EPINEPHRINE (ADRENALINE) Brand Name: epinephrine bitartrate Pregnancy Category: C Drug classes: Sympathomimetic drug, Alpha-adrenergic agonist, Beta1

and beta2-adrenergic agonist, Cardiac stimulant, Vasopressor, Bronchodilator, Antiasthmatic drug, Nasal decongestant, Mydriatic, Antiglaucoma drug Therapeutic actions: Naturally occurring neurotransmitter, the effects of which are mediated by alpha or beta receptors in target organs. Effects on alpha receptors include vasoconstriction, contraction of dilator muscles of iris. Effects on beta receptors include positive chronotropic and inotropic effects on the heart (beta1 receptors); bronchodilation, vasodilation, and uterine relaxation (beta2 receptors); decreased production of aqueous humor.

Indications: Intravenous: In ventricular standstill after other measures have failed to restore circulation, given by trained personnel by intracardiac puncture and intramyocardial injection; treatment and prophylaxis of cardiac arrest and attacks of transitory AV heart block with syncopal seizures (Stokes-Adams syndrome); syncope due to carotid sinus syndrome; acute hypersensitivity (anaphylactoid) reactions, serum sickness, urticaria, angioneurotic edema; in acute asthmatic attacks to relieve bronchospasm not controlled by inhalation or SC injection; relaxation of uterine musculature; additive to local anesthetic solutions for injection to prolong their duration of action and limit systemic absorption Injection: Relief from respiratory distress of bronchial asthma, chronic bronchitis, emphysema, other COPDs Aerosols and solutions for nebulization: Temporary relief from acute attacks of bronchial asthma, COPD Topical nasal solution: Temporary relief from nasal and nasopharyngeal mucosal congestion due to a cold, sinusitis, hay fever, or other upper respiratory allergies; adjunctive therapy in middle ear infections by decreasing congestion around eustachian ostia 0.25%2% ophthalmic solutions: Management of open-angle (chronic simple) glaucoma, often in combination with miotics or other drugs 0.1% ophthalmic solution: Conjunctivitis, during eye surgery to control bleeding, to produce mydriasis

Contraindications: Contraindicated with allergy or hypersensitivity to epinephrine or components of preparation (many of the inhalant and ophthalmic products contain sulfites: sodium bisulfite, sodium or potassium metabisulfite; check label before using any of these products in a sulfite-sensitive patient); narrow-angle glaucoma; shock other than anaphylactic shock; hypovolemia; general anesthesia with halogenated hydrocarbons or cyclopropane; organic brain damage, cerebral arteriosclerosis; cardiac dilation and coronary insufficiency; tachyarrhythmias; ischemic heart disease; hypertension; renal dysfunction (drug may initially decrease renal blood flow); COPD

patients who have developed degenerative heart disease; diabetes mellitus; hyperthyroidism; lactation. Adverse effects: Fear, anxiety, tenseness, restlessness, headache, light-headedness, dizziness, drowsiness, tremor, insomnia, hallucinations, psychological disturbances, convulsions, CNS depression, weakness, blurred vision, ocular irritation, tearing, photophobia, symptoms of paranoid schizophrenia Arrhythmias, hypertension resulting in intracranial hemorrhage, cardiovascular collapse with hypotension, palpitations, tachycardia, precordial pain in patients with ischemic heart disease Nausea, vomiting, anorexia Constriction of renal blood vessels and decreased urine formation (initial parenteral administration), dysuria, vesical sphincter spasm resulting in difficult and painful urination, urinary retention in males with prostatism Pallor, respiratory difficulty, orofacial dystonia, sweating Headache, browache, blurred vision, photophobia, difficulty with night vision, pigmentary (adrenochrome) deposits in the cornea, conjunctiva, or lids with prolonged use Transitory stinging on initial instillation, eye pain or ache, conjunctival hyperemia

Drug Interactions: Increased sympathomimetic effects with other TCAs (eg, imipramine) Excessive hypertension with propranolol, beta-blockers, furazolidone Decreased cardiostimulating and bronchodilating effects with beta-adrenergic blockers (eg, propranolol) Decreased vasopressor effects with chlorpromazine, phenothiazines Decreased antihypertensive effect of guanethidine, methyldopa

Nursing considerations: Use extreme caution when calculating and preparing doses; epinephrine is a very potent drug; small errors in dosage can cause serious adverse effects. Double-check pediatric dosage. Use minimal doses for minimal periods of time; "epinephrine-fastness" (a form of drug tolerance) can occur with prolonged use. Protect drug solutions from light, extreme heat, and freezing; do not use pink or brown solutions. Drug solutions should be clear and colorless (does not apply to suspension for injection). Shake the suspension for injection well before withdrawing the dose. Rotate SC injection sites to prevent necrosis; monitor injection sites frequently. Maintain a rapidly acting alpha-adrenergic blocker (phentolamine) or a vasodilator (a nitrate) on standby in case of excessive hypertensive reaction. Maintain an alpha-adrenergic blocker or facilities for intermittent positive pressure breathing on standby in case pulmonary edema occurs. Maintain a beta-adrenergic blocker (propranolol; a cardioselective beta-blocker, such as atenolol, should be used in patients with respiratory distress) on standby in case cardiac arrhythmias occur. Do not exceed recommended dosage of inhalation products; administer pressurized inhalation drug forms during second half of inspiration, because the airways are open wider and the aerosol distribution is more extensive. If a second inhalation is needed, administer at peak effect of

previous dose, 35 min. Use topical nasal solutions only for acute states; do not use for longer than 35 days, and do not exceed recommended dosage. Rebound nasal congestion can occur after vasoconstriction subsides.

Patient Teaching / Education: Instruct patient to take medication exactly as directed. If on a scheduled dosing regimen, take a missed dose as soon as possible; space remaining doses at regular intervals. Do not double doses. Caution patient not to exceed recommended dose; may cause adverse effects, paradoxical bronchospasm, or loss of effectiveness of medication Instruct patient to contact health care professional immediately if shortness of breath is not relieved by medication or is accompanied by diaphoresis, dizziness, palpitations, or chest pain Advise patient to consult health care professional before taking any OTC medications or alcoholic beverages concurrently with this therapy. Caution patient also to avoid smoking and other respiratory irritants Advise patient to notify health care professional if pregnancy is planned or suspected or if breastfeeding Do not spray inhaler near eyes Advise patients to use bronchodilator first if using other inhalation medications, and allow 5 min to elapse before administering other inhalant medications, unless otherwise directed Advise patient to rinse mouth with water after each inhalation dose to minimize dry mouth Advise patient to maintain adequate fluid intake (20003000 mL/day) to help liquefy tenacious secretions Advise patient to consult health care professional if respiratory symptoms are not relieved or worsen after treatment or if chest pain, headache, severe dizziness, palpitations, nervousness, or weakness occurs Autoinjector: Instruct patients using auto-injector for anaphylactic reactions to remove gray safety cap, placing black tip on thigh at right angle to leg. Press hard into thigh until auto-injector functions, hold in place for 10 seconds, remove, and discard properly. Massage injected area for 10 sec. Pedi: Teach parents or caregivers signs and symptoms of anaphlyaxis, how to use autoinjector safely, and to get the child to a hospital as soon as possible. Instruct parents or caregivers to teach child how to manage his or her allergy, how to self-inject, and what to do in an emergency. For children too young to self-inject and who will be separated from parent, tell parents to always discuss allergy and use of auto-injector with responsible adult

NITROGLYCERINE

Pregnancy Category: C Drug classes: Antianginal agent, Nitrate Therapeutic actions: Relaxes vascular smooth muscle with a resultant decrease in venous return and decrease in arterial BP, which reduces left ventricular workload and decreases myocardial oxygen consumption.

Indications: Acute angina: sublingual, translingual preparations Prophylaxis of angina: oral sustained release, sublingual, topical, transdermal, translingual, transmucosal preparations Angina unresponsive to recommended doses of organic nitrates or beta-blockers (IV preparations) Perioperative hypertension (IV preparations) CHF associated with acute MI (IV preparations) To produce controlled hypertension during surgery (IV preparations) Unlabeled uses: reduction of cardiac workload in acute MI and in CHF (sublingual, topical); adjunctive treatment of Raynaud's disease (topical)

Contraindications : Contraindicated with allergy to nitrates, severe anemia, early MI, head trauma, cerebral hemorrhage, hypertrophic cardiomyopathy, pregnancy, lactation.

Adverse effects: Headache, apprehension, restlessness, weakness, vertigo, dizziness, faintness Tachycardia, retrosternal discomfort, palpitations, hypotension, syncope, collapse, orthostatic hypotension, angina Rash, exfoliative dermatitis, cutaneous vasodilation with flushing, pallor, perspiration, cold sweat, contact dermatitis--transdermal preparations, topical allergic reactions--topical nitroglycerin ointment Nausea, vomiting, incontinence of urine and feces, abdominal pain Local burning sensation at the point of dissolution (sublingual) Ethanol intoxication with high-dose IV use (alcohol in diluent)

Drug Interactions: Increased risk of hypertension and decreased antianginal effect with ergot alkaloids Decreased pharmacologic effects of heparin

Nursing considerations: Give sublingual preparations under the tongue or in the buccal pouch. Encourage patient not to

swallow. Ask patient if the tablet "fizzles" or burns. Always check the expiration date on the bottle; store at room temperature, protected from light. Discard unused drug 6 mo after bottle is opened (conventional tablets); stabilized tablets (Nitrostat) are less subject to loss of potency. Give sustained-release preparations with water; warn the patient not to chew the tablets or capsules; do not crush these preparations. Administer topical ointment by applying the ointment over a 6 6 inch area in a thin, uniform layer using the applicator. Cover area with plastic wrap held in place by adhesive tape. Rotate sites of application to decrease the chance of inflammation and sensitization; close tube tightly when finished. Administer transdermal systems to skin site free of hair and not subject to much movement. Shave areas that have a lot of hair. Do not apply to distal extremities. Change sites slightly to decrease the chance of local irritation and sensitization. Remove transdermal system before attempting defibrillation or cardioversion. Administer transmucosal tablets by placing them between the lip and gum above the incisors or between the cheek and gum. Encourage patient not to swallow and not to chew the tablet. Administer the translingual spray directly onto the oral mucosa; preparation is not to be inhaled. Arrange to withdraw drug gradually. 46 wk is the recommended withdrawal period for the transdermal preparations.

Patient Teaching / Education: Instruct patient to take medication as directed, even if feeling better. Take missed doses as soon as remembered unless next dose is scheduled within 2 hr (6 hr with extended-release preparations). Do not double doses. Do not discontinue abruptly; gradual dose reduction may be necessary to prevent rebound angina Caution patient to change positions slowly to minimize orthostatic hypotension. First dose should be taken while in a sitting or reclining position, especially in geriatric patients Advise patient to avoid concurrent use of alcohol with this medication. Patient should also consult health care professional before taking OTC medications while taking nitroglycerin Inform patient that headache is a common side effect that should decrease with continuing therapy. Aspirin or acetaminophen may be ordered to treat headache. Notify health care professional if headache is persistent or severe Advise patient to notify health care professional if dry mouth or blurred vision occurs Acute Anginal Attacks: Advise patient to sit down and use medication at first sign of attack. Relief usually occurs within 5 min. Dose may be repeated if pain is not relieved in 510 min. Call health care professional or go to nearest emergency room if anginal pain is not relieved by 3 tablets in 15 min SL: Inform patient that tablets should be kept in original glass container or in specially made metal containers, with cotton removed to prevent absorption. Tablets lose potency in containers made of plastic or cardboard or when mixed with other capsules or tablets. Exposure to air, heat, and moisture also causes loss of potency. Instruct patient not to open bottle frequently, handle

tablets, or keep bottle of tablets next to body (i.e., shirt pocket) or in automobile glove compartment. Advise patient that tablets should be replaced 6 mo after opening to maintain potency Lingual Spray: Instruct patient to lift tongue and spray dose under tongue (Nitrolingual, NitroMist) or on tongue (NitroMist)

Sodium Bicarbonate Generic Name:Sodium Bicarbonate Brand Name:Sodium Bicarbonate Classifications:gastrointestinal agent; antacid; fluid and electrolyte balance agent Pregnancy Category:C Actions: Short-acting, potent systemic antacid. Rapidly neutralizes gastric acid to form sodium chloride, carbon dioxide, and water. After absorption of sodium bicarbonate, plasma alkali reserve is increased and excess sodium and bicarbonate ions are excreted in urine, thus rendering urine less acid. Not suitable for treatment of peptic ulcer because it is short-acting, high in sodium, and may cause, gastric, distention, systemic, alkalosis, and possibly acid-rebound.

Therapeutic effects: Shortacting, potent systemic antacid; rapidly neutralizes gastric acid or systemic acidosis.

Uses: Systemic alkalinizer to correct metabolic acidosis (as occurs in diabetes mellitus, shock, cardiac arrest, or vascular collapse), to minimize uric acid crystallization associated with uricosuric agents, to increase the solubility of sulfonamides, and to enhance renal excretion of barbiturate and salicylate overdosage. Commonly used as home remedy for relief of occasional heartburn, indigestion, or sour stomach. Used topically as paste, bath, or soak to relieve itching and minor skin irritations such as sunburn, insect bites, prickly heat, poison ivy, sumac, or oak. Sterile solutions are used to buffer acidic parenteral solutions to prevent acidosis. Also as a buffering agent in many commercial products (e.g., mouthwashes, douches, enemas, ophthalmic solutions). Contraindications: Prolonged therapy with sodium bicarbonate; patients losing chloride (as from vomiting, GI suction, diuresis); heart disease, hypertension; renal insufficiency; peptic ulcer; pregnancy (category C).

Adverse effects : GI:Belching, gastric distention, flatulence. Metabolic:Metabolic alkalosis; electrolyte imbalance: sodium overload (pulmonary edema), hypocalcemia (tetany), hypokalemia, milk-alkali syndrome, dehydration.

other:Rapid IV in neonates (Hypernatremia, reduction in CSF pressure, intracranial hemorrhage). Skin:Severe tissue damage following extravasation of IV solution. Urogenital:Renal calculi or crystals, impaired kidney function.

Nursing Considerations: Assessment & Drug Effects Be aware that long-term use of oral preparation with milk or calcium can cause milk-alkali syndrome: Anorexia, nausea, vomiting, headache, mental confusion, hypercalcemia, hypophosphatemia, soft tissue calcification, renal and ureteral calculi, renal insufficiency, metabolic alkalosis. Lab tests: Urinary alkalinization: Monitor urinary pH as a guide to dosage (pH testing with nitrazine paper may be done at intervals throughout the day and dosage adjustments made accordingly). Lab tests: Metabolic acidosis: Monitor patient closely by observations of clinical condition; measurements of acid-base status (blood pH, Po2, Pco2, Hco3-, and other electrolytes, are usually made several times daily during acute period). Observe for signs of alkalosis (over treatment) Observe for and report S&S of improvement or reversal of metabolic acidosis.

Patient & Family Education: Do not use sodium bicarbonate as antacid. A nonabsorbable OTC alternative for repeated use is safer. Do not take antacids longer than 2 wk except under advice and supervision of a physician. Selfmedication with routine doses of sodium bicarbonate or soda mints may cause sodium retention and alkalosis, especially when kidney function is impaired. Be aware that commonly used OTC antacid products contain sodium bicarbonate: Alka-Seltzer, Bromo-Seltzer, Gaviscon. Do not breast feed while taking this drug without consulting physician.