A. Classifications of Drugs:
For each drug identified, select the correct classification and action.
ACTION Drug Classification Example of a Drug
Example: prevention of (DVT) deep vein thrombosis formation Anticoagulant, antithrombotic Enoxaparin (Lovenox)
1)Increase the force of myocardial contraction, prolongs refractory period of the AV node. Decreases the contraction through the SA and AV nodes.
Therapeutic Effects: Increased cardiac output (Positive inotropic effect) and slowing of the heart rate (Negative chronotropic effect) Regulates heart beat. Therapeutic: Antiarrhythmics, Inotropics,
Pharmacologic: Digitalis, Glycosides Digoxin (Lanoxin)
2) Inhibits prostaglandin synthesis.
Therapeutic Effects: PO: Suppression of pain and inflammation. IV: Closure of patent ductus arteriousus. Therapeutic: Antirheumatics, ductus arteriosus patency adjuncts (IV only), nonsteroidal anti-inflammatory agents Indomethacin (Indocin)
3) Inhibits the reabsorption of sodium and chloride from the loop of Henle and distal renal tubule. Increases renal excretion of water, sodium, chloride, magnesium, hydrogen, and calcium. May have renal and peripheral vasodilatory effects. Effectiveness persists in impaired renal function.
Therapeutic Effects: Diureses and subsequent mobilization of excess fluid (edema, pleural *Continued* - effusions). Decreased blood pressure. Therapeutic: Diuretics
Pharmacologic: Loop diuretics Furosemide (Lasix)
4) Maintain acid-base balance, isotonicity, and electrophysiologic balance of the cell. Activator in many enzymatic reactions; essential to transmission of nerve impulses; contraction of cardiac skeletal, and smooth muscle; gastric secretion; renal function; tissue synthesis; and carbohydrate metabolism.
Therapeutic Effects: Replacement, Prevention of deficiency. Therapeutic: Mineral and electrolyte replacements/supplements Potassium chloride (K-Dur)
5) In pharmacologic doses, all agents suppress inflammation and the normal immune response. All agents have numerous intense metabolic effects. Suppress adrenal function at chronic doses of prednisone/prednisolone---5 mg/day. Have minimal mineralocorticoid activity.
Therapeutic Effect: Suppression of inflammation and modification of the normal immune response. Replacement therapy in adrenal insufficiency. Budesonide improvement in symptoms/sequelai of Crohn’s disease. Therapeutic: Antiasthnatics, corticosteroids
Pharmacologic: Corticosteroids (systemic) Prednisone (Deltasone)
6) Principal effect is increasing metabolic rate of body tissues. Promote gluconeugenesis. Increase utilization and mobilization of glycogen stores, Stimulate protein synthesis. Promote cell growth and differentiation. Aid in the development of the brain and CNS, Contain T, (triiodothyronine) and T, (thyroxine) activity.
Therapeutic Effects: Replacement in deficiency states with restoration of normal hormonal balance, Suppression of thyrotropin-dependent thyroid cancers. Therapeutic: Hormones
Pharmacologic: Thyroid preparations Levothyroxine sodium
7) Blocks stimulation of beta (Myocardial) and beta (Pulmonary, vascular, and uterine)-adrenergic receptor *Continued*- sites.
Therapeutic Effects: Decreased heart rate and blood pressure. Suppression of arrhythmias. Prevention of MI. Therapeutic: Antianginals, antiarrhythmics (Class II), antihypertensives, vascular headache suppressants
Pharmacologic: Beta blockers Propranolol hydrochloride
8) Produce analgesia and reduce inflammation and fever by inhibiting the production of prostaglandins. Aspirin Only Deceases platelet aggregation.
Therapeutic Effects: Analgesia. Reduction of inflammation. Reduction of fever. Aspirin. Decreased incidence of transient ischemic attacks and MI. Therapeutic: Antipyretics, nonopioid analgesics
Pharmacologic: Salicylates Acetylsalicylic acid (Aspirin)
9) Bind to opiate receptors in the CNS. Alter the perception of and response to painful stimuli, while producing generalized CNS depression.
Therapeutic Effects: Decreased pain. Therapeutic: Opioid analgesics
Pharmacologic: Opioid agonists, ofioid agonists/nonopioid analgesic combinations Oxycodone
10) Binds to opiate receptors in the CNS. Alters the perception of and response to painful stimuli while producing generalized CNS depression.
Therapeutic Effects: Decrease in severity of pain. Therapeutic: Opioid analgesics
Pharmacologic: Opioid agonists Morphine sulphate
2) MATCH the appropriate definition from Column B to the term described in Column A, knowing that most drugs have three types of names.
Column A Column B
A 1) Drug’s official name assigned by the U.S. Adopted Names Council. A. Generic
C 2) Describes drug’s molecular structure and identification of its chemical structure B. Trade or Brand
B 3) Name registered by eh U.S. Patent Office and approved for usage by the U.S. Food and Drug Administration C. Chemical
3) SOURCES OF DRUGS: Name FOUR sources of drugs, and for each source, list one example of a drug.
A. Plants: Penicillin
B. Animals: Insulin
C. Minerals: Aluminum hydroxide
D. Laboratory synthesis: Filgrastim
4) PRACTICE PROBLEMS: Using your drug book, locate pertinent information for each of the following situations.
A. Your home health patient, Mrs. B, age 78, has been taking psyllium (Metamucil) for complaints of constipation. When you arrive at her home and assist with medication administration, she complains that the Metamucil gets “stuck in her throat”, so she went back to taking her old Ex-Lax.
1) What important patient education points should you emphasize with this patient for the use of Metamucil? Explain to her that Metamucil is an excellent source of dietary fiber that works by drawing water into the stools. Instruct that the best time for consumption of Metamucil would be at breakfast and that she should not take any regularly scheduled medications for at least one hour after taking Metamucil. Ensure that the patient is aware that Metamucil is supposed to be mixed in a full glass of water or juice. Upon drinking a full glass of water or juice, follow with a second glass of water or juice to rinse Metamucil down before expansion of the Metamucil takes place in the throat. Metamucil should be consumed quickly after mixing, as it will congeal. She should be made aware of the possible side effects, such as; weakness, dizziness, excessive bowel activity, abdominal cramps, and/or perianal irritation, She should report to a health care provider if she experiences sweating, flushing, muscle cramps, or excessive thirst.
2) What will you want to teach her about the use of Ex-Lax? First off, I would want to teach her of the risks of Ex-Lax. Risk of dependency on Ex-Lax, dehydration, and electrolyte imbalance as well as the causes of these problems would need to be explained to her. I would also tell her of how hard Ex-Lax can be on the digestive tract and that there could be possible blood in her stool to watch for. Ex-Lax can’t be used with any other laxatives and she should notify a health care provider if she experiences sweating, flushing, muscle cramps, or excessive thirst.
B. Mr. W, aged 66, is in for repair of a fractured hip. He has been receiving Lovenox (enoxaparin) every day as a shot in his abdomen. He wonders why he is receiving this drug since he has never had a blood clot in his life.
1) What will you tell him is the reason he is receiving Lovenox following his surgery (hint) (look under indications)?
I would tell him that his restricted mobility during recovery from surgery puts him at risk for thromboembolic complications and that Levenox is taken for the prevention of clots during and after the surgery.
2) Why is routine blood work (PT and PTT) not required when a patient is on Lovenox (hint) (look under nursing implications)?
Because the medication does not get measured accurately by prothrombin time (PT), activated thromboplastin time (aPTT), or international standards of heparin or low-molecular-weight heparins.
3) Why is it important to obtain his daily weight (hint) (look under adverse reactions and side effects)?
Because a side effect of Lovenox is constipation and urinary retention. A gain in weight could mean water retention (edema) or constipation. A loss of weight could be from vomiting. These are some of the side effects that could cause weight gain or loss. The importance of weight gain or loss is that the dosage of Lovenox is based upon the weight of the patient.
4)What is the route of administration and special procedure to be used with administration of this medication (hint) (look under implementation)?
The route is subcutaneous and the special procedure is to pinch the skin as to separate the subcutaneous tissue from the muscle and inject the entire length of the needle at a 45 or 90-degree angle. Rotate injection sites frequently.
C. C.S., Age 82, is on digoxin (Lanoxin) 0.125 mg every day by mouth. (Now do this one on your own)
1) What laboratory values (2) should be checked prior to administering this morning’s dose?
Digoxin levels and potassium levels should be checked.
2) What is the therapeutic lab values for a digoxin level for this patient?
0.5 – 2 mL/mg
3) What vital sign for this patient is important for the nurse to check before administering digoxin and why?
Apical pulse. I would check because if pulse is slower than 60 BPM, I would not administer. Digoxin slows the heart rate further at therapeutic levels.
4) What are three signs of digoxin toxicity for this patient?
Abdominal pain, anorexia, and nausea are three of many signs.
B. Lifespan Considerations:
1) What do each of the following “Pregnancy Categories” mean:
a. A= Studies indicate no risk to human fetus.
b. B= Studies indicate no risk to animal fetus; information for humans not available.
c. C= Adverse effects reported in animal fetus; information for humans is not available.
d. D= Possible fetal risk in humans reported; However, consideration for potential benefit vs risk may, in selected cases, warrant use of those drugs in pregnant women.
e. X= Fetal abnormalities reported and positive evidence of fetal risk in humans available from animal and/or human studies. These drugs should not be used in pregnant women.
2) Which legal act required drug manufacturers to establish the safety and efficacy of a new drug before its approval for use?
In 1994, congress passed the dietary supplement health and education act.
3) What does each of the Schedules of Controlled Substances mean?
a. Schedule I – High abuse potential; no medical use; severe physical and psychological dependency.
b. Schedule II – High abuse potential; accepted medical use; severe physical and psychological dependency.
c. Schedule III – Less than C-II abuse potential; accepted medical use; moderate to low physical and high psychologic dependency.
d. Schedule IV – Less than C-III abuse potential; accepted medical use; limited physical or psychologic dependency.
e. Schedule V – Less than C-IV abuse potential; accepted medical use; limited physical or psychologic dependency.
4) What happens if a medication is removed form it’s container but not used?
The medication must be discarded. The medication is disposed of in a controlled waste container according to policy. The name of the medication, the dose, and the reason for discarding medication needs to be documented.
How is it different if it is a narcotic for example a patient who requested pain medication (narcotic) but then decided he didn’t need it after all?
Then the narcotic must be discarded. The narcotic is disposed of in a controlled waste container according to policy and witnessed by a second nurse. The name of the medication, the dose, and the reason for discarding the narcotic needs to be documented along with a co-signature from another nurse.
5) SITUATION: Alice R, 86 years old, complains of dizziness and nausea when she reports to the physician’s office for her yearly flu shot. After a review of her current medications, which include several for hypertension, you discover that she is taking 12 tablets, all with her noon meal. When you suggest that she may need to spread out her medications, she informs you that she has taken them this way for years. Answer the following questions to help guide you in your general medication education for this patient.
a. What is the most likely cause of her dizziness and nausea?
It could be taking all 12 medications at the same time. If she takes more than one hypertensive medication daily and she’s taking them at the same time, the drugs could lead to dizziness and nausea as a side effect of hypertensive medications. Her age may also affect the rate of absorption and metabolism of the medication causing a need to divide her daily meds into different times of the day.
b. What do you suggest she do?
Consult with a physician as to which times of the day are best to take her medications. She should also sit on the side of the bed at night before standing. This will eliminate orthostatic hypotension and reduce the risks of falls.
c. Which drugs are best to be taken at bedtime?
Any medications that are sedatives should be taken at night. Some hypertensive medications are also best taken at night.
d. Explain three physiologic changes that occur with aging that might affect Alice and explain her new symptoms
1. Lower cardiac output which lowers cellular absorption and distribution.
2. Higher gastrointestinal pH which alters absorption.
3. Lower enzyme production which lowers metabolism.
C. Required Drugs:
Complete the following chart, including the trade (brand) name, usual adult dose, classification, action, side effects and nursing implication/patient teaching. You will not want to copy the entire drug book here but read the information and include the most pertinent information paying particular attention what you as the nurse need to know to teach patient and what your nursing implications are.
Name/dosage Classification Action Side Effects Nursing imp/Pt Teaching
PO/IV (Adults): 2.5-10 mg/day for 2-4 days; then adjust daily dose by results of prothrombin time or international normalized ratio (INR). Anticoagulant
coumarins Prevention of thromboembolic events. Interferes with hepatic synthesis of vitamin K-dependent clotting factors GI: cramps, nausea
Derm: dermal necrosis
Misc: fever Assess for signs of bleeding and hemorrhage (stool, nosebleeds, bruising, drop in HCT)
Lab values for PT and INR (therapeutic PT range 1.3-1.5 times >than control)
Patient should take medication exactly as directed, constant limited foods high in Vitamin K, to report any signs of bleeding or bruising, no alcohol and no OTC medications containing aspirins or NSAIDS, frequent monitoring of levels through lab tests, to carry identification of medication regimen.
IV: Digitalizing dose---0.5—1 mg given as 50% of the dose initially and one quarter of the initial dose in each of 2 subsequent doses at 6-12 hr intervals.
PO: Digitalizing dose---0.75-1.5—mg given as 50% of the dose initially and one quarter of the initial dose in each of 2 subsequent doses at 6-12 hr intervals. Maintenance dose---0.125-0.5 mg/day as tablets or 0.350-0.5 mg/day as gelatin capsules, depending on patient’s lean body weight, renal function, and serum level.
Therapeutic: antiarrhythmics, inotropics
Pharmacologic: digitalis glycosides Increases the force of myocardial contraction. Prolongs refractory period of the AV nodes.
Therapeutic Effects: Increased cardiac output (Positive inotropic effect) and slowing of the heart rate (Negative chronotropic effect). CNS: fatigue, headache, weakness. EENT: blurred vision, yellow or green vision. CV: arrhythnias, bradycardia, ECG changes, A-V block, S_A block. GI: anorexia, nausea, vomiting, diarrhea. Endo: gynecomastia. Hemat: thrombocytopenia. Metab: Hyperkalemia with acute toxicity. Assessment:
*Monitor apical pulse for 1 full min before administering. Withhold dose and notify physician if j\pulse rate is <60 bpm in an adult, <70 bpm in a child, or <90 bpm in and infant. Also notify physician or health care professional promptly of any significant changes in rate, rhythm, or quality of pulse.
*Pedi: Heart rate varies in children depending on age, ask physician to specify at what heart rates digoxin should be withheld.
*Monitor blood pressure periodically in patients receiving IV digoxin.
*Monitor ECG throughout IV administration and 6 hours after each dose. Notify physician or health care professional if bradycardia or new arrhythmias occur.
*Observe IV site for redness or infiltration, extravasation can lead to tissue irritation and sloughing.
*Monitor intake and output ratios and daily weights. Assess for peripheral edema, and auscultate lungs for rales/crackles throughout therapy.
*Before administering initial loading dose, determine whether patient has taken any digitalis preparations in the preceding 2-3 wk.
*Geri: Digoxin use has been associated with an increased risk of falls in the elderly. Assess for fall risk and implement prevention strategies per facility protocol.
*Instruct patient to hake medication as directed, at the same time each day. Missed doses should be taken within 12 hr of scheduled dose or not taken at all. Do not double doses. Consult health care professional if doses for 2 or more days are missed. Do not discontinue medication without consulting health care professional.
* Teach patient to take pulse and to contact health care professional before taking medication if pulse rate is <60 or >100.
*Pedi: Teach parents or caregivers that changes in heart rate, especially bradycardia, are among the first signs of digoxon toxicity in infants and children. Instruct parents or caregivers in apical heart rate assessment and ask them to notify a health care professional if heart rate is outside of rang set by health care professional before administering the next scheduled dose.
*Review signs and symptoms of digitalis toxicity with patient and family. Advise patient to notify health care professional immediately if these or symptoms of CHF occur. Inform patient that these symptoms may be mistaken for those of colds or flu.
*Instruct patient to keep digixin tablets in their original container and not to mix in pill boxes with other medications; they may look similar to and may be mistaken for other medications.
*Advise patient that sharing of this medication can be dangerous.
*Caution patient to avoid concurrent use of OTC and herbal products without consulting health care professional. Advise patient to avoid taking antacids or antidiarrheals within 2 hr of digoxin.
*Advise patient to notify health care professional of this medication regimen before treatment.
*Patients taking digoxin should carry identification describing disease process and dedication regimen at all times.
*Geri: Review fall prevention strategies with older adults and their families. High Alert: Emphasize the importance of routine follow-up exams to determine effectiveness and to monitor for toxicity. Teach patents or caregivers of infants and children how to accurately measure medication.
PO: Edema---20-80 mg/day as a single dose initially, may repeat in 6-8 hours; may increase dose by 20-40 mg q 6-8 hr until desired response. Maintenance doses may be given once or twice daily or intermittently for 2-4 days/week (Doses up to 2.5 g/day have been used in patients with CHF or renal disease). Hypertension---40 twice daily initially (When added to regimen, decrease dose of other antihypertensives by 50%); adjust further dosing based on response; Hypercalcemia---120 mg/day in 1-3 doses.
IM, IV: Edema---20-40 mg, may repeat in 2 hr and increase by 20 mg every 2 hr until response is obtained, maintenance dose may be given once-twice daily; acute pulmonary edema---40 mg, after 1 hr may give additional 80 mg (in CHF and renal failure, daily doses of up to 2.5 g have been used; hypercalcemia---80-100 mg, may repeat every 1-2 hr, titrate by response. Continuous infusion-bolus 0.1 mg/kg followed by 0.1 mg/kg/hr, double q 2 hr to a maximum of 0.4 mg/kg/hr.
Pharmacologic: loop diuretics Inhibits the reabsorption of sodium and chloride from the loop of Henle and distal renal tubule. Increases renal excretion of water, sodium chloride, magnesium, hydrogen, and calcium. May have renal and peripheral vasodilatory effects. Effectiveness persists in impaired renal function.
Therapeutic Effects: Diuresis and subsequent mobilization of excess fluid (edema, pleural effusions). Decreased blood pressure. CNS; dizziness, encephalopathy, headache, insomnia, nervousness.
EENT: hearing loss, tinnitus.
GI: constipation, diarrhea, dry mouth, dyspepsia, nausea, vomiting. GU: excessive urination.
Derm: photosensitivity, rashes.
F and E: Dehydration, hypochloremia, hypokalemia, hypomaagnesemia, hyponatremia, hypovulemia, metabolic alkalosis.
Hemat: blood dyscrasias.
Metab: hyperglycemia, hyperuricemia
MS: arthralgia, muscle cramps, myalgia.
Misc: increased BUN. Assessment:
*Assess fluid status during therapy. Monitor daily weight, intake and outut ratios, amount and location of edema, lung sounds, skin turgor, and mucous membranes. Notify physician or other health care provider if thirst, dry mouth, lethargy, weakness, hypotension, or oliguria occurs.
*Monitor blood pressure and pulse before and during administration. Monitor frequency of prescription refills to determine compliance in patients treated for hypertension.
*Geri: Diuretic use is associated with increased risk for falls in older adults. Assess falls risk and implement fall prevention strategies.
*Assess patients receiving digixin for anorexia, nausea, vomiting, muscle cramps, paresthesia, and confusion. Patients taking digitalis glycosides are at increased risk of digitalis toxicity because of the potassium-depleting effect of the diuretic. Potassium supplements or potassium-sparing diuretics may be used concurrently to prevent hypokalemia.
*Assess patient for tinnitus and hearing loss. Audiometry is recommended for patients receiving prolonged high-dose EV therapy. Hearing loss is most common after rapid or high-dose IV administration in patients with decreased renal function or those taking other ototixic drugs.
*Assess for allergy to sulfonamides.
*Instruct patient to take furosemide as directed. Take missed doses as soon as possible; do not double doses.
*Caution patient to change positions slowly to minimize orthostatic hypotension. Caution patient that the use of alcohol, exercise during hot weather, or standing for long periods during therapy may enhance orthostatic hypotension.
*Instruct patient to consult health care professional regarding a diet high in potassium.
*Advise patient to consult health care professional before taking OTC medication or herbal products concurrently with this therapy.
*Instruct patient to notify health care professional of medication regimen before treatment or surgery.
*Caution patient to use sunscreen and protective clothing to prevent photosensitivity reactions.
*Geri: Caution older patients or their caregivers about increased risk for falls. Suggest strategies for fall prevention.
*Advise patient to contact health care professional immediately if muscle weakness, cramps, nausea, dizziness, numbness, or tingling of extremities occurs.
*Advise patient taking furosemide tablets not to change brands when refilling prescription; bioavailability among brands is variable.
*Advise diabetic patients to monitor blood glucose closely; may cause increased blood glucose levels.
*Hypertension: Advise patients on antihypertensive regimen to continue taking medication even if feeling better. Furosemide controls but does not cure hypertension.
*Reinforce the need to continue additional therapies for hypertension (Weight loss, exercise, restricted sodium intake, stress reduction, regular exercise, moderation of alcohol consumption, cessation of smoking).
PO, IV: 40-80 mEq/day.
Therapeutic: Mineral and electrolyte replacements/supplements Maintain acid-base balance, isotonicity, and electrophysiologic balance of the cell. Activator in many enzymatic reactions: essential to transmission of nerve impulses; contraction of cardiac, skeletal, and smooth muscle; gastric secretion; renal function; tissue synthesis; and carbohydrate metabolism.
Therapeutic Effects: Replacement. Prevention of deficiency. CNS: confusion, restlessness, weakness.
CV: arrhythmias, ECG changes.
GI: abdominal pain, diarrhea, flatulence, nausea, vomiting; tablets, capsules only----GI ulceration, stenotic lesions.
Local: irritation at IV site.
Neuro: paralysis, paresthesia. Assessment:
*Assess for signs and symptoms of hypokalemia (Weakness, fatigue, U wave on ECG, arrhythmias, polyuria, polydipsia) and hyperkalemia.
*Monitor pulse, blood pressure, and ECG periodically during IV therapy.
*Explain to patient purpose of the medication and the need to take as directed, especially when concurrent digoxin or diuretics are taken. A missed dose should be taken as soon as remembered within 2 hr; if not, return to gegular dose schedule. Do not double dose.
*Emphasize correct method or administration. GI irritation or ulceration may result from chewing enteric-coated tablets or insufficient dilution of liquid or powder forms.
*Some extended-release tablets are contained in a wax matrix that may be expelled in the stool. This occurrence is not significant.
*Instruct patient to avoid salt substitutes or low salt milk or food unless approved by health care professional. Patient should be advised to read all labels to prevent excess potassium intake.
*Advise patient regarding sources of dietary potassium. Encourage compliance with recommended diet.
*Instruct patient to report dark, tarry, or bloody stools; weakness; unusual fatigue; or tingling of extremities. Notify health care professional if nausea, vomiting, diarrhea, or stomach discomfort persists. Dosage may require adjustment.
*Emphasize the importance of regular follow up exams to monitor serum levels and progress.
PO: Anti-inflammatory---400-800 mg 3-4 times daily (Not to exceed 3,600 mg/day). Analgesic/antidysmenorrheal/antipyretic---200-400 mg q 4-6 hr (Not to exceed 1200 mg/day).
Therapeutic: antipyretics, antirheumatics, nonopioid analgesics, nonsteroidal anti-inflammatory agents
Pharmacologic: nonopioid analgesics Inhibits prostaglandin synthesis.
Therapeutic Effects: Decreased pain and inflammation. Reduction of fever. CNS: headache, dizziness, drowsiness, psychic disturbances.
EENT: anblyopia, blurred vision, tinnitus.
CV: arrhythmias, edema.
GI: GI bleeding, hepatitis, constipation, dyspepsia, nausea, vomiting, abdominal discomfort.
GU: cystitis, hematuria, renal failure.
Derm: exfoliative dermatitis, Steven-Johnson syndrome, toxic epidermal necrolysis, rashes.
Hemat: blood dyscrasias, prolonged bleeding time.
Misc: allergic reactions including anaphylaxis. Assessment:
*Patients who have asthma, aspirin-induced allergy, and nasal polyps are at increased risk for developing hypersensitivity reactions. Assess for rhinitis, asthma, and urticaria.
*Geri: Higher risk for poor outcomes or death from GI bleeding. Age-related renal impairment increases risk or hepatic and renal toxicity. Assess for signs and symptoms of GI bleeding (tarry stools, lightheadedness, hypotension), renal dysfunction (elevated BUN and creatinine levels, decreased urine output), and hepatic impairment (elevated liver enzymes, jaundice).
*Pain: Assess pain (note type, location, and intensity) prior to and 1-2 hr following administration.
*Arthritis: Assess pain and range of motion prior to and 1-2 hr following administration.
*Fever: Monitor temperature; note signs associated with fever (diaphoresis, tachycardia, malaise).
*Advise patients to take ibuprofen with a full glass of water and to remain in an upright position for 15-30 min after administration.
*Instruct patient to take medication as directed. Take missed doses as soon as remembered but not if almost time for next dose. Do not double doses. Pedi” Teach parents or caregivers to calculate and measure doses accurately and to use measuring device supplied with product.
*May cause drowsiness or dizziness. Advise patient to avoid driving or other activities requiring alertness until response to medication is known.
*Caution patient to avoid the concurrent use of alcohol, aspirin, acetaminophen, or other OTC or herbal products without consulting health care professional.
*Advise patient to inform health care professional of medication regimen prior to treatment or surgery.
*Caution patient to wear sunscreen and protective clothing to prevent photosensitivity reactions.
*Instruct patients not to take OTC ibuprofen preparations for more than 3 days for fever, and to consult health care professional if symptoms persist or worsen. Many OTC products contain ibuprofen; avoid duplication.
*Pedi: Teach parents or caregivers to check labels of all OTC products to prevent administration of more than one ibuprofen product.
*Caution patient that used of ibuprofen with 3 or more glasses of alcohol per day may increase the risk of GI bleeding.
*Advise patient to consult health care professional if rash, itching, visual disturbances, tinnitus, weight gain, edema, black stools, persistent headache, or influenza-like syndrome (chills, fever, muscle aches, pain).
*Pedi: Advise parents or caregivers not to administer ibuprofen to children who may be dehydrated (can occur with vomiting, diarrhea, or poor fluid intake); dehydration increases risk or renal dysfunction.
Aspirin for Pain/Fever:
325-500 mg q 3 hr or 325-600 mg q 4 hr or 650-1000 mg q 6 hr (not to exceed 4 g/day) Extended release tablets---650 mg q 8 hr or 800 mg q 12 hr.
Aspirin for inflammation:
PO: 1-1.3 g daily in 2-4 divided doses (doses as low as 325 mg/day may be used in patients who are intolerant of the higher dose).
Aspirin for Prevention of Transient Ischemic Attacks:
PO: 1-1.3 g daily in 2-4 divided doses (doses as low as 325 mg/day may be used in patients who are intolerant of the higher dose).
Aspirin for Prevention of Myocardial Infarction:
PO: 300-325 mg/day (doses as low as 80 mg/day may be effective).
Therapeutic: antipyretics, nonopioid analgesics
Pharmacologic: salicylates Produce analgesia and reduce inflammation and fever by inhibiting the production of prostaglandins. Aspirin only decreases platelet aggregation.
Therapeutic Effects: Analgesia. Reduction of inflammation. Reduction of fevr. Aspirin. Decreased incidence of transient ischemic attacks and MI.
EENT: hearing loss, tinnitus.
GI: GI bleeding, dyspepsia, epigastric distress, heartburn, nausea, abdominal pain, anorexia, hepatotoxicity, vomiting.
Hemat: anemia, hemolysis, increased bleeding time.
Misc: allergic reactions including anaphylaxis and laryngeal edema, noncardiogenic pulmonary edema. Assessment:
*Patients who have asthma, allergies, and nasal polyps or who are allergic to tartrazine are at an increased rsk for developing hypersensitivity reactions.
*Pain: Assess pain and limitation of movement; note type, location, and intensity before and at the peak after administration.
*Fever: Assess fever and note associated signs (diaphoresis, tachycardia, malaise, chills).
*Instruct patient to take salicylates with a full glass of water and to remain in an upright position for 15-30 min after administration.
*Advise patient to report tinnitus; unusual bleeding of gums; bruising; black, tarry stools; or fever lasting longer than 3 days.
*Caution patient to avoid concurrent use of alcohol with this medication to minimize possible gastric irritation; 3 or more glasses of alcohol per day may increase the risk of GI bleeding. Caution patient to avoid taking concurrently with acetaminophen or NSAIDs for more than a few days, unless directed by a health care professional to prevent analgesic nephropathy.
*Teach patients on sodium restricted diet to avoid effervescent tablets or buffered aspirin preparations.
*Tablets with an acetic (vinegar=like) odor should be discarded.
*Advise patients on long-term therapy to inform health care professional of medication regimen before surgery. Aspirin may need to be withheld for 1 wk before surgery.
*Centers for disease control and prevention warns against giving aspirin to children or adolescents with varicella (chickenpox) or influenza-like or viral illnesses because of a possible association with Reye’s syndrome.
*Transient Ischemic Attacks or MI: Advise patients receiving aspirin prophylactically to take only prescribed dose. Increasing the dose has not been found to provide additional benefits.
Subcut: Prophylaxis of DVT before avdominal surgery---2500 IU 1-2 hr before surgery, then once daily for 5-10 days; prophylaxis of DVT in high-risk patients undergoing abdominal surgery---5000 IU daily for 5-10 days or 2500 IU 1-2 hr before surgery, another 2500 IU 12 hr later, then 5000 IU daily for 5-10 days; prophylaxis of DVT in patients undergoing hip replacement surgery---2500 IU evening or the day of surgery greater than or equal to 6 hr after first dose, then 5000 IU daily for 5-10 days (if surgery is in the evening, omit second dose day of surgery) or 5000 IU evening before surgery, then 5000 IU daily for 5-10 days; medical patients with severely restricted mobility: 5000 IU for 12-14 days. Angina/non-Q-wave MI---120 IU/kg (not to exceed 10,000 IU)q 12 hr with concurrent aspirin (75-165 mg/day); systemic anticoagulation (unlabeled)---200 IU/kg once daily or 100 IU/kg twice daily. Therapeutic: anticoagulants
Pharmacologic: antithrombitics Potentiate the inhibitory effect of antithrombin on factor Xa and thrombin.
Therapeutic Effects: Prevention of thrombus formation. CNS: dizziness, headache, insomnia.
GI: constipation, nausea, reversible increase in lier enzymes, vomiting.
GU: urinary retention.
Derm: ecchymoses, pruritus, rash, urticaria.
Hemat: Bleeding, anemia, thrombocylope-nia.
Local: erythema at injection site, hematoma, irritation, pain.
Misc: fever. Assessment:
*Assess for signs of bleeding and hemorrhage (bleeding gums; nosebleed; unusual bruising; black, tarry stools; hematuria; fall in hematocrit or blood pressure; guaiac-positive stools); bleeding from surgical site. Notify physician if these occur.
*Assess for evidence of additional or increased thrombosis. Symptoms depend on area of involvement. Monitor neurological status frequently for signs of neurological impairment. May require urgent treatmen.
*Monitor for hypersensitivity reactions (chills, fever, urticaria). Report signs to physician.
*Monitor patients with epidural catheters frequently for signs and symptoms of neurologic impairment.
*Subcut: Observe injection sites for hematomas, ecchymosis, or inflammation.
*Advise patient to report any symptoms of unusual bleeding or bruising, dizziness, itching, rash, fever, swelling, or difficulty breathing to health care professional immediately.
*Instruct patient not to take aspirin or NSAIDs without consulting health care professional while on therapy.
PO: 5-10 mg once daily; antihypertensive in fragile or small patients or patients already receiving other antihypertensives---- initiate at 2.5 mg/day, increase as required/tolerated (up to 10 mg/day) as an antihypertensive therapy with 2.5 mg/day in patients with hepatic insufficiency.
Pharmacologic: Calcium channel blockers Inhibits the transport of calcium into myocardial and vascular smooth muschle cells, resulting inhibition of excitation contraction.
Therapeutic Effects: Systemic vasodilation resulting in decreased blood pressure. Coronary vasodilation resulting in decreased frequency and severity of attacks of angina. CNS: headache, dizziness, fatigue.
CV: peripheral edema, angina, bradycardia, hypotension, palpitations.
GI: gingival hyperplasia, nausea.
Derm: flushing. Advise pt. to take med as prescribed, even if feeling well. Take missed dose as soon as possible but do not double next dose. Instruct pt. to monitor pulse and to contact health car professional if heart rate is less than 50 bpm. Caution pt. to change positions slowly to minimize orthostatic hypotension. May cause drowsiness and advise to avoid driving or other activities until response to the med is known. Instruct pt. of good dental hygiene. Advise if using beta-blockers to continue using both but notify dr. if chest pain with SOB or if severe or persistent headache occurs. Instruct pt. in monitoring blood pressure
PO, Rect: (Adult >50 kg) 30 mg q 3-4 hr initially. Dosage should not exceed 1600 mg/day.
PO, Rect: (Adult < 50 kg) 0.3 mg/kg q 3-4 hr initially.
IM, IV, Subcut (Adults > 50 kg): 4-10 mg q 3-4 hr. MI 8-15 mg with smaller doses may be given every 3-4 hr.
IM, IV, Subcut (Adults < 50 kg): 0.05-0.2 mg/kg q 3-4 hr.
IV, Subcut: Continuous infusion, 0.8-10 mg/hr.
Epidural: 5 mg/day initially. Dose not to exceed 10 mg/day. Opioid analgesic Binds to opiate receptors in the CNS. Alters perception of and response to painful stimuli while producing generalized CNS depression.* Respiratory
Constipation* Assess LOC, BP, pulse, respirations. If respiration less than 10 p/ min assess level of sedation, subsequent dosage may need to be decreased. Instruct pt. how and when to ask for pain med. Instruct family not to administer PCA doses to the sleeping patient. May cause drowsiness, caution pt. to ask for assistance when ambulating or smoking and to avoid orthostatic hypotension. Encourage pt. who are on prolonged bed rest to turn, cough and breath deeply every 2 hours to prevent atelectasis.*
PO: 300 mg four times daily or 800 at bedtime or 400-600 mg twice daily. Dose not to exceed 2.4 g/day.
IM, IV: 300 mg q 6 hr. Continuous infusion: 900 mg infused over 24 hr. Gastric hypersecretory conditions: 300-600 mg q 6 hr.
Antiulcer agent, histamine H2 antagonist Inhibits the action of histamine at the H2-receptor site located primarily in gastric parietal cells, resulting in inhibition of gastric acid secretion. In addition, ranitidine bismuth citrate has some antibacterial action against H. pylori. *Healing and prevention of ulcers. Decreased symptoms of gastro esophageal reflux. Decreased secretion of gastric acid*
Confusion, dizziness, drowsiness, hallucinations, headache, arrhythmias, altered taste, black tongue (ranitidine bismuth citrate only), constipation, dark stools (ranitidine bismuth citrate only,) diarrhea, drug-induced hepatitis (nizatidine cimetidine), nausea, decreased sperm count, impotence, gynecomastia, agranulocytosis, aplastic anemia, neutropenia, thrombocytopenia, pain at IM site, hypersensitivity reactions, vaculitis.* Assess for epigastric or abdominal pain and frank or occult blood in the stool, emesis, or gastric aspirate. Assess geriatric for confusion. Teach patient to take med as directed. Advise patients taking OTC preparations not to take the maximum dose continuously for more than 2 wk without consulting a health care professional. Notify health care professional if difficulty swallowing occurs or abdominal pain persists or if vomiting blood, or bloody, or tarry stools occur. Inform patient that smoking interferes with the effectiveness of the drug. May cause drowsiness or dizziness so caution patient. Avoid alcohol, products containing asprin or NSAIDs, and foods that may cause an increase in GI irritation. Inform patient that increased fluid and fiber intake and exercise may minimize constipation. Report back, tarry stools; fever; sore throat; diarrhea, dizziness; rash; confusion; or hallucinations.*
PO: 500 mg q 12 hr or 1 g q 24 hr for 10 days.
Anti-infective, first gen-cephalosporin Binds to bacterial cell wall membrane, causing cell death. Bactericidal action against susceptible bacteria.* Seizures, pseudomembranouscolitis, diarrhea, abdominal pain, nausea, vomiting, rashes, urticaria, eosinophilia, hemolytic anemia, neutropenia, thrombocytopenia, allergic reactions including anaphylaxis, superinfection.* Assess patient for infection at beginning of and throughout therapy. Check for allergies to penicillin or cephalosporin’s. Observe patient for signs and symptoms of anaphylaxis. Instruct patient to take medication around the clock at evenly spaced times and to finish the medication completely as directed, even if felling better. Report fever, diarrhea with blood, mucus or pus.*
PO: 50 mcg initial dose. Usual maintenance dose is 75-125 mcg/day
Hormones, thyroid preparations Principal effect is increasing metablic rate of body tissues. Promote gluconeogenesis. Increase utilization and mobilization of glycogen stores. Stimulate protein synthesis. Promote cell growth and differentiation. Aid in the development of the brain and CNS. Contain Tᶾ (triiodothyronine) and T4 (thyroxin) activity. Replacement in deficiency states with restoration of normal hormonal balance. Suppression of thyrotropin-dependent thyroid cancers.* Insomnia, irritability, nervousness, headache, cardiovascular collapse, arrhythmias, tachycardia, angina pectoris, hypotension, increased blood pressure, increased cardiac output, cramps, diarrhea, vomiting, hyperthyroidism, menstrual irregularities, weight loss, heat intolerance, accelerated bone maturation in children.* Assess apical pulse and blood pressure, tachyarrhythmias and chest pain. Monitor thyroid function, blood, and urine glucose in diabetic patients. Caution watch for overdose: symptoms of hyperthyroidism. Take meds as directed, report if more than 2-3 doses are missed. Do not discontinue without consulting health care professional. Instruct patient and family on correct technique for checking pulse. Dose should be withheld and health care professional notified if resting pulse >100 bpm. Explain it is hormone replacement, not a cure. Therapy is life long. Caution patient not to change brands of thyroid preparations, as this may affect drug bioavailability. Report headache, nervousness, diarrhea, excessive sweating, heat intolerance, chest pain, increased pulse rate palpations, weight loss >2 lb/wk, or any unusual symptoms occur. Caution on OTC meds. Emphasize importance of follow up exams and test. Levoxy1 tablets may rapidly swell and disintegrate resulting in chocking, gagging, the tablet getting stuck in the throat, and difficulty swallowing. Taking with water usually prevents this. *
PO: 20 mg once daily for GERD. 40 mg daily in morning for duodenal ulcers for 2 weeks. Then 20 mg daily for 2 weeks. Gastric ulcer: 40 mg once daily for 4-6 wk. Gastric hypersecrtory conditions: 60 mg once daily initially, may be increased up to 120 mg 3 times daily.
Antiulcer agents, proton-pump inhibitors. Binds to an enzyme on gastric parietal cells in the presence of acidic gastric pH, preventing the final transport of hydrogen ions into the gastric lumen with lessened gastroesophageal reflux. Healing of duodenal ulcers.* Dizziness, drowsiness, fatigue, headache, weakness, chest pain, abdominal pain, acid regurgitation, constipation, diarrhea, flatulence, nausea, vomiting, itching, rash.* Asses patient routinely for epigastric or abdominal pain and frank or occult blood in the stool, emesis, or gastric aspirate. Monitor CBC with differential periodically during therapy. May cause ↑AST, ALT, alkaline phosphatase, and bilirubin. May cause serum gastrin concentrations to ↑ during first 1-2 wk of therapy. Levels return to normal after discontinuation of omeprazole. Monitor INR and prothrombin time in patients taking warfarin. Instruct patient to take medication as directed for the full course of therapy, even if feeling better. May cause occasional drowsiness or dizziness so caution patient about activities. Avoid alcohol, products containing aspirin or NSAIDs, and foods that may cause an increase in GI irritation. Advise patient to report onset of black, tarry stools; diarrhea; abdominal pain; or persistent headache to health care professional promptly.*
promethazine hydrocholoride (Phenergan)
PO antihistamine; 25 mg at bedtime or 10-12.5 mg 4 times daily. IM: 25 mg, may be repeated in 2 hr.
PO antivertigo: 25 mg 30-60 min before departure
PO, Rect, IM, IV sedation: 25-30 mg
IM, IV sedation during labor: 50 mg in early labor; additional doses of 25-75 mg may be given 1-2 times at 4 hr intervals.
PO, Rect, IM, IV antiemetic: 10-25 mg q 4 hr as needed. Antiemetics, antihistamines, sedative/
hypnotics phenothiazines Blocks the effects of histamine. Alters the effects of dopamine in the CNS. Possesses significant anticholinergic activity. Produces CNS. Possesses significant anticholingeric activity. Produces CNS depression. Relief of symptoms of histamine excess usually seen in allergic conditions. Diminished nausea or vomiting sedation.* Neuroleptic malignant syndrome, confusion, disorientation, sedation, dizziness, extrapyramidal reactions, fatigue, insomnia, nervousness, blurred vision, diplopia, tinnitus, bradycardia, hypertension, hypotension, tachycardia, constipation, drug-induced hepatitis, dry mouth, photosensitivity, rashes, blood dyscrasias.* Monitor blood pressure, pulse, and respiratory rate frequently in patients receiving IV doses. Asses’ patient for level of sedation after administration. Risk of sedation and respiratory depression are increased when administered concurrently with other drugs that cause CNS depression. Monitor patient for onset of extrapyramidal side effects. Teach pt. to take meds as directed. May cause drowsiness, so caution pt. on activities. Encourage good oral hygiene, and sugarless gum or candy to decrease dry mouth. Health care professional should be notified if dry mouth persists > 2 wk. Teach about sunscreen use. Teach about orthotics hypotension. Caution patient to avoid concurrent use of alcohol and other CNS depressants with this medication. Report soar throat, fever, jaundice, or uncontrolled movements are noted. When used for motion sickness, take medication at least 30 min preferably 1-2 hr before exposure to conditions.*
PO: 30-120 mg 3-4 times daily or 60-120 twice daily
IV: 0.25 mg/kg. May repeat in 15 min with a dose of 0.35 mg/kg. Antianginals, antiarrhythmics (Class IV), antihypertensives calcium channel blockers Inhibits transport of calcium into myocardial and vascular smooth muscle cells, resulting in inhibition of excitation-contraction coupling and subsequent contraction. Sustemic vasodilation resulting in decreased blood pressure. Coronary vasodilation resulting in decreased frequency and severity of attacks of angina. Suppression of arrhythimias. Abnormal dreams, confusion, dizziness, drowsiness, headache, nervousness, psychiatric disturbances\\, weakness, blurred vision, disturbed equilibrium, epistaxis, tinnitus, cough, dyspnea, arrhythmias, CHF, perig\pheral edema, bradycardia, chest pain, hypotension, palpitations, syneope, tachycardia, abnormal liver functions studies, anorexia, constipation, diarrhea, dry mouth, dysgeusia, dyspepsia, nausea, vomiting, dysuria, nocturia, polyuria, sexual dysfunction, urinary frequency, dermatitis, erythemia multiforme, flushing, increased sweating, photosensitivitypruritus/urticarin, rash, gynecomastia, hyperglycemia, anemia, leucopenia, thrombocytopenia, weight gain, joint stiffness, muscle cramps, paresthesia, tremor, stevens Johnson syndrome, gingival hyperplasia. Monitor blood pressure and pulse before therapy, during dose titration, and periodically during therapy. Monitor ECG periodically during prolonged therapy. May cause prolonged PR interval. Monitor intake and output ratios and daily weight. Assess for signs of CHF. Monitor frequency of prescription refills to determine adherence. Patients receiving digoxin concurrently with calcium channel blockers should have routine serum digoxin levels checked and be monitored for signs and symptoms of digoxin toxicity. Monitor ECG continuously during administration. Report bradycardia or prolonged hypotension promptly. Monitor serum potassium periodically and renal and hepatic function. Advise patient to take medication exactly as directed. Teach pt. how to monitor pulse. Report if heart rate is <50 bpm. Caution pt. about orthostatic hypotension. May cause drowsiness or dizziness. Caution pt. on activities. Maintain good dental hygiene and seeing dentist frequently. Caution pt. to avoid concurrent use of alcohol or OTC medications, especially cough and cold preparations. Report irregular heartbeats, dyspnea, swelling of hands and feet, pronounced dizziness, nausea, constipation, or hypotension occurs or if headache is severe or persistent. Advise to wear sunscreen. Instruct patient on concurrent nitrate or beta-blocker therapy to continue taking both medications as directed and to use SL nitroglycerin as needed for angina attacks. Report chest pain that dos not improve, worsens after therapy, or occurs with diaphoresis. If shortness of breath occurs; or if severe, persistent headache occurs. Encourage patient to compy with other interventions for hypertension. Instruct patient and family in proper technique for monitoring blood pressure. Take blood pressure weekly and report significant changes.
D. SITUATION: Rose G. is a 76 year old woman who has been hospitalized for small bowel obstruction. She is NPO this am in preparation for Esophagogastroduodenoscopy (EGD).
Her 9AM medications include:
• digoxin 0.125 mg oral
• furosemide 40 mg oral
• levrothyroxine sodium 25 mcg oral
• diltiazem 480 mg oral
• estrogen, conjugated 1.25 mg oral
• potassium chloride 20mEq oral
Answer the following questions in relation to the above medications:
1) What lab values are important to look up before administering any meds? Creatinine clearance, potassium, serum electrolytes, AST, digoxin serum levels, ALT levels, thyroid function.
2) What medications should be given, if any, prior to going down for EGD? (Why disease process are we most concerned about here)? Any medications that the doctor has ordered prior to the procedure should be administered.
3) What vital signs are important to consider? (Goes with above question) Blood pressure, apical pulse, Pulse is necessary because if digoxin is less than 50 bpm, the medication needs to be held. If Diltiazem is less than 60 bpm, then the medication needs to be held.
4) Which medication order would you question and not give? (Look at dose and side effects of medication) Diltiazem
Why? The dosage appears to be excessive to the usual daily dosage.
5) Within 1 hour after administering the medications ordered following her return to her room, Rose complains of nausea and begins to vomit. If you are sure she has vomited the meds you just administered, what should you do? Do not re-administer medications. Notify physician. Check orders for anti-nausea medications. Document. Re-administer medications at next scheduled time unless ordered otherwise by the physician.
6) Which of these medications should be given to Rose now?
• MS Contin
What route would you expect? Rectal, IM, or IV