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

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 68 hr; may increase by 80 mg at weekly intervals until control is achieved. Maintenance 240480 mg daily. Arrhythmias: 240480 mg/day. In digitalized adults: 240320 mg/day. Hypertension: 40 mg to 80 mg PO tid. ER

Capsules: 120240 mg/day PO in the morning. Titrate dose to a maximum 480 mg/day. Tablets: 120180 mg/day PO in the morning. Titrate to a maximum 240 mg q 12 hr. SR

120180 mg/day PO. Titrate up to a maximum 480 mg PO in the morning. Parenteral

IV use only. Initial dose, 2.510 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, 0.10.2 mg/kg over 2 min. 115 yr: Initial dose, 0.10.3 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 myocytes and 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 (Prinzmetals 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 longterm 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, Statex Classifications: 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; acute alcoholism; 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; Addisons 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 & Dosage Pain Relief

Adult: PO 1030 mg q4h prn or 1530 mg sustained release q812h; (Kadian) dose q1224h, increase dose prn for pain relief IV 2.515 mg q4h or 0.810 mg/h by continuous infusion, may increase prn to control pain or 510 mg given epidurally q24h Epidural (DepoDur only) 1015 mg as single dose 30 min before surgery (max: 20 mg) IM/SC 520 mg q4h PR 1020 mg q4h prn Child: IV 0.050.1 mg/kg q4h or 0.0252.6 mg/kg/h by continuous infusion IM/SC 0.10.2 mg/kg q4h (max: 15 mg/dose) PO 0.20.5 mg/kg q46h; 0.30.6 mg/kg sustained release q12h Neonate: IV/IM/SC 0.05 mg/kg q48h (max: 0.1 mg/kg) or 0.010.02 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 210 mg in at least 5 mL of sterile water for injection. ADMINISTER: Direct: Give a single dose over 45 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 1530 C (5986 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 24/min) or arrest; pulmonary edema. Diagnostic Test Interference

False-positive urine glucose determinations may occur using Benedicts 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. Johns wort may increase sedation. Pharmacokinetics

Absorption: Variably absorbed from GI tract. Peak: 60 min PO; 2060 min PR; 5090 min SC; 30 60 min IM; 20 min IV. Duration: Up to 7 h. Distribution: Crosses bloodbrain 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 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) 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 and excretory 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 Mechanism of action 50gm/L

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 Ringers and 5% Dextrose Injection, is indicated as a source of water, electrolytes and calories or as an alkalinizing agent.

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 Ringers 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

Pregnancy Category C 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 bronchial secretions, 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 0.40.6 mg PO, IM, IV, or subcutaneously.

Hypotonic radiography: 1 mg IM. Surgery: 0.5 mg (0.40.6 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: 0.41 mg (up to 2 mg) IV every 12 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 12 drops into eye 1 hr before refracting. For uveitis: Instill 12 drops into eye qid. PEDIATRIC PATIENTS Systemic administration

Refer to the following table: Weight 716 lb (3.27.3 kg) 1624 lb (7.310.9 kg) 2440 lb (10.918.1 kg) 4065 lb (18.129.5 kg) 6590 lb (29.540.8 kg) > 90 lb (> 40.8 kg) Dose (mg) 0.1 0.15 0.2 0.3 0.4 0.40.6

Surgery: 0.1 mg (newborn) to 0.6 mg (12 yr) injected subcutaneously 30 min before surgery. Antidote: > 90 lb: 2 mg auto-injector. 4090 lb: 1-mg auto-injector. 1540 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 Systemic administration

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 Systemic administration

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. Systemic administration

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 selfadministered 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 dry mouth; 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 :Tablets20, 40, 80 mg; oral solution10 mg/mL, 40 mg/5 mL; injection10 mg/mL Adults Edema:

Initially, 2080 mg/day PO as a single dose. If needed, a second dose may be given in 68 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 (24 consecutive days/wk) is preferred for maintenance, or 2040 mg IM or IV (slow IV injection over 12 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 12 min. M ay be increased to 80 mg IV given over 12 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 12 mg/kg in 68 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 magnesium depletion 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. Addisons disease. Nursing considerations [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 Pregnancy Category C Dosage & Route Patient response is quite variable. Evaluate patient carefully to determine the appropriate dose. Adults

Loading dose, 0.751.25 mg PO or 0.1250.25 mg IV. Maintenance dose, 0.1250.25 mg/day PO. Lanoxicaps capsules Loading dose, 0.40.6 mg PO. Maintenance dose, 0.1 0.3 mg/day PO. Pediatric Patients Loading dose: Oral (mcg/kg) IV (mcg/kg) Premature 2030 1525 Neonate 2535 2030 124 mo 3560 3050 25 yr 3040 2535 510 yr 2035 1530 > 10 yr 1015 812 Maintenance dose, 20%30% of loading dose in divided daily doses. Usually 0.1250.5 mg/day PO; 20%30% for premature babies. Geriatric with Renal Impairement Creatinine Clearance (mL/min) 1025 2649 5079 Therapeutic actions Dose 0.125 mg/day 0.1875 mg/day 0.25 mg/day

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 and indirect 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). Nursing considerations 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: 0.52 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 period of 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. Hypersensitivity 5. 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&V 6. 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 extreme bradycardia 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 and refractory 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 and paroxysmal 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: 8001,600 mg/day PO in divided doses, for 13 wk; reduce dose to 600800 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 hr150 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 toxicitypneumonitis, 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. Nursing considerations 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 (0.52.5 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 36 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; wear sunglasses, 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 cardiomyopathy 1.6. 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 attaching the 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 patients 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 expected results. 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 kidneys 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 patients 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

6. 7. 8. 9. 10. 11.

Headache Anorexia N&V Anxiety GI upset 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 be used 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 12 g b.i.d. to q.i.d. IV 7 mEq q 13d child: PO 4565 mg/kg/d in divided doses. IV 17 mEq q 13d neonate: PO 50130 mg/kg/d (max 1 g). IV mEq q 13d Hypocalcemic Tetany adult: IV 4.516 mEq prn child: IV 0.50.7 mEq/kg t.i.d. or q.i.d. neonate: IV 2.4 mEq/kg/d in divided doses CPR adult: IV 2.33.7 mEq x 1 Hyperkalemia with Cardiac Toxicity adult: IV 2.2514 mEq q 12 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 calcium suddenly 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 1530 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 Assessment & Drug Effects 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) and magnesium frequently, during sustained therapy. Deficiencies in other ions, particularly magnesium, frequently coexist with calcium ion depletion. Patient & Family Education 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 potassiumdepleting steroids. Route & dosage Edema adult:PO 2080 mg in 1 or more divided doses up to 600 mg/d if needed IV/IM 2040 mg in 1 or more divided doses up to 600 mg/d child:PO 2 mg/kg, may be increased by 12 mg/kg q68h (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 14 mg/kg q1224h IV/IM 12 mg/kg q1224h Hypertension adult:PO 1040 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 1530 C (5986 F) unless otherwise directed. Protect from light.

Store oral solution in refrigerator, preferably at 28C (3646 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 1530 C (5986 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, hypochloremia metabolic 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 Assessment & Drug Effects 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.

Patient & Family Education 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 100300 mg/d IV/IM 200600 mg up to 20 mg/kg child:PO/IV 38 mg/kg or 125 mg/m2/d neonate:PO/IV 34 mg/kg/d (max: 5 mg/kg/d) Status Epilepticus adultchild: IV 1518 mg/kg in single or divided doses (max: 20 mg/kg) neonate:IV 1520 mg/kg in single or divided doses Sedative adult:PO 30120 mg/d IV/IM 100200 mg/d child:PO 6 mg/kg/d or 180 mg/m2 in 3 divided doses IV/IM 16100 mg/d (13 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. Ysite: Amphotericin B cholesteryl complex, hydromorphone, TPN with albumin. Be aware that extravasation of IV phenobarbital may cause necrotic tissue changes that necessitate skin grafting. Check injection site frequently. Adverse effects : 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: Assessment & Drug Effects 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 1540 mcg/mL produce anticonvulsant activity in most patients. These values are usually attained after 2 or 3 wk of therapy with a dose of 100200 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 to decreased 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).

Patient & Family Education 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 impair judgment 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 (812 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. Do not breast feed while taking this drug.

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, hemolytic transfusion 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 35 min Positive Response 3050 mL of urine over next 23 h, may repeat test dose 1 time. If still negative, do not use. Treatment 50100 g as 15%20% solution over 90 min to several hours child: IV Test Dose 200 mg/kg (max: 12.5 g) over 35 min Positive Response Urine flow of 1 mL/kg/h for 12 h Maintenance 0.250.5 g/kg q46 h Edema, Ascites adult:IV 100 g as a 10%20% solution over 26 h Elevated IOP or ICP adult:IV 1.52 mg/kg as a 15%25% solution over 3060 min Acute Chemical Toxicity adult:IV 100200 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 to infants, children withphysician. PREPARE IV Infusion: Give undiluted ADMINISTER IV Infusion: Give a single dose over 3090 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 3050 mL/h is produced over 23 h after drug administration; then rate is adjusted to maintain urine flow at 3050 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 1530 C (5986 F) unless otherwise directed. Avoid freezing.

Nursing implications Assessment & Drug Effects 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, untreated open-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 510 mg, repeat if needed at 1015 min intervals up to 30 mg, then repeat if needed q24h child: IV/IM <5 y, 0.20.5 mg slowly q25min up to 5 mg; >5 y, 1 mg slowly q25min up to 10 mg, repeat if needed q24 h Anxiety, Muscle Spasm, Convulsions, Alcohol Withdrawal Adult: PO 210 mg b.i.d. to q.i.d. or 1530 mg/d sustained release IV/IM 210 mg, repeat if needed in 34 h Geriatric:PO 12 mg 12 times/d (max: 10 mg/d) Child: PO >6 mo, 12.5 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), menstrual irregularities, ovulation failure. Respiratory:Hiccups, coughing, laryngospasm. Other:Pain, venous thrombosis, phlebitis at injection site. Nursing implications Assessment & Drug Effects 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 12 wk; patient tolerance to therapeutic effects may develop after 4 wk of treatment. Observe necessary preventive precautions for suicidal tendencies that may be present in anxiety 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: Epinephrine

Brand Names: Bronkaid Mist, Epi-E-Zpen, Epinephrine Pediatric,EpiPen Auto-Injector, Primatene Mist Suspension Epinephrine Bitartrate AsthmaHaler, Bronkaid Mist Suspension, Bronitin Mist Suspension, Epitrate, MedihalerEpi, 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-nefrill borate) 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 prepared synthetically. Acts directly on both alpha and beta receptors; the most potent activator of alpha receptors. Strengthens myocardial contraction; increases systolic but may decrease diastolic blood pressure; increases cardiac rate and cardiac output. 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; Parkinsons 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 0.10.5 mL of 1:1000 q1015min prn IV 0.10.25 mL of 1:1000 q1015min child: SC 0.01 mL/kg of, 1:1000 q1015min prn IV 0.01 mL/kg of 1:1000 q1015min neonate: IV Intratracheal 0.010.03 mg/kg (0.10.3 mL/kg of 1:10,000) q35min prn Cardiac Arrest adult: IV 0.11 mg (110 mL of 1:10,000) q5min as needed Intracardiac 0.11 mg child: IV 0.01 mg/kg (0.1 mL/kg of 1:10,000) q5min as needed Intracardiac 0.050.1 mg/kg Asthma adult: SC 0.10.5 mL of 1:1000 q20min4h Inhalation 1 inhalation q4h prn child: SC 0.01 mL/kg of 1:1000 q20min4h Inhalation 1 inhalation q4h prn Glaucoma adultchild: Instillation 12 drops 0.25%2% solution 1/d or b.i.d. Nasal Hemostasis adultchild: Instillation 12 drops 0.1% ophthalmic or 0.1% nasal solution Topical Hemostatic adultchild: Topical 1:50,0001:1000 applied topically or 1:500,0001:50,000 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 210 min prior to epinephrine because of the conjunctival sacs 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 250500 mL of D5W. ADMINISTER direct: Give each 1 mg over 1 min or longer; may give more rapidly in cardiac arrest. IV Infusion: 110 mcg/min titrated according to patients 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.

Nursing implications Assessment & Drug Effects 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 q35min until stabilized. Advise patient to report to physician if symptoms are not relieved in 20 min or if they become worse following inhalation. Advise patient to report bronchial irritation, nervousness, or sleeplessness. Dosage should be reduced. Monitor blood glucose & HbA1c for loss of glycemic control if diabetic. Patient & Family Education 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 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; Addisons 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 & Dosage Pain Relief adult:PO 1030 mg q4h prn or 1530 mg sustained release q812h; (Kadian) dose q1224h, increase dose prn for pain relief IV 2.515 mg q4h or 0.810 mg/h by continuous infusion, may increase prn to control pain or 510 mg given epidurally q24h IM/SC 520 mg q4h PR 1020 mg q4h prn

child: IV 0.050.1 mg/kg q4h or 0.0252.6 mg/kg/h by continuous infusion IM/SC 0.10.2 mg/kg q4h (max: 15 mg/dose) PO 0.20.5 mg/kg q46h; 0.30.6 mg/kg sustained release q12h neonate:IV/IM/SC 0.05 mg/kg q48h (max: 0.1 mg/kg) or 0.010.02 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 210 mg in at least 5 mL of sterile water for injection. ADMINISTER direct: Give a single dose over 45 min. Avoid rapid administration. Incompatibilities Solution / Additive: Aminophylline, Amobarbital, Chlorothiazide, Floxacillin, Fluorouracil,Haloperido l, Heparin, Meperidine, Pentobarbital, Phenobarbital, Phenytoin, Sodium bicarbonate,Thiopental. Y-site: Amphotericin B Cholesteryl Complex, Cefepime, Doxorubicin Liposome, Minocycline,Sargramostim, Tetracycline. Store at 1530 C (5986 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 cough reflex, 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 24/min) or arrest; pulmonary edema. Nursing implications 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 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) 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.

Generic Name: Mannitol

Brand Name: Osmitrol, Resectisol Classification: Osmotic Diuretic Action Summary

Half-life 100 minutes

Onset 30-60 minutes

Peak 1 hour

Duration 6-8 hours

Indications 1. Acute oliguric renal failure 2. Toxic overdose 3. 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 toxic materials (management for toxic overdose). 2. It also elevates blood plasma osmolality thus, inhibiting the reabsorption of water and electrolytes (for relief of edema) and mobilizing fluids in the cerebral and ocular spaces(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)

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: 1020 mcg/mL; toxic level: 3050 mcg/mL; lethal level: 100 mcg/mL. Steady-state therapeutic levels are not achieved for at least 710 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 Chvosteks and Trousseaus signs, seizures, tremors, ataxia, vertigo, nystagmus, muscular fasciculations. Patient & Family Education 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 to phenytoin 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. Do not breast feed while taking this drug.