bleeding or unusual fatigue

Cholecalciferol Pg. 1236

(Vitamin D3) ACTION Dietary Supplement USES Treatment of Vitamine D Deficiency Prophylaxis of deficiency ADVERSE REACTIONS *Hypervitaminosis D: signs/symptoms: hypercalcemia, resulting in headache, N/V, lethargy, confusion, sluggishness, abdominal pain, bone pain, polyuria, polydipsia, weakness, cardiac arrhythmias CONTRAINIDCATIONS *Hypercalcemia, malabsorption syndrome, evidence of vitamin D toxicity

INTERACTIONS Drug: Vitamin D Analogs may enhance adverse/toxic effect of other Vit D analogs Food: Olestra impairs absorption of Vitamin D NURSING PRECAUTIONS *Vitamin D supplementation has been shown to increase muscle function and strength, as well as improve balance *Patients at risk for falls should have vitamin D serum concentrations measured and be evaluated for supplementation

SOOTHE & COOL

(INZO Zinc Oxide Barrier Cream) ACTION

Ideal for under tape, INZO leaves a non-greasy, invisible barrier. Nonpetrolatum formula wont obstruct brief pores. Ideal for around ostomy sites or peri wound skin to protect skin from maceration damage. Enhanced formula:Vitamins A, D and E, along with aloe, nourish the skin. Ideal for sensitive skin.

Protective barrier to relieve and guard the skin from harsh irritants.

USES
Designed to prevent moisture, urine & fecal matter from contacting skin. INZO allows the skin to breathe without being occlusive. Rubs in clear to permit easy monitoring of skin.

Unique formula: silicone-based barrier that also moisturizes the skin, while zinc oxide provides broad spectrum UVA and UVB protection.

ADVERSE REACTIONS

Mild itching, burning, or stinging.Seek medical attention right away if any of these SEVERE side effects occur: Severe allergic reactions (rash; hives; itching; difficulty breathing; tightness in the chest; swelling of the mouth, face, lips, or tongue); severe or persistent itching, burning, or stinging; skin irritation; worsening dryness.

USES

Calcium carbonate is used to prevent and to treat calcium deficiencies.

ADVERSE REACTIONS *nausea or vomiting, decreased appetite, constipation, dry mouth or increased thirst, urinating more than usual. INTERACTIONS Calcium carbonate may interact with or make it harder for your body to absorb certain drugs. *Tell your doctor about all other medications you take, especially: digoxin (Lanoxin, Lanoxicaps); antacids or other calcium supplements;calcitriol

Oyster Shell Calcium 500

(Calcium Carbonate) Pg. 256 ACTION Maintain cell membrane and capillary permeability

(Rocaltrol) or vitamin D supplements; ora tetracycline antibiotic such as tetracycline (Sumycin, Achromycin V, and others), demeclocycline (Declomycin), doxycycline (Vibramycin, Monodox, Doxy, and others), minocycline (Minocin, Dynacin, and others), or oxytetracycline (Terramycin, and others). NURSING PRECAUTIONS Use cautiously in patients with hypercalcemia, renal calculi, ventricular fibrillation, Pt.s receiving digitalis, glycosides, severe respiratory insufficiency, renal disease, cardiac disease *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.

Myralax Pg.991
(Polyethylene glycol-electrolyte solution) ACTION Polyethylene glycol acts as a osmotic agent, drawing water into the lumen of the GI tract USES Treatment of occasional constipation ADVERSE REACTIONS

GI: Abdominal bloating, cramping, flatulence, nausea CONTRAINIDCATIONS GI obstruction, gastric retention, Toxic colitis, Megacolon

INTERACTIONS None significant NURSING PRECAUTIONS Use cautiously in abdominal pain of uncertain cause, particularly if accompanied by fever, pregnancy, or children

Avandamet

(combo drug) Rosiglitazone (Avandia)/ Meformin 1 mg/500 mg, 2 mg/500 mg, 4mg/500 mg 2 mg/1,000 mg, 4 mg/1,000 mg ACTION Oral Antidiabetic Agent

USES Type 2 Diabetes ADVERSE REACTIONS *Edema, headache, hypoglycemia, diarrhea, anemia, fractures, upper respiratory infections CONTRAINDICATIONS *Patients with fractures, heart failure/cardiac effects *Higher risk for hypoglycemia in patients with combination therapies INTERACTIONS
Drug: Corticosteroids diminish hypoglycemic effect Insulin may enhance fluid-retaining effect of anti-diabetic agent Rifampin may increase metabolism of antidiabetic agent Thiazide diuretics diminish effect of antidiabetic medication

Vasodilators may enhance adverse/toxic effects of Avandia Food: Aloe, bitter melon, celery, garlic, ginger, ginseng, marshmallow

NURSING PRECAUTIONS *Protect from light *May be administered with/out food *Do not chew or crush tablet *Follow dietary & lifestyle recommendations *Monitor HbA1C serum glucose, renal function prior to initiation and periodically during treatment *Monitor weight & fluid retention

Metformin

Pg. 793 (Glucophage, Fortamet, Riomet) ACTION Oral Antidiabetic Agent USES

Type 2 Diabetes

ADVERSE REACTIONS *Nausea, vomiting, flatulence, diarrhea, asthenia CONTRAINIDCATIONS

*Patients with heart failure, renal disease, acute/chronic metabolic acidosis (including ketoacidosis) *Temporarily discontinued for surgical procedures & restarted when patients oral intake has been resumed and renal function is normal. *Stopped 48 hours before and after radiologic studies using iodinated material

Rifampin may increase metabolism of antidiabetic agent Thiazide diuretics diminish effect of antidiabetic medication Vasodilators may enhance adverse/toxic effects of Avandia Food: Aloe, bitter melon, celery, garlic, ginger, ginseng, marshmallow

INTERACTIONS Drug:
Corticosteroids increased risk of lactic acidosis Insulin may enhance fluid-retaining effect of anti-diabetic agent

NURSING PRECAUTIONS *Protect from light *May be administered with/out food *Do not chew or crush tablet *Follow dietary & lifestyle recommendations *Monitor HbA1C serum glucose, renal function prior to initiation and periodically during treatment *Monitor weight & fluid retention

Atorvastatin
(Lipitor) Pg. 629

ACTION HMG-CoA Reductase Inhibitor (Statin Drug) Lowers blood levels of cholesterol, LDLs and trigylerides USES Antihyerlipidemic Drug ADVERSE REACTIONS *Headache, diarrhea, sinusitis, dizziness, insomnia, flatulence, abdominal pain, cramping, constipation, nausea CONTRAINDICATIONS *Patients with serious liver disorders and during pregnancy (category X) and lactation

INTERACTIONS
Drug: Macrolides, erythromycin, clarithromycin
increased risk of severe myopathy or rhabdomyolysis

Amiodarone increased risk of myopathy Niacin increased risk of severe myopathy or rhabdomyolysis Protease inhibitors elevated plasmas levels of statins Verapamil increased risk of myopathy Warfarin increased anticoagulant effect Herbal: St. Johns wort causing a decrease in statin effectiveness

NURSING PRECAUTIONS

*Statin drugs have an addictive effect when used

with bile acid resins, which may provide an added benefit in treating high cholesterol that does not respond to a single-drug regimen. Cholesterol total Highdensity cholesterol 120-220mg/100mL >40mg/100mL Low-density cholesterol <80mg/100mL

ADVERSE REACTIONS *Headache, fatigue, depression, dizziness, syncope *Upper respiratory infections and cough *Abdominal pain, nausea, diarrhea, constipation, anorexia CONTRAINIDCATIONS
*Patients with sick sinus syndrome, 2/3 atrioventricular (AV) block (except with a functioning pacemaker) *Patients with hypotension (systolic pressure less than 90 mm Hg), ventricular dysfunction or cardiogenic shock

Amlodipine
(Norvasc) Pg. 151 ACTION Calcium Channel Blocker USES Antihypertensive Drug Chronic Stable Angina Vasospastic angina

INTERACTION Drug: Cimetidine or rantidine (GI disorders) increased effect of CCblocker Theophyllinetoxic effect of theophylline Digoxinincreased risk digitalis toxicity

Rifampin (TB med) decreased effect of CCblocker MAOIs, antihistamines, sympathomimetic bronchodilators decreased effectiveness of CCblocker Diuretics increased risk of hypotension Herbal: Hawthronincreased sedation & CNS depression NURSING PRECAUTIONS *Take BP and HR prior to administration *Monitor for signs/symptoms of edema, report any swelling or face or extremities *Be careful for postural hypotension *Report shortness of breath or irregular HR

Sertraline
(Zoloft) Pg. 1103, 1327
ACTION Selective Serotonin Reuptake Inhibitor (SSRI) Antidepressant USES Depressive episodes Obsessive-compulsive disorders Bulimia nervous ADVERSE REACTIONS *Nausea, dry mouth, sweating, insomnia, anorexia, diarrhea, anxiety, nervousness, tremor, headache, constipation, sexual dysfunction, ejaculatory disturbances CONTRAINDICATIONS

*Patients with hypersensitivity to antidepressants, during pregnancy, patients taking cisapride (Propulsid), pimozide (Orap) or carbamazepine (Tegretol) should not take with Prozac. *Used cautiously in patients with diabetes

mellitus, cardiac disease, impaired liver/kidney function and risk for suicidal ideation or behavior. *Patients should NOT be switched to an SSRI within 2 weeks of stopping an MAOI antidepressant

INTERACTION
Drug:

Other antidepressants increased risk of toxic effects Cimetidine increased anticholingeric symptoms (dry mouth, urinary retention, blurred vision) NSAIDs increased risk for GI bleeding Lithium increased risk of Li toxicity Herbal: St. Johns wort increased risk for a severe s edative effect NURSING PRECAUTIONS *Watch closely for worsening of depression or

suicidal ideation *Monitor therapeutic levels: 1-4 weeks may be needed before improvement is noted *Monitor HR and BP and cardiac status in known or suspect cardiac disease *Monitor adverse effect especially with doses>20mg *Avoid alcohol *Do not breast feed while taking medication

Clopidogrel
(Plavix) Pg. 324 ACTION Anticoagulant Antiplatelet Agent USES Recent MI Stroke

Acute Coronary Syndrome

Macrolide antibiotics increased

effectiveness

ADVERSE REACTIONS *Dizziness, skin rash, chest pain, constipation *Heart palpitation, bleeding, dyspepsia CONTRAINDICATIONS *Patients with CHF, active bleeding, thrombotic thrombocytopenia purpura (TTP) *Should be used cautiously in elderly patients & those with renal or hepatic impairment INTERACTIONS Drug: Aspirin & NSAIDs increased risk of bleeding

of anti-infective Digoxin decreased digoxin levels Phenytoin increased phenytoin levels Herbal: Feverfew, ginkgo, ginger, valerian may potentiate bleeding NURSING PRECAUTIONS *Lab tests: PT/INR, baseline blood coagulation tests, H/H *Monitor APTT levels closely *In general, dosage is adjusted to keep APTT between 1.5-2.5 times normal control level *Monitor vital signs *Observe all needle sites daily for

hematoma and signs of inflammation

Isosorbide Mononitrate
(ISMO) (Monoket) ACTION Antianginal Drug USES Treatment and prevention of angina pectoris ADVERSE REACTIONS *Headache, hypotension, dizziness, weakness, flushing, restlessness, rash CONTRAINDICATIONS Pg. 707

*Patients with severe anemia, closedangle glaucoma, postural (orthostatic) hypotension, head trauma, cerebral hemorrhage (may increase intracranial hemorrhage) *Patients taking drugs for erectile dysfunction should NOT take nitrates *Used cautiously in the following patients: severe hepatic or renal disease, severe head trauma, hypothryroidism INTERACTIONS Drug:
Aspirin increases nitrate concentration Calcium Channel Blockers increases symptomatic orthostatic hypotension Dihydroergotamine (migrate medicine) Increases risk of hypertension heparin decreased effect of heparin Erectile dysfunction meds severe hypotension & cardiovascular collapse may occur

Alcohol severe hypotension & cardiovascular collapse because of its a vasodilator

NURSING PRECAUTIONS *Heart rate MUST be above 60 *Do NOT crush or chew tablets

*Report S&S of toxicity, hypotension, light-headedness, blurred vision, dyspnea *Do NOT withdraw drug abruptly, it may precipitate acute angina

ADRENERGIC DRUGS
Peripheral Nervous System Autonomic Nervous System Sympathetic v. Parasympathetic nervous system branches Sympathetic (Adrenergic) = regulated by involuntary control. In other words, a person does NOT have control over what this system does. Fight-or-Flight response is activated when the body is confronted with stressful situations, such as danger, intense emotion or severe illness. Controls persons heart rate, breathing rate and ability to divert blood to skeletal muscles. This branch of system is based on the neurohormone adrenalin (epinephrine) and norepinephrine (neurotransmitter).

Examples: Dobutamine, epinephrine (EpiPen), Midodrine (ProAmatine) In the sympathetic branch of ANS, adrenergic drugs produce activity similar to the neurotransmitter norepinephrine. Another name for these drugs is sympathomimetic (for example: mimicking the actions of the sympathetic nervous system) drugs. The adrenergic drugs produce pharmacologic effects similar to the effects that occur in the body when the sympathetic nervous (norepinephrine) and the medulla (epinephrine) are stimulated. The primary effects of these drugs occur on the heart, the blood vessels and the smooth muscles, such as the bronchi of the lungs. DO NOT MIX DOPMINE WITH OTHER DRUGS Norepinephrine & dopamine are administered ONLY via IV route Shock Patients: monitor VS, especially a progressive fall in BP & cardiac output (HR & stroke volume)

Dobutamine
(Dobutrex)

ACTION Adrenergic (Sympathomimetic) Drug

USES Cardiac decompensation due to depressed contractility caused by organic heart disease or cardiac procedures ADVERSE REACTIONS *Headache, nausea, increased heart rate, increase in systolic blood pressure, palpitations, angina and nonspecific chest pain. CONTRAINDICATIONS Used cautiously in patients with coronary insufficiency, cardiac arrhythmias, angina pectoris, diabetes, hyperthyroidism, occlusive vascular disease or prostatic hypertrophy. Patients with diabetes may require an increased dosage of insulin INTERACTIONS Drug:

Oxytocin increased risk of hypertension Bretylium (cardiac med) increased risk of arrhythmias

Herbal: Ephedra hypertension, irregular heart rate, stroke, heart attack NURSING INTERVENTIONS Older adult are vulnerable to adverse reactions, especially cardiac arrhythmias Monitor BP every 2 minutes from beginning of therapy until the desired BP and pulse rate at frequent intervals, usually every 5 to 15 minutes Regardless of the actual numeric reading of the blood pressure, a progressive decrease in blood pressure IS SERIOUS. Report a decrease in systolic BP below 100 mm Hg or any decrease of 20 mm Hg or more of the patients normal blood pressure

Antidepressants increased sympathomimetic effect

Disturbed sleep patterns may occur r/t nervousness to the drug and the environment
pectoris, diabetes, hyperthyroidism, occlusive vascular disease or prostatic hypertrophy. Patients with diabetes may require an increased dosage of insulin

Epinephrine
(EpiPen)
ACTION Adrenergic (Sympathomimetic) Drugs Used for Vasopressor Effects USES Ventricular standstill Treatment & prophylaxis of cardiac arrest, heart block, mucosal congestion and acute sinusitis Prolong regional/local anesthetics Anaphylactic reactions ADVERSE REACTIONS *Anxiety, restlessness, headache, lightheadedness, dizziness, nausea, dysuria, pallor CONTRAINDICATIONS

INTERACTIONS Drug: Antidepressants increased sympathomimetic effect Oxytocin increased risk of hypertension Bretylium (cardiac med) increased risk of arrhythmias Herbal: Ephedra hypertension, irregular heart rate, stroke, heart attack NURSING INTERVENTIONS

Used cautiously in patients with coronary insufficiency, cardiac arrhythmias, angina

The older adult is especially vulnerable to adverse reactions and is more likely to

have preexisting cardiovascular disease that predisposes them to potentially serious cardiac arrhythmias. Nurse NEEDS TO MONITOR all elderly patients and report any changes in pulse rate or rhythm immediately. In patients with Parkinson disease, drug increases rigidity and tremor

Drug of choice in emergency treatment of acute anaphylactic reactions In blood pressure increases sharply, give rapid-acting vasodilators, such as nitrates and alpha blockers, to counteract the marked pressor effect of large doses

Midodrine
(ProAmatine)
ACTION Adrenergic (Sympathomimetic) drugs used primarily for Vasopressor Effects USES Orthostatic hypotension (only when patient is considered impaired) ADVERSE REACTIONS

*Paresthesias, headache, pain, dizziness, supine hypertension, bradycardia, piloerection, pruritus, dysuria, chills CONTRAINDICATIONS Used cautiously in patients with coronary insufficiency, cardiac arrhythmias, angina pectoris, diabetes, hyperthyroidism, occlusive vascular disease or prostatic hypertrophy. Patients with diabetes may require an increased dosage of insulin

INTERACTIONS Drug: Antidepressants increased sympathomimetic effect Oxytocin increased risk of hypertension Bretylium (cardiac med) increased risk of arrhythmias Herbal: Ephedra hypertension, irregular heart rate, stroke, heart attack NURSING INTERVENTIONS *Supine hypertension is a potentially dangerous adverse reaction in the patient taking midodrine. The drug should be given only to patients whose lives are impaired despite standard treatment offered. The

nurse can minimize this reaction by administrating midodrine during the day while the patient is in an upright position. The following is a suggested dosing schedule for the administration of midodrine: shortly before arising in the morning, midday, and late afternoon (not after 6:00 PM). Drug therapy should continue only in the patient whose orthostatic hypotension improves during the initial treatment. *Important to take the drug during daytime hours, take doses in 3-hour intervals and within 4-hours of bedtime, if needed to control symptoms *Sleep with head of bed elevated

ADRENERGIC BLOCKING DRUGS

Peripheral Nervous System Autonomic Nervous System Sympathetic v. Parasympathetic nervous system branches Sympathetic Nervous System (Adrenergic Branch, Fight or Flight): tends to

regulate the expenditure of energy and is operative when the organism is confronted with stressful situations. Anti-adrenergic or Adrenergic Blocking medications block or inhibit the system and sympathetic nervous system. One of the major body systems impacted by adrenergic blocking drugs is the heart and vascular system. Some of the drugs are also used to treat hypertension. Alpha-adrenergic blocking drugs: produce their greatest effect on the alpha-receptors of the adrenergic nerves that control the vascular system, causing vasodilation and relaxing the smooth muscle of blood vessels (also used to constrict pupil). Example: Phentolamin (Regitine) Beta-adrenergic blocking drugs (Beta Blockers): blocks -adrenergic receptors and their effect on receptors, primarily the receptors of the heart, decreasing heart rate and dilates the blood vessels. Examples: Atenolol, Metoprolol (Lopressor, Toprol XL), Propranolol - adrenergic blocking drugs: blocks both AND adrenergic receptors and effects the nerve fibers Example: Carvedilol (Coreg) Anti-adrenergic drugs: prevents the release of neurotransmitter norepinephrine and blocks the adrenergic nerve impulse in both central & peripheral nervous systems

Example: Clonidine (Catapres)

Atenolol
(Tenormin, Tenoretic)
ACTION -Adrenergic Blocking Drug (Beta Blocker) Decreases stimulation of sympathetic nervous system by: Decreasing excitability of heart Decreasing cardiac workload and oxygen consumption Provides membrane-stabilizing effects

*Patients with sinus bradycardia, second or third degree heart block, heart failure and those with asthma, emphysema or hypotension. *Used cautiously in patients with diabetes, thyrotoxicosis or peptic ulcer.
* -Blockers are recommended for pregnant women over other hypertensive drugs because of the risk to the fetus is less with these drugs. INTERACTIONS Drugs:

USES Hypertension Angina Acute MI ADVERSE REACTIONS *Bradycardia, dizziness, fatigue, weakness, hypotension, N/V/D, nervousness CONTRAINICATIONS

Antidepressants (MAOIs, SSRIs) increased effect of -blocker, bradycardia NSAIDs decreased effect of -blocker Loop diuretics increased risk of hypotension Clonidine increased risk of paradoxical hypertensive effect Cimetidine (GI problems) increased serum level of -blocker & higher risk of -blocker toxicity Lidocaine increased serum level of -blocker & higher risk of -blocker toxicity

NURSING INTERVENTIONS

*Older adults are at an increased risk for adverse reactions when taking -blockers. The nurse should monitor older adults closely for confusion, heart failure, worsening of angina, shortness of breath and peripheral vascular insufficiency (examples: cold extremities, paresthesia of the hands, weak peripheral pulses). *Beta-blockers may mask tachycardia caused by hyperthyroidism *Beta-blockers may mask signs/symptoms of hypoglycemia in diabetic patients *With-hold medication is HR is less than 60 bpm, or systolic BP less than 90 mm Hg

USES Cardiac arrhythmias MI, angina Hypertension Migraine prophylaxis Hypertrophic Sub-aortic stenosis Pheochromocytoma Essential Tremor

Provides membrane-stabilizing effects

ADVERSE REACTIONS *Bradycardia, dizziness, hypotension, N/V/D, bronchospasm, hyperglycemia, pulmonary edema CONTRAINICATIONS *Patients with sinus bradycardia, second or third degree heart block, heart failure and those with asthma, emphysema or hypotension. *Used cautiously in patients with diabetes, thyrotoxicosis or peptic ulcer. * -Blockers are recommended for pregnant women over other hypertensive drugs because of the risk to the fetus is less with these drugs. INTERACTIONS Drugs: Antidepressants (MAOIs, SSRIs) increased effect of -blocker, bradycardia

Propranolol
(Inderal)
ACTION -Adrenergic Blocking Drug (Beta Blocker) Decreases stimulation of sympathetic nervous system by: Decreasing excitability of heart Decreasing cardiac workload and oxygen consumption

NSAIDs decreased effect of -blocker Loop diuretics increased risk of hypotension Clonidine increased risk of paradoxical hypertensive effect Cimetidine (GI problems) increased serum level of -blocker & higher risk of -blocker toxicity Lidocaine increased serum level of -blocker & higher risk of -blocker toxicity NURSING INTERVENTIONS *Instruct patient to take drug with food *Older adults are at an increased risk for adverse reactions when taking -blockers. The nurse should monitor older adults closely for confusion, heart failure, worsening of angina, shortness of breath and peripheral vascular insufficiency (examples: cold extremities, paresthesia of the hands, weak peripheral pulses). *Abrupt withdrawal of drug may cause exacerbation of angina or MI, discontinue slowly *Beta-blockers may mask signs/symptoms of hypoglycemia in diabetic patients *With-hold medication is HR is less than 60 bpm, or systolic BO is less than 90 mm Hg

Metoprolol
(Lopressor, Toprol-XL)
ACTION -Adrenergic Blocking Drug (Beta Blocker) Decreases stimulation of sympathetic nervous system by: Decreasing excitability of heart Decreasing cardiac workload and oxygen consumption Provides membranestabilizing effects USES Hypertension Angina MI, Heart Failure ADVERSE REACTIONS *Dizziness, hypotension, HF, cardiac arrhythmias, N/V/D CONTRAINICATIONS

*Patients with sinus bradycardia, second or third degree heart block, heart failure and those with asthma, emphysema or hypotension.

Cimetidine higher risk of B-blocker toxicity Iidocaine higher risk of B-blocker toxicity

*Used cautiously in patients with diabetes, thyrotoxicosis or peptic ulcer. * -Blockers are recommended for pregnant women over other hypertensive drugs because of the risk to the fetus is less with these drugs. INTERACTIONS Drug:
Antidepressants increased effect of Beta blocker, bradycardia NSAIDs decreased effect of beta blocker Loop Diuretic increased risk of hypotension Clonidine increased risk of paradoxical hypertensive effect

NURSING PRECAUTIONS *Take apical pulse and BP before administration *Hold if BP is less than 100/60 OR greater than 140/90, OR HR less than 60 *Monitor BP, HR and ECG carefully during IV administration

Carvedilol
(Coreg)
ACTION - Adrenergic Blocking Drug Blocks both - receptors resulting in peripheral vasodilation USES Hypertension

HF Left ventricular dysfunction

ADVERSE REACTIONS *Bradycardia, hypotension, cardiac insufficiency, fatigue, dizziness, diarrhea CONTRAINIDCATIONS *Patients with bronchial asthma, decompensated heart failure and severe bradycardia. *Used cautiously in patient with drugcontrolled HF, chronic bronchitis or impaired hepatic or cardiac function, in those with diabetes and during pregnancy or lactation.
INTERACTION Drug: Antidepressants (tricyclics, SSRIs) increased risk of tremors Cimetidine increase effect of the adrenergic blocker

Halothane increase effect of the adrenergic blocker Clonidine increased effect of the clonidine (big drop in BP) Digoxin increased levels of digoxin, risk of toxicity NURSING INTERVENTIONS *Monitor patient with heart failure for worsening condition, renal failure or fluid retention; diuretics may need to be increased *If drug must be stopped, do so gradually over 1-2 weeks, if possible *If patient is jaundice, STOP medication IMMEDIATELY hepatic injury *Observe patient for dizziness for lightheadedness for 1 hour after giving each new dose *Monitor elderly patients carefully; drug levels are about 50% higher in elderly patients than in younger patients *Inform patients who wear contact lenses that their eyes may feel dry

*Take medication with food, capsules should NOT BE crushed, chewed or divided

Clonidine
(Catapres)
ACTION Anti-Adrenergic Drugs (Centrallyacting) Inhibits the release of norepinephrine and acts in the Central Nervous System Affects the sympathetic nervous system USES Hypertension Severe pain in patients with cancer ADVERSE REACTIONS *Drowsiness, dizziness, sedation, dry mouth, constipation, syncope, dreams, rash

CONTRAINDICATION *Patients in active hepatic disease and patients on MAOIs *Used cautiously in patients with a history of liver disease or renal impairment and during pregnancy and lactation INTERACTIONS Drug: Adrenergic drugs increased risk of hypertension Levodopa decreased effect of levodopa, hypotension Anesthetic agents increased effect of the
anesthetic

-blockers increased risk of hypertension Lithiumincreased risk for lithium toxicity Haloperidol increased risk of psychotic behavior NURSING INTERVENTIONS *B/P, pulse prior to administration

*If prescribed for opiate withdrawal: monitor for N/V/D, cramps, insomnia, shivering & dilated pupils *Monitor I/Os and edema *Give last dose at bedtime *Discontinuing abruptly may result in anxiety, increased BP, headache, insomnia, increased pulse, tremors, nausea, sweating

*DO NOT use OTC (cough, cold or allergy) medications unless approved by MD *Rise slowly to prevent drop in BP *May cause dry mouth; recommend hard candy or frequent mouth rinsing

CHOLINERGIC (PARASYMPATHOMIMETIC) MEDICATIONS

Acetylcholine (ACh) is the substance that transmits nerve impulses across the parasympathetic branch of the Autonomic Nervous System. Autonomic Nervous System: is concerned with functions essential to the survival of the organism. Functional activity of the autonomic nervous system is not controlled consciously (the activity is automatic). This system controls blood pressure, heart rate, gastrointestinal activity and glandular secretions. Parasympathetic Nervous System (Cholinergic Branch, Rest & Digest): help conserve body energy and is partly responsible for such activities as slowing the heart rate, digested food and eliminating bodily wastes. Cholinergic drugs that enhance neurotransmission and anticholinergic drugs block transmission.

Muscarinic Receptors stimulates smooth muscle Nicotinic Receptors stimulates skeletal muscle Direct Acting Cholinergics: cholinergic drugs that act like the neurotransmitter ACh and acts on the ANS that controls the process of micturition (voiding of urine) by constricting the muscle and relaxing the bladder sphincter. Indirect Acting (Anticholinesterase) Muscle Stimulants: these medications are used to treat myasthenia gravis (disease that rapidly fatigues skeletal muscles because of the lack of ACh released) and promote muscle contraction. Topical Ophthalmics: as indirect-acting cholinergic drugs that produce miosis (constriction of the iris) that are used in the treatment of glaucoma. This opens the blocked channel and allows the normal passage of aqueous humor, thereby reducing intraocular pressure.

Bethanechol
(Duvoid, Urecholine)
ACTION

Direct Acting Cholinergic Drug Acts like the neurotransmitter ACh and controls the process of micturition (voiding of urine) by

USES Acute Non-obstructive Urinary Retention Neurogenic Urinary Bladder (causing retention) ADVERSE REACTIONS *Abdominal discomfort, headache, diarrhea, nausea, salivation, urgency CONTRAINIDICATIONS *Patients with mechanical obstruction of the GI or genitourinary tracts. *Patients with asthmas, peptic ulcer disease, coronary artery disease and hyperthyroidism. *Used cautiously in patients with hypertension, epilepsy, cardiac arrhythmias, bradycardia, recent coronary occlusion and megacolon. INTERACTIONS Drugs:

constricting the muscle and relaxing the bladder sphincter.

Aminoglycoside antibiotics increased neuromuscular blocking effect Corticosteroids decreased effect of cholinergic problems NURSING INTERVENTIONS

*Symptoms of cholinergic crisis (Cholinergic drug toxicity) include severe abdominal cramping, diarrhea, excessive salivation, muscle weakness, rigidity and spasm and clenching of the jaw. Patients exhibiting these symptoms require immediate medical treatment, and their condition must be reported immediately to MD. *In case of over-dosage, an antidote such as atropine is administered and other treatment also may be prescribed. The usual dosage of atropine is 0.4 to 0.6 mg IV *Signs of under dosage of the drug include the disease itself, namely, rapid fatigability of the muscles, drooping of the eyelids and difficulty breathing. If symptoms of drug over OR under-dosage, contact MD immediately. *To avoid N/V, take on an empty stomach *Monitor I/Os *Take medication exactly as prescribed; 1 hr AC or 2 hours PC

Ambenonium
(Mytelase)
ACTION Indirect Acting (Anticholinesterase) Muscle Stimulant Drug Prolongs the activity of ACh by inhibiting the release of AChE (anticholinesterase)and promotes muscle contraction USES Myasthenia gravis (a disease that rapidly fatigues skeletal muscles because of the lack of AChl released) ADVERSE REACTIONS *Increased bronchial secretions, cardiac arrhythmias, muscle weakness, urinary frequency CONTRAINIDICATIONS
*Patients with mechanical obstruction of the GI or genitourinary tracts. *Used cautiously in patients with hypertension,

epilepsy, cardiac arrhythmias, bradycardia, recent coronary occlusion and megacolon. *Patients with asthmas, peptic ulcer disease, coronary artery disease and hyperthyroidism.

INTERACTIONS Drugs: Aminoglycoside antibiotics increased neuromuscular blocking effect Corticosteroids decreased effect of cholinergic problems NURSING INTERVENTIONS *Symptoms of cholinergic crisis (Cholinergic drug toxicity) include severe abdominal cramping, diarrhea, excessive salivation, muscle weakness, rigidity and spasm and clenching of the jaw. Patients exhibiting these symptoms require immediate medical treatment, and their condition must be reported immediately to MD.

*In case of over-dosage, an antidote such as atropine is administered and other treatment also may be prescribed. The usual dosage of atropine is 0.4 to 0.6 mg IV *Signs of under dosage of the drug include the disease itself, namely, rapid fatigability of the muscles, drooping of the eyelids and difficulty breathing. If symptoms of drug over OR underdosage, contact MD immediately.

humor, thereby reducing intraocular pressure USES Glaucoma ADVERSE REACTIONS *Headache, tachycardia, burning, stinging, bitter taste CONTRAINIDICATIONS *Patients with secondary glaucoma, iritis, corneal abrasion or any acute inflammatory disease of the eye should NOT use the ophthalmic cholinergic preparation. *Patients with mechanical obstruction of the GI or genitourinary tracts. *Used cautiously in patients with hypertension, epilepsy, cardiac

Pilocarpine
(Pilopine) ACTION Topical Indirect-acting Cholinergic Ophthalmics: that opens the blocked channel and allows the normal passage of aqueous

arrhythmias, bradycardia, recent coronary occlusion and megacolon. *Patients with asthmas, peptic ulcer disease, coronary artery disease and hyperthyroidism. INTERACTIONS Drugs: Aminoglycoside antibiotics increased neuromuscular blocking effect Corticosteroids decreased effect of cholinergic problems

NURSING INTERVENTIONS *How to instill drops *Teach the patient that the medication my cause burning, itching, blurring or dryness of eye area *Store medication at room temperature away from light

ANTICHOLINEGIC (CHOLINERGIC BLOCKERS/PARASYMPATHOLYTIC) MEDICATIONS Acetylcholine (Ach) is the substance that transmits nerve impulses across
the parasympathetic branch of the Autonomic Nervous System. Parasympathetic Nervous System (Cholinergic Branch, Rest & Digest): help conserve body energy and is partly responsible for such activities as slowing the heart rate, digested food and eliminating bodily wastes.

Cholinergic drugs that enhance neurotransmission and anticholinergic drugs block transmission.

Anti-Cholinergic/ Cholinergic Blocking Drugs: block the action of ACh in the parasympathetic nervous system, working either on the: Muscarinic receptors: treating overactive bladders Nicotinic receptors: as an antispasmodic drug Examples: Atropine, Belladonna, Scopolamine, Oxybutynin

Atropine
(AtroPen)
ACTION

Cholinergic Blocking (Anti-Cholinergic) Medication USES Pylorospasm

Reduction of bronchial & oral secretions Excessive Vagal-Induced bradycardia Ureteral & Biliary Colic

ADVERSE REACTIONS *Drowsiness, blurred vision, tachycardia, dry mouth, urinary hesitancy CONTRAINICATIONS
*Patients with glaucoma, myasthenia gravis, tachyarrhythmias, myocardial infarction and congestive heart failure (unless bradycardia is present) *Used cautiously in patients with GI infections, benign prostatic hypertrophy, urinary retention, hyperthyroidism, hepatic/renal disease and hypertension. *Atropine should be used cautiously in patients with asthma

INTERACTIONS Drug: Antibiotics/antifungals decreases effectiveness of anti-infective drug

Meperidine, flurazepam, phenothiazine (sedation) increased effect of cholinergic blocker Tricyclic antidepressants increased effect of cholinergic blocker Haloperidol decreased effectiveness of antipsychotic drug Digoxin increased serum levels of digoxin OTC: Some Allergy, Cold-Symptom & Sleep-Aids already contain atropine, scopolamine or other cholinergic blocking dugsread label NURSING INTERVENTIONS *I&Os, check for urinary retention (including bowel soundsconstipation) *Respiratory status: rate, rhythm, cyanosis, wheezing, dyspnea, engorged neck veins *Increased intraocular pressure: S/S blurred vision, increased tearing *Do not perform strenuous activity in high temperatures; heat stroke may result *DO NOT SKIP A DOSE

Belladonna
ACTION Cholinergic Blocking (Anti-Cholinergic) Medication USES Peptic Ulcer Digestive Disorders Diverticulitis Pancreatitis Diarrhea ADVERSE REACTIONS *Drowsiness, blurred vision, tachycardia, dry mouth, urinary hesitancy CONTRAINICATIONS *Patients with glaucoma, myasthenia gravis, tachyarrhythmias, myocardial infarction and congestive heart failure (unless bradycardia is present) *Used cautiously in patients with GI infections, benign prostatic hypertrophy, urinary retention, hyperthyroidism, hepatic/renal disease and hypertension.

*Atropine should be used cautiously in patients with asthma INTERACTIONS

Drug: Antibiotics/antifungals decreases effectiveness of anti-infective drug Meperidine, flurazepam, phenothiazine (sedation) increased effect of cholinergic blocker Tricyclic antidepressants increased effect of cholinergic blocker Haloperidol decreased effectiveness of antipsychotic drug Digoxin increased serum levels of digoxin OTC: Some Allergy, Cold-Symptom & Sleep-Aids already contain atropine, scopolamine or other cholinergic blocking dugsread label NURSING INTERVENTIONS *I&Os, check for urinary retention (including bowel soundsconstipation) *Respiratory status: rate, rhythm, cyanosis, wheezing, dyspnea, engorged neck veins *Increased intraocular pressure: S/S blurred vision, increased tearing

*Do not perform strenuous activity in high temperatures; heat stroke may result *DO NOT SKIP A DOSE

Scopolamine
ACTION Cholinergic Blocking (Anti-Cholinergic) Medication USES Preanesthetic Sedation Motion Sickness ADVERSE REACTIONS *Confusion, dry mouth, constipation, urinary hesitancy, urinary retention, blurred vision CONTRAINICATIONS *Patients with glaucoma, myasthenia gravis, tachyarrhythmias, myocardial infarction and congestive heart failure (unless bradycardia is present) *Used cautiously in patients with GI infections, benign prostatic hypertrophy,

urinary retention, hyperthyroidism, hepatic/renal disease and hypertension. *Atropine should be used cautiously in patients with asthma INTERACTIONS
Drug: Antibiotics/antifungals decreases effectiveness of anti-infective drug Meperidine, flurazepam, phenothiazine (sedation) increased effect of cholinergic blocker Tricyclic antidepressants increased effect of cholinergic blocker Haloperidol decreased effectiveness of antipsychotic drug Digoxin increased serum levels of digoxin OTC: Some Allergy, Cold-Symptom & Sleep-Aids already contain atropine, scopolamine or other cholinergic blocking dugsread label NURSING INTERVENTIONS

*I&Os; retention commonly causes decreased urinary output *Watch for shuffling gait, muscle rigidity, involuntary movements *Constipation: increase fluids, bulk, exercise *Mental status change, altered mood, CNS depression/symptoms can worsen on this medication

*Administer parenteral dose slowly; stay in bed for at least 1 hr after dose *Give at bedtime to avoid daytime drowsiness *Hard candy, frequent drinks, sugarless gum to relieve dry mouth *Takes 1 week to taper off, if discontinued

Oxybutynin
(Ditropan)
ACTION Cholinergic Blocking Urinary Antispasmodics USES Overactive Bladder Neurogenic Bladder ADVERSE REACTIONS *Dry mouth, nausea, headache, drowsiness, constipation, urinary retention CONTRAINICATIONS

*Patients with glaucoma, myasthenia gravis, tachyarrhythmias, myocardial infarction and congestive heart failure (unless bradycardia is present) *Used cautiously in patients with GI infections, benign prostatic hypertrophy, urinary retention, hyperthyroidism, hepatic/renal disease and hypertension. *Atropine should be used cautiously in patients with asthma INTERACTIONS Drug: Antibiotics/antifungals decreases effectiveness of anti-infective drug

Meperidine, flurazepam, phenothiazine (sedation) increased effect of cholinergic blocker Tricyclic antidepressants increased effect of cholinergic blocker Haloperidol decreased effectiveness of antipsychotic drug Digoxin increased serum levels of digoxin OTC: Some Allergy, Cold-Symptom & Sleep-Aids already contain atropine, scopolamine or other cholinergic blocking dugsread label

NURSING INTERVENTIONS *Assess urinary patters: distention, nocturia, frequency *Monitor CNS effects: confusion, anxiety, ESPECIALLY in the elderly *Avoid hazardous activities due to dizziness/blurred vision *To prevent photophobic, wear sunglasses *Avoid hot weather, strenuous activity, drug decreased perspiration

CHOLINESTERASE INHIBITORS Acetylcholine is the transmitter in the cholinergic neuropathways. Individuals with early Alzheimers disease (AD) experience degeneration of these cholinergic neuro-pathways. As a result, the patient experience problems with memory and thinking.

Cholinesterase Inhibitors: act to increase the level of acetylcholine in the central nervous system (CNS) by inhibiting its breakdown and slowing neural destruction. Examples: Donepezil (Aricept) and Tacrine (Cognex) Report immediately any elevated ATL (alanine amino-transferase) level; danger of hepatoxicity Levels should be obtained at least 4-16 weeks, and Q 3 months after that Abrupt discontinuation may cause a decline in cognitive function

Donepezil
(Aricept)

ACTION

Cholinesterase Inhibitor Slows down degenerati on of cholinergic neuropathways Mild to moderate dementia due to Alzheimers disease (AD)

*In individuals with a history of ulcer disease, bleeding may occur INTERACTIONS

USES

ADVERSE REACTIONS *Headache, N/D, insomnia, muscle cramps CONTRAINIDCATIONS *Patients who are pregnant; used cautiously in patients with renal/hepatic disease, bladder obstruction, seizure disorder, sick sinus syndrome, gastrointestinal (GI) bleed and asthma.

Drug: Anticholinergics (decrease bodily secretions) decreased effectiveness of anticholinergic NSAIDs increased risk of GI bleeding Theophylilne increased risk of theophyliline toxicity Herbal: Ginseng contraindicated in patients who are pregnant or have hypertension Ginkgo excessively large doses have been reported to cause N/V/D and restlessness. It is contraindicated in patients taking MAOIs because of risk of toxic reactions, and patients on anticoagulants

NURSING INTERVENTIONS

*Report immediately any elevated ATL(alanine aminotransferase) level ; danger of hepatoxicity -Abrupt discontinuation may cause a decline in cognitive function *Administer between meals: may be given with meals for GI symptoms *Assist with ambulation during beginning therapy; dizziness, ataxia may occur *Report twitching, N/V, sweating= indicates overdose *This drug is NOT a cure, it relieves symptoms

USES

neuropathways Mild to moderate dementia due to Alzheimers disease (AD)

ADVERSE REACTIONS *N/V/D, dizziness, headache, elevated liver function CONTRAINIDCATIONS

*Patients who are pregnant; used cautiously in patients with renal/hepatic disease, bladder obstruction, seizure disorder, sick sinus syndrome, gastrointestinal (GI) bleed and asthma. *In individuals with a history of ulcer disease, bleeding may occur *Tacrine is particularly damaging to the liver and can result in hepatoxicity. -Patients should have blood drawn periodically for liver function tests

Tacrine
(Cognex)
ACTION Cholinesterase Inhibitor Slows down degenerati on of cholinergic

INTERACTIONS
Drug:

Anticholinergics (decrease bodily secretions)decreased effectiveness of anticholinergic NSAIDs increased risk of GI bleeding Theophylilne increased risk of theophyliline toxicity Herbal: Ginseng contraindicated in patients who are pregnant or have hypertension Ginkgo excessively large doses have been reported to cause N/V/D and restlessness. It is contraindicated in patients taking MAOIs because of risk of toxic reactions, and patients on anticoagulants

danger of hepatoxicity -Levels should be obtained at least 416 weeks, and Q 3 months after that -Abrupt discontinuation may cause a decline in cognitive function *Administer between meals; may be given with meals for GI symptoms *Assist with ambulation during beginning therapy; dizziness, ataxia may occur *Report twitching or eye spasms = indicates overdose

NURSING INTERVENTIONS *Report immediately any elevated ATL(alanine aminotransferase) level ;

ANTI-PARKINSON MEDICATION Parkinsonism: is a term that refers to a group of symptoms involving

motor movements. Tremors, rigidity and slow movement (bradykinesia), slurred speech,

masklike or emotionless facial expressions, difficulty chewing/swallowing, unsteady or shuffled gait, with the upper body bent slightly forward Although Parkinson-like symptoms may be seen with the use of certain drugs, head injuries and encephalitis, but Parkinsons disease is the most common form of parkinsonism. Drugs used to treat the symptoms associated with parkinsonism are called Antiparkinsonism drugs. Dopaminergic Drugs or MAOIs: drugs that supplement the dopamine in the brain Examples: amantadine (Symmetrel), levodopa, selegiline Anticholinergics: Blocks excess acetylcholine (Ach) for better transmission of nerve impulses occur Examples: benztropine (Cogentin), diphenhydramine (Benadryl)

Amantadine
(Symmetrel) ACTION Antiparkinsonism medication Dopaminergic (Dopamine supplement) drug USES Parkinsons disease Drug-induced extra-pyramidal syndrome (EPS) Prevention and treatment of infection with influenza A virus ADVERSE REACTIONS *Lightheadedness, dizziness, insomnia, confusion, nausea,

constipation, dry mouth, orthostatic hypotension, depression

CONTRAINDICATIONS *Patients who are pregnant, history of epilepsy or other seizures, CHF INTERACTIONS Drug: Tricyclic antidepressants increased risk of hypertension & dyskinesia NURSING PRECAUTIONS *If dizziness, drowsiness or blurred vision occurs, avoid driving or hazardous activities

*Relieve dry mouth by sucking on hard candy *Monitor for orthostatic hypotension *Hallucinations occur more often in the older adult than in the younger adult receiving antiparkinsonism drugs, especially dopamine receptor agonists. The incidence of hallucinations appears to increase with age.

ADVERSE REACTIONS
*Diarrhea, hallucinations, melanoma, somnolence, body fluid discoloration (urine, saliva, sweat red, brown, black in color)

CONTRAINIDCATIONS
*Hypersensitivity to Anti-Parkinsons, use of MAO inhibitor therapy with/in prior 14 days, narrow-angle glaucoma, undiagnosed skin lesions or history of melanoma

INTERACTIONS Drug:

Levodopa Pg.743
(Carbidopa, Entacapone, Stalevo) ACTION Anti-Parkinsons Agent USES Dopamine Precursor

Alcohol enhance CNS depressant effect Antipsychotics diminish anti-Parkinsons agent CNS depressants MAO inhibitors enhance toxic/adverse effects

NURSING PRECAUTIONS

*Swallow tablet whole: do NOT crush, break/chew *May result in false-negative for glucsouria *Monitor CBC, liver & renal function tests, BP, mental status, S/S neuroleptic malignant syndrome *Monitor iron levels in anemic patients *Monitor IOP in patients with glaucoma **Monitor for choreiform and dystonic movements such as facial grimacing, protruding tongue, exaggerated chewing motion and head movements, jerking movement of arms and legs. If these occur, hold the next dose and notify MD

*Do not abruptly discontinue use of levodopa, a neuroleptic malignant-like syndrome may occur or when dosage is reduced. Observe for muscular rigidity, elevated body temperature and mental changes. *When taking levodopa, avoid Vit B6 (pyridoxine) because this vitamin may interfere with the action of levodopa.

ANTICONVULSANTS
activity

A seizure is defined as periodic disturbances of the brains electrical Convulsion and seizure are interchangeable Seizure Disorders are categorized as idiopathic, hereditary or
acquired. Seizures caused by disease, such as epilepsy, may be a permanent, recurrent seizure

disorder. Examples of the known causes of epilepsy include brain injury at birth, head injuries, inborn errors of metabolism and sometimes are never determined. Each seizure disorder is characterized by a specific pattern of events, as well as a different pattern of motor or sensory manifestations.

Anticonvulsants are used in the management of seizure disorders.

Examples: Phenytoin (Dilantin), Phenobarbital (Luminal), Diazepam (Valium), Lorazepam (Ativan)

Partial seizures: most common type of epileptic seizure, localized in the brain; motor seizures with uncontrolled stiffening or jerking in one part of the body such as the finger, mouth, hand or foot that may progress to the entire limb. They may present as flashing lights or a change in taste or speech (somatosensory seizure). Generalized seizures: involve a loss of consciousness and may or may not include convulsive movements. Manifestations of a generalized tonic-clonic seizure include alternate contraction and relaxation of muscles, a loss of consciousness and abnormal behavior. Myoclonic seizures involve sudden, forceful contractions of single of multiple groups of muscles.

Phenytoin
(Dilantin) ACTION
Anticonvulsant medication

*Patients with bradycardia, AV blocks, hepatic abnormalities, glaucoma or increased intraocular pressure. *Should not be given to pregnant patients, increased risk children will be born with birth defects INTERACTIONS
Drug: Antibiotics/antifungals increased effect of anticonvulsant Tricyclic antidepressants increased effect of
anticonvulsant

USED
Tonic-clonic seizures Status Epilepticus Prophylactic seizures prevention

ADVERSE REACTIONS
*Ataxia, CNS depression, headache, hypotension, nystagmus (constant involuntary eye movement), mental confusion, slurred speech, dizziness, drowsiness, N/V, gingival hyperplasia (overgrowth of gum tissue), rash

CONTRAINDICATIONS

Salicylates increased effect of anticonvulsant Cimetidine increased effect of anticonvulsant Theophylline decreased serum levels of anticonvulsant Antiseizure medication may increase seizure activity Oral contraceptives decreased effectiveness of birth control, resulting in bleeding or pregnancy

Analgesic or alcohol increased depressant effect Antidiabetic medication increased blood glucose levels

ACTION Anticonvulsant medication USED Status epilepticus Cortical Focal seizures Tonic-clonic seizures ADVERSE REACTIONS *Somnolence, agitation, confusion, ataxia, CNS depression, nervousness, N/V/D, constipation, rash CONTRAINDICATIONS *Patients with bradycardia, AV blocks, hepatic abnormalities, glaucoma or increased intraocular pressure. *Should not be given to pregnant patients, increased risk children will be born with birth defects

NURSING PRECAUTIONS *Status epliepticus may result from abrupt discontinuation *Phenyotin is usually discontinued if a skin reaction occurs: red rash with scaling of skin, pupuric small hemorrhages or bruising or bullous (skin vesicles with fluid, blisters). *Phenyotin can cause hematologic changes (aplastic anemia, leucopenia and thrombocytopenia). S/S of thrombocytopenia: bleeding gums, easy bruising, increased menses, tarry stools. S/S of leucopenia: sore throat, chills, swollen glands, excessive fatigue, SOB. *Signs of drug toxicity: slurred speech, ataxia, lethargy, dizziness, N/V, nystagmus & mental status changes. Levels should be between 10-20 mcg/mL.

Phenobarbital
(Luminal)

INTERACTIONS Drug:

Antibiotics/antifungals increased effect of anticonvulsant

Tricyclic antidepressants increased effect of anticonvulsant Salicylates increased effect of anticonvulsant Cimetidine increased effect of anticonvulsant Theophylline decreased serum levels of anticonvulsant
Antiseizure medication may increase seizure activity

*May cause daytime drowsiness, avoid driving and other hazardous tasks *Avoid alcohol or other CNS depressants *Use alternative form of birth control *Take VS prior to administration

Diazepam Pg. 404

(Valium)
ACTION Benzodiazepines Sedative USES Anxiety disorders (short term relief of anxiety) Acute alcohol withdrawal Anticovulsant Preoperative muscle relaxant ADVERSE REACTIONS *Transient mild drowsiness, lightheadedness, headache, depression, constipation, diarrhea, dry mouth CONTRAINICATIONS

Oral contraceptives decreased effectiveness of birth control, resulting in bleeding or pregnancy Analgesic or alcohol increased depressant effect Antidiabetic medication increased blood glucose levels NURSING PRECAUTIONS *Take missed doses as soon as remembered if not almost time for next dose: DO NOT double doses

*Hypersensitivity to benzos, myasthenia gravis, severe respiratory insufficiency, severe hepatic insufficiency, sleep apnea syndrome, acute narrow-angle glaucoma, not for use in children under 6 months of age *Narcotic dosages should be reduced by approximately 1/3 when valium is added *Fall risk: use extreme caution in patients who are at risk of falls INTERACTIONS

St. Johns Wort, valerian, kava kava, gotu kola increases CNS depression Yohimbine may diminish the therapeutic effect of anti-anxiety agent

NURING PRECAUTIONS
*Monitor CBC, liver function tests *Observe patient for excess sedation, respiratory depression, suicidality (example: suicidal thoughts, depression, behavioral changes) *Risk of addiction *Taper dosage slowly when discontinuing *Take exactly as direction; do NOT increase dose/frequency

Drug: CNS depressants enhances adverse/toxic effect of other CNS depressants Analgesis increased risk for CNS depression Tricyclic antidepressants increased risk for sedation and respiratory depression Antipsychotics increased risk for sedation and respiratory depression Digoxin increased risk for digitalis toxicity Food: Alcohol increased risk for CNS depression or convulsions Herbal:

Lorazepam Pg. 762

(Ativan)
ACTION Benzodiazepines Sedative USES

Anxiety disorders (short term relief of anxiety) Pre-anesthetic ADVERSE REACTIONS *Transient mild drowsiness, lightheadedness, headache, depression, constipation, diarrhea, dry mouth CONTRAINICATIONS *Hypersensitivity to benzos, patients with sleep apnea, severe respiratory insuifficency, CNS depression, anterograde amnesia, patients who are a fall risk INTERACTIONS Drug: CNS depressants enhances adverse/toxic effect of other CNS depressants Analgesis increased risk for CNS depression Tricyclic antidepressants increased risk for sedation and respiratory depression Antipsychotics increased risk for sedation and respiratory depression

Digoxin increased risk for digitalis toxicity Food: Alcohol increased risk for CNS depression or convulsions Herbal: St. Johns Wort, valerian, kava kava, gotu kola increases CNS depression Yohimbine may diminish the therapeutic effect of anti-anxiety agent NURSING PRECAUTIONS *Oral: assess history of addiction, longterm use can result in dependence, abuse or tolerance *Avoid alcohol, OTC medications (especially pain medication, sedatives, antihistamines and hypnotics) *Maintain adequate hydration *IM/IV: monitor vital signs and CNS status (possible retrograde amnesia with I.V.) and ability to void

SKELETAL MUSCLE RELAXANTS

A variety of drugs are used in treating musculoskeletal (bone and
muscle) injuries and disorders. Skeletal muscle relaxants are used to assist in the relaxing certain muscle groups, as strain and sprains are repaired. Many of these drugs do not directly relax skeletal muscles, but their ability to relieve acute painful musculoskeletal conditions may be due to their sedative actions Cyclobenzaprine (Flexeril) appears to have an effect on muscle tone, thereby reducing muscle spasm Carisoprodol (Soma) provides relief of discomfort from acute musculoskeletal pain

Cyclobenzaprine
(Flexeril, Amrix)

ACTION Skeletal Muscle Relaxant USES Relief of discomfort due to acute, painful musculoskeletal conditions ADVERSE REACTIONS *Drowsiness, dizziness, dry mouth, nausea, constipation CONTRAINDICATIONS

*Used cautiously in patients with CVS, cerebral palsy, parkinsonism , pregnancy or seizure disorder *Used with caution in patients with cardiovascular disease INTERACTIONS Drug: CNS depressants/alcohol/antihistamines/ opiates/sedativesincrease CNS depression MAOIs risk for high fever and convulsions Haloperidol increased psychosis

Antihypertensives increased risk of hypotension NURSING PRECAUTIONS *This drug may cause drowsiness. Do not drive or other hazardous tasks *This drug is for short-term use. Do NOT use longer than 2 -3 weeks *Avoid alcohol and other CNS depressants while taking drug

Musculoskeletal Relaxant USES Relief of discomfort due to acute, painful musculoskeletal conditions ADVERSE REACTIONS *Dizziness, drowsiness, tachycardia, nausea, vomiting CONTRAINDICATIONS *In patients with recent MI, cardiac conduction disorder and hyperthyroidism. *Contraindicated within 14 days of a MAOI *Used cautiously in patients with severe liver or kidney disease and during pregnancy

Carisoprodol
(Soma)

ACTION

INTERACTIONS Drug: CNS depressants/alcohol/antihistamines/ opiates/sedativesincrease CNS depression MAOIs risk for high fever and convulsions Haloperidol increased psychosis Antihypertensives increased risk of hypotension NURSING PRECAUTIONS

*This drug may cause drowsiness. Do not drive or other hazardous tasks *This drug is for short-term use. Do NOT use longer than 2 -3 weeks *Avoid alcohol and other CNS depressants while taking drug

BONE RESORPTION INHIBITORS: Bisphosphonates

Bisphosphonates are drugs used to treat musculoskeletal
disorders such as osteoporosis, Pagets disease and bone cancers.

They act primarily on the bone by inhibiting normal and abnormal bone resorption. This results in increased bone mineral density, reversing the progression of osteoporosis. Example: Alendronate (Fosamax), ibandronate (Boniva)

Alendronate

(Fosamax)

ACTION Bone Resorption Inhibitors: Bisphosphonates USES Treatment and prevention of postmenopausal osteoporosis Glucocorticoid-steroid induced osteoporosis Osteoporosis in men Pagets disease

impairment. Concurrent use of these drugs with hormone replacement therapy is NOT recommended *Used cautiously in patients with GI disorders or renal impairment. INTERACTIONS Drug: Ca+ supplements or Antacids decreased effectiveness of bisphosphonates Aspirin increased risk of GI bleed

ADVERSE REACTIONS *Abdominal pain, esophageal reflux

Therophylline increased risk of theophylline toxicity

CONTRAINDICATIONS
*In patients with hypocalcemia, patients with delayed esophageal emptying or renal

NURSING PRECAUTIONS *Take these drugs with 6-8 oz of water first thing in the morning *Do not lie down for at least 30 minutes after taking the drug and wait at least 30 mins before taking any other food or drink *Take supplement calcium and vitamin D if dietary intake is inadequate

ANTI-RHEUMATIC & URIC ACID INHIBITORS

Anti-Rheumatic Drugs Rheumatoid Arthritis is a chronic disorder (an autoimmune disease) involving the inflammation and accumulation of fluid in joints This condition is typically treated using three classification of drugs (1) NSAIDs, (2) corticosteroids and (3) DMARDs Disease-Modifying Antirheymatic Drugs: have properties to produce immunosuppression, which in turn decreases the bodys autoimmune response. Example: Methotrexate (MTX) (Rheumatrex) DMARDs may also be used for other purpose, such as cancer therapy Uric Acid Inhibitors (Gout) Drugs Gout is a condition in which uric acid accumulates in increased amounts in the blood and often is deposited in the joints. The deposit or collection or urate crystals in the joints causes the symptoms (pain, redness, swelling, joint deformity) of gout.

These medications reduce the production of uric acid, thereby decreasing serum uric acid levels and the deposit of urate crystals in joints. This probably accounts for its ability to relieve the severe pain of acute gout. Example: Allopurinol (Zyloprim) and Colchicine

*Nausea, stomatitis, alopecia

Methotrexate (MTX)
(Rheumatrex)
ACTION Anti-Rheumatic medication Disease-Modifying Anti-Rheumatic medication USES Rheumatoid Arthritis Cancer chemotherapy ADVERSE REACTIONS

CONTRAINDICATIONS *Patients with renal insufficiency, liver disease, alcohol abuse, pancytopenia, or folate deficiency *Used cautiously in patients with obesity, diabetes, and hepatitis B and C *Women should not become pregnant, and sexual partners should use barrier contraception to prevent transmission of the drug by semen INTERACTIONS

Drug: Sulfa Antibiotics increased risk of methotrexate toxicity Aspirin and NSAIDs increased risk of methotrexate toxicity NURSING PRECAUTIONS *Because DMARDs are designed to produce immunosuppression, patients need to be monitored routinely for infections. Instruct patients to report any problems, no matter how minor, such as a cold or open soreeven these can become life threatening. *When taking methotrexate, use a calendar or some memory device to remember to take the drug on the same day each week. *Call MD immediately if you have: sore mouth or sores in the mouth, N/V/D, fever, sore throat, easy bruising, rash or itching

Colchicine
ACTION Uric Acid Inhibitor USES Relief of acute attacks of gout Prevention of gout attacks ADVERSE REACTIONS *N/V/D, abdominal pain, bone marrow depression CONTRAINDICATIONS *In patients with serious GI, renal, hepatic, or cardiac disorder and those with blood dyscrasias

*Used cautiously in older adults INTERACTIONS Drug: Ampicillin increased risk of rash Theophylline increased risk of theophylline toxicity Al-based antacids decreased effectiveness of medication NURSING PRECAUTIONS *Drink at least 10 glasses of water/day

until the acute attack has subsided *Take this drug with food to minimize GI upset *If drowsiness occurs, avoid driving or performing hazardous tasks *Acute goutnotify MD if symptoms are not relieved in a few days *Call MD if rash occurs

ANTIHISTAMINES & DECONGESTANTS

Antihistamines: histamines are produced in response to an allergic reactions or tissue injury. It acts on areas such as the vascular system

and smooth muscle, producing dilating of arterioles and an increased permeability of capillaries and venules. Antihistamines are used to block the cell receptors, this counteracting the effects of histamine on body organs and structures. Examples: diphenhydramine (Benadryl), loratatine (Claritin), fexofendaine (Allegra) and cetirizine (Zyrtec) Decongestants: are drugs that reduces swelling of the nasal passages, which in turn, opens clogged nasal passages and enhances drainage of the sinuses. These drugs are used for the temporary relief of nasal congestion caused by the common cold, hay fever, sinusitis and other respiratory allergies. Examples: pseudoephedrine (Sudafed)

Diphenhydramine
(Benadryl) ACTION USES

*Contraindicated in newborns, premature infants and nursing mothers; pt taking MAOIs, pts with angle-closure glaucoma, stenosing peptic ulcer, symptomatic prostatic hypertrophy and bladder neck obstruction INTERACTIONS
Drug: Rifapin may reduce absorption of antihistamins MAOIs increase anticholinergic & sedative effect CNS depressants possible additive CNS depressant effect Beta-Blockers risk for increased cardiovascular effects Al or Mg antacids decreased concentrations of drug in blood

Antihistamine
Allergic symptoms Hypersensitivity reactions

Anaphylaxis Transfusion reactions Motion sickness Sleep aid Antitussive Antiparkinsomism effects

ADVERSE REACTIONS *Drowsiness, dry mouth, anorexia, blurred vision, urinary frequency CONTRAINDICATIONS

NURSING PRECAUTIONS

*Older adults are more likely to experience anticholinergic effects (dry mouth, nose, throat, dizziness, sedation, hypotension & confusion) *Monitor older adult for sensorimotor deficits: hearing loss, visual impairment, unsteady gait

USES
Seasonal rhinitis Urticaria Allergic rhinitis

*Do not perform hazardous tasks: watch for drowsiness *Avoid alcohol

ADVERSE REACTIONS *Drowsiness, dry mouth, glossitis, nose bleeds, sedation, somnolence, dizziness, headache, fatigue CONTRAINDICATIONS
*Contraindicated in newborns, premature infants and nursing mothers; pt taking MAOIs, pts with angleclosure glaucoma, stenosing peptic ulcer, symptomatic prostatic hypertrophy and bladder neck obstruction

Cetirizine Loratadine
(Zrytec) (Claritin)

Fexofenadine Levocetirizine
(Allergra) ACTION (Xyzal) Antihistamine

INTERACTIONS

Drug:
Rifapin may reduce absorption of antihistamins MAOIs increase anticholinergic & sedative effect CNS depressants possible additive CNS depressant effect Beta-Blockers risk for increased cardiovascular effects Al or Mg antacids decreased concentrations of drug in blood

Pseudoephedrine
(Sudafed) ACTION Decongestant USES Nasal Decongestant ADVERSE REACTIONS *Anxiety, restlessness, anorexia, arrhythmias, nervousness, nausea, vomiting, blurred vision CONTRAINDICATIONS *Pts taking MAOIs or patients younger than 12 years old. Used cautiously in patients with: thyroid disease, diabetes mellitus, CV disease,

NURSING PRECAUTIONS

*Older adults are more likely to experience anticholinergic effects (dry mouth, nose, throat, dizziness, sedation, hypotension & confusion) *Monitor older adult for sensorimotor deficits: hearing loss, visual impairment, unsteady gait *Do not perform hazardous tasks: watch for drowsiness *Avoid alcohol *Loratadine should be taken on an empty stomach

prostatic hypertrophy, CAD, PVD, hypertension, glaucoma

INTERACTIONS Drug: MAOIs severe headache, hypertension and possible hypertensive crisis Beta-blockersinitial hypertension episode followed by bradycardia NURSING PRECAUTIONS *Because it is OTC, nurses need to stress importance of patient checking with the MD first before taking if history of heart disease, hypertension, hyperthyroidism, glaucoma and diabetes.

*Patients old than 60 years old are at greater risk for experiencing side effects *Over-dosages may cause hallucinations, convulsion and CNS depression *If symptoms do not improve in 7 days or are accompanied by a high fever, call MD

Mometasone furoate monohydrate

(Nasonex) Pg. 343 ACTION Glucocorticoid USES Antiasthmatic, anti-inflammatory

ADVERSE REACTIONS
CNS: Headache, CV: Chest pain EENT: Cataracts, conjunctivitis, dry mouth, earache, epistaxis, glaucoma, nasal irritation, oral and pharyngeal candidiasis, otitis media, pharyngitis, rhinitis, sinusitis, throat tightness, unpleasant taste, ENDO: Adrenal insufficiency, growth suppression, GI: Diarrhea, dyspepsia, nausea, vomiting, GU: Dysmenorrhea MS: Arthralgia, decreased bone mineral density, myalgia, pain, RESP: Asthma, bronchitis, bronchospasm, increased cough, upper respiratory tract infection, wheezing SKIN: Urticaria, Other: Angioedema, flulike symptoms, viral infection

asthmaticus or other asthma episodes that require emergency care INTERACTIONS Drug: Ketoconazoleincreased levels of
Mometasone

NURSING PRECAUTIONS

CONTRAINDICATIONS Hypersensitivity to mometasone or its components; recent septal ulcers, nasal surgery, or nasal trauma; status

*Use cautiously if patient has tubercular infection; untreated fungal, bacterial, or systemic viral infection; ocular herpes simplex. *Monitor patient for symptoms of systemically active corticosteroid withdrawal such as joint and muscle pain, lassitude, and depression despite maintenance or even improvement of respiratory symptoms. *Notify prescriber immediately if patient has bronchospasm after mometasone oral inhalation, and expect to administer a fast-acting inhaled bronchodilator. Report oropharyngeal candidiasis, and expect patient to receive appropriate antifungal therapy.

Guaifenesin
(Mucinex)

Pg. 610

ACTION Glyceryl guaiacolate Expectorant USES To relieve cough, when secretions are thick ADVERSE REACTIONS CNS: Dizziness, headache GI: Nausea and vomiting (with large doses) SKIN: Rash, urticaria CONTRAINDICATIONS *Hypersensitivity to guaifenesin

INTERACTIONS
Drug: None significant NURSING PRECAUTIONS *As prescribed and as appropriate, give liquid forms of guaifenesin to children. *Watch for signs of more serious condition, such as cough that lasts longer than 1 week, fever, persistent headache, and rash. *Instruct patient to take each dose with a full glass of water. *Advise patient not to break, crush, or chew E.R. tablets but to swallow them

whole. *Instruct patient to increase fluid intake (unless contraindicated) to help thin secretions. *Advise patient not to take drug longer than 1 week and to notify prescriber about fever, persistent headache, or rash.

BRONCHODILATORS
Bronchodilators: (two types of bronchodilators) When
bronchospasm occurs, there is a decrease in the lumen of the bronchi, which decreases the amount of air taken into the lungs with each breath. A decrease in the amount of air taken into the lungs results in respiratory distress. Use of a bronchodilating drug opens the bronchi by relaxing the smooth muscle and allows more air to enter the lungs, which, in turn completely or partially relieves respiratory distress. 2 Adrenergic agonists (sympathomimetics: When the sympathetic system in the lungs are stimulated, bronchoconstriction results. During bronchodilation, -adrenergic receptors are stimulated.

Short-acting: Albuterol (Proventil, Ventolin) and Terbutaline (Brethine) Long-acting: Salmeterol (Serevent Diskus) Xanthine Derivative Bronchodilator: (also called methylxanthines). They stimulate the central nervous system to promote bronchodilation. The cause direct relaxation of the smooth muscles of the bronchi.
(Ventolin, Volmax, Proventil, Provenil)

ACTION Bronchodilator Inhaler USES Bronchospasm, bronchitis, emphysema Acute & Chronic bronchial asthma

Albuterol

ADVERSE REACTIONS *Headache, palpitations, tachycardia, tremor, dizziness, shakiness, nervousness, hyperactivity, vertigo CONTRAINIDATIONS *Contraindicated in patients with cardiac arrhythmias associated with tachycardia, organic brain damage & cerebral arteriosclerosis, patients with history of seizures and patients who are pregnant INTERACTIONS

Beta-adrenergic blockers (hypertension) inhibits the cardiac, bronchodilating & vasodilating effects of the adrenergic methyldopa (hypertensive med) possible hypotension oxytocic drugs possible severe hypotension theophylline (asthma/COPD med) increased risk for cardiotoxicity

NURSING PRECAUTIONS
*Monitor for signs/symptoms of fine tremor in fingers, CNS stimulation (particularly in children 2-6 y), excitement, nervousness, insomnia, tachycardia, GI symptoms *Lab tests: periodic ABGs, pulse oximetry and pulmonary function *Avoid contact of inhalation drug with eyes *Do not use OTC drugs without physician approval, including cold medicine

Drug: Adrenergic drugs possible additive adrenergic effects Tricyclics (anti-depressives) possible hypotension

Levalbuterol HCl
(Xopenex) ACTION

Bronchodi lator Inhaler

USES Treat and prevent bronchospasm ADVERSE REACTIONS *Tachycardia, nervousness, anxiety, pain, dizziness, rhinitis, cough, cardiac arrhythmias CONTRAINDICATIONS *Hypersensitivity to other sympathomimetic amines * Use levalbuterol cautiously in patients with arrhythmias, diabetes mellitus, hypertension, hyperthyroidism, or a history of seizures.

INTERACTIONS Drug: Beta blockers blocks effect of both drugs Digoxin decreased blood digoxin levels Diuretics increased risk of hypokalemia
MAOI & tricyclic antidepressants increased risk of adverse cardiovascular effects

NURSING PRECAUTIONS *Monitor the patients pulse and BP before and after nebulizer treatment * Because drug may provoke paradoxical bronchospasm, observe for dyspnea, wheezing, and increased coughing. * Show patient how to clean nebulizer or inhaler, and explain the need to do

so at least once weekly

CONTRAINDICATIONS * Angina, cerebral arteriosclerosis, dilated heart failure, heart block from digitalis toxicity, hypersensitivity to metaproterenol or its components, labor, local anesthesia, organic brain damage, tachyarrhythmias INTERACTIONS Drug:
Beta blockers increased risk of bronchospasm

Metaproterenol Sulfate
(Alupent) ACTION Bronchodilator Inhaler & Tablets USES Asthma Bronchospasm ADVERSE REACTIONS *Tachycardia, tremor, nervousness, shakiness, nausea, vomiting

MAOIs & Tricyclic antidepressants possibly potentiated cardiovascular effects Other sympathomimetics possibly additive effects of both drugs & risk of toxicity Theophylline increased risk arrhythmias NURSING PRECAUTIONS

* Anticipate that a single dose of nebulized metaproterenol may not completely stop an acute asthma attack. *Signs of toxicity: diarrhea, increased shortness of breath, insomnia, or irregular heartbeat occur * Advise patient to use metaproterenol 5 minutes before using corticosteroid inhaler, if prescribed, to maximize airway opening and drug effects * Caution patient not to use metaproterenol inhaler or nebulizer more often than prescribed.

ACTION Bronchodilator Inhaler, SubQ USES Treat & Prevent bronchospasm ADVERSE REACTIONS *Palpitations, tremor, dizziness, vertigo, shakiness, nervousness, drowsiness, headache, nausea, vomiting, gastrointestinal (GI) upset CONTRAINDICATIONS * Use terbutaline cautiously in patients with cardiovascular disease because drug can adversely affect cardiovascular function. Monitor patients heart rate and rhythm and blood pressure, and assess for chest pain. INTERACTIONS Drug:

Terbutaline Sulfate
(Brethine)

antihypertensives, diuretics Decreased antihypertensive effect beta blockers increased risk of bronchospasm

CNS stimulants Additive CNS stimulation Digoxin Increased risk of arrhythmias, possibly digitalis toxicity halogenated anesthetics Possibly ventricular arrhythmias MAOIs, tricyclic antidepressants headache, hyperpyrexia, hypertension, possible hypertensive crisis Nitrates Decreased effectiveness of nitrates Ritodrine Increased effects of either drug and potential for adverse effects Sympathomimetics Increased CNS stimulation and risk of adverse cardiovascular effects, including prolonged QT interval thyroid hormones Increased effects of either drug, risk of coronary insufficiency in patients with coronary artery disease xanthines (theophylline) Increased CNS stimulation and other additive toxic effects

* Inform patient that she may experience transient nervousness or tremors during terbutaline therapy * Assess patients respiratory rate, depth, and quality; oxygen saturation

Salmeterol Xinafoate
(Serevent Diskus)
ACTION Bronchodilator Oral inhalation powder USES Long-term treatment & prevention or bronchospasm ADVERSE REACTIONS *Tremor, headache, cough CONTRAINDICATIONS * Watch for arrhythmias and changes in blood pressure after use in patients with cardiovascular disorders, including ischemic cardiac disease, hypertension, and

Foods:

Caffeine Increased CNS stimulation and other additive toxic effects

NURSING PRECAUTIONS * For subcutaneous use, inject into lateral deltoid area

arrhythmias, because of drugs betaadrenergic effects INTERACTIONS Drug: atazanavir, clarithromycin, indinavir, itraconazole, ketoconazole, nefazodone, nelfinavir, ritonavir, saquinavir, telithromycin increased risk of adverse cardio effects beta blockers Mutual inhibition of therapeutic effects loop or thiazide diureticsIncreased risk of hypokalemia & potentially life-threatening arrhythmias MAO inhibitors, tricyclic antidepressants Potentiated adverse vascular effects, such as hypertensive crisis NURSING PRECAUTIONS * Be aware that salmeterol shouldnt be used to relieve bronchospasm quickly because of its prolonged onset of action and that patients already taking drug twice

daily shouldnt take additional doses for exercise-induced bronchospasm * Be aware that Serevent Diskus delivers full dose of salmeterol in only one inhalation * Stop salmeterol immediately and notify prescriber if patient develops paradoxical bronchospasm. Risk is greatest with first use of a new canister or vial used as an inhalant * Teach patient how to use the diskus by instructing him to slide the lever only once when preparing dose to avoid wasting doses. Advise him to exhale immediately before using the diskus and then to place mouthpiece to his lips and inhale through his mouth, not his nose. Then he should remove mouthpiece from his mouth, hold his breath for at least 10 seconds, and exhale slowly

Aminophylline

(Truphylline)
-ER tablets, oral liquid, tablets and rectal suppository
ACTION Bronchodilator Xanthine Derivative USES Symptomatic relief or prevention of bronchial asthma Reversible bronchospasm of chronic bronchitis & emphysema ADVERSE REACTIONS *Nausea, vomiting, restlessness, nervousness, tachycardia, tremors, headache, palpitations, hyperglycemia, electrocardiography changes, cardiac arrhythmias CONTRAINDICATIONS * Active peptic ulcer disease, hypersensitivity to aminophylline, rectal or lower intestine irritation or infection (suppository form), underlying seizure disorder INCOMPATIBILITIES *Don't add other drugs to prepared bag or bottle of aminophylline. Don't mix aminophylline in same syringe with doxapram. Also avoid administering amiodarone, cipro-floxacin, diltiazem, dobutamine, hydralazine, or ondansetron into the Y-port of a continuous infusion of aminophylline.
INTERACTIONS Drug: activated charcoal, aminoglutethimide, barbiturates,

ketoconazole, rifampin, sulfinpyrazone, sympathomimetics Decreased serum theophylline level allopurinol, calcium channel blockers, cimetidine, corticosteroids, disulfiram,

ephedrine, influenza virus vaccine, interferon, macrolides, mexiletine, nonselective beta blockers, oral contraceptives, quinolones, thiabendazole Increased serum theophylline level benzodiazepinesincreased sedative effects of benzodiazepines beta agonistsIncreased effects of aminophylline and beta agonist carbamazepine, isoniazid, loop diureticsAltered serum theophylline level halothane Increased risk of cardiotoxicity hydantoins Decreased serum hydantoin level ketamine Increased risk of seizures lithium Decreased serum lithium level nondepolarizing muscle relaxants Reversed neuromuscular blockade propofol increased sedative effects of propofol tetracyclines Enhanced adverse effects of theophylline Foods all foodsAltered bioavailability and absorption of E.R. aminophylline, leading to toxicity high-carbohydrate, low-protein diet Decreased theophylline elimination and prolonged aminophylline half-life low-carbohydrate, high-protein diet; charcoalbroiled beef Increased theophylline elimination and shortened aminophylline half-life Smoking increases effect of aminophylline Alcohol decreases effect of aminophylline

NURSING PRECAUTIONS * watch for evidence of toxicity (tachycardia, tachypnea, nausea, vomiting, restlessness, seizures). *Keep in mind that acetaminophen, furosemide, phenylbutazone, probenecid, theobromine, coffee, tea, soft drinks, and chocolate can alter serum theophylline result * Give immediate-release and liquid forms with food to reduce GI upset. Give E.R. form 1 hour before or 2 hours after meals because food can alter drug absorption *Aminophylline has a narrow therapeutic window (10 to 20 mcg/ml) * To determine peak serum theophylline level, draw blood sample 15 to 30 minutes after administering I.V. loading dose

Reversible bronchospasm of chronic bronchitis & emphysema

ADVERSE REACTIONS *Nausea, vomiting, restlessness, nervousness, tachycardia, tremors, headache, palpitations, hyperglycemia, electrocardiography changes, cardiac arrhythmias CONTRAINDICATIONS * Hypersensitivity to theophylline or its components, peptic ulcer disease, uncontrolled seizure disorder INTERACTIONS Drug:
adenosine Decreased adenosine effectiveness allopurinol, cimetidine, ciprofloxacin, clarithromycin, disulfiram, enoxacin, erythromycin, fluvoxamine, interferon alpha (human recombinant), methotrexate, mexiletine, pentoxifylline, propafenone, propranolol, tacrine, thiabendazole, ticlopidine, troleandomycin, verapamil Increased blood theophylline level and risk of toxicity aminoglutethimide, carbamazepine, isoproterenol (I.V.), moricizine, oral contraceptives (containing estrogen), phenobarbital, phenytoin, rifampin Decreased blood theophylline level and possibly drug effectiveness benzodiazepines Possibly reversal of benzodiazepine sedation beta blockers Possibly decreased bronchodilator effect of theophylline ephedrine Increased adverse effects, including insomnia, nausea, and nervousness halothane anesthetics Increased risk of ventricular arrhythmias ketamine Lowered seizure threshold lithium Decreased lithium effectiveness

Theophylline
(Theo-Dur, Theolair, Slo-bid, Unipyl)
-Capsules, Elixir, Oral Soultion, Syrup, Tablets, IV ACTION Bronchodilator Xanthine Derivative USES Symptomatic relief or prevention of bronchial asthma

neuromuscular blockers Possibly antagonized neuromuscular blockade sucralfate Decreased absorption of oral theophylline Foods high-carbohydrate, low-protein diet Possibly decreased theophylline elimination low-carbohydrate, high-protein diet; daily intake of charbroiled beef Possibly increased theophylline elimination Activities alcohol use Increased blood theophylline level and risk of toxicity smoking Increased drug clearance, decreased drug effectiveness

NURSING PRECAUTIONS * Be aware that E.R. capsules and tablets shouldnt be used for oral loading doses * Monitor blood theophylline level, as ordered, to gauge therapeutic level and detect toxicity * Frequently assess heart rate and rhythm because theophylline can exacerbate existing arrhythmias * Be especially alert for signs of toxicity in patient with acute pulmonary edema, hypothyroidism, influenza

vaccination, prolonged fever, sepsis with multiple organ failure, shock, or viral pulmonary infection because of decreased drug clearance * Suspect toxicity if patient experiences vomiting, and be prepared to obtain blood theophylline level * Instruct patient to take drug with a full glass of water on an empty s tomach (30 to 60 minutes before meals or 2 hours after meals). However, suggest that she take drug with food or antacids if GI distress occurs. *Encourage patient to take drug at the same times every day. *Advise patient to notify prescriber if she develops a fever, makes a significant dietary change, or starts or stops smoking or taking other drugs because these factors may alter blood theophylline level

ANTIASTHMAS
Inhaled Corticosteroids: ICSs are the most consistently
effective long-term control medication at all steps of care for persistent asthma. ICS and LABA drugs may be combined to ease administration of the medications and produce positive outcomes in management of asthma.

Example: Fluticasone (Flovent, Flonase)

ICS/LABA Combination: Anti-inflammatory medication that

reduce airway hyper-responsiveness, reduce the number of mast cells in the airways and block reaction to allergens. Examples: Budesonide/formoterol (Symbicort), Fluticasone/Salmeterol (Advair) Leukotriene Receptor Antagonists: Asthma attacks are often triggered by allergens or exercise. Inflammatory substance called leukotrienes are one of the several substances that are released by mast cells during an asthma attack. These medications are considered leukotriene receptor antagonists because they inhibit leukotriene receptor sites in the respiratory tract, preventing airway edema and facilitating bronchodilation. Example: Montelukast (Singulair)

Fluticasone

(Flovent, Flovent Diskus, Flonase) -Inhaled aerosol, nasal suspension

ACTION Antiasthma drug Inhaled Corticosteroid USES Prophylatic maintenance & treatment of asthma ADVERSE REACTIONS *Oral, laryngeal, pharyngeal irritation, fungal infections, suppression of HPA function CONTRAINDICATIONS *Hypersensitivity to fluticasone or its components, primary treatment of status asthmaticus or other acute asthma episodes that require intensive measures, untreated nasal mucosal infection (nasal suspension) * Although anaphylaxis is rare, monitor patient closely at start of therapy,

especially if patient has severe allergy to milk *Use fluticasone cautiously in patients with ocular herpes simplex, pulmonary tuberculosis, or untreated systemic bacterial, fungal, parasitic, or viral infection INTERACTIONS Drug: ketoconazole, ritonavir and other strong cytochrome Possibly increased fluticasone level and increased risk of reduced serum cortisol level NURSING PRECAUTIONS
* If patient is switched from systemic corticosteroid to fluticasone, assess for adrenal insufficiency (fatigue, hypotension, lassitude, nausea, vomiting, weakness) early in therapy and when patient has infection, stress, trauma, surgery, or other electrolytedepleting conditions or procedures. Notify prescriber immediately if signs or symptoms develop * Urge patient to use fluticasone regularly, as prescribed,

but not for acute bronchospasm * Caution patient to avoid contact with people who have infections because fluticasone suppresses the immune system, increasing the risk of infection. Instruct patient to notify prescriber about exposure to chickenpox, measles, or other infections because additional treatment may be needed

CONTRAINDICATIONS
*Hypersensitivity to budesonide or its components, recent septal ulcers or nasal surgery or trauma (nasal spray); status asthmaticus or other acute asthma episodes (oral inhalation) * Use budesonide cautiously if patient has tubercular infection; untreated fungal, bacterial, or systemic viral infection; or ocular herpes simplex * Caution patient to avoid exposure to chickenpox and measles and, if exposed, to contact prescriber immediately

Budesonide/Formoterol
(Symbicort) -Nasal, Oral, Nebulized, Capsules
ACTION Antiasthma drug Inhaled Corticosteroid & LABA Combination drug USES Long-term maintenance of asthma ADVERSE REACTIONS *Oral, laryngeal, pharyngeal irritation, fungal infections, suppression of HPA function

INTERACTIONS Drug: clarithromycin, erythromycin, itraconazole, ketoconazole

Possibly increased blood budesonide level NURSING PRECAUTIONS * Assess patient who switches from a systemic corticosteroid to inhaled budesonide for adrenal insufficiency (fatigue, hypotension, lassitude, nausea, vomiting, weakness), which may be lifethreatening. Hypothalamic-pituitary-adrenal axis function may take several months to recover after systemic corticosteroids stop. Stopping budesonide abruptly may cause adrenal insufficiency * Closely monitor a child's growth pattern; budesonide may stunt growth

* Assess patient for effectiveness of budesonide therapy, especially if patient is being weaned from a systemic corticosteroid. If patient has increased symptoms of asthma or an immunologic condition previously suppressed by the systemic corticosteroidsuch as rhinitis, conjunctivitis, an eosinophilic condition, eczema, or arthritisnotify MD * Instruct patient who uses nasal spray to shake container before each use. Instruct her to blow her nose, tilt her head slightly forward, and insert tube into a nostril, pointing toward inner corner of eye, away from nasal septum. Tell her to hold the other nostril closed and spray while inhaling gently. Then have her repeat in the other nostril * Advise patient to rinse her mouth with water after each dose and to spit the water out. Tell her to contact her prescriber if she develops a mouth or throat infection

-Inhaled granules
ACTION Antiasthma drug Inhaled Corticosteroid/LABA Combination drug USES Long-term maintenance of asthma COPD ADVERSE REACTIONS *Oral, laryngeal, pharyngeal irritation, fungal infections, suppression of HPA function CONTRAINDICATIONS *Hypersensitivity to fluticasone or its components, primary treatment of status asthmaticus or other acute asthma episodes that require intensive measures, untreated nasal mucosal infection (nasal suspension) * Although anaphylaxis is rare, monitor patient closely at start of therapy, especially if patient has severe allergy to milk

Fluticasone/Salmeterol
(Advair)

*Use fluticasone cautiously in patients with ocular herpes simplex, pulmonary tuberculosis, or untreated systemic bacterial, fungal, parasitic, or viral infection INTERACTIONS Drug: ketoconazole, ritonavir and other strong cytochrome Possibly increased fluticasone level and increased risk of reduced serum cortisol level NURSING PRECAUTIONS
* Urge patient to use fluticasone regularly, as ordered, but not for acute bronchospasm * Instruct patient to shake canister and to use inhaler according to package insert instructions. On first use, advise her to spray 4 times into the air. If inhaler hasnt been used for more than 7 days or its dropped, it will need to be primed again by shaking well and then releasing 1 test spray into the air (away from her face).

* If patient uses more than 1 inhaler, instruct them to use fluticasone last, at least 5 minutes after previous inhaler * Caution patient to avoid contact with people who have infections because fluticasone suppresses the immune system, increasing the risk of infection. Instruct patient to notify prescriber about exposure to chickenpox, measles, or other infections because additional treatment may be needed

Montelukast
(Singulair) -Oral granules, chewable tablets, tablets
ACTION Antiasthma drug Leukotriene Receptor Antagonists USES Prophylaxis & Treatment of chronic asthmas in adults & pediatric patients 12 months of age and older

Seasonal allergic rhinitis in adults & pediatric patients 2 years of age and older

ADVERSE REACTIONS *Headache, influenza-like symptoms CONTRAINIDCATIONS *Be aware that drug shouldnt be given for acute asthma attack or status asthmaticus *Caution patient with aspirin sensitivity to avoid aspirin and NSAIDs during montelukast therapy. Montelukast may not effectively reduce bronchospasm in such a patient

INTERACTIONS Drug: Phenobarbital Decreased amount of circulating montelukast NURSING PRECAUTIONS

*Monitor patient for adverse reactions, such as cardiac and pulmonary symptoms, eosinophilia, and vasculitis, in patient undergoing corticosteroid

withdrawal, if so call MD *Watch patient closely for suicidal tendencies throughout montelukast therapy *Advise patient to take montelukast daily as ordered, even when he feels well. Urge him not to decrease dosage or stop taking other prescribed asthma drugs unless instructed by prescriber *Caution patient not to use drug for acute asthma attack or status asthmaticus; make sure he has appropriate short-acting rescue drug available *Tell parents administering oral granules to pour contents directly into the childs mouth or mix with ice cream or cold or room temperature applesauce, carrots, or rice but not liquids or other foodsjust before administration. Liquids may be given after drug has been administered. Once packet is opened, the full dose must be administered within 15 minutes. Drug must not be stored for future use if mixed with food

ANTIHYPERLIPIDEMIC MEDICATIONS

Hyperlipidemia is an increase in lipids in the blood. Cholesterol and the triglycerides are the two lipids in the blood. Elevation of one or both of these occur in hyperlipidemia Serum cholesterol levels above 240 mg/dL Triglyceride levels above 150 mg/dL HMG-CoA Reductase Inhibitors (Statins): these medications inhibit the manufacture of cholesterol and promote the breakdown of cholesterol. Both actions lower the blood levels of choelestrol, LDLs and serum triglycerides. Example: Atorvastatin (Lipitor), Simvastatin (Zocor), Rosuvastatin (Crestor)

Atorvastatin
(Lipitor)
ACTION Antihyperlipidemic Medication HMG-CoA Reductase Inhibitor (Statin Drug) USES Reduce risk of CHD event Hyperlipidemia Hypercholesterolemia ADVERSE REACTIONS

*Headache, diarrhea, sinusitis, dizziness, insomnia, flatulence, abdominal pain, cramping, constipation, nausea CONTRAINDICATIONS *Patients with serious liver disorders and during pregnancy (category X) and lactation INTERACTIONS
Drug: Macrolides, erythromycin, clarithromycin increased risk of severe myopathy or rhabdomyolysis Amiodarone increased risk of myopathy Niacin increased risk of severe myopathy or rhabdomyolysis

Protease inhibitors elevated plasmas levels of statins Verapamil increased risk of myopathy Warfarin increased anticoagulant effect Herbal: St. Johns wort causing a decrease in statineffectiveness

* Advise patient to notify prescriber immediately if he develops unexplained muscle pain, tenderness, or weakness, especially if accompanied by fatigue or fever

NURSING PRECAUTIONS

Simvastatin
(Zocor)
ACTION Antihyperlipidemic Medication HMG-CoA Reductase Inhibitor (Statins) USES Reduce risk of CHD event Hyperlipidemia Hypercholesterolemia ADVERSE REACTIONS *Atrial fibrillation, edema, headache, vertigo, abdominal pain, eczema CONTRAINICATIONS

* Expect atorvastatin to be used in patients without obvious coronary artery disease (CAD) but with multiple risk factors (such as age 55 or over, smoker, history of hypertension or low HDL level, or family history of early CAD). Drug is used to reduce risk of MI, angina * Expect to measure lipid levels 2 to 4 weeks after therapy starts, to adjust dosage as directed, and to repeat periodically until lipid levels are within desired range * Instruct patient to take a missed dose as soon as possible. If it's almost time for his next dose, he should skip the missed dose. Tell him not to double the dose

*Patients with acute liver disease, pregnancy, breast-feeding or patients with myopathy *Should not be used on patients who hepatic impairment and/or ethanol use INTERACTIONS
Drug: Antacids decrease antilipemic concentration Diltiazem increase concentration of diltiazem Niacin enhance adverse/toxic effect of antilipemic agent Vitamin K Antagonist (ex. Warfarin) may enhance anticoagulant effect Food: Grapefruit juice & Green Tea decrease antilipemic metabolism, risk of drug toxicity Herbal: St. Johns Wort increase metabolism of antilipemic agent

*Red yeast rice contains an estimated 2.4 mg lovastatin per 600 mg rice *Avoid alcohol consumption * Expect to monitor liver function test results every 3 to 6 months for abnormal elevations * Monitor serum lipoprotein level, as ordered, to evaluate response to therapy * Urge patient to take drug in the evening, Take same time/each day in evening with/without food *Report unusual muscle cramping/weakness, yellow of skin/eyes, easy bruising/bleeding or unusual fatigue * Encourage patient to follow a low fat, cholesterol-lowering diet * Urge patient to notify prescriber immediately about muscle pain, tenderness, or weakness and other symptoms of myopathy

NURSING PRECAUTIONS

Rosuvastin
(Crestor)

ACTION Antihyperlipidemic Medication

HMG-CoA Reductase Inhibitor (Statin Drug)

Drug:

USES

Hyperlipid emia

ADVERSE REACTIONS *Headache

CONTRAINDICATIONS * Active liver disease, breast-feeding, hypersensitivity to rosuvastatin or its components, pregnancy, unexplained persistent elevations of serum transaminase levels * Use rosuvastatin cautiously in patients who consume large quantities of alcohol or have a history of liver disease because drug is contraindicated in patients with active liver disease or unexplained persistent elevations of transaminase levels * Also use cautiously in patients with risk factors for myopathy, such as renal impairment, advanced age, and hypothyroidism INTERACTIONS

Antacids Decreased blood rosuvastatin level if given within 2 hours of rosuvastatin cyclosporine, gemfibrozil, lopinavir/ritonavir, niacin, other lipid-lowering drugs Increased blood rosuvastatin level and risk of myopathy oral contraceptives Increased blood ethinyl estradiol and norgestrel levels warfarin Increased INR

NURSING PRECAUTIONS

* Obtain baseline liver function test results and expect to monitor them every 3 months for abnormal elevations. Notify prescriber if elevations occur. If ALT or AST levels increase to more than three times the normal range, expect dosage to be reduced or drug discontinued * Monitor serum lipoprotein levels, as ordered, to evaluate patients response to therapy * Expect rosuvastatin to be temporarily withheld if patient develops any condition that may be related to myopathy or that predisposes her to renal failure, such as sepsis, hypotension, major surgery, trauma, uncontrolled seizures, or severe metabolic, endocrine, or electrolyte disorders * Notify prescriber if proteinuria or hematuria appears on patients routine urinalysis because rosuvastatin dosage

may need to be reduced * Encourage patient to follow a low-fat, low cholesterol diet * Tell patient to wait at least 2 hours after taking rosuvastatin before taking antacids * Instruct patient to notify prescriber immediately about muscle pain, tenderness, or weakness, especially if accompanied by malaise or fever

with other medicatio n to treat hyperlipid emia ADVERSE REACTIONS *Generalized flushing sensation of warmth, severe itching and tingling, nausea, vomiting, abdominal pain CONTRAINIDCATIONS *Pts with active peptic ulcer, hepatic dysfunction and arterial bleeding. *Used cautiously in patients with renal dysfunction, high alcohol consumption, unstable angina, gout, and pregnancy. INTERACTIONS Food:

Niacin (Nicotinic Acid)

(Niaspan, Niacor) ACTION Antihyperl ipidemic Medicatio n Used in adjunction

USES

Garlic mild stomach upset and irritation, increased risk of bleeding NURSING PRECAUTIONS *The nurse should advise the patient to contact PCP if the skin reactions are severe or cause extreme discomfort. Aspirin may be recommended before taking niacin to reduce adverse reactions. * Encourage patient to follow a lowfat, low cholesterol diet

* Monitor serum lipoprotein levels, as ordered, to evaluate patients response to therapy

ANTIHYPERTENSIVE MEDICATIONS

Hypertension is a disorder in which that patients blood pressure is elevated above normal values for their age. Research has shown that blood pressure above 140/90mmHg are associated with accelerated vascular damage of the heart, brain and kidneys. There are (5) types of antihypertensive medication:

1.

Diuretics: indirectly reduce blood pressure by producing sodium and water loss and lowering the tone or rigidity of the arteries. -Loop Diuretics: Fuosemide (Lasix) -Thiazide & Sulfonamide Diuretics: Hydrochlorothiazide (HCTZ)

2. 3.

-Potassium-Sparing: Spironolacton (Aldactone) Adrenergic Antagonists: are nervous system stimulants and inhibitors that assist in lowering cardiac output and/or peripheral resistance Examples: Clonidine (Catapres, Duraclon), Metoprolol (Lopressor Topol XL) ACE Inhibitors: affect the renin-angiotensin system of the kidneys. Angiotension-converting enzyme (ACE) inhibitors act on the rennin-angiotension system to promote a decrease in the work of the heart (vascular afterload and preload) through vasodilation (vascular opening) when angiotension II is inhibited. Angiotensin II is a powerful vasoconstrictor that acts on the adrenal cortex to increase aldosterone secretion. If a patient is in shock, this renin-angiotensin reaction is important in saving sodium and water to keep the blood pressure up but at other times, it may help lead to the high blood pressure found in hypertension. Examples: Benazepril (Lotensin), Lisinopril (Zestril)) Vasodilators: Vasodilators reduce systolic and diastolic blood pressure by direct relaxation of vascular smooth muscle, thus lowering peripheral resistance. Examples: Hydralazine (Apresoline), Minozidil (Loniten) Calcium Channel Blocking Agents: selectively limit the passage of extracellular calcium ions through specific ion channels of the cell membrane in cardiac, vascular and smooth muscle cells. This causes a lowered peripheral vascular resistance and a fall in systolic and diastolic blood pressure. Examples: Amlodipine (Norvasc), Diltiazem (Cardizem), Nifedipine (Procardia) and Verapamil (Calan

4. 5.

Furosemide
(Lasix)
ACTION Antihypertensive Loop Diuretics USES Edema due to heart failure, cirrhosis of the liver, renal disease, acute pulmonary edema and hypertension ADVERSE REACTIONS *Electrolyte and hematologic imbalances, anorexia, N/V, dizziness, rash, photosensitivity, orthostatic hypotension CONTRAINIDCATIONS *Patients with electrolyte imbalances, severe kidney or liver dysfunction and anuria (cessation of urine production). INTERACTIONS Drug: Cisplatin (cancer med) AND aminoglycosidesincreased risk of ototoxicity anticoagulants or thrombolytic (increases risk of

bleeding) digitalis increased risk of arrhythmias lithium increased risk of Li toxicity hydantoins (seizure med) decreases effectiveness of diuretic NSAIDs decreases effectiveness of diuretic NURSING PRECAUTIONS
* Obtain patients weight before and periodically during furosemide therapy to monitor fluid loss. * Monitor blood pressure and hepatic and renal function as well as BUN, blood glucose, and serum creatinine, electrolyte, and uric acid levels, as appropriate * Be aware that elderly patients are more susceptible to hypotensive and electrolyte-altering effects and thus are at greater risk for shock and thromboembolism * If patient is at high risk for hypokalemia, give potassium supplements along with furosemide, as prescribed * Call MD if patient experiences hearing loss, vertigo, or ringing, buzzing, or sense of fullness in her ears. Drug may need to be discontinued * Instruct patient to take the last dose of furosemide several hours before bedtime to avoid sleep interruption from diuresis. If patient receives once-daily dosing, advise her to take the dose in the morning to avoid sleep disturbance caused by nocturia

* Advise patient to change position slowly to minimize effects of orthostatic hypotension and to take furosemide with food or milk to reduce GI distress * Caution patient about drinking alcoholic beverages, standing for prolonged periods, and exercising in hot weather because these actions increase the hypotensive effect of furosemide

* Inform diabetic patient that furosemide may increase blood glucose level, and advise her to check her blood glucose level frequently

Hydrochlorothiazide (HCTZ)
(HydroDIURIL, Microzide)
ACTION Antihypertensive Medication Loop Diuretic USES Edema due to HF Cirrhosis of the liver Renal disease Acute pulmonary edema ADVERSE REACTIONS *Electrolyte and hematologic imbalances, anorexia, nausea, vomiting, dizziness, rash, photosensitivity, orthostatic hypotension, glycosuria CONTRAINDICATIONS

* Anuria; hypersensitivity to hydrochlorothiazide, other thiazides, sulfonamide derivatives, or their components; renal failure * If patient has gouty arthritis, expect an increased risk of gout attacks during therapy INTERACTIONS
Drug: ACTH, amphotericin B, corticosteroids Increased electrolyte depletion, especially potassium Amantadine Possibly increased blood level and risk of toxicity of amantadine Amiodarone Increased risk of arrhythmias from hypokalemia Antihypertensives Increased antihypertensive effects barbiturates, opioids Possibly orthostatic hypotension calcium: Possibly increased serum calcium level cholestyramine, colestipol Reduced GI absorption of hydrochlorothiazide diazoxide Increased antihypertensive and hyperglycemic effects of hydrochlorothiazide diflunisal Possibly increased blood hydrochlorothiazide level digoxin Increased risk of digitalis toxicity from hypokalemia dopamine Possibly increased diuretic effects of both drugs

insulin, oral antidiabetic drugsPossibly increased blood glucose level lithiumDecreased lithium clearance, increased risk of lithium toxicity neuromuscular blockersPossibly enhanced neuromuscular blockade from hypokalemia nondeplarizing skeletal muscle relaxantsPossibly increased response to muscle relaxants NSAIDsDecreased diuretic effect of hydrochlorothiazide, increased risk of renal failure oral anticoagulantsPossibly decreased anticoagulant effects sympathomimeticsPossibly decreased antihypertensive effect of HCTZ vitamin Dncreased risk of hypercalcemia Activities: alcohol usePossibly orthostatic hypotension

*Instruct patient to eat a diet high in potassium rich food, including citrus fruits, bananas, tomatoes, and dates *Advise patient to change position slowly to minimize effects of orthostatic hypotension

Metoprolol
(Lopressor, Toprol-XL)
ACTION -Adrenergic Blocking Drug (Beta Blocker) Decreases stimulation of sympathetic nervous system by: Decreasing excitability of heart Decreasing cardiac workload and oxygen consumption Provides membrane-stabilizing effects USES Hypertension Angina Myocardial Infraction

NURSING PRECAUTIONS *Give hydrochlorothiazide in the morning and early in the evening to avoid nocturia. *Monitor fluid intake and output, daily weight, blood pressure, and serum levels of electrolytes, especially potassium, BUN & creatinine *Assess for signs of hypokalemia, such as muscle spasms & weakness, unusual bleeding or bruising *Frequently monitor blood glucose level as ordered in diabetic patients, and expect to increase antidiabetic drug dosage, as needed *Tell patient to weigh herself at the same time each day wearing the same amount of clothing and to notify prescriber if she gains more than 2 lb (0.9 kg) per day or 5 lb (2.3 kg) per week

Heart Failure

ADVERSE REACTIONS *Dizziness, hypotension, heart failure, cardiac arrhythmia, nausea, vomiting, diarrhea CONTRAINIDICATIONS
* Use metoprolol with extreme caution in patients with bronchospastic disease who dont respond to or cant tolerate other

antihypertensive therapy. Expect to give smaller doses more often to avoid higher plasma levels that occur with longer dosage intervals * Use cautiously in patients with hypertension or angina who have congestive heart failure because beta blockers such as metoprolol can further depress myocardial contractility, causing heart failure to worsen *Contraindicated in patients with sinus bradycardia, second or third degree heart block, heart failure and in those with asthma, emphysema or hypotension. *Used cautiously in patients with diabetes, thyrotoxicosis or peptic ulcer. *B-blockers are recommended for pregnant woman over other hypertensive because of the risk to the fetus is less with these drugs

INTERACTIONS Drug: Antidepressants increased effect of Beta blocker, bradycardia NSAIDs decreased effect of beta blocker Loop Diuretic increased risk of hypotension Clonidine increased risk of paradoxical hypertensive effect Cimetidine higher risk of B-blocker toxicity Iidocaine higher risk of B-blocker toxicity NURSING PRECAUTIONS
*Be aware that the metoprolol dosage for heart failure is highly individualized. Monitor patient for signs and symptoms of worsening heart failure during dosage increases. If heart failure worsens, expect to increase the diuretic dosage and possibly decrease the metoprolol dosage or temporarily discontinue drug, as prescribed. Be aware that the metoprolol dosage shouldnt be increased until

signs and symptoms of worsening heart failure have been stabilized * If dosage exceeds 400 mg daily, monitor patient for bronchospasm and dyspnea because metoprolol competitively blocks beta2-adrenergic receptors in bronchial and vascular smooth muscles * Check for signs of poor glucose control in patient with diabetes mellitus. Metoprolol may interfere with therapeutic effects of insulin and oral antidiabetic drugs. It also may mask evidence of hypoglycemia, such as palpitations, tachycardia, and tremor * Expect to taper dosage when drug is discontinued; stopping abruptly can cause myocardial ischemia, MI, ventricular arrhythmias, or severe hypertension, especially in patients with cardiac disease * Instruct patient to take metoprolol with food at the same time each dayonce daily for E.R. tablets. Inform them that they may halve tablets but not chew or crush them * Advise patient to notify prescriber if pulse rate falls below 60 beats/minute or is significantly lower than usual

Amlodipine
(Norvasc)
ACTION Calcium Channel Blocker USES Antihypertensive Drug Chronic Stable Angina

Vasospastic angina

ADVERSE REACTIONS *Headache, fatigue, depression, dizziness, syncope *Upper respiratory infections and cough *Abdominal pain, nausea, diarrhea, constipation, anorexia CONTRAINIDCATIONS *Patients with sick sinus syndrome, 2/3 atrioventricular (AV) block (except with a functioning pacemaker) *Patients with hypotension (systolic pressure less than 90 mm Hg), ventricular dysfunction or cardiogenic shock INTERACTION
Drug: Cimetidine or rantidine (GI disorders) increased effect of CCblocker Theophyllinetoxic effect of theophylline Digoxinincreased risk digitalis toxicity Rifampin (TB med) decreased effect of CCblocker

MAOIs, antihistamines, sympathomimetic bronchodilators decreased effectiveness of CCblocker Diuretics increased risk of hypotension Herbal: Hawthronincreased sedation & CNS depression

NURSING PRECAUTIONS

*Use amlodipine cautiously in patients with heart block, heart failure, impaired renal function, hepatic disorder, or severe aortic stenosis * Monitor blood pressure while adjusting dosage, especially in patients with heart failure or severe aortic stenosis *Hold medication is systolic BP is less than 100 or HR is less than 60 * Tell patient to take missed dose as soon as it's remembered and next dose in 24 hours * Tell patient to immediately notify prescriber of dizziness, arm or leg swelling, difficulty breathing, hives, or rash * Suggest taking amlodipine with food to reduce GI upset * Advise patient to routinely have blood pressure checked for possible hypotension

Clonidine
(Catapres)
ACTION Anti-Adrenergic Drugs (Centrallyacting) Inhibits the release of norepinephrine and acts in the Central Nervous System Affects the sympathetic nervous system USES Hypertension Severe pain in patients with cancer ADVERSE REACTIONS *Drowsiness, dizziness, sedation, dry mouth, constipation, syncope, dreams, rash CONTRAINDICATION

*Patients in active hepatic disease and patients on MAOIs *Used cautiously in patients with a history of liver disease or renal impairment and during pregnancy and lactation INTERACTIONS Drug: Adrenergic drugs increased risk of hypertension Levodopa decreased effect of levodopa, hypotension
Anesthetic agents increased effect of the anesthetic

-blockers increased risk of hypertension Lithiumincreased risk for lithium toxicity Haloperidol increased risk of psychotic behavior NURSING INTERVENTIONS *B/P, pulse prior to administration

*If prescribed for opiate withdrawal: monitor for N/V/D, cramps, insomnia, shivering & dilated pupils *Monitor I/Os and edema *Give last dose at bedtime *Discontinuing abruptly may result in anxiety, increased BP, headache, insomnia, increased pulse, tremors, nausea, sweating *DO NOT use OTC (cough, cold or allergy) medications unless approved by MD *Rise slowly to prevent drop in BP *May cause dry mouth; recommend hard candy or frequent mouth rinsing

INTERACTIONS

Benazapril
(Lotensin)
ACTION Antihypertensive medication ACE Inhibitor USES Hypertension ADVERSE REACTIONS *Headache, dizziness, fatigue CONTRAINDICATIONS *Pts with impaired renal function, HF, salt or volume depletion, bilateral stenosis, or angioedema, during pregnancy or lactation. *Used cautiously in patients with coronary or cerebrovascular insufficiency and those receiving diuretic therapy or dialysis.

Drug: NSAIDs reduced hypotensive effects of the ACEI Rifampin decreased effects of ACEI Allopurinol (antigout med) higher risk of hypersensitivity Digoxin increased or decreased digoxin levels Loop diuretics decreased diuretic effects

NURSING PRECAUTIONS

* Take ortho BPs before initiating benazepril and then every 4 to 8 hours, as appropriate, to monitor drug's effectiveness * Monitor urine output and BUN and serum creatinine levels, as n eeded, before therapy * Be alert for angioedema, especially after first dose. If it extends to larynx and patient has laryngeal stridor or signs of airway obstruction, prepare to give epinephrine subcutaneously immediately, as prescribed, and discontinue benazepril * Monitor WBC count periodically to detect neutropenia and agranulocytosis * Monitor serum potassium and other electrolyte levels to detect electrolyte imbalances * Strongly urge patient to contact prescriber before using any OTC salt substitutes, which may contain potassium, or

potassium supplements. These substances increase the risk of hyperkalemia * Inform patient that a persistent dry cough may develop and may not subside unless benazepril is discontinued. If cough becomes bothersome or interferes with her sleep or activities, instruct her to notify prescriber * Instruct patient to contact prescriber immediately if she experiences signs of angioedema, such as swelling of the face, eyes, lips, or tongue * Caution women of childbearing age to use a reliable form of contraception and to notify prescriber immediately if pregnancy is suspected because benazepril may cause fetal harm and should be discontinued

Heart Failure

ADVERSE REACTIONS *Cough, hyperkalemia, Orthostatic hypotension, headache, dizziness, D/N/V, upper respiratory infection CONTRAINDICATIONS * Use lisinopril cautiously in patients with fluid volume deficit, heart failure, impaired renal function, or sodium depletion, chloestatic jaundice, hyperkalemia, hypotension/syncope, neutropenia, renal function deterioration INTERACTIONS Drug: Antacids decrease ACE inhibitors concentration Lithium increase concentration of Li Diuretics, MAO inhibitors, antihypertensives enhance hypotensive effect

Lisinopril
(Prinivil, Zestril)
ACTION Antihypertensive medication Angiotension-Converting Enzyme (ACE) Inhibitor USES Hypertension

NSAIDs & Salicylates diminish antihypertensive effect K+ salts: enhance hyperkalemic effect NURSING PRECAUTIONS
* Monitor blood pressure often, especially early in treatment. If excessive hypotension develops, expect to withhold drug for several days * If angioedema affects face, glottis, larynx, limbs, lips, mucous membranes, or tongue, notify prescriber immediately and expect to stop lisinopril and start appropriate therapy at once. If airway obstruction threatens, promptly give 0.3 to 0.5 ml of epinephrine 1:1, 000 solution subcutaneously, as prescribed * Monitor for dehydration, which can lead to hypotension. Be aware that diarrhea and vomiting can cause dehydration * If patient takes insulin or an oral antidiabetic, monitor blood glucose level closely because risk of hypoglycemia increases, especially during the first month of therapy *Use K+ containing salt substitutes cautiously in patients with diabetes, patients with renal dysfunction or those maintained on K+ supplements or K+ sparing diuretics *Take first dose at bedtime

Hydralazine
(Apresoline)
ACTION Antihypertensive medication Vasodilator USES Primary hypertension (oral) When need to lower BP is urgent (parenteral) ADVERSE REACTIONS *Dizziness, palpitations, tachycardia, numb/tingling in legs, nasal congestion CONTRAINDICATIONS * Coronary artery disease, hypersensitivity to hydralazine or its components, mitral valve disease * Monitor CBC, lupus erythematosus cell preparation, and ANA titer before therapy and periodically as appropriate during long-term treatment INTERACTIONS Drug:

beta blockers Increased effects of both drugs diazoxide, MAO inhibitors, other antihypertensives Risk of severe hypotension epinephrine Possibly decreased vasopressor effect of epinephrine NSAIDs Decreased hydralazine effects Sympathomimetics Possibly decreased antihypertensive effect of hydralazine Foods: all foods Possibly increased bioavailability of hydralazine NURSING PRECAUTIONS *Anticipate that drug may change color in solution. Consult pharmacist if color change occurs *Monitor blood pressure and pulse rate regularly and weigh patient daily during therapy *Watch for signs of orthostatic hypotension. Expect orthostatic hypotension to be most common in the morning, during hot weather, and with exercise *Expect to discontinue drug immediately if patient experiences lupus-like symptoms, such as arthralgia, fever, myalgia, pharyngitis, and splenomegaly

*Expect prescriber to withdraw hydralazine gradually to avoid a rapid increase in blood pressure *Instruct patient to take hydralazine tablets with food *Caution patients hot showers may increase hypotension *Report any fever, muscle and joint aches, and sore throat, numbness and tingling in her limbs to MD

Diltiazem
(Cardizem)
ACTION Antihypertensive medication Calcium Channel Blocker USES Hypertension Chronic stable angina Atrial Fibrilation/flutter Paroxysmal superventricular tachycardia

ADVRESE REACTIONS *Headache, dizziness, atroventricular block, bradycardia, edema, dyspnea, rhinitis CONTRAINDICATIONS * Use diltiazem cautiously in patients with impaired hepatic or renal function, and monitor liver and renal function test results, as appropriate; diltiazem is metabolized mainly in the liver and excreted by the kidneys INTERACTIONS

Drug: Cimetidine or rantidine (GI meds) increased effects of Ca+ channel blocker Theophylline (asthma med) increased toxic effects of theophylline Digoxin increased risk for digitalis toxicity Rifampindecreased effect of Ca+ channel blocker

* Monitor patients blood pressure, pulse rate, and heart rate and rhythm by continuous ECG as appropriate during therapy. Keep emergency equipment and drugs available * Assess patient for signs and symptoms of heart failure * If patient takes digoxin, watch for signs of digitalis toxicity, such as nausea, vomiting, halo vision, and elevated serum digoxin level * Expect to discontinue drug if adverse skin reactions, usually transient, persist * Tell patient that stopping drug suddenly may cause life-threatening effects * Urge patient to report chest pain, difficulty breathing, dizziness, fainting, irregular heartbeat, rash, or swollen ankles * Instruct patient to maintain good oral hygiene, perform gum massage, and see a dentist every 6 months to prevent gingival bleeding and hyperplasia and gingivitis

NURSING PRECAUTIONS

Nifedipine
(Procardia)
ACTION Antihypertensive medication Calcium Channel Blocker USES Hypertension (sustained-release only) Vasopastic Angina Chronic Stable Angina ADVERSE REACTIONS *Headache, dizziness, weakness, edema, nausea, muscle cramps, cough, nasal congestion, wheexing CONTRAINDICATIONS * Hypersensitivity to a calcium channel blocker, second- or third-degree AV block without artificial pacemaker, sick sinus syndrome INTERACTIONS Drug:

Cimetidine or rantidine (GI meds) increased effects of Ca+ channel blocker Theophylline (asthma med) increased toxic effects of theophylline Digoxin increased risk for digitalis toxicity Rifampin decreased effect of Ca+ channel blocker Food: grapefruit, grapefruit juice Possibly increased bioavailability of nifedipine high-fat meals Possibly delayed nifedipine absorption NURSING PRECAUTIONS * For closely monitored hospitalized patient with angina, dosage may be increased 10 mg every 4 to 6 hours to control chest pain * Because of drugs negative inotropic effect on some patients, frequently monitor heart rate and rhythm and blood pressure in patients who take a beta blocker or have heart failure or significant left ventricular dysfunction * Monitor fluid intake and output and daily weight; fluid retention may lead to heart failure. Also assess for signs of heart failure, such as

crackles, dyspnea, jugular vein distention, peripheral edema, and weight gain * Instruct patient to swallow E.R. tablets whole, not to crush, chew, or break them. Inform her that their empty shells may appear in stool * Urge patient not to take drug within 1 hour of a high-fat meal or grapefruit. Urge her not to alter the amount of grapefruit in her diet without consulting prescriber * Caution patient against stopping nifedipine abruptly because angina or dangerously high blood pressure could result.

Chronic stable angina Vasospastaic angina Chronic atrial flutter Paroxysmal syperventricular tachycardia

ADVERSE REACTIONS *Headache, constipation CONTRAINDICATIONS

* Cardiogenic shock, concomitant use of beta blockers (with I.V. verapamil), hypersensitivity to verapamil or its components, hypotension, severe heart failure unless secondary to supraventricular tachycardia that responds to verapamil, severe left ventricular dysfunction, sick sinus syndrome or second- or third-degree heart block unless artificial pacemaker is in place, ventricular tachycardia (with I.V. verapamil)

Verapamil
(Calan, Isoptin, Verelan)
ACTION Antihypertensive medication Calcium Channel Blocker USES Hypertension

INTERACTIONS

Drug: Cimetidine or rantidine (GI meds) increased effects of Ca+ channel blocker Theophylline (asthma med) increased toxic effects of theophylline Digoxin increased risk for digitalis toxicity Rifampin decreased effect of Ca+ channel blocker Food: grapefruit juiceIncreased concentrations of verapamil

Activities: alcohol use Increased blood alcohol level and prolonged CNS effects

NURSING PRECAUTIONS
* Maintain continuous ECG monitoring and keep emergency resuscitative equipment and drugs readily available during I.V. therapy * Assess patient with hypertrophic cardiomyopathy for early development of hypotension and pulmonary edema because second-degree AV block and sinus arrest can result * Assess for bradycardia and hypotension, and notify prescriber if heart rate or blood pressure declines significantly * Be aware that disopyramide or flecainide shouldnt be given within 48 hours before or 24 hours after verapamil because additive negative inotropic effects can result * Institute measures to prevent constipation, including a high-fiber diet and a stool softener, as prescribed * Instruct patient not to crush or chew verapamil E.R. tablets or capsules. Inform her that she may break E.R. tablets in half if necessary to aid swallowing

CONTRAINDICATIONS

Lorsartan Potassium
(Cozarr)
ACTION

Antihypert ensive Angiotens in II receptor anatagoni st

* Be aware that patients who have severe heart failure or renal artery stenosis may experience acute renal failure from losartan therapy because losartan inhibits the angiotensinaldosterone system, on which renal function depends
INTERACTIONS: Drug: Fluconazole (Antifungal) increased antihypertensive and adverse effects Indomethacin (pain relief) decreased hypotensive effect
NURSING PRECAUTIONS
*Be aware that patients who have severe heart failure or renal artery stenosis may experience acute renal failure from losartan therapy because losartan inhibits the angiotensin-aldosterone system, on which renal function depends. *Monitor patients blood pressure and renal function studies to evaluate drug effectiveness.

USES Hypertension Hypertension with LVD Diabetic Nephropathy (for Type II patients) ADVERSE REACTIONS *Dizziness, URI symptoms

*Periodically monitor patients serum potassium level, as appropriate, to detect hyperkalemia. *Monitor patient for muscle pain; rarely, rhabdomyolysis develops in patients taking other angiotensin II receptor blockers. * Instruct patient taking losartan to avoid potassium-containing salt substitutes because thay may increase the risk of hyperkalemia.

*Advise patient to avoid exercising in hot weather and drinking excessive amounts of alcohol; instruct her to notify prescriber if she experiences prolonged diarrhea, nausea, or vomiting

ANTIANGINAL MEDICATION

Angina is pain caused by narrowing or constriction of the smooth muscle in the coronary arteries and the peripheral vascular system that reduces the amount of blood carried to the heart. When there is a lack of blood supply to being oxygen and nutrients to the heart or to peripheral tissues, the pain of angina or peripheral vascular disease is felt. Nitrates are the best dry for treating coronary artery disease, whereas vasodilating agents are used for peripheral vascular disease. The use of beta blockers and calcium channel blockers may also play a role in treating angina, although concern about their possible role in changes to the heart (which may lead to heart failure) in patients who have had a myocardial infarction has limited their use.

 Nitrate products have a direct action on vascular

smooth muscle and cause it to relax. The effect is felt in both the arterial and venous circulation. In addition, nitrates increase the use of the other small blood vessels in the heart (collaterals) so that there is better oxygen supply to the inner layers of the heart muscle Examples: Nitroglycerin, Amlodipine (Norvasc), Diltiazem (Cardizem), Nifedipine (Procardia) and Verapamil (Calan)

Nitroglycerin
(Paste, patch or sublingual) ACTION Antiangial medicaiton

Nitrate Vasodilator

USES Angina Preventative of MI

ADVERSE REACTIONS *headache, weakness, vertigo, dizziness, faintness, hypotension, circulatory collapse CONTRAINDICATIONS *Patients with severe anemia, cerebral hemorrhage *Used cautiously in the following patients: severe hepatic/renal disease, severe head trauma and hypothyroidism INTERACTIONS Drug: Acetylcholine, norepinephrine Possibly decreased therapeutic effects of these drugs Aspirin increases nitrate concentration Calcium Channel Blockers

increases symptomatic orthostatic hypotension Dihydroergotamine (migrate medicine) Increases risk of hypertension heparin decreased effect of heparin Erectile dysfunction meds severe hypotension & cardiovascular collapse may occur Food: Alcohol severe hypotension & cardiovascular collapse because of its a vasodilator

NURSING PRECAUTIONS * Use nitroglycerin cautiously in elderly patients, especially those who are volume depleted or taking several medications, because of the increased risk of hypotension

and falls. Hypotension may be accompanied by angina and paradoxical slowing of the heart rate. Notify prescriber if these occur, and provide appropriate treatment, as ordered *For sublingual or buccal use, advise patient to place a tablet under her tongue or in her buccal pouch when angina starts and then to sit or lie down. Instruct her not to swallow drug, but to let it dissolve. Explain that moisture in her mouth helps drug absorption. If angina doesnt subside, instruct patient to place another tablet under her tongue or in her buccal pouch after 5 minutes and to repeat, if needed, for three doses total. If pain doesnt subside after 20 minutes, urge patient to call 911 or another emergency service * When applying transdermal ointment, apply correct amount on dose-measuring paper. Then place paper on hairless area of body and spread in a thin even layer over an area at least 2 inches by 3 inches. Dont place on cuts or irritated areas. Wash your hands after application. Rotate sites. Store at room temperature

* Open transdermal patch package immediately before use. Apply patch to hairless area, and press edges to seal. *Rotate sites. Store at room temperature. If patient needs cardioversion or defibrillation, remove transdermal patch * Be aware that I.V. nitroglycerin should be diluted only in D5W or normal saline solution and shouldnt be mixed with other infusions. The pharmacist should add drug to a glass bottle, not a container made of polyvinyl chloride. Dont use a filter because plastic absorbs drug. Administer with infusion pump * Frequently monitor heart and breath sounds, level of consciousness, fluid intake and output, and pulmonary artery wedge pressure, if possible * Assess patient for signs and symptoms of overdose, such as confusion, diaphoresis, dyspnea, flushing, headache, hypotension, nausea, palpitations, tachycardia, vertigo, vision changes, and

vomiting. Treat as prescribed by removing nitroglycerin source, if possible; elevating the legs above heart level; and administering an alpha-adrenergic agonist, such as phenylephrine, as prescribed, to treat severe hypotension *Nurse should NOT rub nitro ointment into

patients skin, it will be absorbed into their skin & causes a severe headache *Heart rate MUST be above 60

ANTICOAGULANTS & THROMBOLYTIC MEDICATION

Hematologic products act in the formation, repair or function of red blood cells. They include the anticoagulants (heparin and Coumadin) and the heparin antagonist protamine sulfate. Thrombolytic agents and antiplatelet factors also have a major influence on blood clotting. Related vitamin and minerals that are needed for red blood cell development are iron, vitamin K, vitamin B12 and folic acid. Anticoagulants: Warfarin (Coumadin), Heparin, Enoxparin (Lovenox) Warfarin (Coumadin): limit formation of blood coagulants factors in the liver by interfering with vitamin K. These drugs do not destroy existing blood clots; however, they may limit the extension of existing blood clots or thrombi. Heparin: acts at multiple sites in coagulation to stop reactions that lead to the clotting of blood and the formation of fibrin cloths. It increases coagulation factors to slow new clot development. Heparin does not dissolve existing clots either, although thrombolytic agents do.

Protamine & Phytonadione (Vitamin K): are proteins that act as a heparin antagonist to neutralize (reverse) the actions of heparin. However, it may also serve as an anticoagulant when used as the sole medication. In the presence of heparin, results will occur almost immediately and may persist for 2 hours or more Thrombolyric Agents: convert plasminogen to the enzyme plasmin, which degrades or breaks down fibrin cloths, fibrinogen and other plasma proteins. The products are used for lysis or dissolving of thrombi. Examples: Streptokinase (Streptase) Antiplatelet Agents: through a variety of mechanisms, these products act to limit or inhibit platelet aggregation (clumping) and thus reduce thrombus formation. ASA reduces the incidence of myocardial infarction-related deaths in mean older than 50 years old. ASA is the drug of choice in ischemic stroke; it plays no role in hemorrhagic stroke. Clospidogrel (Plavix) is used for myocardial infarction prophylaxis for men and as additional or adjunct therapy with thrombolytics in preventing infarction or stroke.

Protamine
ACTION

Anticoagulant Antagonist

USES Treatment of heparin overdose

ADVERSE REACTIONS *Flushing and warm feeling, dyspnea, bradycardia, hypotension CONTRAINDICATIONS * Allergy to fish, hypersensitivity to protamine or its components. IMCOMPATIBILITIES * Dont mix protamine sulfate in same syringe with other drugs unless theyre known to be compatible. Several cephalosporins, penicillins, and other antibiotics are incompatible INTERACTIONS Drug: Heparin Neutralized anticoagulant effect of both drugs NURSING PRECAUTIONS

* Be aware that rapid delivery may cause severe hypotension and anaphylaxis * Be prepared to obtain coagulation studies (APTT, activated clotting time) 5 to 15 minutes after administering drug and to repeat studies in 2 to 8 hours to assess for heparinrebound hypotension, shock, and bleeding * Monitor vital signs, hemodynamic parameters, and fluid intake and output, and assess for flushing sensation * Have fluidsepinephrine 1:1,000, dobutamine, or dopamineavailable for allergic or hypotensive reactions * Be aware that vasectomized males have an increased risk of hypersensitivity reaction because of possible accumulation of antiprotamine antibodies

Streptokinase
(Streptase)
ACTION Thrombolytic USES Acute MI DVT Pulmonary Embolism Embolism ADVERSE REACTIONS *Minor bleeding (superficial and surface) and major bleeding (internal and severe) CONTRAINDICATIONS * Active internal bleeding, AV malformation or aneurysm, bleeding diathesis, history of stroke or intracranial or intraspinal surgery within the previous 2 months, hypersensitivity to streptokinase or its components, intracranial cancer, severe uncontrolled hypertension INTERACTIONS

Drug: anticoagulants, enoxaparin, heparin, NSAIDs, platelet

aggregation inhibitors increased risk of bleeding antifibrinolyticsAntagonized effects of both drugs antihypertensives Increased risk of severe hypotension, especially when streptokinase is administered rapidly to treat coronary artery occlusion cefamandole, cefoperazone, cefotetan, plicamycin, valproic acid Possibly hypoprothrombinemia and increased risk of severe hemorrhage corticosteroids, ethacrynic acid, salicylates Possibly GI ulceration or bleeding NURSING PRECAUTIONS *Obtain hematocrit, platelet count, APTT, PT, and INR, as ordered, before giving streptokinase *To prevent foaming, dont shake drug during reconstitution

*Check requently for bleeding at I.V. site and for blood in urine and stool. Perform neurologic assessment to detect intracranial bleeding *Monitor heart rate and rhythm by continuous ECG, as ordered *Treat fever with acetaminophen, as prescribed, rather than aspirin to reduce the risk of bleeding

*Explain to patient that theyll be on bed rest during streptokinase therapy *Advise patient to wear or carry medical alert identification stating that he takes streptokinase

CARDIOTONIC MEDICATION

Cardiotonics make the heart beat stronger and slower. These drugs are also call cardiac glycodsides. All cardiotonic have the following two acitons: -They increase the strength or force of the contraction (or pumping) of the heart muscle (myocardium). -They slow the heart rate The normal heart pumps oxygenated blood from the left ventricle out through the body. If the heart is weak, less oxygenated blood can be pumped out with each contraction or beat of the heart. When cardiac

output (the amount of blood pumped out with each heartbeat x HR) decreases, other organs are affected. Example: Digoxin (Digitek, Lanoxin) Digoxin-Specific Antidote: Digoxin Immune Fab (Digibind) given for massive digoxin overose. It binds with digoxin or digitoxin molecules. The resulting complex is excreted through the kidneys.

Digoxin Immune Fab

(Digitibind) ACTION Digoxin-Specific Antidote USES

Antidote for massive digoxin overdose

ADVERSE REACTIONS *Hypokalemia, reemergence of atrial fibrillation or HF

CONTRAINDICATIONS *Hypersensitivity to the drug INTERACTIONS Drug: None NURSING PRECAUTIONS

* Before administering digoxin immune Fab to high-risk patient, test for allergic reaction. After 20 minutes, observe for an urticarial wheal surrounded by erythema. Test is considered positive if it produces a wheal surrounded by erythema. If test causes a systemic reaction, apply tourniquet above test site, notify prescriber, and prepare to respond to anaphylaxis. Be aware that if a skin or systemic reaction occurs, additional drug

shouldnt be given unless essential; if more of the drug must be given, expect prescriber to pretreat patient with corticosteroids and diphenhydramine. Prescriber should be on standby to treat anaphylaxis * When administering to a child, watch for fluid volume overload * When giving a large dose, expect a faster onset but watch closely for febrile reaction * Monitor serum potassium level often, especially during first few hours of therapy. The potassium level may drop rapidly

GASTROINTESTINAL MEDICATIONS

There are 3 major types of GI medications.

The first major type includes the products designed to help restore or maintain the lining that protects the GI tract. These drugs include: Antacids, which act to neutralize or reduce aciditiy of the gastric contents Histamine H2-receptor antagonists, which reduce gastric acid secretion by limiting the action of histamine at the H2 receptors in the stomach, Proton pump inhibitors, which reduce gastric acid by blocking the proton pump. A second major type of GI medication affects the general motility, or movement, of the GI tract. These medications include: Anticholinergics and antispasmodics, which not only reduce gastric motility by also decrease the amount of acid secreted by the stomach. Antidiarrheals, which help reduce diarrhea by slowing the intestinal peristalsis. The third major type of GI drugs also affect motility, but their action is primarily in the colon. These are the laxative agents. These prepareations

promote bowel emptying in a variety of ways. They may increase intestinal bulk, lubricate the intestinal walls, soften the fecal mass by retaining water, or produce increase peristalsis through local tissue irritation or by direction action on the intestine.

Calcium Carbonate
(Tums, Mylanta) ACTION Acid Neutralize r Symptom atic relief of peptic ulcer and ADVERSE REACTIONS *Acid rebound CONTRAINDICATIONS

stomach hyperacidi ty Calcium deficienci es (osteopor osis)

USES

*Contradindicated in patients with severe abdominal pain, during lactation, and patients with renal calculi or hypercalcemia. *Used cautiously in patients with respiratory insufficiency, renal impairment or cardiac disease
INTERACTIONS Drug:

drugs, no oral drugs should be administered within 1 or 2 hours of an antacid. *Do not use an antacid indiscriminately, always check with MD for other drug interactions *Antacids may change the color of stool (white, white streaks); this is normal *Do not use the maximum dose for more than 2 weeks

Digoxin, isoniaszid, phenytoin & chlorpromazine decreased absorption of the results in a decreased effect of those drugs Tetracycline decreased effectiveness of antiinfective Corticosteroidsdecreased antiinflammatory properties Salicylatespain reliever is excreted more rapidly in
the urine

Magnesium Hydroxide
(Milk of Magnesia) ACTION Acid Neutralizers USES Symptomatic relief of peptic ulcer and stomach hyperacidity Constipation

Quinidine & Amphetamines drugs are excreted more slowly in the urine

NURSING PRECAUTIONS *Because of the possibility of an antacid interfering with the activity of other oral

ADVERSE REACTIONS *Diarrhea, bone loss in patients with chronic renal failure, dehydration, hypermagnesemia (nausea, vomiting, hypotension, decreased respirations) CONTRAINDICATIONS *Used cautiously in patients with decreased kidney function and patients with severe abdominal pain
INTERACTIONS Drug:

Quinidine & Amphetamines drugs are excreted more slowly in the urine

NURSING PRECAUTIONS *Because of the possibility of an antacid interfering with the activity of other oral drugs, no oral drugs should be administered within 1 or 2 hours of an antacid. *Do not use an antacid indiscriminately, always check with MD for other drug interactions *Antacids may change the color of stool (white, white streaks); this is normal *Do not use the maximum dose for more than 2 weeks

Digoxin, isoniaszid, phenytoin & chlorpromazine decreased absorption of the results in a decreased effect of those drugs Tetracycline decreased effectiveness of antiinfective Corticosteroidsdecreased antiinflammatory properties Salicylatespain reliever is excreted more rapidly in
the urine

Cimetidine
(Tagamet)

ACTION Histamine H2 Antagonist Acid Reducer USES Gastric/duodenal ulcers GERD Gastric hypersecretory conditions GI bleeding Heartburn ADVERE REACTIONS *Headache, somnolence, diarrhea, dizziness, reversible impotence, confusion

CONTRAINDICATIONS
*Used cautiously in patients with renal or hepatic impairment, severely ill, elderly, or debilitated patients. *Used cautiously in diabetic patients, patients who are pregnant or lactating.

Antacids & metoclopramidedecreased absorption of H2 antagonist Carmustine decreased WBC count Opioid analgesics increased risk of respiratory depression Oral anticoagulants increased risk of bleeding Digoxin may decrease digoxin levels benzodiazepines, calcium channel blockers, carbamazepine, chloroquine, labetalol, lidocaine, metoprolol, metronidazole, moricizine, pentoxifylline, phenytoin, propafenone, propranolol, quinidine, quinine, sulfonylureas, tacrine, theophyllines, triamterene, tricyclic antidepressants, valproic acid, warfarin Reduced metabolism and increased blood levels and effects of these drugs, possibly toxicity from these drugs Foods Caffeine Reduced metabolism and increased blood level and effects of caffeine Alcohol Possibly increased blood alcohol levels

NURSING PRECAUTIONS
*Be aware that rapid administration of cimetidine can increase the patients risk of developing arrhythmias and hypotension * Instruct patient to avoid taking antacids within 1 hour of taking cimetidine * Warn patient that cigarette smoking increases gastric acid secretion and can worsen gastric disease

INTERACTIONS
Drug:

* Caution patient not to take drug for more than 14 days, unless prescribed

elderly or debilitated patients. *Used cautiously in diabetic patients *Pregnancy Category B

Famotidine
(Pepcid) ACTION INTERACTIONS Drug:
Antacids & metoclopramide (GI distress) decreased absorption of the H2 antagonists Carmustine (anticancer) decreases WBC Opioid Analgesics increased risk of respiratory depression Anticoagulants increased risk of bleeding digoxin may decrease digoxin levels

Histamine H2 Antagonist Acid Reducer

USES Gastric/duodenal ulcers GERD, heartburn GI Bleeding ADVERSE RACTIONS *Headache, somnolence, diarrhea CONTRAINICATIONS
*Hypersensitivity to the drug *Cautiously used in patients with renal/hepatic impairment, severely ill,

NURSING PRECAUTIONS
*BIG risk of potential toxicity from decreased elimination in older adults or patients with hepatic or renal dysfunction *Monitor liver function tests & early signs of
hepatoxicity

-jaundice, dark urine, pruritius, yellow sclera and skin *Long-term therapy may lead to vitamin B12 deficiency *Remember to provide pain relief through the night *Do NOT supplement with OTC gastric distress remedies (Mylanta, Pepto, Zantac reduces pepcid absorption) *Do NOT SMOKE *Do NOT breast feed without consulting MD

Erosive easophagitis GERD H. pylori eradication NSAID-associated gastric ulcers

ADVERSE REACTIONS *Headache, nausea, diarrhea, abdominal pain CONTRAINCATIONS *Used cautiously in older adults and patients with hepatic impairment. Prolonged treatments may decrease the bodys ability to absorb vitamin B12 resulting in anemia. INTERACTIONS Drug: Sucralfate decreased absorption of PPI

Esomeprazole Omeprazole (Nexium) (Prilosec)

Lansoprazole (Prevacid)

ACTION Proton Pump Inhibitor Acid Reducer USES

Ketoconazole & Ampicillin decreased WBC Oral Anticoagulant increased risk of

bleeding

applesauce. Tell them not to chew pellets and to discard any unused pellets

Digoxin increased absorption of digoxin Benzos & Phenytoin risk for toxic level of antiseizure medication Clarithromycin risk for increase in plasma level of both drugs NURSING PRECAUTIONS
*Give at least 1 hour before meals because food decreases bioavail-ability * If patient takes drug with amoxicillin or clarithromycin for H. pylorirelated ulcer, severe diarrhea may indicate pseudomembranous colitis. Obtain stool cultures, as ordered * If patient has trouble swallowing esomeprazole capsules, tell him to open capsule and sprinkle pellets into a tablespoon of cool

Prochlorperazine
(Compazine)
ACTION Antiemetic USES Control of nausea & vomiting ADVERSE REACTIONS *Drowsiness, hypotension, dry mouth, nasal congestion CONTRAINDICATIONS * Age less than 2 years, blood dyscrasias, bone marrow depression, cerebral arteriosclerosis, coma, coronary artery disease, hepatic dysfunction, hypersensitivity to phenothiazines, myeloproliferative disorders, pediatric surgery, severe CNS depression, severe hypertension or hypotension, subcortical brain damage, use of large quantities of CNS depressants, weight less than 9 kg (20 lbs)

INTERACTIONS Drug:
Al- or Mg-containing antacids, antidiarrhealPossibly inhibited absorption of oral prochlorperazine amantadine, anticholinergics, antidyskinetics, antihistaminePossibly intensified anticholinergic adverse effects

amphetamines Decreased stimulant effect of amphetamines, decreased antipsychotic effect of prochlorperazine anticonvulsants Lowered seizure threshold beta blockers Increased risk of additive hypotensive effects, irreversible retinopathy, arrhythmias, and tardive dyskinesia CNS depressants Additive CNS depression Dopamine peripheral vasoconstriction levodopa Inhibited antidyskinetic effect of levodopa LithiumReduced absorption of oral prochlorperazine, increased excretion of Li,
increased extrapyramidal effects, possibly masking of early symptoms of lithium toxicity MAO inhibitors, maprotiline, tricyclic anti-depressants Possibly prolonged and intensified anticholinergic and sedative effects, increased blood antidepressant levels, and increased risk of neuroleptic malignant syndrome

related psychosis in the elderly because of an increased mortality risk. *Avoid contact between skin and solution forms of prochlorperazine because contact dermatitis could result * Expect antipsychotic effects to occur in 2 to 3 weeks, although the range is days to months * Instruct patient using a suppository to refrigerate it for 30 minutes or hold it under running cold water before removing the wrapper if it softens during storage * Caution patient on long-term therapy not to stop taking prochlorperazine abruptly; doing so may lead to such adverse reactions as nausea, vomiting, and trembling * Urge patient to avoid alcohol and OTC drugs that may contain CNS depressants * Instruct patient to avoid excessive sun exposure and to wear sunscreen outdoors

opioid analgesics Increased risk of CNS and respiratory depression, orthostatic hypotension, severe constipation, and urine retention phenytoin Possibly inhibited phenytoin metabolism & increased risk of
phenytoin toxicity

Ondansetron
(Zofran) ACTION Antiemetic

thiazide diuretics Possibly potentiated hyponatremia and water intoxication

NURSING PRECAUTIONS
*Prochlorperazine shouldnt be used to treat dementia-

USES Prevention of chemotherapyinduced & posteroperative nausea & vomiting Bulimia Spinal analgesic-induced pruritus Levodopa-induced psychosis ADVERSE REACITONS *Headache, fatigue, drowsiness, sedation, constipation, hypoxia CONTRAINDICATIONS *none INTERACTIONS Drug: cisplatin, cyclophosphamide Possibly altered blood levels of these drugs

Alcohol Increased stimulant and sedative effects, including mood and physical sedation NURSING PRECAUTIONS * Be aware that oral disintegrating tablets may contain aspartame, which is metabolized to phenylalanine and must be used cautiously in patients with phenylketonuria * Place disintegrating tablet on patients tongue immediately after opening package. It dissolves in seconds

Bismuth
(Pepto-Bismol, Pink Bismuth) ACTION Antidiarrheal USES Nausea Diarrhea Abdominal cramps H. pylori infection with duodenal ulcer ADVERSE REACTIONS *Dry skin and mucous membranes, nausea, constipation, lightheadedness CONTRAINDICATIONS

*In patients with diarrhea associated with E. coli, salmonella and shigella, patients with pseudomembranous colitis, obstructive jaundice, children younger than 2 years of age, or is diarrhea persists for more than 2 days. *Used cautiously in patients with severe hepatic impairment or IBD. INTERACTIONS Drug:
Antihistamines, opioids, sedatives or hypnotics increased risk of CNS

depression Antidepressants increased cholinergic blocking adverse reactions MAOIs increased risk hypertensive crisis

NURSING PRECAUTIONS *Do not exceed the recommended dosage *If diarrhea persists for more than 2 days, call MD.

ANTIPSYCHOTIC DRUGS
(Lithium, Haldol, Compazine, Abilify, Zyprexa, Seroquel, Risperdal) Antipsychotic medications are administered to patients experiencing a psychotic disorder. Psychosis refers to a group of symptoms that affect mood and behavior Hallucinations (false sensation or perceptions have no basis in reality) Delusions (false beliefs that cannot be changed with reason) Disorganized speech Behavior disturbances, social withdrawal Flatten affect (absence of an emotional response to any situation/condition)

Anhedonia (finding no pleasure in activities that are normally pleasurable Antipsychotics are usually given to bipolar disorder patients during an manic phase: During the manic phase, the person experiences altered thought processes, which can lead to bizarre delusions Antipsychotic diminished the frequency and intensity of hyperactive (manic) episodes

Lithium Haloperidol Prochlorperazine Aprpiprazole (Haldol) (Compazine) (Abilify) Olanzapine Quetiapine Risperidone (Zyprexa) (Seroquel) (Risperdal) ACTION Antipsychotic
USES Acute & Chronic psychoses, such as schizophrenia Bipolar (manic-depressive) illness Agitated behaviors associated with dementia ADVERSE REACTIONS
*Sedation, headache, hypotension, dry mouth, nasal congestion, urticaria, photophobia, photosensitivity

*Possible behavioral changes: possible increase of intensity of psychotic symptoms (paradoxical effects), lethargy, hyperactivity, paranoid reactions, agitation and confusion

Extrapyramidal Syndrome (EPS): a group of

adverse reactions that affects posture, promotes smooth and uninterrupted movement of carious muscle groups. Causes abnormal muscles movements:

Parkinson-like symptoms: fine tremors, muscle rigidity, masklike appearance of face, slowness of movement, slurred speech and unsteady gait

Akathsia: extreme restlessness and increased motor activity Dystonia: facial grimacing and twisting of the neck into unnatural positions

Tardive Dyskinesia (TD): a syndrome

consisting of irreversible, involuntary dyskinetic movements, characterized by: rhythmic, involuntary movements of the tongue, face, mouth or jaw and sometimes the extremities. The tongue may protrude and there may be chewing

Because of the risk of TD, it is best to use the smallest dose & shortest duration of treatment that produces satisfactory clinical response. Neuroleptic Malignant Syndrome (NMS): a rare reaction, characterized by a combination of EPS effects, hyperthermia and autonomic disturbances. It typically occurs within 1 month after the antipsychotic drug regimen is begun. NMS is p otentially fatal and requires intensive symptomatic treatment, once the drug is discontinued recover occurs within 7-10 days. Shaking, involuntary movements + fever = NMS (FATAL)

movements, pucking of the mouth and facial grimacing.

disease, liver impairment, coronary artery disease, or severe hypo OR hypertension *Antipsychotics should be used only when clearly needed and when the potential benefit outweighs any potential harm to the fetus *Used cautiously in patients with respiratory disorders, glaucoma, prostate hypertrophy, epilepsy, decreased renal function and peptic ulcer disease.

INTERACTIONS
Drug: Anticholingeric drugs increased risk for TD & psychotic symptoms Antacids decreased effectiveness of lithium Loop Diuretics increased risk for lithium toxicity, since increased urination & fluid removal Li combined with other antipsychotics increased risk of Li toxicity Alcohol increased risk for CNS depression

CONTRAINICATIONS

*Comatose patients, those who are severely depressed, have bone marrow depression, Pakinsons

NURSING PRECAUTIONS
*In combative patients or those who have serious manifestations of acute psychosis (example: hallucinations or lost of contact with reality), parenteral administration

may be repeated every 1 to 4 hours until the desired effects are obtained. The nurse monitors the patient closely for cardiac arrhythmias or rhythm changes or hypotension *Gerontology: older adults are at increased risk for Li toxicity because of a decreased rate of excretion. Lower dosages may be necessary to decrease the risk of toxicity. -Because drug metabolism and excretion are altered in elderly or debilitated patients, doses may be instituted at one-half to one-third the recommended dose for younger adults and increased more gradually than in younger adults. Special Considerations for Lithium

*It is rapidly absorbed after oral administration. *Most common adverse reactions include: tremors, nausea, vomiting, thirst and polyuria. *Desirable serum Li levels = 0.6 1.2 mEq/L Lithium Toxicity 1.5-2 mEq/L = N/V/D, drowsiness, weakness, lack of coordination 2-3 mEq/L= Giddiness, blurred vision, tinnitus, vertigo, confusion, agitation/manic behavior, twitching of limbs >3 mEq/L= multiple organ/system failure, seizures, arrhythmias, hypotension, muscle group twitching, spasticity, coma