E-Cart meds.

7/30/2019 E-Cart meds.

http://slidepdf.com/reader/full/e-cart-meds 1/46

Generic Name: Verapamil hydrochloride

Brand Name: Apo-Verapamil (CAN), Calan, Calan SR, Covera-HS, Gen-Verapamil (CAN), Gen-

Verapamil SR (CAN), Isoptin SR, Novo-Verapamil SR (CAN), Nu-Verap (CAN), Verelan, Verelan PM

Classification: Calcium channel-blocker, Antianginal, Antiarrhythmic, Antihypertensive

Pregnancy Category C

Dosage & Route

ADULTS

Oral

Immediate release

Angina: 80 mg q 6–8 hr; may increase by 80 mg at weekly intervals until control is achieved.

Maintenance 240–480 mg daily. Arrhythmias: 240–480 mg/day.

In digitalized adults: 240–320 mg/day.

Hypertension: 40 mg to 80 mg PO tid.

ER

Capsules: 120–240 mg/day PO in the morning. Titrate dose to a maximum 480 mg/day.

Tablets: 120–180 mg/day PO in the morning. Titrate to a maximum 240 mg q 12 hr.

SR

120–180 mg/day PO. Titrate up to a maximum 480 mg PO in the morning.

Parenteral

IV use only. Initial dose, 2.5–10 mg over 2 min; may repeat dose of 10 mg 30 min after first dose if

initial response is inadequate.

PEDIATRIC PATIENTS

IV

< 1 yr: Initial dose, 0.1–0.2 mg/kg over 2 min.

1–15 yr: Initial dose, 0.1–0.3 mg/kg over 2 min. Do not exceed 5 mg. Repeat above dose 30 min

after initial dose if response is not adequate. Repeat dose should not exceed 10 mg.

GERIATRIC PATIENTS OR PATIENTS WITH RENAL IMPAIRMENT



Reduce dosage, and monitor patient response carefully. Give IV doses over 3 min to reduce risk of

serious side effects. Administer IV doses very slowly, over 2 min.

Therapeutic actions

Verapamil inhibits entry of calcium ions into arterial smooth muscle cells as well as the myocytesand conducting tissue. These actions lead to reversal and preventions of coronary artery spasm,

reduction in afterload through peripheral vasodilatation and reduction in ventricular rate in

patients with chronic atrial flutter or fibrillation and reduction in the occurrence of paroxysmal

supraventricular tachycardia. Verapamil reduces BP, relieves angina and slows AV conduction.

Indications

Angina pectoris due to coronary artery spasm (Prinzmetal’s variant angina)

Effort-associated angina

Chronic stable angina

Unstable, crescendo, preinfarction angina Essential hypertension

Parenteral: Treatment of supraventricular tachyarrhythmias

Parenteral: Temporary control of rapid ventricular rate in atrial flutter or atrial fibrillation

Adverse effects

Bradycardia, CHF, MI, AV block, worsening heart failure, transient asystole, hypotension,

pulmonary and peripheral edema, nausea. Constipation, fatigue, hypotension, dizziness,

headache, palpitation, flushing, nausea, rashes, alopecia, hyperprolactinaemia, increased LFT and

arthralgia.

Potentially Fatal: Heart block and cardiac failure in patients with preexisting cardiac disease.

Hepatotoxicity.

Contraindications

Cardiogenic shock, severe bradycardia, severe left ventricular dysfunction, uncompensated heart

failure, hypotension (systolic pressure

Nursing considerations

Assessment

History: Allergy to verapamil; sick sinus syndrome; heart block; IHSS; cardiogenic shock, severe

CHF; hypotension; impaired hepatic or renal function; pregnancy, lactation

Physical: Skin color, edema; orientation, reflexes; P, BP, baseline ECG, peripheral perfusion,

auscultation; R, adventitious sounds; liver evaluation, normal output; LFTs, renal function tests,

urinalysis

Interventions



WARNING: Monitor patient carefully (BP, cardiac rhythm, and output) while drug is being titrated

to therapeutic dose. Dosage may be increased more rapidly in hospitalized patients under close

supervision.

Ensure that patient swallows SR tablets whole; patient should not cut, crush, or chew them.

Monitor BP very carefully with concurrent doses of antihypertensives. Monitor cardiac rhythm regularly during stabilization of dosage and periodically during long-

term therapy.

Administer SR form in the morning with food to decrease GI upset.

Protect IV solution from light.

Monitor patients with renal or hepatic impairment carefully for possible drug accumulation and

adverse reactions.

Teaching points

Take sustained-release form in the morning with food; swallow it whole, do not cut, crush, or

chew it. Do not drink grapefruit juice while using this drug. You may experience these side effects: Nausea, vomiting (eat frequent small meals); headache

(adjust lighting, noise, and temperature; request medication); dizziness, sleepiness (avoid driving

or operating dangerous equipment); emotional depression (reversible); constipation (request

aid).

Report irregular heartbeat, shortness of breath, swelling of the hands or feet, pronounced

dizziness, nausea, constipation.

MORPHINE SULFATE

Brand Names: Astramorph PF, Avinza, DepoDur, Duramorph, Epimorph , Kadian, MSIR, MS Contin,

Oramorph SR, Roxanol, RMS, StatexClassifications: central nervous system (cns) agent; analgesic; narcotic (opiate) agonist

Pregnancy Category: B (D in long-term use or high dose)

Controlled Substance: Schedule II

Availability

10 mg, 15 mg, 30 mg tablets/capsules; 15 mg, 20 mg, 30 mg, 60 mg, 100 mg, 120 mg, 200 mg

controlled release tablets/capsules; 10 mg/2.5 mL, 10 mg/5 ml, 20 mg/mL, 20 mg/5 mL, 30

mg/1.5 mL, 100 mg/5 mL oral solution; 0.5 mg/mL, 1 mg/mL, 2 mg/mL, 4 mg/mL, 5 mg/mL, 8

mg/mL, 10 mg/mL, 15 mg/mL, 25 mg/mL, 50 mg/mL injection; 10 mg/mL, 15 mg/1.5 mL, 20

mg/2 mL extended-release lysosomal injection; 5 mg, 10 mg, 20 mg, 30 mg suppositories

Actions of Morphine Sulfate

Natural opium alkaloid with agonist activity by binding with the same receptors as endogenous

opioid peptides.



Narcotic agonist effects are identified with 3 types of receptors: Analgesia at supraspinal level,

euphoria, respiratory depression and physical dependence; analgesia at spinal level, sedation and

miosis; and dysphoric, hallucinogenic and cardiac stimulant effects.

Therapeutic Effects

Controls severe pain; also used as an adjunct to anesthesia.

Uses

Symptomatic relief of severe acute and chronic pain after nonnarcotic analgesics have failed and

as preanesthetic medication; also used to relieve dyspnea of acute left ventricular failure and

pulmonary edema and pain of MI.

Contraindications

Hypersensitivity to opiates; increased intracranial pressure; convulsive disorders; acutealcoholism; acute bronchial asthma, chronic pulmonary diseases, severe respiratory depression;

chemical-irritant induced pulmonary edema; prostatic hypertrophy; diarrhea caused by

poisoning until the toxic material has been eliminated; undiagnosed acute abdominal conditions;

following biliary tract surgery and surgical anastomosis; pancreatitis; acute ulcerative colitis;

severe liver or renal insufficiency; Addison’s disease; hypothyroidism; during labor for delivery of

a premature infant, in premature infants; pregnancy (category B; D in long-term use or when high

dose is used); lactation.

Cautious Use

Toxic psychosis; cardiac arrhythmias, cardiovascular disease; emphysema; kyphoscoliosis; corpulmonale; severe obesity; reduced blood volume; very old, very young, or debilitated patients;

labor.

Route & Dosage

Pain Relief

Adult: PO 10–30 mg q4h prn or 15–30 mg sustained release q8–12h; (Kadian) dose q12–24h,

increase dose prn for pain relief IV 2.5–15 mg q4h or 0.8–10 mg/h by continuous infusion, may

increase prn to control pain or 5–10 mg given epidurally q24h Epidural (DepoDur only) 10–15

mg as single dose 30 min before surgery (max: 20 mg) IM/SC 5–20 mg q4h PR 10–20 mg q4h prn Child: IV 0.05–0.1 mg/kg q4h or 0.025–2.6 mg/kg/h by continuous infusion IM/SC 0.1–0.2 mg/kg

q4h (max: 15 mg/dose) PO 0.2–0.5 mg/kg q4–6h; 0.3–0.6 mg/kg sustained release q12h

Neonate: IV/IM/SC 0.05 mg/kg q4–8h (max: 0.1 mg/kg) or 0.01–0.02 mg/kg/h

Administration

Oral



Use a fixed, individualized schedule when narcotic analgesic therapy is started to provide

effective management; blood levels can be maintained and peaks of pain can be prevented

(usually a 4-h interval is adequate).

Use lower dosage for older adult or debilitated patients than for adults.

Do not break in half, crush, or allow sustained release tablet to be chewed.

Do not give patient sustained release tablet within 24 h of surgery. Dilute oral solution in approximately 30 mL or more of fluid or semisolid food. A calibrated

dropper comes with the bottle. Read labels carefully when using liquid preparation; available

solutions: 20 mg/mL; 100 mg/mL.

Intravenous

Note: Verify correct IV concentration and rate of infusion/injection for administration to

neonates, infants, or children with physician.

PREPARE: Direct: Dilute 2–10 mg in at least 5 mL of sterile water for injection.

ADMINISTER: Direct: Give a single dose over 4–5 min. Avoid rapid administration.

INCOMPATIBILITIES Solution/additive: Aminophylline, amobarbital, chlorothiazide, floxacillin,fluorouracil, haloperidol, heparin, meperidine, pentobarbital, phenobarbital, phenytoin, sodium

bicarbonate, thiopental. Y-site: Amphotericin B cholesteryl complex, cefepime, doxorubicin

liposome, minocycline, sargramostim, tetracycline.

Store at 15°–30° C (59°–86° F). Avoid freezing. Refrigerate suppositories. Protect all formulations

from light.

Adverse Effects ( 1%)

Body as a Whole: Hypersensitivity [Pruritus, rash, urticaria, edema, hemorrhagic urticaria (rare),

anaphylactoid reaction (rare)], sweating, skeletal muscle flaccidity; cold, clammy skin,

hypothermia.

CNS: Euphoria, insomnia, disorientation, visual disturbances, dysphoria, paradoxic CNS

stimulation (restlessness, tremor, delirium, insomnia), convulsions (infants and children);

decreased cough reflex, drowsiness, dizziness, deep sleep, coma, continuous intrathecal infusion

may cause granulomas leading to paralysis.

Special Senses: Miosis.

CV: Bradycardia, palpitations, syncope; flushing of face, neck, and upper thorax; orthostatic

hypotension, cardiac arrest.

GI: Constipation, anorexia, dry mouth, biliary colic, nausea, vomiting, elevated transaminase

levels.

Urogenital: Urinary retention or urgency, dysuria, oliguria, reduced libido or potency (prolonged

use).

Other: Prolonged labor and respiratory depression of newborn. Hematologic: Precipitation of

porphyria. Respiratory: Severe respiratory depression (as low as 2–4/min) or arrest; pulmonary

edema.

Diagnostic Test Interference



False-positive urine glucose determinations may occur using Benedict’s solution. Plasma amylase

and lipase determinations may be falsely positive for 24 h after use of morphine; transaminase

levels may be elevated.

Interactions

Drug: cns depressants, sedatives, barbiturates, alcohol, benzodiazepines, and tricyclic

antidepressants potentiate CNS depressant effects. Use mao inhibitors cautiously; they may

precipitate hypertensive crisis. phenothiazines may antagonize analgesia.

Herbal: Kava-kava, valerian, St. John’s wort may increase sedation.

Pharmacokinetics

Absorption: Variably absorbed from GI tract. Peak: 60 min PO; 20–60 min PR; 50–90 min SC; 30–

60 min IM; 20 min IV. Duration: Up to 7 h.

Distribution: Crosses blood–brain barrier and placenta; distributed in breast milk.

Metabolism: Metabolized primarily in liver. Elimination: 90% of drug and metabolites excreted in urine in 24 h; 7%–10% excreted in bile.

Nursing Considerations

Assessment & Drug Effects

Obtain baseline respiratory rate, depth, and rhythm and size of pupils before administering the

drug. Respirations of 12/min or below and miosis are signs of toxicity. Withhold drug and report

to physician.

Observe patient closely to be certain pain relief is achieved. Record relief of pain and duration of

analgesia. Be alert to elevated pulse or respiratory rate, restlessness, anorexia, or drawn facial expression

that may indicate need for analgesia.

Differentiate among restlessness as a sign of pain and the need for medication, restlessness

associated with hypoxia, and restlessness caused by morphine-induced CNS stimulation (a

paradoxic reaction that is particularly common in women and older adult patients).

Monitor for respiratory depression; it can be severe for as long as 24 h after epidural or

intrathecal administration.

Monitor carefully those at risk for severe respiratory depression after epidural or intrathecal

injection: Older adult or debilitated patients or those with decreased respiratory reserve (e.g.,

emphysema, severe obesity, kyphoscoliosis).

Continue monitoring for respiratory depression for at least 24 h after each epidural or intrathecaldose.

Assess vital signs at regular intervals. Morphine-induced respiratory depression may occur even

with small doses, and it increases progressively with higher doses (generally max: 90 min after

SC, 30 min after IM, and 7 min after IV).

Encourage changes in position, deep breathing, and coughing (unless contraindicated) at

regularly scheduled intervals. Narcotic analgesics also depress cough and sigh reflexes and thus

may induce atelectasis, especially in postoperative patients.



Be alert for nausea and orthostatic hypotension (with light-headedness and dizziness) in

ambulatory patients or when a supine patient assumes the head-up position or in patients not

experiencing severe pain.

Monitor I&O ratio and pattern. Report oliguria or urinary retention. Morphine may dull

perception of bladder stimuli; therefore, encourage the patient to void at least q4h. Palpate lower

abdomen to detect bladder distention.

Patient & Family Education

Avoid alcohol and other CNS depressants while receiving morphine.

Do not use of any OTC drug unless approved by physician.

Do not smoke or ambulate without assistance after receiving drug. Bedside rails are advised.

Use caution or avoid tasks requiring alertness (e.g., driving a car) until response to drug is known

since morphine may cause drowsiness, dizziness, or blurred vision.

Do not breast feed while taking this drug.

Dextrose 5% in Water (D5W) raises total fluid volume it is also helpful in rehydrating andexcretory purposes.

Type of Solution

Dextrose 5% Water

Isotonic then hypotonic (once inside the body)

Classifcation

Isotonic then hypotonic

Nonpyrogenic Parenteral fluid

Electrolyte

Nutrient replenisher

Contents

Dextrose Hydrous 50gm/L

Mechanism of action

Dextrose provides a source of calories. Dextrose is readily metabolized, may decrease losses of body protein and nitrogen, promotes glycogen deposition and decreases or prevents ketosis if

sufficient doses are provided

Indications

Lactated Ringer’s and 5% Dextrose Injection, is indicated as a source of water, electrolytes and

calories or as an alkalinizing agent.

http://nurseslabs.com/d5w-iv-fluid-study/





Contraindications

solutions containing dextrose may be contraindicated in patients with known

Allergy to corn or corn products.

Dose

As directed by a physician. Dosage is dependent upon the age, weight and clinical condition of the

patient as well as laboratory determinations.

Parenteral drug products should be inspected visually for particulate matter and discoloration

prior to administration whenever solution and container permit.

All injections in VIAFLEX plastic containers are intended for intravenous administration using

sterile equipment.

As reported in the literature, the dosage and constant infusion rate of intravenous dextrose must

be selected with caution in pediatric patients, particularly neonates and low weight infants,

because of the increased risk of hyperglycemia/hypoglycemia.

Additives may be incompatible. Complete information is not available. Those additives known to

be incompatible should not be used. Consult with pharmacist, if available. If, in the

informed judgement of the physician, it is deemed advisable to introduce additives, use aseptic

technique. Mix thoroughly when additives have been introduced. Do not store solutions

containing additives

Nursing Responsibilities

Suspend container from eyelet support.

Remove plastic protector from outlet port at bottom of container.

Attach administration set. Refer to complete directions accompanying set

Clinical evaluation and periodic laboratory determinations are necessary to monitor changes in

fluid balance, electrolyte concentrations, and acid base balance during prolonged parenteral

therapy or whenever the condition of the patient warrants such evaluation.

Lactated Ringer’s and 5% Dextrose Injection, USP should be used with caution. Excess

administration may result in metabolic alkalosis.

Caution must be exercised in the administration of parenteral fluids, especially those containing

sodium ions to patients receiving corticosteroids or corticotrophin.

Solution containing acetate should be used with caution as excess administration may result in

metabolic alkalosis.

If an adverse reaction does occur, discontinue the infusion, evaluate the patient, institute

appropriate therapeutic countermeasures

Atropine sulfate

Parenteral and oral preparations:

AtroPen, Minims (CAN), Sal-Tropine

Ophthalmic solution:

Atropine Sulfate S.O.P., Isopto Atropine Ophthalmic




Drug classes of Atrophine Sulfate

Anticholinergic Antimuscarinic

Parasympatholytic

Antiparkinsonian

Antidote

Diagnostic agent (ophthalmic preparations)

Belladonna alkaloid

Therapeutic actions of Atrophine Sulfate

Competitively blocks the effects of acetylcholine at muscarinic cholinergic receptors that mediate

the effects of parasympathetic postganglionic impulses, depressing salivary and bronchialsecretions, dilating the bronchi, inhibiting vagal influences on the heart, relaxing the GI and GU

tracts, inhibiting gastric acid secretion (high doses), relaxing the pupil of the eye (mydriatic

effect), and preventing accommodation for near vision (cycloplegic effect); also blocks the effects

of acetylcholine in the CNS.

Dosage & Route

ADULTS

Systemic administration

0.4–0.6 mg PO, IM, IV, or subcutaneously.

Hypotonic radiography: 1 mg IM.

Surgery: 0.5 mg (0.4–0.6 mg) IM (or subcutaneously or IV) prior to induction of anesthesia;

during surgery, give IV; reduce dose to < 0.4 mg with cyclopropane anesthesia.

Bradyarrhythmias: 0.4–1 mg (up to 2 mg) IV every 1–2 hr as needed.

Antidote: For poisoning due to cholinesterase inhibitor insecticides, give large doses of at least 2–

3 mg parenterally, and repeat until signs of atropine intoxication appear; for rapid type of

mushroom poisoning, give in doses sufficient to control parasympathetic signs before coma and

CV collapse intervene. Auto-injector provides rapid administration.

Ophthalmic solution

For refraction: Instill 1–2 drops into eye 1 hr before refracting.

For uveitis: Instill 1–2 drops into eye qid.

PEDIATRIC PATIENTS




Refer to the following table:

Weight Dose (mg)

7–16 lb (3.2–7.3 kg) 0.1

16–24 lb (7.3–10.9 kg) 0.15

24–40 lb (10.9–18.1 kg) 0.2

40–65 lb (18.1–29.5 kg) 0.3

65–90 lb (29.5–40.8 kg) 0.4

> 90 lb (> 40.8 kg) 0.4–0.6

Surgery: 0.1 mg (newborn) to 0.6 mg (12 yr) injected subcutaneously 30 min before surgery.

Antidote:

> 90 lb: 2 mg auto-injector.

40–90 lb: 1-mg auto-injector.

15–40 lb: 0.5 mg auto-injector.

< 15 lb: 0.25 mg auto-injector.

GERIATRIC PATIENTS

More likely to cause serious adverse reactions, especially CNS reactions, in elderly patients; use

with

Indications of Atrophine


Antisialagogue for preanesthetic medication to prevent or reduce respiratory tract secretions

Treatment of parkinsonism; relieves tremor and rigidity

Restoration of cardiac rate and arterial pressure during anesthesia when vagal stimulation

produced by intra-abdominal traction causes a decrease in pulse rate, lessening the degree of AV

block when increased vagal tone is a factor (eg, some cases due to digitalis)

Relief of bradycardia and syncope due to hyperactive carotid sinus reflex Relief of pylorospasm, hypertonicity of the small intestine, and hypermotility of the colon

Relaxation of the spasm of biliary and ureteral colic and bronchospasm

Relaxation of the tone of the detrusor muscle of the urinary bladder in the treatment of urinary

tract disorders

Control of crying and laughing episodes in patients with brain lesions

Treatment of closed head injuries that cause acetylcholine release into CSF, EEG abnormalities,

stupor, neurologic signs



Relaxation of uterine hypertonicity

Management of peptic ulcer

Control of rhinorrhea of acute rhinitis or hay fever

Antidote (with external cardiac massage) for CV collapse from overdose of parasympathomimetic

(cholinergic) drugs (choline esters, pilocarpine), or cholinesterase inhibitors (eg, physostigmine,

isoflurophate, organophosphorus insecticides) Antidote for poisoning by certain species of mushroom (eg, Amanita muscaria)

Ophthalmic preparations

Diagnostically to produce mydriasis and cycloplegia-pupillary dilation in acute inflammatory

conditions of the iris and uveal tract

Adverse effects of Atrophine


CNS: Blurred vision, mydriasis, cycloplegia, photophobia, increased IOP, headache, flushing,

nervousness, weakness, dizziness, insomnia, mental confusion or excitement (after even small

doses in the elderly), nasal congestion

CV: Palpitations, bradycardia (low doses), tachycardia (higher doses)

GI: Dry mouth, altered taste perception, nausea, vomiting, dysphagia, heartburn, constipation,

bloated feeling, paralytic ileus, gastroesophageal reflux

GU: Urinary hesitancy and retention; impotence

Other: Decreased sweating and predisposition to heat prostration, suppression of lactation

Ophthalmic preparations

Local: Transient stinging

Systemic: Systemic adverse effects, depending on amount absorbed

Contraindications of Atrophine

Contraindicated with hypersensitivity to anticholinergic drugs.


Contraindicated with glaucoma; adhesions between iris and lens; stenosing peptic ulcer;

pyloroduodenal obstruction; paralytic ileus; intestinal atony; severe ulcerative colitis; toxic

megacolon; symptomatic prostatic hypertrophy; bladder neck obstruction; bronchial asthma;

COPD; cardiac arrhythmias; tachycardia; myocardial ischemia; impaired metabolic, hepatic, or

renal function; myasthenia gravis.

Use cautiously with Down syndrome, brain damage, spasticity, hypertension, hyperthyroidism,

lactation.



Ophthalmic solution

Contraindicated with glaucoma or tendency to glaucoma.

Nursing considerations of Atrophine

Assessment

History: Hypersensitivity to anticholinergics; glaucoma; adhesions between iris and lens;

stenosing peptic ulcer; pyloroduodenal obstruction; paralytic ileus; intestinal atony; severe

ulcerative colitis; toxic megacolon; symptomatic prostatic hypertrophy; bladder neck obstruction;

bronchial asthma; COPD; cardiac arrhythmias; myocardial ischemia; impaired metabolic, liver, or

renal function; myasthenia gravis; Down syndrome; brain damage; spasticity; hypertension;

hyperthyroidism; lactation

Physical: Skin color, lesions, texture; T; orientation, reflexes, bilateral grip strength; affect;

ophthalmic examination; P, BP; R, adventitious sounds; bowel sounds, normal GI output; normal

urinary output, prostate palpation; LFTs, renal function tests, ECG

Interventions

Ensure adequate hydration; provide environmental control (temperature) to prevent

hyperpyrexia.

Have patient void before taking medication if urinary retention is a problem.

Teaching points

When used preoperatively or in other acute situations, incorporate teaching about the drug with

teaching about the procedure; the ophthalmic solution is mainly used acutely and will not be self-administered by the patient; the following apply to oral medication for outpatients:

Take as prescribed, 30 minutes before meals; avoid excessive dosage.

Avoid hot environments; you will be heat intolerant, and dangerous reactions may occur.

You may experience these side effects: Dizziness, confusion (use caution driving or performing

hazardous tasks); constipation (ensure adequate fluid intake, proper diet); dry mouth (sugarless

lozenges, frequent mouth care may help; may be transient); blurred vision, sensitivity to light

(reversible; avoid tasks that require acute vision; wear sunglasses in bright light); impotence

(reversible); difficulty in urination (empty the bladder prior to taking drug).

Report rash; flushing; eye pain; difficulty breathing; tremors, loss of coordination; irregular

heartbeat, palpitations; headache; abdominal distention; hallucinations; severe or persistent drymouth; difficulty swallowing; difficulty in urination; constipation; sensitivity to light.

Generic Name: Furosemide

Brand Name:

Apo-Furosemide (CAN),



Furosemide Special (CAN),

Lasix

Classification of Furosemide

Loop diuretic Pregnancy Category C

Dosage & Route of Furosemide

Available forms :Tablets—20, 40, 80 mg; oral solution—10 mg/mL, 40 mg/5 mL; injection—10

mg/mL

Adults

Edema:

Initially, 20–80 mg/day PO as a single dose. If needed, a second dose may be given in 6–8 hr.

If response is unsatisfactory, dose may be increased in 20- to 40-mg increments at 6- to 8-hr

intervals.

Up to 600 mg/day may be given.

Intermittent dosage schedule (2–4 consecutive days/wk) is preferred for maintenance, or 20–40

mg IM or IV (slow IV injection over 1–2 min).

May increase dose in increments of 20 mg in 2 hr. High-dose therapy should be given as infusion

at rate not exceeding 4 mg/min.

Acute pulmonary edema:

40 mg IV over 1–2 min. M ay be increased to 80 mg IV given over 1–2 min if response is unsatisfactory after 1 hr.

Hypertension:

40 mg bid PO. If needed, additional antihypertensive agents may be added.

Pediatric Patients

Avoid use in premature infants: stimulates prostaglandin E2 synthesis and may increase incidence

of patent ductus arteriosus and complicate respiratory distress syndrome.

Edema:

Initially, 2 mg/kg/day PO. If needed, increase by 1–2 mg/kg in 6–8 hr. Do not exceed 6 mg/kg.

Adjust maintenance dose to lowest effective level.

Pulmonary edema:



1 mg/kg IV or IM. May increase by 1 mg/kg in 2 hr until the desired effect is seen. Do not exceed 6

mg/kg.

Patients with Renal Impairment

Up to 4 g/day has been tolerated. IV bolus injection should not exceed 1 g/day given over 30 min.

Therapeutic actions of Furosemide

Furosemide inhibits reabsorption of Na and chloride mainly in the medullary portion of the

ascending Loop of Henle. Excretion of potassium and ammonia is also increased while uric acid

excretion is reduced. It increases plasma-renin levels and secondary hyperaldosteronism may

result. Furosemide reduces BP in hypertensives as well as in normotensives. It also reduces

pulmonary oedema before diuresis has set in.

Indications of Furosemide

Oral, IV: Edema associated with CHF, cirrhosis, renal disease

IV: Acute pulmonary edema

Oral: Hypertension

Adverse Effects

Fluid and electrolyte imbalance.

Rashes, photosensitivity, nausea, diarrhoea, blurred vision, dizziness, headache, hypotension.

Bone marrow depression (rare), hepatic dysfunction.

Hyperglycaemia, glycosuria, ototoxicity.

Potentially Fatal: Rarely, sudden death and cardiac arrest. Hypokalaemia and magnesiumdepletion can cause cardiac arrhythmias.

Contraindications

Severe sodium and water depletion, hypersensitivity to sulphonamides and furosemide,

hypokalaemia, hyponatraemia, precomatose states associated with liver cirrhosis, anuria or renal

failure.

Addison’s disease.


[stextbox id="alert" caption="Clinical Alert!"]Name confusion has occurred between furosemide

and torsemide; use extreme caution.[/stextbox]

Assessment

History: Allergy to furosemide, sulfonamides, tartrazine; electrolyte depletion anuria, severe

renal failure; hepatic coma; SLE; gout; diabetes mellitus; lactation, pregnancy



Physical: Skin color, lesions, edema; orientation, reflexes, hearing; pulses, baseline ECG, BP,

orthostatic BP, perfusion; R, pattern, adventitious sounds; liver evaluation, bowel sounds; urinary

output patterns; CBC, serum electrolytes (including calcium), blood sugar, LFTs, renal function

tests, uric acid, urinalysis, weight

Interventions

[stextbox id="black"]BLACK BOX WARNING: Profound diuresis with water and electrolyte

depletion can occur; careful medical supervision is required.[/stextbox]

Reduce dosage if given with other antihypertensives; readjust dosage gradually as BP responds.

Administer with food or milk to prevent GI upset.

Give early in the day so that increased urination will not disturb sleep.

Avoid IV use if oral use is at all possible.

WARNING: Do not mix parenteral solution with highly acidic solutions with pH below 3.5.

Do not expose to light, may discolor tablets or solution; do not use discolored drug or solutions.

Discard diluted solution after 24 hr.

Refrigerate oral solution.

Measure and record weight to monitor fluid changes.

Arrange to monitor serum electrolytes, hydration, liver and renal function.

Arrange for potassium-rich diet or supplemental potassium as needed.

Teaching points

Record intermittent therapy on a calendar or dated envelopes. When possible, take the drug early

so increased urination will not disturb sleep. Take with food or meals to prevent GI upset.

Weigh yourself on a regular basis, at the same time and in the same clothing, and record the

weight on your calendar. Blood glucose levels may become temporarily elevated in patients with diabetes after starting

this drug.

You may experience these side effects: Increased volume and frequency of urination; dizziness,

feeling faint on arising, drowsiness (avoid rapid position changes; hazardous activities, like

driving; and consumption of alcohol); sensitivity to sunlight (use sunglasses, wear protective

clothing, or use a sunscreen); increased thirst (suck on sugarless lozenges; use frequent mouth

care); loss of body potassium (a potassium-rich diet or potassium supplement will be needed).

Report loss or gain of more than 3 pounds in 1 day, swelling in your ankles or fingers, unusual

bleeding or bruising, dizziness, trembling, numbness, fatigue, muscle weakness or cramps.

Generic Name: Digoxin

Brand Name

Digitek,

Lanoxicaps,

Lanoxin



Classification

Cardiac glycoside,

Cardiotonic


Dosage & Route

Patient response is quite variable. Evaluate patient carefully to determine the appropriate dose.

Adults

Loading dose, 0.75–1.25 mg PO or 0.125–0.25 mg IV. Maintenance dose, 0.125–0.25 mg/day PO.

Lanoxicaps capsules

Loading dose, 0.4–0.6 mg PO. Maintenance dose, 0.1 –0.3 mg/day PO.

Pediatric Patients

Loading dose:

Oral (mcg/kg) IV (mcg/kg)

Premature 20–30 15–25

Neonate 25–35 20–30

1–24 mo 35–60 30–50

2–5 yr 30–40 25–35

5–10 yr 20–35 15–30

> 10 yr 10–15 8–12

Maintenance dose, 20%–30% of loading dose in divided daily doses. Usually 0.125–0.5 mg/day

PO; 20%–30% for premature babies.Geriatric with Renal Impairement

Creatinine Clearance (mL/min) Dose

10–25 0.125 mg/day

26–49 0.1875 mg/day

50–79 0.25 mg/day

Therapeutic actions

Digoxin is a cardiac glycoside which has positive inotropic activity characterized by an increase in

the force of myocardial contraction. It also reduces the conductivity of the heart through the

atrioventricular (AV) node. Digoxin also exerts direct action on vascular smooth muscle andindirect effects mediated primarily by the autonomic nervous system and an increase in vagal

activity.

Indications

CHF

Atrial fibrillation



Adverse Effects

Extra beats, anorexia, nausea and vomiting.

Diarrhea in elderly, confusion, dizziness, drowsiness, restlessness, nervousness, agitation and

amnesia, visual disturbances, gynecomastia, local irritation (IM/SC inj), rapid IV admin may lead

to vasoconstriction and transient hypertension. Potentially Fatal: Cardiac arrhythmias in combination with heart block.

Contraindications

Digitalis toxicity, ventricular tachycardia/fibrillation, obstructive cardiomyopathy.

Arrhythmias due to accessory pathways (e.g. Wolff-Parkinson-White syndrome).


Assessment

History: Allergy to digitalis preparations, ventricular tachycardia, ventricular fibrillation, heart

block, sick sinus syndrome, IHSS, acute MI, renal insufficiency, decreased K+, decreased Mg2+

increased Ca2+, pregnancy, lactation

Physical: Weight; orientation, affect, reflexes, vision; P, BP, baseline ECG, cardiac auscultation,

peripheral pulses, peripheral perfusion, edema; R, adventitious sounds; abdominal percussion,

bowel sounds, liver evaluation; urinary output; electrolyte levels, LFTs, renal function tests

Interventions

WARNING: Monitor apical pulse for 1 min before administering; hold dose if pulse < 60 in adult or

< 90 in infant; retake pulse in 1 hr. If adult pulse remains < 60 or infant < 90, hold drug and notify

prescriber. Note any change from baseline rhythm or rate.

Take care to differentiate Lanoxicaps from Lanoxin; dosage is very different

Check dosage and preparation carefully.

Avoid IM injections, which may be very painful.

Follow diluting instructions carefully, and use diluted solution promptly.

Avoid giving with meals; this will delay absorption.

Have emergency equipment ready; have K+ salts, lidocaine, phenytoin, atropine, and cardiac

monitor readily available in case toxicity develops.

WARNING: Monitor for therapeutic drug levels: 0.5–2 ng/mL.

Teaching points

Do not stop taking this drug without notifying your health care provider.

Take pulse at the same time each day, and record it on a calendar (normal pulse for you is___; call

your health care provider if your pulse rate falls below ____.)

Weigh yourself every other day with the same clothing and at the same time. Record this on the

calendar.



Do not start taking any prescription or over-the-counter products without talking to your health

care provider. Some combinations may increase the risk of digoxin toxicity and may put you at

risk of adverse reactions.

Wear or carry a medical alert tag stating that you are on this drug.

Have regular medical checkups, which may include blood tests, to evaluate the effects and dosage

of this drug. Report unusually slow pulse, irregular pulse, rapid weight gain, loss of appetite, nausea, diarrhea,

vomiting, blurred or “yellow” vision, unusual tiredness and weakness, swelling of the ankles, legs

or fingers, difficulty breathing.

Generic Name: Digoxin With cardiac disease being the number one cause of

death worldwide, many people are using drugs like Digoxin to improve the pumping ability of their

hearts.

Brand Name: Lanoxin

Classification: Cardiac glycoside Uses:

1. Treatment of congestive heart failure

2. Control of rapid ventricular contractions in clients with atrial fibrillation/flutter

3. Slow the heart rate in sinus tachycardia

4. Treatment of SVT

5. Treatment of cardiogenic shock

6. Prophylaxis and treatment of recurrent paroxysmal atrial tachycardia with paroxysmal AV

junctional rhythm

Actions:

1. Increases the force and velocity of myocardial contraction by increasing the refractory periodof the AV node and increasing total peripheral resistance

2. Inhibits sodium/potassium-ATPase resulting in increased calcium influx and increased release

of free calcium ions within the myocardial cells, which potentiates the contractility of cardiac

muscle fibers

3. Decreases the rate of conduction thereby decreasing heart rate

Contraindications:

1. Ventricular fibrillation

2. Ventricular tachycardia

3. Presence of digoxin toxicity

4.

Hypersensitivity5. Beriberi heart disease

6. Hypersensitive carotid sinus syndrome

Special Concerns:

1. Use caution in clients with ischemic heart disease, acute myocarditis, hypertropic subaortic

stenosis, hypoxic states, cyanotic heart and lung diseases

2. Use caution in clients with viral myocarditis or rheumatic fever



Side-Effects:

1. Tachycardia

2. Headache

3. Dizziness

4. Mental disturbances

5.

N&V6. Diarrhea

7. Anorexia

8. Blurred vision

9. Death from ventricular fibrillation

10. Acute hemorrhage

11. Convulsions

12. Visual disturbances

13. Angioneurotic edema

Dosage:

Per Orem: 0.4-0.6 mg initially, followed by 0.1-0.3mg q6h or q8h

IV: 0.125-0.5mg/day

Nursing Considerations:

1. Assess cardiac function

2. Measure liquids precisely

3. Assess for signs of toxicity, especially in children and the elderly

4. Give IV slowly over 5 minutes

5. Note possible drug interactions

6. Assess for hyperthyroidism or hypothyroidism

7. Obtain ECG

8. Monitor CBC, serum electrolytes, calcium, MG, renal and liver function tests

9. Obtain written heart rate parameters for drug administration as drug may cause extremebradycardia

10. Do not administer if HR is <50. Hold if HR is 90-110 bpm in children

11. Obtain pulse deficit of apical and radial pulse

12. Monitor weight and I&o

13. Use antacid if gastric distress occurs

14. Use caution during withdrawal

15. Do not take with grapefruit juice

16. Take after meals to lessen gastric irritation

17. Maintain a sodium-restricted diet

18. Do not take OTC drugs

Generic name: Amiodarone hydrochloride

Brand Name: Cordarone, Pacerone

Pregnancy Category D

Drug classes



Antiarrhythmic

Adrenergic blocker (not used as sympatholytic drug)

Therapeutic actions

Type III antiarrhythmic: Acts directly on cardiac cell membrane; prolongs repolarization andrefractory period; increases ventricular fibrillation threshold; acts on peripheral smooth muscle

to decrease peripheral resistance

Indications

Only for treatment of the following documented life-threatening recurrent ventricular

arrhythmias that do not respond to other antiarrhythmics or when alternative agents are not

tolerated: Recurrent ventricular fibrillation, recurrent hemodynamically unstable ventricular

tachycardia. Serious and even fatal toxicity has been reported with this drug; use alternative

agents first; very closely monitor patient receiving this drug

Unlabeled uses: Treatment of refractory sustained or paroxysmal atrial fibrillation andparoxysmal supraventricular tachycardia; treatment of symptomatic atrial flutter

Dosages

Careful patient assessment and evaluation with continual monitoring of cardiac response are

necessary for titrating the dosage. Therapy should begin in the hospital with continual

monitoring and emergency equipment on standby. The following is a guide to usual dosage.

ADULTS

Oral

Loading dose: 800–1,600 mg/day PO in divided doses, for 1–3 wk; reduce dose to 600–800

mg/day in divided doses for 1 mo; if rhythm is stable, reduce dose to 400 mg/day in one to two

divided doses for maintenance dose. Adjust to the lowest possible dose to limit side effects.

IV

1,000 mg IV over 24 hr—150 mg loading dose over 10 min, followed by 360 mg over 6 hr at rate

of 1 mg/min. For maintenance infusion, 540 mg at 0.5 mg/min over 18 hr. May be continued up to

96 hr or until rhythm is stable. Switch to oral form as soon as possible.

PEDIATRIC PATIENTS

Safety and efficacy not established.

Adverse effects



CNS: Malaise, fatigue, dizziness, tremors, ataxia, paresthesias, lack of coordination

CV: Cardiac arrhythmias, CHF, cardiac arrest , hypotension

EENT: Corneal microdeposits (photophobia, dry eyes, halos, blurred vision); ophthalmic

abnormalities including permanent blindness

Endocrine: Hypothyroidism or hyperthyroidism

GI: Nausea, vomiting, anorexia, constipation, abnormal LFTs, hepatotoxicity Respiratory: Pulmonary toxicity—pneumonitis, infiltrates (shortness of breath, cough, rales,

wheezes)

Other: Photosensitivity, angioedema

Contraindications

Contraindicated with hypersensitivity to amiodarone, sinus node dysfunction, heart block, severe

bradycardia, hypokalemia, lactation.

Use cautiously with thyroid dysfunction, pregnancy.


CLINICAL ALERT! Name confusion has occurred with amrinone (name has now been changed

to inamrinone, but confusion may still occur); use caution.

Assessment

History: Hypersensitivity to amiodarone, sinus node dysfunction, heart block, severe bradycardia,

hypokalemia, lactation, thyroid dysfunction, pregnancy

Physical: Skin color, lesions; reflexes, gait, eye examination; P, BP, auscultation, continuous ECG

monitoring; R, adventitious sounds, baseline chest X-ray; liver evaluation; LFTs, serum

electrolytes, T4, and T3

Interventions

WARNING: Reserve use for life-threatening arrhythmias; serious toxicity, including arrhythmias,

pulmonary toxicity can occur.

Monitor cardiac rhythm continuously.

Monitor for an extended period when dosage adjustments are made.

WARNING: Monitor for safe and effective serum levels (0.5–2.5 mcg/mL).

WARNING: Doses of digoxin, quinidine, procainamide, phenytoin, and warfarin may need to be

reduced one-third to one-half when amiodarone is started.

Give drug with meals to decrease GI problems. Arrange for ophthalmologic examinations; reevaluate at any sign of optic neuropathy.

Arrange for periodic chest X-ray to evaluate pulmonary status (every 3–6 mo).

Arrange for regular periodic blood tests for liver enzymes, thyroid hormone levels.

Teaching points



Drug dosage will be changed in relation to response of arrhythmias; you will need to be

hospitalized during initiation of drug therapy; you will be closely monitored when dosage is

changed.

Have regular medical follow-up, monitoring of cardiac rhythm, chest X-ray, eye examination,

blood tests.

You may experience these side effects: Changes in vision (halos, dry eyes, sensitivity to light; wearsunglasses, monitor light exposure); nausea, vomiting, loss of appetite (take with meals; eat

frequent small meals); sensitivity to the sun (use a sunscreen or protective clothing when

outdoors); constipation (a laxative may be ordered); tremors, twitching, dizziness, loss of

coordination (do not drive, operate dangerous machinery, or undertake tasks that require

coordination until drug effects stabilize and your body adjusts to it).

Report unusual bleeding or bruising; fever, chills; intolerance to heat or cold; shortness of breath,

difficulty breathing, cough; swelling of ankles or fingers; palpitations; difficulty with vision.

Generic Name: Amiodarone Hydrochloride

Brand Name: Cordarone, Pacerone

Brand Names:

1. Cordarone

1.2. Pacerone

Indications:

1. Premature ventricular fibrillation

2. Unstable ventricular tachycardia

3. Atrial fibrillation

4. Angina

5.

Hypertrophic cardiomyopathy1.6. Supraventricular arrhythmias

Dosages:

Adults:

Oral: Loading dose is between 800 to 1,600 mg good for one to three weeks. Maintenance dosage

may range between 600 to 800 mg per day. It is advised to use the possible lowest dose in reaching

cardiac stability.

I.V. Infusion: A 150 mg loading dose must be given with 10 minutes slowly. For maintenance dose, a

540 mg amiodarone must be run with 18 hours. The rate on the first day of therapy can be

increased depending on the situation.

Mechanism of Action:

Since the problem is focused on the rapid beating of the heart which is not effective anymore in

supplying the needed blood supply for the whole body, this drug works on cardiac cell membranes

directly in order to lengthen the repolarization and refractory period. As it relaxes the smooth

muscles, the myocardial blood flow is also ensured to be at its height of function. Aside from that, it

also decreases myocardial oxygen consumption and peripheral vascular resistance too.

Pointers in giving amiodarone hydrochloride intravenously:

A loading dose of 150 mg must be infused for 10 minutes.



Monitor the cardiac rate and status of the patient in giving amiodarone hydrochloride

intravenously.

Always remember that the initial dose of administration starts in 5mg/kg. It should be mixed

with 250mL D5Water.

The maximum dose a patient can receive within a day is 1.2 grams mixed in a 500mL D5Water.

Periodic monitoring of the cardiac activity can be done through ECG monitoring or attachingthe patient in a cardiac monitor.

Monitor the patient closely and refer for significant changes since this is a drug that has life

threatening adverse reactions. “Gasping syndrome” is common among neonates receiving this

drug. Symptoms may include: sudden onset of gasping, low blood pressure and bradycardia.

Drug to drug interactions:

Precipitation may occur when amiodarone is administered together with heparin. Aside from that it

is important to note that using evacuated glass containers for admixing may induce precipitation.

Amiodarone with antihypertensive: Hypotension may be rapid.

Amiodarone with beta blockers, calcium channel blockers: May depress the cardiac functioning

thus it should be used with caution.

Amiodarone with Digoxin: Digoxin levels should be monitored closely since it amiodarone can

increase the serum digoxin levels rapidly with a rate 70% to 100%.

Nursing Process:

Assessment:

Before the therapy, assess the patient’s vital signs and put more focus on the cardiac activity.

For patients with cardiac device implants, check its condition and if it works properly before

during and after administration.

Monitor also the pulmonary, liver and thyroid function tests as it may infer with the expectedresults.

Watch out for adverse drug interactions such as: peripheral neuropathy, abnormal gait, ataxia,

dizziness, headache, fatigue. Bradycardia can occur followed with hypotension and eventual

sinus arrest. Photosensitivity is an expected adverse reaction.

Nursing Diagnoses

1. Decreased cardiac output related to ventricular arrhythmia

1.2. Risk for injury related to adverse reactions of the drug

Planning and Implementation:

1. Close monitoring is an ongoing process all throughout the therapy. An updated data is a must.2. For oral dosages, each dose should be taken with meals since it is a gastric irritant.

3. Encourage the patient to verbalize any discomfort since this drug may have several adverse

reactions.

4. On the beginning of the therapy, IV infusion should be monitored well since it may affect the

kidney’s normal functioning resulting to hepatocellular necrosis and acute renal failure.



1.5. Coordinate with other health care personnel such as in obtaining pulmonary, liver

and renal function tests. ECG monitoring should also be done thus reading the ECG tracing can

be an edge at this time.

Evaluation

1.The patient’s cardiac status has been stabilized. 2.There are no adverse reactions noted.

3.The patient understands what he or she has gone through in order to prevent recurrent

arrhythmia.

Generic Name: Diphenhydramine hydrochloride is a common antihistamine used by the

general public to treat allergies.

Brand Name: Benadryl

Classification: Antihistamine, second generation, ethanolamine

Uses:

1. Treatment of hypersensitivity reactions

2. Treatment of motion sickness

3. Treatment of Parkinsonism

4. Nighttime sleep aid

5. Antitussive

Actions:

1. Has high sedative, anticholinergic and antiemetic effects

2. Blocks the action of acetylcholine

3. Blocks H-1 receptors on effector cells of the GI tract, blood vessels, and respiratory tract

Contraindications:

1. Use with other products containing diphenhydramine

2. Hypersensitivity to antihistamines

Special Concerns:

1. Increases the risk of cognitive decline in the elderly

2. Use with caution in clients suffering from the following: Increased Pressure in the Eye, Closed

Angle Glaucoma, Chronic Difficulty having a Bowel Movement, High Blood Pressure, Stenosing

Peptic Ulcer, Blockage of Urinary Bladder, Enlarged Prostate, Cannot Empty Bladder,

Overactive Thyroid Gland

Side-Effects:

1. Drowsiness

2. Constipation

3. Diarrhea

4. Dizziness

5. Dry mouth/nose/throat

http://rnspeak.com/case-study/anaphylactic-shock-case-study-the-impending-doom/





6. Headache

7. Anorexia

8. N&V

9. Anxiety

10. GI upset

11. Asthenia

Dosage:

Per Orem: 25-50 mg TID- QID

IV: 10-50mg up to 100mg/IV

Nursing Considerations:

1. Give full prophylactic dose 30min. prior to travel if used as a prophylaxis for motion sickness

2. Take similar doses with meals and at bedtime

3. Do not use more than 2 weeks to treat insomnia

4. For IV, may give undiluted

5. Do not exceed IV rate of 25mg/minute

6. Drug causes drowsiness. Avoid activities requiring mental alertness

7. Use sun protection as it may cause photosensitivity

8. Use sugarless candy/gum to diminish dry mouth effects

9. Avoid alcohol and other CNS depressants

10. Stop therapy 72-96 hr. prior to skin testing. Report adverse effect and lack of response

Generic Name: Calcium Gluconate

Brand Name: Kalcinate

Classifications: fluid and electrolytic and water balance agent; replacement solution

Pregnancy Category: B

Availability

500 mg, 650 mg, 975 mg, 1 gm tablets; 10% injection

Actions

Calcium is an essential element for regulating the excitation threshold of nerves and muscles, for

blood clotting mechanisms, cardiac function (rhythm, tonicity, contractility), maintenance of renal

function, for body skeleton and teeth. Also plays a role in regulating storage and release of

neurotransmitters and hormones; regulating amino acid uptake and absorption of vitamin B12,gastrin secretion, and in maintaining structural and functional integrity of cell membranes and

capillaries. Calcium gluconate acts like digitalis on the heart, increasing cardiac muscle tone and

force of systolic contractions (positive inotropic effect).

Therapeutic effects

Rapidly and effectively restores serum calcium levels in acute hypocalcemia of various origins and

effective cardiac stabilizer under conditions of hyperkalemia or resuscitation.



Uses

Negative calcium balance (as in neonatal tetany, hypoparathyroidism, vitamin D

deficiency, alkalosis). Also to overcome cardiac toxicity of hyperkalemia, for cardiopulmonary

resuscitation, to prevent hypocalcemia during transfusion of citrated blood. Also as antidote for

magnesium sulfate, for acute symptoms of lead colic, to decrease capillary permeability in

sensitivity reactions, and to relieve muscle cramps from insect bites or stings. Oral calcium may beused to maintain normal calcium balance during pregnancy, lactation, and childhood growth and to

prevent primary osteoporosis. Also in osteoporosis, osteomalacia, chronic hypoparathyroidism,

rickets, and as adjunct in treatment of myasthenia gravis and Eaton-Lambert syndrome.

Contraindicatons

Ventricular fibrillation, metastatic bone disease, injection into myocardium; administration by SC or

IM routes; renal calculi, hypercalcemia, predisposition to hypercalcemia (hyperparathyroidism,

certain malignancies); pregnancy (category B).

Cautious use

Digitalized patients, renal or cardiac insufficiency, sarcoidosis, history of lithiasis, immobilized

patients; lactation.

Route & Dosage

Supplement for Osteoporosis

adult: PO 1–2 g b.i.d. to q.i.d.

IV 7 mEq q 1–3d

child: PO 45–65 mg/kg/d in divided doses.

IV 1–7 mEq q 1–3d

neonate: PO 50–130 mg/kg/d (max 1 g).

IV mEq q 1–3d

Hypocalcemic Tetany

adult: IV 4.5–16 mEq prnchild: IV 0.5–0.7 mEq/kg t.i.d. or q.i.d.

neonate: IV 2.4 mEq/kg/d in divided doses

CPR

adult: IV 2.3–3.7 mEq x 1

Hyperkalemia with Cardiac Toxicity

adult: IV 2.25–14 mEq q 1–2 min

Exchange Transfusions with Citrated Blood

adult: IV 1.35 mEq for each 100 mL of blood

neonate: IV 0.45 mEq for each 100 mL of blood

Administration

Oral

Ensure that chewable tablets are chewed or crushed before being swallowed with a liquid.

Give with meals to enhance absorption.

Intravenous



PREPARE direct: May be given undiluted intermittent: /continuous: May be diluted in 1000 mL

of NS.

ADMINISTER direct: Give direct IV at a rate of 0.5 mL or a fraction thereof over 1 min. Do not

exceed 2 mL/min.intermittent: /continuous: Give slowly, not to exceed 200 mg/min, through a

small-bore needle into a large vein to avoid possibility of extravasation and resultant necrosis. With

children, scalp veins should be avoided. Avoid rapid infusion. High concentrations of calciumsuddenly reaching the heart can cause fatal cardiac arrest.

Incompatibilities Solution / Additive: Amphotericin B, cefamandole, dobutamine,

methylprednisolone, metoclopramide. Y-site: Amphotericin B cholesteryl complex, fluconazole,

Indomethacin.

Injection should be stopped if patient complains of any discomfort. · Patient should be advised

to remain in bed for 15–30 min or more following injection, depending on response.

Adverse Effects

BodyWhole: Tingling sensation. With rapid IV, sensations of heat waves (peripheral vasodilation),

fainting.

GI: PO preparation: Constipation, increased gastric acid secretion.

CV: (With rapid infusion) hypotension, bradycardia, cardiac arrhythmias, cardiac arrest,

Skin: Pain and burning at IV site, severe venous thrombosis, necrosis and sloughing (with

extravasation).

Nursing Implications


Assess for cutaneous burning sensations and peripheral vasodilation, with moderate fall in BP,

during direct IV injection.

Monitor ECG during IV administration to detect evidence of hypercalcemia: decreased QT

interval associated with inverted T wave.

Observe IV site closely. Extravasation may result in tissue irritation and necrosis.

Monitor for hypocalcemia and hypercalcemia.

Lab tests: Determine levels of calcium and phosphorus (tend to vary inversely) andmagnesium frequently, during sustained therapy. Deficiencies in other ions, particularly

magnesium, frequently coexist with calcium ion depletion.


Report S&S of hypercalcemia promptly to your care provider.

Milk and milk products are the best sources of calcium (and phosphorus). Other good sources

include dark green vegetables, soy beans, tofu, and canned fish with bones.

Calcium absorption can be inhibited by zinc-rich foods: nuts, seeds, sprouts, legumes, soy

products (tofu).

Check with physician before self-medicating with a calcium supplement.

Do not breast feed while taking this drug without consulting physician

Generic Name: Furosemide

Brand Name: Fumide,Furomide,Lasix,Luramide

Classifications: electrolytic and water balance agent ; loop diuretic

Pregnancy Category: C



Availability

20 mg, 40 mg, 80 mg tablets; 10 mg/mL, 40 mg/5 mL oral solution; 10 mg/mL injection

Actions:

Rapid-acting potent sulfonamide “loop” diuretic and antihypertensive with pharmacologic effects

and uses almost identical to those of ethacrynic acid. Exact mode of action not clearly defined;decreases renal vascular resistance and may increase renal blood flow.

Therapeutic effects:

Inhibits reabsorption of sodium and chloride primarily in loop of Henle and also in proximal and

distal renal tubules; an antihypertensive that decreases edema and intravascular volume.

Reportedly less ototoxic than ethacrynic acid.

Uses

Treatment of edema associated with CHF, cirrhosis of liver, and kidney disease, including nephrotic

syndrome. May be used for management of hypertension, alone or in combination with other

antihypertensive agents, and for treatment of hypercalcemia. Has been used concomitantly with

mannitol for treatment of severe cerebral edema, particularly in meningitis.

Contraindications

History of hypersensitivity to furosemide or sulfonamides; increasing oliguria, anuria, fluid and

electrolyte depletion states; hepatic coma; pregnancy (category C), lactation.

Cautious use

Infants, older adults; hepatic cirrhosis, nephrotic syndrome; cardiogenic shock associated with

acute MI; history of SLE, history of gout; patients receiving digitalis glycosides or potassium-

depleting steroids.

Route & dosage Edema

adult:PO 20–80 mg in 1 or more divided doses up to 600 mg/d if needed

IV/IM 20–40 mg in 1 or more divided doses up to 600 mg/d

child:PO 2 mg/kg, may be increased by 1–2 mg/kg q6–8h (max: 6 mg/kg/dose)

IV/IM 1 mg/kg, may be increased by 1 mg/kg q2h if needed (max: mg/kg/dose)

neonate:PO 1–4 mg/kg q12–24h

IV/IM 1–2 mg/kg q12–24h

Hypertension

adult:PO 10–40 mg b.i.d. (max: 480 mg/d)

Administration Oral

Give with food or milk to reduce possibility of gastric irritation.

Schedule doses to avoid sleep disturbance (e.g., a single dose is generally given in the morning;

twice-a-day doses at 8 a.m. and 2 p.m.).

Note: Slight discoloration of tablets reportedly does not alter potency.

Store tablets at controlled room temperature, preferably at 15°–30° C (59°–86° F) unless

otherwise directed. Protect from light.



Store oral solution in refrigerator, preferably at 2°–8°C (36°–46 F). Protect from light and

freezing.

Intramuscular

Protect syringes from light once they are removed from package.

Discard yellow or otherwise discolored injection solutions.

Intravenous

Note: Verify correct IV concentration and rate of infusion/injection with physician before

administration to infants or children.

PREPARE direct: Give undiluted.

ADMINISTER direct: Give undiluted at a rate of 20 mg or a fraction thereof over 1 min. With high

doses a rate of 4 mg/min is recommended to decrease risk of ototoxicity.

Incompatibilities Solution / Additive:Buprenorphine, chlorpromazine, ciprofloxacin, diazepam,

diphenhydramine, dobutamine, doxapram, doxorubicin, droperidol, erythromycin, gentamicin,

isoproterenol, labetalol, meperidine, metoclopramide, milrinone, netilmicin, pancuronium,

prochlorperazine, promethazine, quinidine, thiamine vinblastine, vincristine. Y-site: Amrinone,

amsacrine, ciprofloxacin, diazepam, diltiazem, dobutamine, diphenhydramine, dopamine,

doxorubicin, droperidol, esmolol, filgrastim, fluconazole, gemcitabine, gentamicin, hydralazine,

idarubicin, methocarbamol, metoclopramide, midazolam, milrinone, morphine, netilmicin,

nicardipine, ondansetron, quinidine, thiopental, tobramycin, vecuronium, vinblastine, vincristine,

vinorelbine, TPN.

Use infusion solutions within 24 h. • Store parenteral solution at controlled room temperature,

preferably at 15°–30° C (59°–86° F) unless otherwise directed. Protect from light.

Adverse effects

CV:Postural hypotension, dizziness with excessive diuresis, acute hypotensive episodes, circulatory

collapse.

Metabolic:Hypovolemia, dehydration, hyponatremia, hypokalemia, hypochloremiametabolic alkalosis, hypomagnesemia, hypocalcemia (tetany), hyperglycemia, glycosuria, elevated

BUN, hyperuricemia;.

GI:Nausea, vomiting, oral and gastric burning, anorexia, diarrhea, constipation, abdominal

cramping, acute pancreatitis, jaundice.

Urogenital:Allergic interstitial nephritis, irreversible renal failure, urinary frequency.

Hematologic:Anemia, leukopenia, thrombocytopenic purpura; aplastic anemia, agranulocytosis

(rare).

SpecSenses:Tinnitus, vertigo, feeling of fullness in ears, hearing loss (rarely permanent), blurred

vision.

Skin:Pruritus, urticaria, exfoliative dermatitis, purpura, photosensitivity, porphyria cutanea tarde,

necrotizing angiitis (vasculitis).BodyWhole:Increased perspiration; paresthesias; activation of SLE, muscle spasms, weakness;

thrombophlebitis, pain at IM injection site.

Nursing implications


Observe patients receiving parenteral drug carefully; closely monitor BP and vital signs.

Sudden death from cardiac arrest has been reported.



Monitor BP during periods of diuresis and through period of dosage adjustment.

Observe older adults closely during period of brisk diuresis. Sudden alteration in fluid and

electrolyte balance may precipitate significant adverse reactions. Report symptoms to

physician.

Lab tests: Obtain frequent blood count, serum and urine electrolytes, CO2, BUN, blood sugar,

and uric acid values during first few months of therapy and periodically thereafter. Monitor for S&S of hypokalemia .

Monitor I&O ratio and pattern. Report decrease or unusual increase in output. Excessive

diuresis can result in dehydration and hypovolemia, circulatory collapse, and hypotension.

Weigh patient daily under standard conditions.

Monitor urine and blood glucose & HbA1C closely in diabetics and patients with

decompensated hepatic cirrhosis. Drug may cause hyperglycemia.

Note: Excessive dehydration is most likely to occur in older adults, those with chronic cardiac

disease on prolonged salt restriction, or those receiving sympatholytic agents.


Consult physician regarding allowable salt and fluid intake.

Ingestion potassium-rich foods daily (e.g., bananas, oranges, peaches, dried dates) to reduce or

prevent potassium depletion.

Learn S&S of hypokalemia . Report muscle cramps or weakness to physician.

Make position changes slowly because high doses of antihypertensive drugs taken

concurrently may produce episodes of dizziness or imbalance.

Avoid replacing fluid losses with large amounts of water.

Avoid prolonged exposure to direct sun.

Do not breast feed while taking this drug

Generic Name: Phenobarbital Sodium

Brand Name: Luminal Sodium

Classifications:central nervous system agent;anticonvulsant ; sedative-hypnotic; barbiturate

Pregnancy Category: D

Availability

15 mg, 16 mg, 16.2 mg, 30 mg, 60 mg, 90 mg, 100 mg tablets; 16 mg capsules; 15 mg/5 mL, 20

mg/5 mL liquid; 30 mg/mL, 60 mg/mL, 65 mg/mL, 130 mg/mL injection

Actions :

Long-acting barbiturate. Sedative and hypnotic effects of barbiturates appear to be due primarily to

interference with impulse transmission of cerebral cortex by inhibition of reticular activating

system. CNS depression may range from mild sedation to coma, depending on dosage, route of administration, degree of nervous systemexcitability, and drug tolerance. Initially, barbiturates

suppress REM sleep, but with chronic therapy REM sleep returns to normal.

Therapeutic effects:

Produces sedative and hypnotic effects with no analgesic properties, and small doses may increase

reaction to painful stimuli. Phenobarbital limits spread of seizure activity by increasing threshold

for motor cortex stimuli. Barbiturates are habit forming.



Uses:

Long-term management of tonic-clonic (grand mal) seizures and partial seizures; status epilepticus,

eclampsia, febrile convulsions in young children. Also used as a sedative in anxiety or tension

states; in pediatrics as preoperative and postoperative sedation and to treat pylorospasm in infants.

Contraindications Sensitivity to barbiturates; manifest hepatic or familial history of porphyria; severe respiratory or

kidney disease; history of previous addiction to sedative hypnotics; uncontrolled pain; pregnancy

(particularly early pregnancy) (category D), lactation; sustained release formulation for children <

12 y of age.

Cautious use

Impaired liver, kidney, cardiac, or respiratory function; history of allergies; older adult or

debilitated patients; patients with fever; hyperthyroidism; diabetes mellitus or severe anemia;

during labor and delivery; patient with borderline hypoadrenal function.

Route & dosage

Anticonvulsant

adult:PO 100–300 mg/d

IV/IM 200–600 mg up to 20 mg/kg

child:PO/IV 3–8 mg/kg or 125 mg/m2/d

neonate:PO/IV 3–4 mg/kg/d (max: 5 mg/kg/d)

Status Epilepticus

adultchild: IV 15–18 mg/kg in single or divided doses (max: 20 mg/kg)

neonate:IV 15–20 mg/kg in single or divided doses

Sedative

adult:PO 30–120 mg/d

IV/IM 100–200 mg/dchild:PO 6 mg/kg/d or 180 mg/m2 in 3 divided doses

IV/IM 16–100 mg/d (1–3 mg/kg)

Administration

Oral

Make sure patient actually swallows pill and does not “cheek” it.

Give crushed and mixed with a fluid or with food if patient cannot swallow pill. Do not permit

patient to swallow dry crushed drug.

Intramuscular

Give IM deep into large muscle mass; do not exceed 5 mL at any one site.

Intravenous Note: Verify correct IV concentration and rate of infusion for neonates, infants, children with

physician. Use IV route ONLY if other routes are not feasible.

PREPARE direct: Slowly add at least 10 mL of sterile water for injection to ampule. Rotate ampule

to dissolve (may take several minutes). If solution not clear in 5 min or if a precipitate remains,

discard.

ADMINISTER direct: Give 60 mg or fraction thereof over at least 60 sec. Give within 30 min after

preparation.



Incompatibilities Solution / Additive: Benzquinamide, cephalothin,

chlorpromazine, codeine phosphate, ephedrine, hydralazine, hydrocortisone sodium succinate,

hydroxyzine, insulin, levorphanol, meperidine, methadone, morphine, norepinephrinetetracyclines,

procaine, prochlorperazine, promazine, promethazine, ranitidine, streptomycin, vancomycin. Y-

site: Amphotericin B cholesteryl complex, hydromorphone, TPN with albumin.

Be aware that extravasation of IV phenobarbital may cause necrotic tissue changes that necessitateskin grafting. Check injection site frequently.

Adverse effect s :

BodyWhole:Myalgia, neuralgia, CNS depression, coma, and death.

CNS:Somnolence, nightmares, insomnia, “hangover,” headache, anxiety, thinking abnormalities,

dizziness, nystagmus, irritability, paradoxic excitement and exacerbation of hyperkinetic behavior

(in children); confusion or depression or marked excitement (older adult or debilitated patients);

ataxia.

CV:Bradycardia, syncope, hypotension.

GI:Nausea, vomiting, constipation, diarrhea, epigastric pain, liver damage.

Hematologic:Megaloblastic anemia, agranulocytosis, thrombocytopenia.

Metabolic:Hypocalcemia, osteomalacia, rickets.

Musculoskeletal:Folic acid deficiency, vitamin D deficiency.

Respiratory:Respiratory depression.

Skin:Mild maculopapular, morbilliform rash; erythema multiforme, Stevens-Johnson syndrome,

exfoliative dermatitis (rare).

Nursing implications:


Observe patients receiving large doses closely for at least 30 min to ensure that sedation is not

excessive.

Keep patient under constant observation when drug is administered IV, and record vital signs

at least every hour or more often if indicated. Lab tests: Obtain liver function and hematology tests and determinations of serum folate and

vitamin D levels during prolonged therapy.

Monitor serum drug levels. Serum concentrations >50 mcg/mL may cause coma. Therapeutic

serum concentrations of 15–40 mcg/mL produce anticonvulsant activity in most patients.

These values are usually attained after 2 or 3 wk of therapy with a dose of 100–200 mg/d.

Expect barbiturates to produce restlessness when given to patients in pain because these

drugs do not have analgesic action.

Be prepared for paradoxical responses and report promptly in older adult or debilitated

patient and children (i.e., irritability, marked excitement [inappropriate tearfulness and

aggression in children], depression, and confusion).

Monitor for drug interactions. Barbiturates increase the metabolism of many drugs, leading todecreased pharmacologic effects of those drugs. Whenever a barbiturate is added to an

established regimen of another drug, observe for changes in effectiveness of the first drug at

least during early phase of barbiturate use.

Monitor for and report chronic toxicity symptoms (e.g., ataxia, slurred speech, irritability, poor

judgment, slight dysarthria, nystagmus on vertical gaze, confusion, insomnia, somatic

complaints).




Be aware that anticonvulsant therapy may cause drowsiness during first few weeks of

treatment, but this usually diminishes with continued use.

Avoid potentially hazardous activities requiring mental alertness until response to drug is

known.

Do not consume alcohol in any amount when taking a barbiturate; it may severely impairjudgment and abilities.

Increase vitamin D-fortified foods (e.g., milk products) because drug increases vitamin D

metabolism. A vitamin D supplement may be prescribed.

Maintain adequate dietary folate intake: fresh vegetables (especially green leafy), fresh fruits,

whole grains, liver. Long-term therapy may result in nutritional folate (B9) deficiency. A

supplement of folic acid may be prescribed.

Adhere to drug regimen (i.e., do not change intervals between doses or increase or decrease

doses) without contacting physician.

Do not stop taking drug abruptly because of danger of withdrawal symptoms (8–12 h after last

dose), which can be fatal.

Report to physician the onset of fever, sore throat or mouth, malaise, easy bruising or bleeding,

petechiae, jaundice, rash when on prolonged therapy.

Avoid pregnancy when receiving barbiturates. Use or add barrier device to hormonal

contraceptive when taking prolonged therapy.


Generic Name: Mannitol

Brand Name:Osmitrol

Classifications:electrolytic and water balance agent;osmotic diuretic

Pregnancy Category:C

Availability

5%, 10%, 15%, 20%, 25% injectio

Actions

In large doses, increases rate of electrolyte excretion by the kidney, particularly sodium, chloride,

and potassium.

Therapeutic effects

Induces diuresis by raising osmotic pressure of glomerular filtrate, thereby inhibiting tubular

reabsorption of water and solutes. Reduces elevated intraocular and cerebrospinal pressures by

increasing plasma osmolality, thus inducing diffusion of water from these fluids back into plasma

and extravascular space.

Uses

To promote diuresis in prevention and treatment of oliguric phase of acute kidney failure following

cardiovascular surgery, severe traumatic injury, surgery in presence of severe jaundice, hemolytictransfusion reaction. Also used to reduce elevated intraocular (IOP) and intracranial pressure (ICP),

to measure glomerular filtration rate (GFR), to promote excretion of toxic substances, to relieve

symptoms of pulmonary edema, and as irrigating solution in transurethral prostatic reaction to

minimize hemolytic effects of water.Commercially available in combination with sorbitol for

urogenital irrigation.

Contraindications

Anuria; marked pulmonary congestion or edema; severe CHF; metabolic edema; organic CNS



disease, intracranial bleeding; shock, severe dehydration, history of allergy; pregnancy (category C),

lactation; concomitantly with blood.

Route & dosage

Acute Kidney Failure

adult:IV Test Dose 0.2 g/kg or 12.5 g as a 15%–20% solution over 3–5 min

Positive Response 30–50 mL of urine over next 2–3 h, may repeat test dose 1 time. If stillnegative, do not use.

Treatment 50–100 g as 15%–20% solution over 90 min to several hours

child: IV Test Dose 200 mg/kg (max: 12.5 g) over 3–5 min

Positive Response Urine flow of 1 mL/kg/h for 1–2 h

Maintenance 0.25–0.5 g/kg q4–6 h

Edema, Ascites

adult:IV 100 g as a 10%–20% solution over 2–6 h

Elevated IOP or ICP

adult:IV 1.5–2 mg/kg as a 15%–25% solution over 30–60 min

Acute Chemical Toxicity

adult:IV 100–200 g depending on urine output

Measurement of GFR

adult:IV 100 mL of 20% solution diluted with 180 mL NaCl injection infused at a rate of 20

mL/min

Administration

Intravenous

Note: Verify correct IV concentration and rate of infusion for administration toinfants, children withphysician.

PREPARE IV Infusion: Give undiluted

ADMINISTER IV Infusion: Give a single dose over 30–90 min. Oliguria: A test dose is given to

patients with marked oliguria to check adequacy of kidney function. Response is considered

satisfactory if urine flow of at least 30–50 mL/h is produced over 2–3 h after drug administration;

then rate is adjusted to maintain urine flow at 30–50 mL/h with a single dose usually being infused

over >=90 min. Concentrations higher than 15% have a greater tendency to crystallize. Use an

administration set with an in-line IV filter when infusing concentrations of 15% or above.

Incompatibilities Solution / Additive: Imipenem-cilastatin. Y-site: Cefepime, doxorubicin

liposome, filgrastim.

Store at 15°–30° C (59°–86° F) unless otherwise directed. Avoid freezing.



Take care to avoid extravasation. Observe injection site for signs of inflammation or edema.

Lab tests: Monitor closely serum and urine electrolytes and kidney function during therapy.

Measure I&O accurately and record to achieve proper fluid balance.



Monitor vital signs closely. Report significant changes in BP and signs of CHF.

Monitor for possible indications of fluid and electrolyte imbalance (e.g., thirst, muscle

cramps or weakness, paresthesias, and signs of CHF).

Be alert to the possibility that a rebound increase in ICP sometimes occurs about 12 h after

drug administration. Patient may complain of headache or confusion.

Take accurate daily weight.Patient & Family Education

Report any of the following: Thirst, muscle cramps or weakness, paresthesia, dyspnea, or

headache.

Family members should immediately report any evidence of confusion.

Do not breast feed while using this drug.

Generic Name: Diazepam

Brand Name:Apo-Diazepam,Diastat,Diazemuls,E-Pam,Meval,Novodipam,Valium,Valrelease,Vivol

Classifications: central nervous system agent; benzodiazepine anticonvulsant ; anxiolytic

Pregnancy Category:D

Availability

2 mg, 5 mg, 10 mg tablets; 1 mg/mL, 5 mg/mL, 5 mg/5 mL oral solution; 5 mg/mL injection; 2.5

mg, 5 mg, 10 mg, 15 mg, 20 mg rectal gel

Actions

Psychotherapeutic agent related to chlordiazepoxide; reportedly superior in antianxiety and

anticonvulsant activity, with somewhat shorter duration of action. Like chlordiazepoxide, it appears

to act at both limbic and subcortical levels of CNS.

Therapeutic effects

Shortens REM and stage 4 sleep but increases total sleep time. Antianxiety and anticonvulsant agent.

Uses

Drug of choice for status epilepticus. Management of anxiety disorders, for short-term relief of

anxietysymptoms, to allay anxiety and tension prior to surgery, cardioversion and endoscopic

procedures, as an amnesic, and treatment for restless legs. Also used to alleviate acute

withdrawal symptoms of alcoholism, voiding problems in older adults, and adjunctively for relief

of skeletal muscle spasm associated with cerebral palsy, paraplegia, athetosis, stiff-man

syndrome, tetanus.

Contraindications

Injectable form:Shock, coma, acute alcohol intoxication, depressed vital signs, obstetrical patients,

infants <30 d of age. Tablet form: Infants <6 mo of age, acute narrow-angle glaucoma, untreatedopen-angle glaucoma; during or within 14 d of MAO inhibitor therapy. Safe use during pregnancy

(category D) and lactation is not established.

Cautious use

Epilepsy, psychoses, mental depression; myasthenia gravis; impaired hepatic or renal function;

drug abuse, addiction-prone individuals. Injectable diazepam used with extreme caution in older

adults, the very ill, and patients with COPD.

Route & dosage



Status Epilepticus

adult: IV/IM 5–10 mg, repeat if needed at 10–15 min intervals up to 30 mg, then repeat if needed

q2–4h

child: IV/IM <5 y, 0.2–0.5 mg slowly q2–5min up to 5 mg; >5 y, 1 mg slowly q2–5min up to 10 mg,

repeat if needed q2–4 h

Anxiety, Muscle Spasm, Convulsions, Alcohol Withdrawal Adult: PO 2–10 mg b.i.d. to q.i.d. or 15–30 mg/d sustained release

IV/IM 2–10 mg, repeat if needed in 3–4 h

Geriatric:PO 1–2 mg 1–2 times/d (max: 10 mg/d)

Child: PO >6 mo, 1–2.5 mg b.i.d. or t.i.d.

Administration

Oral

Ensure that sustained release form is not chewed or crushed. It MUST be swallowed whole.

Give other tablets crushed with fluid or mixed with food if necessary.

Supervise oral ingestion to ensure drug is swallowed.

Avoid abrupt discontinuation of diazepam. Taper doses to termination.

Intramuscular

Give deep into large muscle mass. Inject slowly. Rotate injection sites.

Do NOT give emulsion form (Dizac) as IM or SC. It is for IV use only.

Adverse effects

BodyWhole: Throat and chest pain.

CNS: Drowsiness, fatigue, ataxia, confusion, paradoxic rage, dizziness, vertigo, amnesia, vivid

dreams, headache, slurred speech, tremor; EEG changes, tardive dyskinesia.

CV: Hypotension, tachycardia, edema, cardiovascular collapse

SpecSenses:Blurred vision, diplopia, nystagmus.

GI: Xerostomia, nausea, constipation, hepatic dysfunction.

Urogenital:Incontinence, urinary retention, gynecomastia (prolonged use), menstrualirregularities, ovulation failure.

Respiratory:Hiccups, coughing, laryngospasm.

Other:Pain, venous thrombosis, phlebitis at injection site.



Monitor for adverse reactions. Most are dose related. Physician will rely on accurate

observation and reports of patient response to the drug to determine lowest effective

maintenance dose.

Monitor for therapeutic effectiveness. Maximum effect may require 1–2 wk; patient tolerance

to therapeutic effects may develop after 4 wk of treatment.

Observe necessary preventive precautions for suicidal tendencies that may be present inanxiety states accompanied by depression.

Observe patient closely and monitor vital signs when diazepam is given parenterally;

hypotension, muscular weakness, tachycardia, and respiratory depression may occur.

Lab tests: Periodic CBC and liver function tests during prolonged therapy.

Supervise ambulation. Adverse reactions such as drowsiness and ataxia are more likely to

occur in older adults and debilitated or those receiving larger doses. Dosage adjustment may

be necessary.



Monitor I&O ratio, including urinary and bowel elimination.

Note: Smoking increases metabolism of diazepam; lowering clinical effectiveness.

Heavy smokers may need a higher dose than the nonsmoker.

Note: Psychic and physical dependence may occur in patients on long-term high dosage

therapy, in those with histories of alcohol or drug addiction, or in those who self-medicate.

Patient & Family Education Avoid alcohol and other CNS depressants during therapy unless otherwise advised by

physician. Concomitant use of these agents can cause severe drowsiness, respiratory

depression, and apnea.

Do not drive or engage in other potentially hazardous activities or those requiring mental

precision until reaction to drug is known.

Tell physician if you become or intend to become pregnant during therapy; drug may need to

be discontinued.

Take drug as prescribed; do not change dose or dose intervals.

Check with physician before taking any OTC drugs.

Do not breast feed while taking this drug without consulting physician.

Generic Name: EpinephrineBrand Names: Bronkaid Mist, Epi-E-Zpen, Epinephrine Pediatric,EpiPen Auto-Injector, Primatene

Mist Suspension

Epinephrine Bitartrate

AsthmaHaler, Bronkaid Mist Suspension, Bronitin Mist Suspension, Epitrate, Medihaler-

Epi, Primatene Mist Suspension

Epinephrine Hydrochloride

Adrenalin Chloride, Bronkaid Mistometer, Dysne-Inhal, Epifrin, Glaucon, SusPhrine

Epinephrine ,Racemic

AsthmaNefrin, Dey-Dose Epinephrine, microNefrin, Vaponefrin

Epinephryl borate (ep-i-ne´frill bor´ate)

Epinal, Eppy/N

Classifications: autonomic nervous system agent; alpha- and beta-adrenergic agonist ;

bronchodilator

Pregnancy Category: C

Availability

1:100, 1:1000, 2.25% solution for inhalation; 0.35 mg, 0.2 mg spray; 1:1000, 1:2000, 1:10,000,

1:100,000 injection; 1:200 suspension; 0.1%, 0.5%, 1%, 2% ophthalmic solution; 0.1% nasal

solution

Actions

Naturally occurring catecholamine obtained from animal adrenal glands; also preparedsynthetically. Acts directly on both alpha and beta receptors; the most potent activator of

alpha receptors. Strengthens myocardial contraction; increases systolic but may decrease diastolic

blood pressure; increases cardiac rate and cardiac output.

Therapeutic effects

Constricts bronchial arterioles and inhibits histamine release, thus reducing congestion and edema

and increasing tidal volume and vital capacity. Relaxes uterine smooth musculature and inhibits



uterine contractions. Imitates all actions of sympathetic nervous system except those on arteries of

the face and sweat glands.

Uses

Temporary relief of bronchospasm, acute asthmatic attack, mucosal congestion, hypersensitivity

and anaphylactic reactions, syncope due to heart block or carotid sinus hypersensitivity, and to

restore cardiac rhythm in cardiac arrest. Ophthalmic preparation is used in management of simple(open-angle) glaucoma, generally as an adjunct to topical miotics and oral carbonic anhydrase

inhibitors; also used as ophthalmic decongestant. Relaxes myometrium and inhibits uterine

contractions; prolongs action and delays systemic absorption of local and intraspinal anesthetics.

Used topically to control superficial bleeding

Cautious Use

Older adult or debilitated patients; prostatic hypertrophy; hypertension; diabetes mellitus;

hyperthyroidism; Parkinson’s disease; tuberculosis; psychoneurosis; in patients with long-standing

bronchial asthma and emphysema with degenerative heart disease; in children <6 y of age.

Route & Dosage

Anaphylaxis

adult: SC 0.1–0.5 mL of 1:1000 q10–15min prn

IV 0.1–0.25 mL of 1:1000 q10–15min

child: SC 0.01 mL/kg of, 1:1000 q10–15min prn

IV 0.01 mL/kg of 1:1000 q10–15min

neonate: IV Intratracheal 0.01–0.03 mg/kg (0.1–0.3 mL/kg of 1:10,000) q3–5min prn

Cardiac Arrest

adult: IV 0.1–1 mg (1–10 mL of 1:10,000) q5min as needed

Intracardiac 0.1–1 mg

child: IV 0.01 mg/kg (0.1 mL/kg of 1:10,000) q5min as needed

Intracardiac 0.05–0.1 mg/kg

Asthma adult: SC 0.1–0.5 mL of 1:1000 q20min–4h

Inhalation 1 inhalation q4h prn

child: SC 0.01 mL/kg of 1:1000 q20min–4h

Inhalation 1 inhalation q4h prn

Glaucoma

adultchild: Instillation 1–2 drops 0.25%–2% solution 1/d or b.i.d.

Nasal Hemostasis

adultchild: Instillation 1–2 drops 0.1% ophthalmic or 0.1% nasal solution

Topical Hemostatic

adultchild: Topical 1:50,000–1:1000 applied topically or 1:500,000–1:50,000 mixed with a local

anesthetic

Administration

Inhalation

Have patient in an upright position when aerosol preparation is used. The

reclining position can result in overdosage by producing large droplets instead of fine spray.



Instruct patient to rinse mouth and throat with water immediately after inhalation to avoid

swallowing residual drug (may cause epigastric pain and systemic effects from the propellant

in the aerosol preparation) and to prevent dryness of oropharyngeal membranes.

Do not give isoproterenol concurrently with epinephrine. Allow 4-h interval to elapse before a

change is made from one drug to the other.

Instillation

Instill nose drops with head in lateral, head-low position to prevent entry of drug into throat.

Instruct patient to rinse nose dropper or spray tip with hot water after each use to prevent

contamination of solution with nasal secretions.

Ophthalmic

Remove soft contact lenses before instilling eye drops.

Instruct patient to apply gentle finger pressure against nasolacrimal duct immediately after

drug is instilled for at least 1 or 2 min following instillation to prevent excessive systemic

absorption.

When separate solutions of epinephrine and a topical miotic are used, the miotic should be

instilled 2–10 min prior to epinephrine because of the conjunctival sac’s limited capacity.

Subcutaneous

Use tuberculin syringe to ensure greater accuracy in measurement of parenteral doses.

Protect, epinephrine, injection, from exposure to light at all times. Do not remove ampul or

vial from carton until ready to use.

Shake vial or ampul thoroughly to disperse particles before withdrawing epinephrine

suspension into syringe; then inject promptly.

Aspirate carefully before injecting epinephrine. Inadvertent IV injection of usual SC doses can

result in sudden hypertension and possibly cerebral hemorrhage.

Rotate injection sites and observe for signs of blanching. Vascular constriction from repeated

injections may cause tissue necrosis.

Intravenous

Note: Verify correct rate of IV injection to neonates, infants, children with physician.

Note: 1:1000 solution contains 1 mg/1 mL. 1:10,000 solution contains 0.1 mg/1 mL.

PREPARE direct: Dilute each 1 mg of 1:1000 solution with 10 mL of NS to yield 1:10,000 solution.

IV Infusion: Further dilute in 250–500 mL of D5W.

ADMINISTER direct: Give each 1 mg over 1 min or longer; may give more rapidly in cardiac arrest.

IV Infusion: 1–10 mcg/min titrated according to patient’s condition.

Incompatibilities Solution / Additive: Aminophylline, cephapirin, hyaluronidase,

mephentermine, sodium bicarbonate, warfarin. Y-site: Ampicillin, thiopental, sodium

bicarbonate.

Adverse effects

SpecSenses:Nasal burning or stinging, dryness of nasal mucosa, sneezing, rebound congestion.

Transient stinging or burning of eyes, lacrimation, browache, headache, rebound conjunctival



hyperemia, allergy, iritis; with prolonged use: melanin-like deposits on lids, conjunctiva, and

cornea; corneal edema; loss of lashes (reversible); maculopathy with central scotoma in aphakic

patients (reversible).

BodyWhole:Nervousness, restlessness, sleeplessness, fear, anxiety, tremors, severe headache,

cerebrovascular accident, weakness, dizziness, syncope, pallor, sweating, dyspnea.

other:Nausea, vomiting.other:Precordial pain, palpitations, hypertension, MI, tachyarrhythmias including ventricular

fibrillation.

Respiratory:Bronchial and pulmonary edema.

Urogenital:Urinary retention.

Skin:Tissue necrosis with repeated injections.

Metabolic:Metabolic acidoses, elevated serum lactic acid, transient elevations of blood glucose.

other:Altered state of perception and thought, psychosis.



Monitor BP, pulse, respirations, and urinary output and observe patient closely following IV

administration. Epinephrine may widen pulse pressure. If disturbances in cardiac rhythm

occur, withhold epinephrine and notify physician immediately.

Keep physician informed of any changes in intake-output ratio.

Use cardiac monitor with patients receiving epinephrine IV. Have full crash cart immediately

available.

Check BP repeatedly when epinephrine is administered IV during first 5 min, then q3–5min

until stabilized.

Advise patient to report to physician if symptoms are not relieved in 20 min or if they become

worse following inhalation.

Advise patient to report bronchial irritation, nervousness, or sleeplessness. Dosage should be

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


Be aware intranasal application may sting slightly.

Administer ophthalmic drug at bedtime or following prescribed miotic to minimize mydriasis,

with blurred vision and sensitivity to light (possible in some patients being treated for

glaucoma).

Transitory stinging may follow initial ophthalmic administration and that headache and

browache occur frequently at first but usually subside with continued use. Notify physician if

symptoms persist.

Discontinue epinephrine eye drops and consult a physician if signs of hypersensitivity develop

(edema of lids, itching, discharge, crusting eyelids). Learn how to administer epinephrine subcutaneously. Keep medication and equipment

available for home emergency. Confer with physician.

Note: Inhalation epinephrine reduces bronchial secretions and thus may make mucous plugs

more difficult to dislodge.

Report tolerance to physician; may occur with repeated or prolonged use. Continued use of

epinephrine in the presence of tolerance can be dangerous.



Take medication only as prescribed and immediately notify physician of onset of systemic

effects of epinephrine.

Discard discolored or precipitated solutions.

Do not breast feed while taking this drug without consulting physician.

Generic Name:Morphine Sulfate Brand Name:Astramorph PF, Avinza, Duramorph, Epimorph , Kadian, MSIR, MS Contin,

Oramorph SR, Roxanol, RMS, Statex

Classifications: central nervous system agent;analgesic; narcotic (opiate) agonist

Prototype:Morphine

Pregnancy Category:B

Availability: 10 mg 15 mg, 30 mg tablets/capsules; 15 mg, 20 mg, 30 mg, 60 mg, 100 mg, 120mg,

200 mg controlled release tablets/capsules; 10 mg/2.5 mL, 10 mg/5 ml, 20 mg/mL, 20 mg/5 mL, 30

mg/1.5 mL, 100 mg/5 mL oral solution; 0.5 mg/mL, 1 mg/mL, 2 mg/mL, 4 mg/mL, 5 mg/mL, 8

mg/mL, 10 mg/mL, 15 mg/mL, 25 mg/mL, 50 mg/mL injection; 5 mg, 10 mg, 20 mg,

Actions

Natural opium alkaloid with agonist activity by binding with the same receptors as endogenous

opioid peptides. Narcotic agonist effects are identified with 3 types of receptors: Analgesia at

supraspinal level, euphoria, respiratory depression and physical dependence; analgesia at spinal

level, sedation and miosis; and dysphoric, hallucinogenic and cardiac stimulant effects.

Therapeutic effects

Controls severe pain; also used as an adjunct to anesthesia.

Uses

Symptomatic relief of severe acute and chronic pain after nonnarcotic analgesics have failed and as

preanesthetic medication; also used to relieve dyspnea of acute left ventricular failure and

pulmonary edema and pain of MI.

Contraindications

Hypersensitivity to opiates; increased intracranial pressure; convulsive disorders;

acute alcoholism; acute bronchial asthma, chronic pulmonary diseases, severe respiratorydepression; chemical-irritant induced pulmonary edema; prostatic hypertrophy; diarrhea caused

by poisoning until the toxic material has been eliminated; undiagnosed acute abdominal conditions;

following biliary tract surgery and surgical anastomosis; pancreatitis; acute ulcerative colitis;

severe liver or renal insufficiency; Addison’s disease; hypothyroidism; during labor for delivery of a

premature infant, in premature infants; pregnancy (category B; D in long-term use or when high

dose is used); lactation

Cautious use

Toxic psychosis; cardiac arrhythmias, cardiovascular disease; emphysema; kyphoscoliosis; cor

pulmonale; severe obesity; reduced blood volume; very old, very young, or debilitated patients;

labor.

Route & DosagePain Relief

adult:PO 10–30 mg q4h prn or 15–30 mg sustained release q8–12h; (Kadian) dose q12–24h,

increase dose prn for pain relief

IV 2.5–15 mg q4h or 0.8–10 mg/h by continuous infusion, may increase prn to control pain or 5–10

mg given epidurally q24h

IM/SC 5–20 mg q4h

PR 10–20 mg q4h prn



child: IV 0.05–0.1 mg/kg q4h or 0.025–2.6 mg/kg/h by continuous infusion

IM/SC 0.1–0.2 mg/kg q4h (max: 15 mg/dose)

PO 0.2–0.5 mg/kg q4–6h; 0.3–0.6 mg/kg sustained release q12h

neonate:IV/IM/SC 0.05 mg/kg q4–8h (max: 0.1 mg/kg) or 0.01–0.02 mg/kg/h

Administration Oral

Use a fixed, individualized schedule when narcotic analgesic therapy is started to provide

effective management; blood levels can be maintained and peaks of pain can be prevented

(usually a 4-h interval is adequate).

Use lower dosage for older adult or debilitated patients than for adults.

Do not break in half, crush, or allow sustained release tablet to be chewed.

Do not give patient sustained release tablet within 24 h of surgery.

Dilute oral solution in approximately 30 mL or more of fluid or semisolid food. A calibrated

dropper comes with the bottle. Read labels carefully when using liquid preparation; available

solutions: 20 mg/mL; 100 mg/mL.

Intravenous

Note: Verify correct IV concentration and rate of infusion/injection for administration to

neonates, infants, or children with physician.

PREPARE direct: Dilute 2–10 mg in at least 5 mL of sterile water for injection.

ADMINISTER direct: Give a single dose over 4–5 min. Avoid rapid administration.

Incompatibilities Solution

/ Additive: Aminophylline, Amobarbital, Chlorothiazide , Floxacillin, Fluorouracil,Haloperido

l, Heparin, Meperidine, Pentobarbital, Phenobarbital, Phenytoin, Sodium bi-

carbonate,Thiopental. Y-site: Amphotericin B Cholesteryl Complex, Cefepime, DoxorubicinLiposome, Minocycline,Sargramostim, Tetracycline.

Store at 15°–30° C (59°–86° F). Avoid freezing. Refrigerate suppositories. Protect all

formulations from light.

Adverse effects

BodyWhole:Hypersensitivity (Pruritus, rash, urticaria, edema, hemorrhagic urticaria (rare),

anaphylactoid reaction (rare)), sweating, skeletal muscle flaccidity; cold, clammy skin,

hypothermia.

CNS:Euphoria, insomnia, disorientation, visual disturbances, dysphoria, paradoxic CNS stimulation

(restlessness, tremor, delirium, insomnia), convulsions (infants and children); decreased coughreflex, drowsiness, dizziness, deep sleep, coma.

SpecSenses:Miosis.

CV:Bradycardia, palpitations, syncope; flushing of face, neck, and upper thorax; orthostatic

hypotension, cardiac arrest.

GI:Constipation, anorexia, dry mouth, biliary colic, nausea, vomiting, elevated transaminase levels.

Urogenital:Urinary retention or urgency, dysuria, oliguria, reduced libido or potency (prolonged

use).



other:Prolonged labor and respiratory depression of newborn.

Hematologic:Precipitation of porphyria.

Respiratory:Severe respiratory depression (as low as 2–4/min) or arrest; pulmonary edema.



Obtain baseline respiratory rate, depth, and rhythm and size of pupils before administering thedrug. Respirations of 12/min or below and miosis are signs of toxicity. Withhold drug and

report to physician.

Observe patient closely to be certain pain relief is achieved. Record relief of pain and duration

of analgesia.

Be alert to elevated pulse or respiratory rate, restlessness, anorexia, or drawn facial

expression that may indicate need for analgesia.

Differentiate among restlessness as a sign of pain and the need for medication, restlessness

associated with hypoxia, and restlessness caused by morphine-induced CNS stimulation (a

paradoxic reaction that is particularly common in women and older adult patients).

Monitor for respiratory depression; it can be severe for as long as 24 h after epidural or

intrathecal administration.

Monitor carefully those at risk for severe respiratory depression after epidural or intrathecal

injection: Older adult or debilitated patients or those with decreased respiratory reserve (e.g.,

emphysema, severe obesity, kyphoscoliosis).

Continue monitoring for respiratory depression for at least 24 h after each epidural or

intrathecal dose.

Assess vital signs at regular intervals. Morphine-induced respiratory depression may occur

even with small doses, and it increases progressively with higher doses (generally max: 90 min

after SC, 30 min after IM, and 7 min after IV).

Encourage changes in position, deep breathing, and coughing (unless contraindicated) at

regularly scheduled intervals. Narcotic analgesics also depress cough and sigh reflexes and

thus may induce atelectasis, especially in postoperative patients.

Be alert for nausea and orthostatic hypotension (with light-headedness and dizziness) inambulatory patients or when a supine patient assumes the head-up position or in patients not

experiencing severe pain.

Monitor I&O ratio and pattern. Report oliguria or urinary retention. Morphine may dull

perception of bladder stimuli; therefore, encourage the patient to void at least q4h. Palpate

lower abdomen to detect bladder distention.


Avoid alcohol and other CNS depressants while receiving morphine.

Do not use of any OTC drug unless approved by physician.

Do not smoke or ambulate without assistance after receiving drug. Bedside rails are advised.

Use caution or avoid tasks requiring alertness (e.g., driving a car) until response to drug is

known since morphine may cause drowsiness, dizziness, or blurred vision. Do not breast feed while taking this drug.

Generic Name: Mannitol Brand Name: Osmitrol, Resectisol

Classification: Osmotic Diuretic Action Summary



Half-life Onset Peak Duration

100 minutes 30-60 minutes 1 hour 6-8 hours

Indications

1. Acute oliguric renal failure

2. Toxic overdose3. Edema

4. Increased intracranial pressure (ICP)

5. Intraocular pressure (IOP)

Action

1. In the oliguric phase of acute renal failure, Mannitol increases osmotic pressure (pressure

needed to stop the absorption of something or osmosis) of the glumerular filtrate,

thereby,promoting diuresis (treating the oliguric phase of renal failure) and excretes toxicmaterials (management for toxic overdose).

2. It also elevates blood plasma osmolality thus, inhibiting the reabsorption of water andelectrolytes (for relief of edema) and mobilizing fluids in the cerebral and ocularspaces(lowers intracranial or intraocular pressure).

Contraindications

1. Susceptibility

2. Dehydration

Adverse reactions

1. Dehydration

2. Anuria

3. Intracranial bleeding

4. Headache

5. Blurred vision

6. Nausea and vomiting

7. Volume expansion

8. Chest pain

9. Pulmonary edema

10. Thirst

11. Tachycardia

12. Hypokalemia (increases the risk of digoxin toxicity)

13. Chronic renal failure

Dosage

Adult

Oliguria: 50-100 g as a 5-25% solution.

Intracranial/Intraocular pressure: 0.25-2 g/kg as 15-25% solution administered for 30-60 minutes.

Children

Oliguria: 0.25-2 g/kg as a 15-20% solution for 2-6 hours

Intracranial/Intraocular pressure: 1-2 g/kg as a 15-20% solution administered for 30-60 minutes.Nursing considerations

Assessment – Monitor the following:

1. 1. Vital signs

2. 2. Intake and output

3. 3. Central venous pressure

4. Pulmonary artery pressure

5. Signs and symptoms of dehydration (e.g. poor skin turgor, dry skin, fever, thirst)

http://nursingcrib.com/pathophysiology/increased-intracranial-pressure/


http://nursingcrib.com/nursing-notes-reviewer/acute-renal-failure/







6. Signs of electrolyte imbalance/deficit (e.g. muscular weakness, paresthesia, numbness,

confusion, tingling sensation of extremity and excessive thirst)

7. (for increase ICP) Neurologic status and intracranial pressure readings.

8. (for increase IOP) Elevating eye pain or decreased visual acuity.

Laboratory Tests

1. Renal function (BUN and Creatinine)

2. Serum Electrolyte (Sodium and Potassium)Precaution

Pregnancy and lactation (safe use during these conditions is not established)

Interventions

1. Observe the IV site regularly for infiltration.

2. Administration rate for oliguria should be titrated to produce a urine output. (about 30-50 ml/hr

in adult and 2-6 hours in children)

Generoc Name: Phenytoin

Brand Names:Dilantin-125, Dilantin-30 Pediatric, Dilantin Infatab, PHENYTOIN SODIUM

EXTENDED, Dilantin Kapseals, PHENYTOIN SODIUM PROMPT, Dilantin

Classifications: central nervous system agent; anticonvulsant; hydantoin

Pregnancy Category: D

NURSING IMPLICATIONS

Assessment & Drug Effects Continuously monitor vital signs and symptoms during IV infusion and for an hour afterward.

Watch for respiratory depression. Constant observation and a cardiac monitor are necessary

with older adults or patients with cardiac disease. Margin between toxic and therapeutic IV

doses is relatively small.

Be aware of therapeutic serum concentration: 10–20 mcg/mL; toxic level: 30–50 mcg/mL; lethal

level: 100 mcg/mL. Steady-state therapeutic levels are not achieved for at least 7–10 d.

Lab tests: Periodic serum phenytoin concentration; CBC with differential, platelet count, and Hct

and Hgb; serum glucose, serum calcium, and serum magnesium; and liver funtion tests.

Observe patient closely for neurologic adverse effects following IV administration. Have on hand

oxygen, atropine, vasopressor, assisted ventilation, seizure precaution equipment (mouth gag,

nonmetal airway, suction apparatus).

Be aware that gingival hyperplasia appears most commonly in children and adolescents and

never occurs in patients without teeth.

Make sure patients on prolonged therapy have adequate intake of vitamin D-containing foods

and sufficient exposure to sunlight.

Monitor diabetics for loss of glycemic control.

Check periodically for decrease in serum calcium levels. Particularly susceptible: patients

receiving other anticonvulsants concurrently, as well as those who are inactive, have limited

exposure to sun, or whose dietary intake is inadequate.

Observe for symptoms of folic acid deficiency: neuropathy, mental dysfunction.

Be alert to symptoms of hypomagnesemia (see Appendix F); neuromuscular symptoms: tetany,

positive Chvostek’s and Trousseau’s signs, seizures, tremors, ataxia, vertigo, nystagmus,

muscular fasciculations.


Be aware that drug may make urine pink or red to red-brown.



Report symptoms of fatigue, dry skin, deepening voice when receiving long-term therapy

because phenytoin can unmask a low thyroid reserve.

Do not alter prescribed drug regimen. Stopping drug abruptly may precipitate seizures and

status epilepticus.

Do not to request/accept change in drug brand when refilling prescription without consulting

physician.

Understand the effects of alcohol: Alcohol intake may increase phenytoin serum levels, leading tophenytoin toxicity.

Discontinue drug immediately if a measles-like skin rash or jaundice appears and notify

physician.

Be aware that influenza vaccine during phenytoin treatment may increase seizure activity.

Understand that a change in dose may be necessary.


E-Cart meds.

Documents

Transcript of E-Cart meds.