fentanyl

(fen' ta nil)
Actiq; Duragesic 25, 50, 75, 100;
Sublimaze
Pregnancy Category C
Controlled Substance C-II
Drug class
Opioid agonist analgesic
Theraeutic acti!ns
Acts at specific opioid receptors, causing
analgesia, respiratory depression, physical
depression, euphoria.
"n#icati!ns
Analgesic action of short duration
during anesthesia and immediate
postoperative period
Analgesic supplement in general or
regional anesthesia
Administration with a neuroleptic as
an anesthetic premedication, for
induction of anesthesia, and as an
adjunct in maintenance of general
and regional anesthesia
For use as an anesthetic agent with
oxygen in selected high-ris patients
!ransdermal system" #anagement
of chronic pain in patients re$uiring
opioid analgesia over an extended
period of time who cannot %e
managed %y other means and who
are already receiving opioid therapy
Actiq" !reatment of %reathrough
pain in cancer patients %eing treated
with and tolerant to opioids
$!ntrain#icati!ns an# cauti!ns
&ontraindicated with hypersensitivity
to opioids, diarrhea caused %y
poisoning, acute %ronchial asthma,
upper airway o%struction, pregnancy.
'se cautiously with %radycardia,
history of sei(ures, lactation, renal
dysfunction) history of drug
addiction.
A%ailable f!rms
*o(enge on a stic (Actiq)+,--, .--, /--,
0--, 1,,--, 1,/-- mcg) transdermal+1,.2,
,2, 2-, 32, 1-- mcg4hr) injection+2-
mcg4m*
Dosages
5ndividuali(e dosage) monitor vital signs.
AD&'TS
6arenteral
Premedication: 2-71-- mcg 5# 8-7
/- min %efore surgery.
Adjunct to general anesthesia: !otal
dosage is , mcg4g. #aintenance
dose, ,7,- mcg 59 or 5# when
changes in vital signs indicate
surgical stress or lightening of
analgesia.
With oxygen for anesthesia: !otal
high dose is ,-72- mcg4g 59.
Adjunct to regional anesthesia: 2--7
1-- mcg 5# or slowly 59 over 17,
min.
Postoperatively: 2-71-- mcg 5# for
the control of pain, tachypnea, or
emergence delirium) repeat in 17, hr
if needed.
!ransdermal
5nitiate therapy with ,2 mcg4hr system) adjust
dose as needed and tolerated. Apply to
nonirritated and nonirradiated sin on a flat
surface of the upper torso) may re$uire
replacement in 3, hr if pain has not
su%sided) do not use torn or damaged
systems, serious overdose can occur.
*o(enges
6lace Actiq unit in mouth %etween chee and
lower gum. :tart with initial dose of ,-- mcg.
'ntil appropriate dose is reached, an
additional dose can %e used to treat an
episode of %reathrough pain. ;edosing may
182
start 12 min after the previous lo(enge has
%een completed. <o more than two lo(enges
should %e used for each %reathrough pain
episode. &an consider increasing dose if
re$uiring more than one lo(enge for
treatment of several consecutive
%reathrough pain episodes. 5f more than
four lo(enges are needed daily, increase the
dosage of long-acting opioid. Actiq should %e
suced slowly over 12 min.
()D"AT*"$ (AT")+TS 2,12 -*
6arenteral
,78 mcg4g 59 as vital signs indicate.
!ransdermal
=o not exceed 12 mcg4g.
*o(enges
2712 mcg4g transmucosal.
(harmac!.inetics
;oute Onset =uration
59 17, min -.271 hr
5# 370 min 17, hr
!ransdermal >radual 3, hr
!ransmucosal 12 min 1 hr
/etab!lism0 *iver) !
14,
" 1.27/ hr
Distributi!n0 &rosses placenta) may enter
%reast mil
)1creti!n0 'nnown
IV facts
(rearati!n0 #ay %e used undiluted or
diluted with ,2- m* of =
2
?. 6rotect vials
from light.
"nfusi!n0 Administer slowly %y direct
injection, each milliliter over at least 1 min, or
into running 59 tu%ing.
"nc!matibilities0 =o not mix with
methohexital, pento%ar%ital, thiopental.
A#%erse effects
$+S0 Sedation, clamminess,
seating, headache, vertigo, floating
feeling, di!!iness, lethargy,
confusion, light"headedness,
nervousness, unusual dreams,
agitation, euphoria, hallucinations,
delirium, insomnia, anxiety, fear,
disorientation, impaired mental and
physical performance, coma, mood
changes, weaness, headache,
tremor, sei(ures
$20 6alpitation, increase or
decrease in @6, circulatory
depression, car#iac arrest, sh!c.,
tachycardia, %radycardia, arrhythmia,
palpitations
Dermat!l!gic0 ;ash, hives, pruritus,
flushing, warmth, sensitivity to cold
))+T0 =iplopia, %lurred vision
3"0 #ausea, vomiting, dry mouth,
anorexia, constipation, %iliary tract
spasm
3&0 'reteral spasm, spasm of
vesical sphincters, urinary retention
or hesitancy, oliguria, antidiuretic
effect, reduced li%ido or potency
'!cal0 6hle%itis following 59
injection, pain at injection site) tissue
irritation and induration
(su%cutaneous injection)
*esirat!ry0 :low, shallow
respiration, anea, suppression of
cough reflex, laryngospasm,
%ronchospasm
4ther0 6hysical tolerance and
dependence, psychological
dependence) local sin irritation with
transdermal system
"nteracti!ns
Drug-drug
6otentiation of effects when given
with other &<: acting drugs or
%ar%iturate anesthetics) decrease
dose of fentanyl when
coadministering
6otentiation of effects may occur
when given with macrolide
anti%iotics, etocona(ole,
itracona(ole, and protease inhi%itors
183
=o not administer an #AO5 within 1.
days of fentanyl (increased &<:
effects)
5ncreased ris of adverse effects and
toxicity if com%ined with alcohol
Drug-food
=ecreased meta%olism and ris of
toxic effects if taen with grapefruit
juice) avoid this com%ination
Drug-lab test
Alevated %iliary tract pressure may
cause increases in plasma amylase,
lipase) determinations of these levels
may %e unrelia%le for ,. hr after
administration of opioids
Nursing considerations
$'"+"$A' A')*T5
Name confusion has occurred between
fentanyl and sufentanil; use extreme
caution.
Assessment
6ist!ry0 Bypersensitivity to fentanyl
or opioids, physical dependence on
an opioid analgesic, pregnancy,
la%or, lactation, &O6=, respiratory
depression, anoxia, increased
intracranial pressure, acute #5,
ventricular failure, coronary
insufficiency, hypertension, %iliary
tract surgery, renal or hepatic
dysfunction
(hysical0 Orientation, reflexes,
%ilateral grip strength, affect) pupil
si(e, vision) 6, auscultation, @6) ;,
adventitious sounds) %owel sounds,
normal output) *F!s, renal function
tests
Interentions
Administer to women who are
nursing a %a%y .7/ hr %efore the
next scheduled feeding to minimi(e
the amount in mil.
7A*+"+30 Ceep opioid antagonist
and facilities for assisted or
controlled respiration readily
availa%le during parenteral
administration.
6repare site for transdermal form %y
clipping (not shaving) hair at site) do
not use soap, oils, lotions, alcohol)
allow sin to dry completely %efore
application. Apply immediately after
removal from the sealed pacage)
firmly press the transdermal system
in place with the palm of the hand for
1-7,- sec, maing sure the contact
is complete. #ust %e worn
continually for 3, hr. =o not use any
system that has %een torn or
damaged. ;emove old patch %efore
applying a new one.
<ote that the patch does not wor
$uicly. 5t may tae up to 1, hr to get
the full therapeutic effect.
@reathrough medications need to
%e used.
=o not use Actiq in patients who
never received opioids %efore)
should %e used only in opioid
tolerant patients.
'se caution with Actiq form to eep
this drug out of the reach of children
(it loos lie a lollipop) and follow the
distri%ution restrictions in place with
this drug very carefully.
!eaching "oints
=o not drin grapefruit juice while
using this drug.
Dou may experience these side
effects" =i((iness, sedation,
drowsiness, impaired visual acuity
(as for assistance if you need to
move)) nausea, loss of appetite (lie
$uietly, eat fre$uent small meals))
constipation (a laxative may help).
184
;eport severe nausea, vomiting,
palpitations, shortness of %reath, or
difficulty %reathing.
Adverse effects in Italic are most common)
those in 8!l# are life-threatening.
fe1!fena#ine hy#r!chl!ri#e
(fecs oh fen' a deen)
Allegra
Pregnancy Category C
Drug class
Antihistamine (nonsedating type)
Theraeutic acti!ns
&ompetitively %locs the effects of histamine
at peripheral B
1
-receptor sites) has no
anticholinergic (atropine-lie) or sedating
effects.
"n#icati!ns
:ymptomatic relief of symptoms
associated with seasonal allergic
rhinitis in adults and children E / yr
&hronic idiopathic urticaria in adults
and children E / yr
$!ntrain#icati!ns an# cauti!ns
&ontraindicated with allergy to any
antihistamines, pregnancy, lactation.
'se cautiously with hepatic or renal
impairment, in geriatric patients.
A%ailable f!rms
!a%lets+8-, /-, 10- mg) capsules+/- mg
Dosages
AD&'TS A+D (AT")+TS 9 12 -*
Allergic rhinitis: /- mg 6O %id or
10- mg once4day.
$hronic idiopathic urticaria: /- mg
6O %id.
()D"AT*"$ (AT")+TS :,11 -*
Allergic rhinitis and chroninc
idiopathic urticaria: 8- mg 6O %id.
3)*"AT*"$ (AT")+TS 4* (AT")+TS
7"T6 *)+A' "/(A"*/)+T
For geriatric patients or adults with renal
impairment, use /- mg 6O daily. For children
/711 yr with renal impairment, use 8- mg 6O
daily.
(harmac!.inetics
;oute Onset 6ea
Oral ;apid ,./ hr
/etab!lism0 Bepatic) !
14,
" 1... hr
Distributi!n0 &rosses placenta) may enter
%reast mil
)1creti!n0 Feces, urine
A#%erse effects
$+S0 Fatigue, drowsiness
3"0 <ausea, dyspepsia
4ther0 =ysmenorrhea, flulie illness
"nteracti!ns
Drug-drug
5ncreased levels and possi%le toxicity
with etocona(ole, erythromycin)
fexofenadine dose may need to %e
decreased
=ecreased effects when taen with
antacids
Nursing considerations
Assessment
6ist!ry0 Allergy to any
antihistamines, renal impairment,
pregnancy, lactation
(hysical0 #ucous mem%ranes,
oropharynx, ;, adventitious sounds)
sin color, lesions) orientation, affect)
renal function tests
Interentions
Arrange for use of humidifier if
thicening of secretions, nasal
185
dryness %ecome %othersome)
encourage ade$uate intae of fluids.
6rovide supportive care if flulie
symptoms occur.
!eaching "oints
Avoid excessive dosage) tae only
the dosage prescri%ed.
=o not tae at the same time as
antacids.
Dou may experience these side
effects" =i((iness, sedation,
drowsiness (use caution if driving or
performing tass that re$uire
alertness)) thicening of %ronchial
secretions, dryness of nasal mucosa
(use of a humidifier may help))
menstrual irregularities) flulie
symptoms (medication may %e
helpful).
;eport difficulty %reathing, severe
nausea, fever.
Adverse effects in Italic are most common)
those in 8!l# are life-threatening.
finasteri#e
(fin as' teh ride)
(r!ecia, (r!scar
Pregnancy Category #
Drug class
Androgen hormone inhi%itor
Theraeutic acti!ns
5nhi%its the intracellular en(yme that converts
testosterone into a potent androgen (=B!))
does not affect androgen receptors in the
%ody) the prostate gland depends on =B! for
its development and maintenance.
"n#icati!ns
Proscar: !reatment of symptomatic
@6B) most effective with long-term
use) reduces the need for prostate
surgery and reduces the ris of
urinary retention) with doxa(osin, to
reduce the ris of progression of
@6B symptoms
Propecia: 6revention of male pattern
%aldness in patients with family
history or early signs of loss
'nla%eled uses" Adjuvant
monotherapy following radical
prostatectomy) prevention of the
progression of first-stage prostate
cancer) hirsutism) male chronic
pelvic pain syndrome
$!ntrain#icati!ns an# cauti!ns
&ontraindicated with allergy to
finasteride or any component of the
product, pregnancy, lactation.
'se cautiously with hepatic
impairment.
A%ailable f!rms
!a%lets+1 mg (Propecia), 2 mg (Proscar)
Dosages
AD&'TS
%P&: 2 mg daily 6O with or without
meals) may tae /71, mo for
response.
'ale pattern (aldness: 1 mg4day
6O.
()D"AT*"$ (AT")+TS
:afety and efficacy not esta%lished.
3)*"AT*"$ (AT")+TS 4* (AT")+TS
7"T6 *)+A' "+S&;;"$")+$-
<o dosage adjustment is needed.
(harmac!.inetics
;oute Onset 6ea =uration
Oral ;apid 0 hr ,. hr
/etab!lism0 Bepatic) !
14,
" / hr
Distributi!n0 &rosses placenta) may enter
%reast mil (not used in women)
)1creti!n0 Feces, urine
A#%erse effects
186
3"0 A%dominal upset
3&0 Impotence, decreased li(ido,
decreased volume of ejaculation
4ther0 >ynecomastia
"nteracti!ns
Drug-lab test
=ecreased 6:A levels when
measured) false decrease does not
mean patient is free of ris of
prostate cancer
Nursing considerations
Assessment
6ist!ry0 Allergy to finasteride or any
component, hepatic impairment,
pregnancy, lactation
(hysical0 *iver evaluation,
a%dominal examination) renal
function tests, normal urine output,
prostate examination
Interentions
&onfirm that pro%lem is @6B, and
other disorders (prostate cancer,
infection, strictures, hypotonic
%ladder) have %een ruled out.
Administer without regard to meals)
protect container from light.
Arrange for regular follow-up,
including prostate examination, 6:A
levels, and evaluation of urine flow.
#onitor urine flow and output)
increase in urine flow may not occur
in all situations.
7A*+"+30 =o not allow pregnant
women to handle crushed or %roen
ta%lets %ecause of ris of inadvertent
a%sorption, adversely affecting the
fetus.
Alert patient that li%ido may %e
decreased as well as the volume of
ejaculate) usually reversi%le when
the drug is stopped.
!eaching "oints
!ae this drug once a day without
regard to meals) protect from light.
Bave regular medical follow-up to
evaluate your response. Dour health
care provider will monitor your liver
and idney function as well as
prostate-specific antigen (6:A)
levels.
!his drug has serious adverse
effects on un%orn %a%ies. =o not
allow a pregnant woman to handle
the ta%let if it is crushed or %roen.
Dou may experience these side
effects" *oss of li%ido, impotence,
decreased amount of ejaculate
(usually reversi%le when the drug is
stopped)) %reast enlargement,
tenderness.
;eport ina%ility to void, groin pain,
sore throat, fever, weaness.
Adverse effects in Italic are most common)
those in 8!l# are life-threatening.
fluc!naz!le
(floo .!n' a (ole)
Diflucan
Pregnancy Category C
Drug class
Antifungal
Theraeutic acti!ns
@inds to sterols in the fungal cell mem%rane,
changing mem%rane permea%ility) fungicidal
or fungistatic depending on concentration
and organism.
"n#icati!ns
!reatment of oropharyngeal,
esophageal, vaginal, and systemic
candidiasis
!reatment of cryptococcal meningitis
187
6rophylaxis of candidiasis in %one
marrow transplants
$!ntrain#icati!ns an# cauti!ns
&ontraindicated with hypersensitivity
to flucona(ole, lactation.
'se cautiously with renal or hepatic
impairment.
A%ailable f!rms
!a%lets+2-, 1--, 12-, ,-- mg) powder for
oral suspension+1-, .- mg4m*) injection+
, mg4m*
Dosages
5ndividuali(e dosage) same for oral or 59
routes %ecause of rapid and almost complete
a%sorption.
AD&'TS
)ropharyngeal candidiasis: ,-- mg
6O or 59 on the first day, followed %y
1-- mg daily. &ontinue treatment for
at least , w to decrease lielihood
of relapse.
*sophageal candidiasis: ,-- mg 6O
or 59 on the first day, followed %y
1-- mg daily. =osage up to .--
mg4day may %e used in severe
cases. !reat for a minimum of 8 w)
at least , w after resolution.
Systemic candidiasis: .-- mg 6O or
59 on the first day, followed %y
,-- mg daily. !reat for a minimum of
. w) at least , w after resolution.
Vaginal candidiasis: 12- mg 6O as a
single dose.
$ryptococcal meningitis: .-- mg 6O
or 59 on the first day, followed %y
,-- mg daily. .-- mg daily may %e
needed. &ontinue treatment for 1-7
1, w after cultures of &:F %ecome
negative.
Suppression of cryptococcal
meningitis in AI+S patients: ,-- mg
daily 6O or 59.
Prevention of candidiasis in (one
marro transplants: .-- mg 6O daily
for several days %efore and 3 days
after neutropenia.
()D"AT*"$ (AT")+TS
)ropharyngeal candidiasis: / mg4g
6O or 59 on the first day, followed %y
8 mg4g once daily for at least , w.
*sophageal candidiasis: / mg4g 6O
or 59 on the first day, followed %y
8 mg4g once daily. !reat for a
minimum of 8 w) at least , w after
resolution.
Systemic &andida infections: =aily
doses of /71, mg4g4day 6O or 59.
$ryptococcal meningitis: 1, mg4g
6O or 59 on the first day, followed %y
/ mg4g once daily. &ontinue
treatment for 1-71, w after cultures
of &:F %ecome negative.
Suppression of cryptococcal
meningitis in children ith AI+S:
/ mg4g daily 6O or 59.
(AT")+TS 7"T6 *)+A' "/(A"*/)+T
5nitial dose of 2-7.-- mg 6O or 59. 5f
creatinine clearance E 2- m*4min, use 1--F
recommended dose) for creatinine clearance
,172- m*4min, use 2-F of the
recommended dose) for creatinine clearance
117,- m*4min, use ,2F of recommended
dose) for patients on hemodialysis, use one
dose after each dialysis.
(harmac!.inetics
;oute Onset 6ea =uration
Oral :low 17, hr ,7. days
59 ;apid 1 hr ,7. days
/etab!lism0 Bepatic) !
14,
" 8- hr
Distributi!n0 &rosses placenta) may enter
%reast mil
)1creti!n0 'rine
IV facts
(rearati!n0 =o not remove overwrap until
ready for use. 5nner %ag maintains sterility of
188
product. =o not use plastic containers in
series connections. !ear overwrap down side
at slit, and remove solution container. :ome
opacity of plastic may occur) chec for
minute leas, s$uee(ing %ag firmly. =iscard
solution if any leas are found.
"nfusi!n0 5nfuse at a maximum rate of
,-- mg4hr given as a continuous infusion.
"nc!matibilities0 =o not add any
supplementary medications.
A#%erse effects
$+S0 &eadache
3"0 #ausea, vomiting, diarrhea,
a(dominal pain, A:!4A*! elevations
4ther0 ;ash
"nteracti!ns
Drug-drug
5ncreased serum levels and
therefore therapeutic and toxic
effects of cyclosporine, phenytoin,
%en(odia(epines, oral
hypoglycemics, warfarin
anticoagulants, (idovudine
=ecreased serum levels with
rifampin, theophylline, tacrolimus
Nursing considerations
Assessment
6ist!ry0 Bypersensitivity to
flucona(ole, renal impairment,
lactation, pregnancy
(hysical0 :in color, lesions) !)
injection site) orientation, reflexes,
affect) %owel sounds) *F!s, renal
function tests) &@& and differential)
culture of area involved
Interentions
&ulture infection %efore therapy)
%egin treatment %efore la% results
are returned.
=ecrease dosage in cases of renal
failure.
5nfuse 59 only) not intended for 5# or
su%cutaneous use.
=o not add supplement medication
to flucona(ole.
Administer through sterile e$uipment
at a maximum rate of ,-- mg4hr
given as a continuous infusion.
7A*+"+30 #onitor renal function
tests weely, discontinue or
decrease dosage of drug at any sign
of increased renal toxicity. #onitor
*F!s monthly during therapy.
!eaching "oints
=rug may %e given orally or 59 as
needed. !he drug will need to %e
taen for the full course and may
need to %e taen long term.
'se hygiene measures to prevent
reinfection or spread of infection.
Arrange for fre$uent follow-up while
you are taing this drug. @e sure to
eep all appointments, including
those for %lood tests.
Dou may experience these side
effects" <ausea, vomiting, diarrhea
(fre$uent small meals may help))
headache (analgesics may %e
ordered).
;eport rash, changes in stool or
urine color, difficulty %reathing,
increased tears or salivation.
Adverse effects in Italic are most common)
those in 8!l# are life-threatening.
f!lic aci# <f!late=
(f!e' li)
;!l%ite
Pregnancy Category A
Drug class
Folic acid
9itamin supplement
189
Theraeutic acti!ns
;e$uired for nucleoprotein synthesis and
maintenence of normal erythropoiesis.
"n#icati!ns
!reatment of mego%lastic anemias
due to sprue, nutritional deficiency,
pregnancy, infancy, and childhood
$!ntrain#icati!ns an# cauti!ns
&ontraindicated with allergy to folic
acid preparations) pernicious,
aplastic, normocytic anemias.
'se cautiously during lactation.
A%ailable f!rms
!a%lets+-.., -.0, 1 mg) injection+2 mg4m*
Dosages
Administer orally unless patient has severe
intestinal mala%sorption.
AD&'TS
-herapeutic dose: 'p to 1 mg4day
6O, 5#, 59, or su%cutaneously.
*arger doses may %e needed in
severe cases.
'aintenance dose: -.. mg4day.
Pregnancy and lactation: -.0 mg4day.
()D"AT*"$ (AT")+TS
'aintenance dose:
Infants: -.1 mg4day.
. / yr: 'p to -.8 mg4day.
0 / yr: -.. mg4day.
(harmac!.inetics
;oute Onset 6ea
Oral, 5#, :&, or
59
9aries 8-7/- min
/etab!lism0 Bepatic) !
14,
" 'nnown
Distributi!n0 &rosses placenta) enters
%reast mil
)1creti!n0 'rine
IV facts
(rearati!n0 :olution is yellow to yellow-
orange) may %e added to hyperalimentation
solution or dextrose solutions.
"nfusi!n0 5nfuse at rate of 2 mg4min %y direct
59 injection) may %e diluted in
hyperalimentation for continuous infusion.
A#%erse effects
6yersensiti%ity0 Allergic reactions
'!cal0 Pain and discomfort at
injection site
"nteracti!ns
Drug-drug
=ecrease in serum phenytoin and
increase in sei(ure activity with folic
acid preparations
=ecreased a%sorption with
sulfasala(ine, aminosalicyclic acid
Nursing considerations
$'"+"$A' A')*T5
Name confusion has been re"orted
between folinic acid $leucoorin% and folic
acid; use extreme caution.
Assessment
6ist!ry0 Allergy to folic acid
preparations) pernicious, aplastic,
normocytic anemias) lactation
(hysical0 :in lesions, color) ;,
adventitious sounds) &@&, Bg%, Bct,
serum folate levels, serum vitamin
@
1,
levels, :chilling test
Interentions
Administer orally if at all possi%le.
?ith severe >5 mala%sorption or
very severe disease, give 5#, 59, or
su%cutaneously.
!est using :chilling test and serum
vitamin @
1,
levels to rule out
pernicious anemia. !herapy may
mas signs of pernicious anemia
190
while the neurologic deterioration
continues.
7A*+"+30 'se caution when giving
the parenteral preparations to
premature infants. !hese
preparations contain %en(yl alcohol
and may produce a fatal gasping
syndrome in premature infants.
7A*+"+30 #onitor patient for
hypersensitivity reactions, especially
if drug previously taen. Ceep
supportive e$uipment and
emergency drugs readily availa%le in
case of serious allergic response.
!eaching "oints
?hen the cause of megalo%lastic
anemia is treated or passes (infancy,
pregnancy), there may %e no need
for folic acid %ecause it normally
exists in sufficient $uantities in the
diet.
;eport rash, difficulty %reathing, pain
or discomfort at injection site.
Adverse effects in Italic are most common)
those in 8!l# are life-threatening.
f!rm!ter!l fumarate
(for m!h' te rol)
;!ra#il Aer!lizer
Pregnancy Category C
Drug classes
@eta
,
agonist
Antasthmatic
Theraeutic acti!ns
*ong-acting agonist that %inds to %eta
,

receptors in the lungs causing
%ronchodilation) may also inhi%it the release
of inflammatory mediators in the lung,
%locing swelling and inflammation.
"n#icati!ns
*ong-term maintenance treatment of
asthma in adults and children E 2 yr
6revention of exercise-induced
%ronchospasm in adults and children
E 1, yr when used on an occasional,
as-needed %asis
*ong-term maintenance treatment of
%ronchoconstriction in patients with
&O6=
$!ntrain#icati!ns an# cauti!ns
&ontraindicated with hypersensitivity
to adrenergics, amines, or to
formoterol, acute asthma attac,
acute airway o%struction.
'se cautiously in the elderly, with
pregnancy, lactation.
A%ailable f!rms
5nhalation powder in capsules+1, mcg
Dosages
AD&'TS
'aintenance treatment of $)P+:
Oral inhalation of contents of 1
capsule (1, mcg) using Aeroli!er
Inhaler $ 1, hr. =o not exceed a total
daily dose of ,. mcg.
AD&'TS A+D ()D"AT*"$ (AT")+TS 9 12
-*
Prevention of exercise"induced
(ronchospasm: Oral inhalation of
contents of one capsule (1, mcg)
using the Aeroli!er Inhaler 12 min
%efore exercise. 'se on an
occasional, as-needed %asis.
AD&'TS A+D ()D"AT*"$ (AT")+TS 9 5
-*
'aintenance treatment of asthma:
Oral inhalation of contents of 1
capsule (1, mcg) using the Aeroli!er
Inhaler every 1, hr. =o not exceed 1
capsule every 1, hr.
(harmac!.inetics
191
;oute Onset 6ea =uration
5nhalation 178 min 178 hr 07,- hr
/etab!lism0 Bepatic) !
14,
" 1-71. hr
Distributi!n0 &rosses placenta) may enter
%reast mil
)1creti!n0 Feces, urine
A#%erse effects
$+S0 !remor, di((iness, insomnia,
dysphonia, headache, nervousness
$20 Bypertension, tachycardia, chest
pain
3"0 <ausea, dyspepsia, a%dominal
pain, irritation of the throat and
mouth
*esirat!ry0 @ronchitis, respiratory
infection, dyspnea, tonsillitis
4ther0 Viral infection (most liely in
children)
Nursing considerations
$'"+"$A' A')*T5
Name confusion has occurred between
&oradil $formoterol% and !oradol
$'etorolac%; use extreme caution.
Assessment
6ist!ry0 Bypersensitivity to
adrenergics, amines, or formoterol,
acute asthma attac, acute airway
o%struction, pregnancy, lactation
(hysical0 ;, adventitious sounds, 6,
@6, A&>, orientation, reflexes
Interentions
5nstruct patient in the proper use of
Aeroli!er Inhaler1 Ansure that patient
does not swallow the capsule.
#onitor use of inhaler. 6atient should
not wash the inhaler %ut should eep
it dry) it should not %e used for
delivering any other medication. 5f a
%ronchodilator is needed %etween
doses, consult with health care
provider. =o not use more often than
every 1, hr.
Ancourage patient who experiences
exercise-induced asthma to use drug
12 min %efore activity, and to reserve
this drug for occasional, as-needed
use.
Ansure that patient continues with
appropriate use of corticosteroids or
other drugs used to %loc
%ronchospasm, as appropriate.
Arrange for periodic evaluation of
respiratory condition during therapy.
Arrange for analgesics as
appropriate for headache.
Asta%lish safety precautions if tremor
%ecomes a pro%lem.
!eaching "oints
'se the Aeroli!er Inhaler as
instructed. !his is the only inhaler
that can %e used with this drug.
'se only twice a day. =o not wash
the inhaler) eep it dry at all times.
=o not use this inhaler to deliver any
other drugs. &hec the Guse %yG date
on your drug and discard any
capsules that have expired.
5f drug is to %e used periodically for
exercise-induced asthma, use 12
minutes %efore activity.
Arrange for periodic evaluation of
your respiratory pro%lem while using
this drug) continue to use any other
therapies that have %een prescri%ed
to control your asthma.
Dou may experience these side
effects" Beadache (appropriate
analgesics may %e ordered)) tremors
(use care in performing dangerous
tass if this occurs)) fast heart%eat,
palpitations (monitor activity if this
occurs, rest fre$uently).
192
;eport severe headache, irregular
heart%eat, worsening of asthma,
difficulty %reathing.
Adverse effects in Italic are most common)
those in 8!l# are life-threatening.
f!sin!ril s!#ium
(foh sin' oh pril)
/!n!ril
Pregnancy Category C $first trimester%
Pregnancy Category D $second and third
trimesters%
Drug classes
Antihypertensive
A&A inhi%itor
Theraeutic acti!ns
;enin, synthesi(ed %y the idneys, is
released into the circulation where it acts on
a plasma precursor to produce angiotensin 5,
which is converted %y A&A to angiotensin 55,
a potent vasoconstrictor that also causes
release of aldosterone from the adrenals)
fosinopril %locs the conversion of
angiotensin 5 to angiotensin 55, leading to
decreased @6, decreased aldosterone
secretion, an increase in serum potassium
levels, and sodium and fluid loss) increased
prostaglandin synthesis may %e involved in
the antihypertensive action.
"n#icati!ns
!reatment of hypertension, alone or
in com%ination with thia(ide-type
diuretics
#anagement of &BF as adjunctive
therapy
$!ntrain#icati!ns an# cauti!ns
&ontraindicated with allergy to
fosinopril or other A&A inhi%itors)
pregnancy.
'se cautiously with impaired renal
function, hyperalemia, salt or
volume depletion, lactation.
A%ailable f!rms
!a%lets+1-, ,-, .- mg
Dosages
AD&'TS
5nitial dose, 1- mg 6O daily. #aintenance
dose, ,-7.- mg4day 6O as a single dose or
two divided doses. 5n patients receiving
diuretic therapy, %egin fosinopril therapy with
1- mg. =o not exceed maximum dose of
0- mg.
()D"AT*"$ (AT")+TS
:afety and efficacy not esta%lished.
(harmac!.inetics
;oute Onset 6ea =uration
Oral 1 hr 8 hr ,. hr
/etab!lism0 Bepatic) !
14,
" 1, hr
Distributi!n0 &rosses placenta) enters
%reast mil
)1creti!n0 Feces, urine
A#%erse effects
$20 Angina pectoris, orthostatic
hypotension in salt- or volume-
depleted patients, palpitations
Dermat!l!gic0 ;ash, pruritus,
diaphoresis, flushing
3"0 #ausea, a%dominal pain,
vomiting, diarrhea
*esirat!ry0 $ough, asthma,
%ronchitis, dyspnea, sinusitis
4ther0 Angioedema, asthenia,
myalgia, arthralgia, hyperalemia
"nteracti!ns
Drug-drug
=ecreased effectiveness if com%ined
with indomethacin or other <:A5=s
193
;is of lithium toxicity if com%ined
with A&A inhi%itors
;is of increased potassium levels if
taen with potassium-sparing
diuretics
=ecreased a%sorption when given
with antacids) separate %y at least ,
hr.
Nursing considerations
$'"+"$A' A')*T5
Name confusion has occurred between
fosino"ril and lisino"ril; use caution.
Assessment
6ist!ry0 Allergy to fosinopril and
other A&A inhi%itors, impaired renal
or hepatic function, hyperalemia,
salt or volume depletion, lactation,
pregnancy
(hysical0 :in color, lesions, turgor)
!) 6, @6, peripheral perfusion)
mucous mem%ranes, %owel sounds,
liver evaluation) urinalysis, *F!s,
renal function tests, &@&, and
differential
Interentions
7A*+"+30 Alert surgeon and mar
patientHs chart with notice that
fosinopril is %eing taen) the
angiotensin 55 formation su%se$uent
to compensatory renin release
during surgery will %e %loced)
hypotension may %e reversed with
volume expansion.
Arrange to switch to a different drug
if pregnancy occurs) suggest using
%arrier contraceptives.
#onitor patient closely for a fall in @6
secondary to reduction in fluid
volume (excessive perspiration and
dehydration, vomiting, diarrhea)
%ecause excessive hypotension may
occur.
!eaching "oints
=o not stop taing the medication
without consulting your prescri%er.
Avoid pregnancy while taing this
drug) using %arrier contraceptives is
advised.
@e careful in any situation that may
lead to a drop in %lood pressure
(diarrhea, sweating, vomiting,
dehydration)) if light-headedness or
di((iness occurs, consult your care
provider.
Dou may experience these side
effects" >5 upset, loss of appetite
(these may %e transient)) light-
headedness (transient) change
position slowly and limit activities to
those that do not re$uire alertness
and precision)) dry cough (not
harmful).
;eport mouth sores) sore throat,
fever, chills) swelling of the hands,
feet) irregular heart%eat, chest pains)
swelling of the face, eyes, lips,
tongue, difficulty %reathing,
persistent cough.
Adverse effects in Italic are most common)
those in 8!l# are life-threatening.
fur!semi#e
(fur !h' se mide)
A!>;ur!semi#e <$A+=, ;ur!semi#e
Secial <$A+=, 'asi1
Pregnancy Category C
Drug class
*oop diuretic
Theraeutic acti!ns
5nhi%its the rea%sorption of sodium and
chloride from the ascending lim% of the loop
of Benle, leading to a sodium-rich diuresis.
194
"n#icati!ns
Oral, 59" Adema associated with
&BF, cirrhosis, renal disease
59" Acute pulmonary edema
Oral" Bypertension
$!ntrain#icati!ns an# cauti!ns
&ontraindicated with allergy to
furosemide, sulfonamides) allergy to
tartra(ine (in oral solution)) anuria,
severe renal failure) hepatic coma)
pregnancy) lactation.
'se cautiously with :*A, gout,
dia%etes mellitus.
A%ailable f!rms
!a%lets+,-, .-, 0- mg) oral solution+
1- mg4m*, .- mg42 m*) injection+1- mg4m*
Dosages
AD&'TS
*dema: 5nitially, ,-70- mg4day 6O
as a single dose. 5f needed, a
second dose may %e given in /70 hr.
5f response is unsatisfactory, dose
may %e increased in ,-- to .--mg
increments at /- to 0-hr intervals. 'p
to /-- mg4day may %e given.
5ntermittent dosage schedule (,7.
consecutive days4w) is preferred for
maintenance, or ,-7.- mg 5# or 59
(slow 59 injection over 17, min). #ay
increase dose in increments of
,- mg in , hr. Bigh-dose therapy
should %e given as infusion at rate
not exceeding . mg4min.
Acute pulmonary edema: .- mg 59
over 17, min. #ay %e increased to
0- mg 59 given over 17, min if
response is unsatisfactory after 1 hr.
&ypertension: .- mg %id 6O. 5f
needed, additional antihypertensive
agents may %e added.
()D"AT*"$ (AT")+TS
Avoid use in premature infants" stimulates
prostaglandin A
,
synthesis and may increase
incidence of patent ductus arteriosus and
complicate respiratory distress syndrome.
*dema: 5nitially, , mg4g4day 6O. 5f
needed, increase %y 17, mg4g in /7
0 hr. D! n!t e1cee# : mg?.g@ Adjust
maintenance dose to lowest effective
level.
Pulmonary edema: 1 mg4g 59 or 5#.
#ay increase %y 1 mg4g in , hr until
the desired effect is seen. D! n!t
e1cee# : mg?.g@
(AT")+TS 7"T6 *)+A' "/(A"*/)+T
'p to . g4day has %een tolerated. 59 %olus
injection should not exceed 1 g4day given
over 8- min.
(harmac!.inetics
;oute Onset 6ea =uration
Oral /- min /-71,-
min
/70 hr
59, 5# 2 min 8- min , hr
/etab!lism0 Bepatic) !
14,
" 8-7/- min
Distributi!n0 &rosses placenta) enters
%reast mil
)1creti!n0 Feces, urine
IV facts
(rearati!n0 :tore at room temperature)
exposure to light may slightly discolor
solution.
"nfusi!n0 5nject directly or into tu%ing of
actively running 59) inject slowly over 17,
min.
"nc!matibilities0 =o not mix with acidic
solutions. 5sotonic saline, lactated ;ingerHs
injection, and 2F dextrose injection may %e
used after pB has %een adjusted (if
necessary)) precipitates form with
gentamicin, netilimicin, milrinone in 2F
dextrose, -.IF sodium chloride.
A#%erse effects
195
$+S0 +i!!iness, vertigo,
paresthesias, xanthopsia,
ea2ness, headache, drowsiness,
fatigue, %lurred vision, tinnitus,
irreversi%le hearing loss
$20 )rthostatic hypotension, volume
depletion, cardiac arrhythmias,
throm(ophle(itis
Dermat!l!gic0 Photosensitivity,
rash, pruritus, urticaria, purpura,
exfoliative dermatitis, erythema
multiforme
3"0 #ausea, anorexia, vomiting, oral
and gastric irritation, constipation,
diarrhea, acute pancreatitis, jaundice
3&0 6olyuria, nocturia, glycosuria,
urinary (ladder spasm
6emat!l!gic0 3eu2openia, anemia,
throm(ocytopenia, fluid and
electrolyte im%alances,
hyperglycemia, hyperuricemia
4ther0 'uscle cramps and muscle
spasms
"nteracti!ns
Drug-drug
5ncreased ris of cardiac arrhythmias
with digitalis glycosides (due to
electrolyte im%alance)
5ncreased ris of ototoxicity with
aminoglycoside anti%iotics, cisplatin
=ecreased a%sorption of furosemide
with phenytoin
=ecreased natriuretic and
antihypertensive effects with
indomethacin, i%uprofen, other
<:A5=s
=ecreased >5 a%sorption with
charcoal
#ay reduce effect of insulin or oral
antidia%etic agents %ecause %lood
glucose levels can %ecome elevated
Nursing considerations
$'"+"$A' A')*T5
Name confusion has occurred between
furosemide and torsemide; use extreme
caution.
Assessment
6ist!ry0 Allergy to furosemide,
sulfonamides, tartra(ine) electrolyte
depletion anuria, severe failure)
hepatic coma) :*A) gout) dia%etes
mellitus) lactation, pregnancy
(hysical0 :in color, lesions,
edema) orientation, reflexes,
hearing) pulses, %aseline A&>, @6,
orthostatic @6, perfusion) ;, pattern,
adventitious sounds) liver evaluation,
%owel sounds) urinary output
patterns) &@&, serum electrolytes
(including calcium), %lood sugar,
*F!s, renal function tests, uric acid,
urinalysis, weight
Interentions
Administer with food or mil to
prevent >5 upset.
;educe dosage if given with other
antihypertensives) readjust dosage
gradually as @6 responds.
>ive early in the day so that
increased urination will not distur%
sleep.
Avoid 59 use if oral use is at all
possi%le.
7A*+"+30 =o not mix parenteral
solution with highly acidic solutions
with pB %elow 8.2.
=o not expose to light, may discolor
ta%lets or solution) do not use
discolored drug or solutions.
=iscard diluted solution after ,. hr.
;efrigerate oral solution.
#easure and record weight to
monitor fluid changes.
196
Arrange to monitor serum
electrolytes, hydration, liver and
renal function.
Arrange for potassium-rich diet or
supplemental potassium as needed.
!eaching "oints
;ecord intermittent therapy on a
calendar or dated envelopes. ?hen
possi%le, tae the drug early so
increased urination will not distur%
sleep. !ae with food or meals to
prevent >5 upset.
?eigh yourself on a regular %asis, at
the same time and in the same
clothing, and record the weight on
your calendar.
@lood glucose levels may %ecome
temporarily elevated in patients with
dia%etes after starting this drug.
Dou may experience these side
effects" 5ncreased volume and
fre$uency of urination) di((iness,
feeling faint on arising, drowsiness
(avoid rapid position changes)
ha(ardous activities, lie driving) and
consumption of alcohol)) sensitivity
to sunlight (use sunglasses, wear
protective clothing, or use a
sunscreen)) increased thirst (suc on
sugarless lo(enges) use fre$uent
mouth care)) loss of %ody potassium
(a potassium-rich diet or potassium
supplement will %e needed).
;eport loss or gain of more than 8
pounds in 1 day, swelling in your
anles or fingers, unusual %leeding
or %ruising, di((iness, trem%ling,
num%ness, fatigue, muscle
weaness or cramps.
Adverse effects in Italic are most common)
those in 8!l# are life-threatening.
gabaentin
(ga% ah en' tin)
+eur!ntin
Pregnancy Category C
Drug class
Antiepileptic
Theraeutic acti!ns
#echanism of action not understood)
antiepileptic activity may %e related to its
a%ility to inhi%it polysynaptic responses and
%loc posttetanic potentiation.
"n#icati!ns
Adjunctive therapy in the treatment
of partial sei(ures with and without
secondary generali(ation in adults
and children 871, yr with epilepsy
Orphan drug use" !reatment of
amyotrophic lateral sclerosis
#anagement of postherpetic
neuralgia or pain in the area affected
%y herpes (oster after the disease
has %een treated
'nla%eled uses" !remors of #:,
neuropathic pain, %ipolar disorder,
migraine prophylaxis
$!ntrain#icati!ns an# cauti!ns
&ontraindicated with hypersensitivity
to ga%apentin.
'se cautiously with pregnancy,
lactation.
A%ailable f!rms
&apsules+1--, 8--, .-- mg) ta%lets+/--,
0-- mg) oral solution+,2- mg42 m*
Dosages
AD&'TS
*pilepsy: :tarting dose is 8-- mg
6O tid, then titrated up as needed.
'aintenance: I--71,0-- mg4day 6O
in divided doses tid) maximum
197
interval %etween doses should not
exceed 1, hr. 'p to ,,.--7
8,/-- mg4day has %een used.
Postherpetic neuralgia: 5nitial dose of
8-- mg4day 6O) 8-- mg %id 6O on
day ,) 8-- mg tid 6O on day 8.
()D"AT*"$ (AT")+TS A,12 -*
5nitially, 1-712 mg4g4day 6O in three divided
doses) adjust upward over a%out 8 days to
,2782 mg4g daily in three divided doses in
children E 2 yr, and up to .- mg4g4day in
three divided doses in children 87. yr.
3)*"AT*"$ (AT")+TS 4* (AT")+TS
7"T6 *)+A' "/(A"*/)+T
&reatinine clearance
(m*4min)
=osage (mg4day)
E /- I--78,/-- in three
divided doses
E 8-72I .--71,.-- in two
divided doses
E 127,I ,--73-- in one
dose
J 12 1--78-- in one
dose
6ostdialysis supplemental dosing, 1,27
82- mg 6O following each . hr of dialysis.
(harmac!.inetics
;oute Onset =uration
Oral 9aries /70 hr
/etab!lism0 Bepatic) !
14,
" 273 hr
Distributi!n0 &rosses placenta) enters
%reast mil
)1creti!n0 'rine, unchanged
A#%erse effects
$+S0 +i!!iness, insomnia,
nervousness, fatigue, somnolence,
ataxia, diplopia, tremor
Dermat!l!gic0 6ruritus, a%rasion
3"0 =yspepsia, vomiting, nausea,
constipation, dry mouth
*esirat!ry0 ;hinitis, pharyngitis
4ther0 ?eight gain, facial edema,
cancer, impotence
"nteracti!ns
Drug-drug
=ecreased serum levels with
antacids
Drug-lab test
False positives may occur with
Ames #"'ultistix S4 dipstic test for
protein in the urine
Nursing considerations
Assessment
6ist!ry0 Bypersensitivity to
ga%apentin) lactation, pregnancy
(hysical0 ?eight) !) sin color,
lesions) orientation, affect, reflexes)
6) ;, adventitious sounds) %owel
sounds, normal output
Interentions
>ive drug with food to prevent >5
upset.
Arrange for consultation with support
groups for people with epilepsy.
7A*+"+30 5f overdose occurs,
hemodialysis may %e an option.
!eaching "oints
!ae this drug exactly as prescri%ed)
do not discontinue a%ruptly or
change dosage, except on the
advice of your health care provider.
?ear a medical alert 5= at all times
so that any emergency medical
personnel will now that you have
epilepsy and are taing antiepileptic
medication.
Dou may experience these side
effects" =i((iness, %lurred vision
(avoid driving or performing other
tass re$uiring alertness or visual
acuity)) >5 upset (tae drug with food
or mil, eat fre$uent small meals))
198
headache, nervousness, insomnia)
fatigue (periodic rest periods may
help).
;eport severe headache,
sleepwaling, rash, severe vomiting,
chills, fever, difficulty %reathing.
Adverse effects in Italic are most common)
those in 8!l# are life-threatening.
gemfibr!zil
(jem fi' %roe (il)
A!>3emfibr!zil <$A+=, 3en>3emfibr!zil
<$A+=, '!i#, +!%!>3emfibr!zil <$A+=
Pregnancy Category C
Drug class
Antihyperlipidemic
Theraeutic acti!ns
5nhi%its peripheral lipolysis and decreases
the hepatic excretion of free fatty acids) this
reduces hepatic triglyceride production)
inhi%its synthesis of 9*=* carrier
apolipoprotein) decreases 9*=* production)
increases B=* concentration.
"n#icati!ns
Bypertriglyceridemia in adult patients
with very high elevations of
triglyceride levels (type 59 and 9
hyperlipidemia) at ris of pancreatitis
unresponsive to diet therapy
;eduction of coronary heart disease
ris in patients who have not
responded to diet, exercise, and
other agents and have low B=*
levels in addition to high *=* and
triglyceride levels
$!ntrain#icati!ns an# cauti!ns
&ontraindicated with allergy to
gemfi%ro(il, hepatic or renal
dysfunction, primary %iliary cirrhosis,
gall%ladder disease.
'se cautiously with pregnancy,
lactation, cholethiasis, and renal
impairment.
A%ailable f!rms
!a%lets+/-- mg
Dosages
AD&'TS
7A*+"+30 1,,-- mg4day 6O in two divided
doses, 8- min %efore morning and evening
meals. $auti!n0 'se only if strongly
indicated and lipid studies show a definite
response) hepatic tumorigenicity occurs in
la%oratory animals.
()D"AT*"$ (AT")+TS
:afety and efficacy not esta%lished.
(harmac!.inetics
;oute Onset 6ea
Oral 9aries 17, hr
/etab!lism0 Bepatic) !
14,
" I- min
Distributi!n0 &rosses placenta) enters
%reast mil
)1creti!n0 Feces, urine
A#%erse effects
$+S0 &eadache, di!!iness, (lurred
vision, vertigo, insomnia,
paresthesia, tinnitus, fatigue,
malaise, syncope
Dermat!l!gic0 *c!ema, rash,
dermatitis, pruritus, urticaria
3"0 A(dominal pain, epigastric pain,
diarrhea, nausea, vomiting,
flatulence, dry mouth, constipation,
anorexia, dyspepsia, cholelithiasis,
elevated A*! and A:!
3&0 5mpairment of fertility
6emat!l!gic0 Anemia, eosinophilia,
leuopenia, hypoalemia, liver
function changes, hyperglycemia
199
4ther0 6ainful extremities, %ac
pain, arthralgia, muscle cramps,
myalgia, swollen joints
"nteracti!ns
Drug-drug
;is of rha%domyolysis from 8 w to
several mo after therapy when
com%ined with B#>-&oA inhi%itors
(eg lovastatin, simvastatin)
;is of increased %leeding when
com%ined with anticoagulants)
monitor patient closely
;is of hypoglycemia if com%ined
with sulfonylureas and repaglinide)
monitor closely
Nursing considerations
Assessment
6ist!ry0 Allergy to gemfi%ro(il,
hepatic or renal dysfunction, primary
%iliary cirrhosis, gall%ladder disease,
pregnancy, lactation
(hysical0 :in lesions, color, !) gait,
range of motion) orientation, affect,
reflexes) %owel sounds, normal
output, liver evaluation) lipid studies,
&@&, *F!s, renal function tests,
%lood glucose
Interentions
Administer drug with meals or mil if
>5 upset occurs.
Arrange for regular follow-up visits,
including %lood tests for lipids, liver
function, &@&, %lood glucose during
long-term therapy.
!eaching "oints
!ae the drug with meals or with mil
if >5 upset occurs) changes in diet
will %e needed.
Bave regular follow-up visits to your
doctor for %lood tests to evaluate
drug effectiveness.
Dou may experience these side
effects" =iarrhea, loss of appetite,
flatulence (eat fre$uent small meals))
muscular aches and pains, %one and
joint discomfort) di((iness, faintness,
%lurred vision (use caution if driving
or operating dangerous e$uipment).
;eport severe stomach pain with
nausea and vomiting, fever and chills
or sore throat, severe headache,
vision changes.
Adverse effects in Italic are most common)
those in 8!l# are life-threatening.
gentamicin sulfate
(jen ta mye' sin)
Parenteral( intrathecal)
Alc!micin <$A+=, 3aramycin, (e#iatric
3entamicin Sulfate
!o"ical dermatologic cream( ointment)
3aramycin
*"hthalmic)
3aramycin, 3entaci#in, 3enta., 3en!tic,
3en!tic S@4@(@
+entamicin im"regnated P,,A beads)
Set!al
+entamicin -i"osome in.ection)
/aitec
Pregnancy Category D
Drug class
Aminoglycoside
Theraeutic acti!ns
@actericidal" 5nhi%its protein synthesis in
suscepti%le strains of gram-negative
%acteria) appears to disrupt functional
integrity of %acterial cell mem%rane, causing
cell death.
"n#icati!ns
6arenteral
:erious infections caused %y
suscepti%le strains of Pseudomonas
200
aeruginosa, Proteus species,
*scherichia coli, 5le(siella"
*ntero(acter"Serratia species,
$itro(acter, Staphylococcus species
:erious infections when causative
organisms are not nown (often in
conjunction with a penicillin or
cephalosporin)
'nla%eled use" ?ith clindamycin as
alternative regimen in 65=
5ntrathecal
>ram-negative infections
:erious &<: infections, such as
meningitis, ventriculitis, infections
caused %y suscepti%le
Pseudomonas species
Ophthalmic preparations
!reatment of superficial ocular
infections due to strains of
microorganisms suscepti%le to
gentamicin
!opical dermatologic preparation
5nfection prophylaxis in minor sin
a%rasions and treatment of
superficial infections of the sin due
to suscepti%le organisms amena%le
to local treatment
>entamicin-impregnated 6#AA %eads on
surgical wire
Orphan drug use" !reatment of
chronic osteomyelitis of
posttraumatic, postoperative, or
hematogenous origin
>entamicin liposome injection
Orphan drug use" !reatment of
disseminated 'yo(acterium avium"
intracellulare infection
$!ntrain#icati!ns an# cauti!ns
&ontraindicated with allergy to any
aminoglycosides.
'se cautiously with renal or hepatic
disease) preexisting hearing loss)
active infection with herpes, vaccinia,
varicella, fungal infections,
myo%acterial infections (ophthalmic
preparations)) myasthenia gravis)
parinsonism) infant %otulism) %urn
patients) lactation) pregnancy.
A%ailable f!rms
5njection+1-, .- mg4m*) ophthalmic solution
+8 mg4m*) ophthalmic ointment+8 mg4g)
topical ointment+-.1F) topical cream+
-.1F) ointment+1 mg) cream+1 mg
Dosages
6arenteral
AD&'TS
8 mg4g4day in three e$ual doses $ 0 hr 5#
or 59. 'p to 2 mg4g4day in three to four
e$ual doses in severe infections. For 59 use,
a loading dose of 17, mg4g may %e infused
over 8-7/- min, followed %y a maintenance
dose, usually for 371- days.
PI+: , mg4g 59 followed %y
1.2 mg4g tid plus clindamycin
/-- mg 59 $id. &ontinue for at least
. days and at least .0 hr after
patient improves, then continue
clindamycin .2- mg orally $id for
1-71. days total therapy.
Surgical prophylaxis regimens:
:everal complex, multidrug
prophylaxis regimens are availa%le
for preoperative use) consult
manufacturerHs instructions.
()D"AT*"$ (AT")+TS
,7,.2 mg4g $ 0 hr 5# or 59.
Infants and neonates: ,.2 mg4g $ 0 hr.
Premature or full"term neonates: ,.2 mg4g $
1, hr.
3)*"AT*"$ (AT")+TS 4* (AT")+TS
7"T6 *)+A' ;A"'&*)
;educe dosage or extend time dosage
intervals, and carefully monitor serum drug
levels and renal function tests.
Ophthalmic solution
AD&'TS A+D ()D"AT*"$ (AT")+TS
17, drops into affected eye or eyes $ . hr)
use up to , drops hourly in severe infections.
201
Ophthalmic ointment
AD&'TS A+D ()D"AT*"$ (AT")+TS
Apply small amount to affected eye %id7tid.
=ermatologic preparations
AD&'TS A+D ()D"AT*"$ (AT")+TS
Apply tid to $id. &over with sterile %andage if
needed.
(harmac!.inetics
;oute Onset 6ea
5#, 59 ;apid 8-7I- min
/etab!lism0 Bepatic) !
14,
" ,78 hr
Distributi!n0 &rosses placenta) enters
%reast mil
)1creti!n0 'rine
IV facts
(rearati!n0 =ilute single dose in 2-7,--
m* of sterile isotonic saline or =
2
?. =o not
mix in solution with any other drugs.
"nfusi!n0 5nfuse over 8-71,- min.
"nc!matibilities0 =o not mix in solution with
any other drugs.
A#%erse effects
$+S0 Ototoxicity+tinnitus,
di!!iness, vertigo, deafness (partially
reversi%le to irreversi%le), vesti%ular
paralysis, confusion, disorientation,
depression, lethargy, nystagmus,
visual distur%ances, headache,
num(ness, tingling, tremor,
paresthesias, muscle twitching,
sei(ures, muscular weaness,
neuromuscular %locade
$20 6alpitations, hypotension,
hypertension
3"0 Bepatic toxicity, nausea,
vomiting, anorexia, weight loss,
stomatitis, increased salivation
3&0 +ehr!t!1icity
6emat!l!gic0 3eu2emoid reaction,
agranulocytosis, granulocytosis,
leuopenia, leuocytosis,
throm%ocytopenia, eosinophilia,
pancytopenia, anemia, hemolytic
anemia, increased or decreased
reticulocyte count, electrolyte
distur%ances
6yersensiti%ity0 Purpura, rash,
urticaria, exfoliative dermatitis,
itching
'!cal0 Pain, irritation, arachnoiditis
at I' injection sites
4ther0 Fever, apnea, splenomegaly,
joint pain, superinfections
Ophthalmic preparations
'!cal0 -ransient irritation, (urning,
stinging, itching, angioneurotic
edema, urticaria, vesicular and
maculopapular dermatitis
!opical dermatologic preparations
'!cal0 Photosensiti!ation,
superinfections
"nteracti!ns
Drug-drug
5ncreased ototoxic, nephrotoxic,
neurotoxic effects with other
aminoglycosides, cephalothin, potent
diuretics, cephalosporins,
vancomycin, methoxyflurane,
enflurane
5ncreased neuromuscular %locade
and muscular paralysis with
anesthetics, nondepolari(ing
neuromuscular %locing drugs,
succinylcholine, citrate-
anticoagulated %lood
6otential inactivation of %oth drugs if
mixed with %eta-lactam7type
anti%iotics (space doses with
concomitant therapy)
5ncreased %actericidal effect with
penicillins, cephalosporins (to treat
some gram-negative organisms and
enterococci), car%enicillin, ticarcillin
(to treat Pseudomonas infections)
Nursing considerations
202
Assessment
6ist!ry0 Allergy to any
aminoglycosides) renal or hepatic
disease) preexisting hearing loss)
active infection with herpes, vaccinia,
varicella, fungal infections,
myo%acterial infections (ophthalmic
preparations)) myasthenia gravis)
parinsonism) infant %otulism)
lactation, pregnancy
(hysical0 :ite of infection) sin
color, lesions) orientation, reflexes,
eighth cranial nerve function) 6, @6)
;, adventitious sounds) %owel
sounds, liver evaluation) urinalysis,
@'<, serum creatinine, serum
electrolytes, *F!s, &@&
Interentions
>ive %y 5# route if at all possi%le)
give %y deep 5# injection.
&ulture infected area %efore therapy.
'se , mg4m* intrathecal preparation
without preservatives, for intrathecal
use.
Avoid long-term therapies %ecause
of increased ris of toxicities.
;eduction in dose may %e clinically
indicated.
6atients with edema or ascites may
have lower pea concentrations due
to expanded extracellular fluid
volume.
&leanse area %efore application of
dermatologic preparations.
Ansure ade$uate hydration of patient
%efore and during therapy.
7A*+"+30 #onitor renal function
tests, &@&s, serum drug levels
during long-term therapy. &onsult
with prescri%er to adjust dosage.
!eaching "oints
Apply ophthalmic preparations %y
tilting head %ac) place medications
into conjunctival sac and close eye)
apply light pressure on lacrimal sac
for 1 minute. &leanse area %efore
applying dermatologic preparations)
area may %e covered if necessary.
Dou may experience these side
effects" ;inging in the ears,
headache, di((iness (reversi%le) use
safety measures if severe)) nausea,
vomiting, loss of appetite (eat
fre$uent small meals, perform
fre$uent mouth care)) %urning,
%lurring of vision with ophthalmic
preparations (avoid driving or
performing dangerous activities if
visual effects occur))
photosensiti(ation with dermatologic
preparations (wear sunscreen and
protective clothing).
;eport pain at injection site, severe
headache, di((iness, loss of hearing,
changes in urine pattern, difficulty
%reathing, rash or sin lesions)
itching or irritation (ophthalmic
preparations)) worsening of the
condition, rash, irritation
(dermatologic preparation).
Adverse effects in Italic are most common)
those in 8!l# are life-threatening.
glimeiri#e
(glye meh' per ide)
Amaryl
Pregnancy Category C
Drug classes
Antidia%etic
:ulfonylurea (second generation)
Theraeutic acti!ns
:timulates insulin release from functioning
%eta cells in the pancreas) may improve
%inding %etween insulin and insulin receptors
or increase the num%er of insulin receptors)
203
thought to %e more potent in effect than first-
generation sulfonylureas.
"n#icati!ns
As an adjunct to diet to lower %lood
glucose in patients with type , (non7
insulin-dependent) dia%etes mellitus
whose hypoglycemia cannot %e
controlled %y diet and exercise alone
5n com%ination with metformin or
insulin to %etter control glucose as
an adjunct to diet and exercise in
patients with type , dia%etes mellitus
$!ntrain#icati!ns an# cauti!ns
&ontraindicated with allergy to
sulfonylureas) dia%etes complicated
%y fever, severe infections, severe
trauma, major surgery, etosis,
acidosis, coma (insulin is indicated in
these conditions)) type 1 (insulin-
dependent) dia%etes, serious hepatic
or renal impairment, uremia, thyroid
or endocrine impairment, glycosuria,
hyperglycemia associated with
primary renal disease) la%or and
delivery+if glimepiride is used
during pregnancy, discontinue drug
at least 1 mo %efore delivery)
lactation, safety not esta%lished.
'se cautiously with pregnancy.
A%ailable f!rms
!a%lets+1, ,, . mg
Dosages
AD&'TS
'sual starting dose is 17, mg 6O once daily
with %reafast or first meal of the day) usual
maintenance dose is 17. mg 6O once daily,
depending on patient response and glucose
levels. =o not exceed 0 mg4day.
$om(ination ith insulin therapy:
0 mg 6O daily with first meal of the
day with low-dose insulin.
-ransfer from other hypoglycemic
agents: <o transition period is
necessary.
()D"AT*"$ (AT")+TS
:afety and efficacy not esta%lished.
(AT")+TS 7"T6 *)+A' "/(A"*/)+T
'sual starting dose is 1 mg 6O once daily)
titrate dose carefully, lower maintenance
doses may %e sufficient to control %lood
sugar.
(harmac!.inetics
;oute Onset 6ea
Oral ,78 hr ,78 hr
/etab!lism0 Bepatic) !
14,
" 2.273 hr
Distributi!n0 &rosses placenta) enters
%reast mil
)1creti!n0 @ile, urine
A#%erse effects
$+S0 =rowsiness, asthenia,
nervousness, tremor, insomnia
$20 "ncrease# ris. !f
car#i!%ascular m!rtality (possi%le)
)n#!crine0 &ypoglycemia, :5A=B
3"0 Anorexia, nausea, vomiting,
epigastric discomfort, heart(urn,
diarrhea
6emat!l!gic0 *euopenia,
throm%ocytopenia, anemia
6yersensiti%ity0 Allergic s2in
reactions, ec(ema, pruritus,
erythema, urticaria, photosensitivity,
fever, eosinophilia, jaundice
4ther0 =iuresis, tinnitus, fatigue,
weight gain
"nteracti!ns
Drug-drug
5ncreased ris of hypoglycemia with
androgens, anticoagulants, a(ole
antifungals, chloramphenicol,
clofi%rate, fenfluramine, flucona(ole,
gemfi%ro(il, B
,
%locers, magnesium
204
salts, #AO5s, methyldopa,
oxyphen%uta(one, phenyl%uta(one,
pro%enecid, salicylates,
sulfinpyra(one, sulfonamides, !&As,
urinary acidifiers
=ecreased effectiveness of %oth
glimepiride and dia(oxide if taen
concurrently
5ncreased ris of hyperglycemia with
rifampin, thia(ides
;is of hypoglycemia and
hyperglycemia with ethanol)
Gdisulfiram reactionG has also %een
reported
6ossi%le decreased hypoglycemic
effect with %eta %locers, calcium
channel %locers, cholestyramine,
corticosteroids, dia(oxide, estrogens,
hydantoins, hormonal
contraceptives, isonia(id, nicotinic
acid, phenothia(ines, rifampin,
sympathomimetics, thia(ide
diuretics, thyroid agents, urinary
alalini(ers
Drug-alternatie thera"y
5ncreased ris of hypoglycemia if
taen with juniper %erries, ginseng,
garlic, fenugree, coriander,
dandelion root, celery
Nursing considerations
Assessment
6ist!ry0 Allergy to sulfonylureas)
dia%etes complicated %y fever,
severe infections, severe trauma,
major surgery, etosis, acidosis,
coma (insulin is indicated in these
conditions)) type 1 dia%etes, serious
hepatic or renal impairment, uremia,
thyroid or endocrine impairment,
glycosuria, hyperglycemia
associated with primary renal
disease) pregnancy
(hysical0 :in color, lesions) !)
orientation, reflexes, peripheral
sensation) ;, adventitious sounds)
liver evaluation, %owel sounds)
urinalysis, @'<, serum creatinine,
*F!s, %lood glucose, &@&
Interentions
#onitor urine or serum glucose
levels fre$uently to determine
effectiveness of drug and dosage
%eing used.
7A*+"+30 !ransfer to insulin
therapy during periods of high stress
(eg infections, surgery, trauma).
'se 59 glucose if severe
hypoglycemia occurs as a result of
overdose.
Arrange for consultation with dietitian
to esta%lish weight-loss program and
dietary control.
Arrange for thorough dia%etic
teaching program, including disease,
dietary control, exercise, signs and
symptoms of hypoglycemia and
hyperglycemia, avoidance of
infection, hygiene.
!eaching "oints
!ae this drug once a day with
%reafast or the first main meal of
the day.
=o not discontinue this drug without
consulting your health care provider)
continue with diet and exercise
program for dia%etes control.
#onitor urine or %lood for glucose
and etones as prescri%ed.
=o not use this drug if you are
pregnant.
Avoid alcohol while using this drug.
;eport fever, sore throat, unusual
%leeding or %ruising, rash, dar
urine, light-colored stools,
hypoglycemic or hyperglycemic
reactions.
205
Adverse effects in Italic are most common)
those in 8!l# are life-threatening.
gliizi#e
(gli' i (ide)
3luc!tr!l, 3luc!tr!l B'
Pregnancy Category C
Drug classes
Antidia%etic
:ulfonylurea (second generation)
Theraeutic acti!ns
:timulates insulin release from functioning
%eta cells in the pancreas) may improve
%inding %etween insulin and insulin receptors
or increase the num%er of insulin receptors)
more potent in effect than first-generation
sulfonylureas.
"n#icati!ns
Adjunct to diet and exercise to lower
%lood glucose with type , (non7
insulin-dependent) dia%etes mellitus
Adjunct to insulin therapy in the
sta%ili(ation of certain cases of type
1 (insulin-dependent) dia%etes,
reducing the insulin re$uirement and
decreasing the chance of
hypoglycemic reactions
$!ntrain#icati!ns an# cauti!ns
&ontraindicated with allergy to
sulfonylureas) dia%etes with
etoacidosis, sole therapy of type 1
dia%etes or dia%etes complicated %y
pregnancy, dia%etes complicated %y
fever, severe infections, severe
trauma, major surgery, etosis,
acidosis, coma (insulin is indicated))
type 1 dia%etes, serious hepatic
impairment, serious renal
impairment.
'se cautiously with uremia, thyroid
or endocrine impairment, glycosuria,
hyperglycemia associated with
primary renal disease) la%or and
delivery (if glipi(ide is used during
pregnancy, discontinue drug at least
1 mo %efore delivery)) lactation)
pregnancy.
A%ailable f!rms
!a%lets+2, 1- mg) A; ta%lets+,.2, 2, 1- mg
Dosages
>ive approximately 8- min %efore %reafast
to achieve greatest reduction in postprandial
hyperglycemia.
AD&'TS
Initial therapy: 2 mg 6O %efore
%reafast. Adjust dosage in
increments of ,.272 mg as
determined %y %lood glucose
response. At least several days
should elapse %etween adjustments.
#aximum once-daily dose should
not exceed 12 mg) a%ove 12 mg,
divide dose, and administer %efore
meals. =o not exceed .- mg4day.
A; ta%lets" 2 mg4day. Adjust dosage
in 2-mg increments every 8 mo)
maximum dose+,- mg4day.
'aintenance therapy: !otal daily
doses a%ove 12 mg 6O should %e
divided) total daily doses a%ove
8- mg are given in divided doses
%id.
*xtended release: 2 mg4day with
%reafast, may %e increased to
1- mg4day after 8 mo if indicated.
()D"AT*"$ (AT")+TS
:afety and efficacy not esta%lished.
3)*"AT*"$ (AT")+TS
>eriatric patients tend to %e more sensitive
to the drug. :tart with initial dose of
,.2 mg4day 6O. #onitor for ,. hr and
gradually increase dose after several days as
needed.
(harmac!.inetics
206
;oute Onset 6ea =uration
Oral 171.2 hr 178 hr 1-7,. hr
/etab!lism0 Bepatic) !
14,
" ,7. hr
Distributi!n0 &rosses placenta) enters
%reast mil
)1creti!n0 @ile, urine
A#%erse effects
$+S0 =rowsiness, asthenia,
nervousness, tremor, insomnia,
tinnitus, fatigue
$20 "ncrease# ris. !f $2 m!rtality
)n#!crine0 &ypoglycemia, :5A=B
3"0 Anorexia, nausea, vomiting,
epigastric discomfort, heart(urn,
diarrhea
6emat!l!gic0 *euopenia,
throm%ocytopenia, anemia
6yersensiti%ity0 Allergic s2in
reactions, ec(ema, pruritus,
erythema, urticaria, photosensitivity,
fever, eosinophilia, jaundice
4ther0 ?eight gain
"nteracti!ns
Drug-drug
5ncreased ris of hypoglycemia with
sulfonamides, chloramphenicol,
oxyphen%uta(one, phenyl%uta(one,
salicylates, clofi%rate
=ecreased effectiveness of glipi(ide
and dia(oxide if taen concurrently
5ncreased ris of hyperglycemia with
rifampin, thia(ides
;is of hypoglycemia and
hyperglycemia with ethanol)
Gdisulfiram reactionG also has %een
reported
Drug-alternatie thera"y
5ncreased ris of hypoglycemia if
taen with juniper %erries, ginseng,
garlic, fenugree, coriander,
dandelion root, celery
Nursing considerations
Assessment
6ist!ry0 Allergy to sulfonylureas)
dia%etes with complications) type 1
dia%etes, serious hepatic or renal
impairment, uremia, thyroid or
endocrine impairment, glycosuria,
hyperglycemia associated with
primary renal disease) pregnancy
(hysical0 :in color, lesions) !)
orientation, reflexes, peripheral
sensation) ;, adventitious sounds)
liver evaluation, %owel sounds)
urinalysis, @'<, serum creatinine,
*F!s, %lood glucose, &@&
Interentions
>ive drug 8- min %efore %reafast) if
severe >5 upset occurs or more than
12 mg4day is re$uired, dose may %e
divided and given %efore meals.
#onitor urine or serum glucose
levels fre$uently to determine drug
effectiveness and dosage.
7A*+"+30 !ransfer to insulin
therapy during periods of high stress
(eg, infections, surgery, trauma).
7A*+"+30 'se 59 glucose if severe
hypoglycemia occurs as a result of
overdose.
!eaching "oints
!ae this drug 8- minutes %efore
%reafast for %est results.
=o not discontinue this drug without
consulting your health care provider.
#onitor urine or %lood for glucose
and etones.
=o not use this drug during
pregnancy) consult health care
provider.
Avoid alcohol while using this drug.
;eport fever, sore throat, unusual
%leeding or %ruising, rash, dar
urine, light-colored stools,
207
hypoglycemic or hyperglycemic
reactions.
Adverse effects in Italic are most common)
those in 8!l# are life-threatening.
glyburi#e
(glye' %yoor ide)
Dia8eta, )ugluc!n <$A+=, 3en>3lybe
<$A+=, 3libenclami#e, 3lynase (resTab,
/icr!nase
Pregnancy Category /
Drug class
Antidia%etic
:ulfonylurea
Theraeutic acti!ns
:timulates insulin release from functioning
%eta cells in the pancreas) may improve
%inding %etween insulin and insulin receptors
or increase the num%er of insulin receptors)
more potent in effect than first-generation
sulfonylureas.
"n#icati!ns
Adjunct to diet to lower %lood
glucose with type , (non7insulin-
dependent) dia%etes mellitus
Adjunct to metformin when ade$uate
results are not achieved with either
drug alone
Adjunct to insulin therapy in the
sta%ili(ation of certain cases of type
, dia%etes, reducing the insulin
re$uirement, and decreasing the
chance of hypoglycemic reactions
$!ntrain#icati!ns an# cauti!ns
&ontraindicated with allergy to
sulfonylureas) dia%etes with
etoacidosis, sole therapy of type 1
(insulin-dependent) dia%etes or
dia%etes complicated %y pregnancy,
serious hepatic or renal impairment,
uremia) dia%etes mellitus
complicated %y fever, severe
infections, severe trauma, major
surgery, etosis, acidosis, coma
(insulin is contraindicated).
'se cautiously with pregnancy,
lactation, thyroid or endocrine
impairment, glycosuria,
hyperglycemia associated with
primary renal disease) la%or and
delivery (if gly%uride is used during
pregnancy, discontinue drug at least
1 mo %efore delivery).
A%ailable f!rms
!a%lets+1.,2, 1.2, ,.2, 8, ..2, 2, / mg
Dosages
AD&'TS
Initial therapy: ,.272 mg 6O with
%reafast (+ia%eta, 'icronase)) 1.27
8 mg4day 6O (4lynase).
'aintenance therapy: 1.,27
,- mg4day 6O given as a single
dose or in divided doses. 5ncrease in
increments of no more than ,.2 mg
at weely intervals %ased on
patientHs %lood glucose response
(+ia%eta, 'icronase)) -.327
1, mg4day 6O (4lynase).
()D"AT*"$ (AT")+TS
:afety and efficacy not esta%lished.
3)*"AT*"$ (AT")+TS
>eriatric patients tend to %e more sensitive
to the drug) start with initial dose of
1.,2 mg4day 6O (+ia%eta, 'icronase)
-.32 mg4day 6O (4lynase). #onitor for ,. hr,
and gradually increase dose after at least 1
w as needed.
(harmac!.inetics
;oute Onset =uration
Oral,
microni(ed
1 hr 1,7,. hr
Oral,
nonmicroni(e
,7. hr 1,7,. hr
208
d
/etab!lism0 Bepatic) !
14,
" . hr
Distributi!n0 &rosses placenta) enters
%reast mil
)1creti!n0 @ile, urine
A#%erse effects
$+S0 =rowsiness, tinnitus, fatigue,
asthenia, nervousness, tremor,
insomnia
$20 "ncrease# ris. !f $2 m!rtality
)n#!crine0 &ypoglycemia
3"0 Anorexia, nausea, vomiting,
epigastric discomfort, heart(urn,
diarrhea, eight gain
6emat!l!gic0 *euopenia,
throm%ocytopenia, anemia
6yersensiti%ity0 Allergic s2in
reactions, ec(ema, pruritus,
erythema, urticaria, photosensitivity,
fever, eosinophilia, jaundice
"nteracti!ns
Drug-drug
5ncreased ris of hypoglycemia with
sulfonamides, chloramphenicol,
oxyphen%uta(one, phenyl%uta(one,
salicylates, clofi%rate
=ecreased effectiveness of gly%uride
and dia(oxide if taen concurrently
5ncreased ris of hyperglycemia with
rifampin, thia(ides
;is of hypoglycemia and
hyperglycemia with ethanol)
Gdisulfiram reactionG has %een
reported
Drug-alternatie thera"y
5ncreased ris of hypoglycemia if
taen with juniper %erries, ginseng,
garlic, fenugree, coriander,
dandelion root, celery
Nursing considerations
$'"+"$A' A')*T5
Name confusion has occurred between
Dia/eta $glyburide% and 0ebeta
$biso"rolol%; use caution.
Assessment
6ist!ry0 Allergy to sulfonylureas)
dia%etes with complications) type 1
dia%etes, serious hepatic or renal
impairment, uremia, thyroid or
endocrine impairment, glycosuria,
hyperglycemia associated with
primary renal disease, pregnancy
(hysical0 :in color, lesions) !)
orientation, reflexes, peripheral
sensation) ;, adventitious sounds)
liver evaluation, %owel sounds)
urinalysis, @'<, serum creatinine,
*F!s, %lood glucose, &@&
Interentions
>ive drug %efore %reafast. 5f severe
>5 upset occurs, dose may %e
divided and given %efore meals.
#onitor urine or serum glucose
levels fre$uently to determine drug
effectiveness and dosage.
#onitor dosage carefully if switching
to or from 4lynase1
7A*+"+30 !ransfer to insulin
therapy during periods of high stress
(eg, infections, surgery, trauma).
7A*+"+30 'se 59 glucose if severe
hypoglycemia occurs as a result of
overdose.
!eaching "oints
=o not discontinue this medication
without consulting your health care
provider.
#onitor urine or %lood for glucose
and etones.
=o not use this drug during
pregnancy) consult health care
provider.
209
Avoid alcohol while using this drug.
;eport fever, sore throat, unusual
%leeding or %ruising, rash, dar
urine, light-colored stools,
hypoglycemic or hyperglycemic
reactions.
Adverse effects in Italic are most common)
those in 8!l# are life-threatening.
guaifenesin
(gwye fen' e sin)
Allfen; A/8" 1000, 1200; Diabetic Tussin;
6ytuss; 6ytuss 2B; 'iquibi#; /ucine1;
/uc!>;en; 4rgani#in +*; *!bitussin,
Sc!t>Tussin )1ect!rant; Siltussin SA
Pregnancy Category C
Drug class
Axpectorant
Theraeutic acti!ns
Anhances the output of respiratory tract fluid
%y reducing adhesiveness and surface
tension, facilitating the removal of viscous
mucus.
"n#icati!ns
:ymptomatic relief of respiratory
conditions characteri(ed %y dry,
nonproductive cough when there is
mucus in the respiratory tract.
$!ntrain#icati!ns an# cauti!ns
&ontraindicated with allergy to
guaifenesin.
'se cautiously with pregnancy,
lactation, and persistent coughs.
A%ailable f!rms
:yrup+1-- mg42 m*) li$uid+1--, ,-- mg42
m*) capsules+,-- mg) ta%lets+1--, ,--,
.-- mg) A; ta%lets+/-- mg
Dosages
AD&'TS A+D ()D"AT*"$ (AT")+TS 9 12
-*
,--7.-- mg 6O $ . hr. =o not exceed ,..
g4day.
()D"AT*"$ (AT")+TS :,12 -*
1--7,-- mg 6O $ . hr. =o not exceed 1.,
g4day.
()D"AT*"$ (AT")+TS 2,: -*
2-71-- mg 6O $ . hr. =o not exceed
/-- mg4day.
(harmac!.inetics
;oute Onset =uration
Oral 8- min .7/ hr
/etab!lism0 <ot nown) !
14,
" 'nnown
Distributi!n0 <ot nown
)1creti!n0 'rine
A#%erse effects
$+S0 Beadache, di((iness
Dermat!l!gic0 ;ash, urticaria
3"0 #ausea, vomiting, >5 discomfort
"nteracti!ns
Drug-lab test
&olor interference and false results
of 2-B5AA and 9#A urinary
determinations
Nursing considerations
$'"+"$A' A')*T5
Name confusion has been re"orted
between ,ucinex $guaifenesin% and
,ucomyst $acetylcysteine%; use caution.
Assessment
6ist!ry0 Allergy to guaifenesin)
persistent cough due to smoing,
asthma, or emphysema) very
productive cough) pregnancy
(hysical0 :in lesions, color) !)
orientation, affect) ;, adventitious
sounds
Interentions
210
7A*+"+30 #onitor reaction to drug)
persistent cough for more than 1 w,
fever, rash, or persistent headache
may indicate a more serious
condition.
!eaching "oints
:ome extended-release formulations
may %e cut in half %ut cannot %e
crushed or chewed. 'ucinex cannot
%e crushed, chewed, or cut.
=o not tae for longer than 1 wee) if
fever, rash, or headache occur,
consult your health care provider.
Dou may experience these side
effects" <ausea, vomiting (eat
fre$uent small meals)) di((iness,
headache (avoid driving or operating
dangerous machinery).
;eport fever, rash, severe vomiting,
persistent cough.
Adverse effects in Italic are most common)
those in 8!l# are life-threatening.
hearin
(heH ah rin)
hearin s!#ium inCecti!n
6ealean <$A+=, 6earin 'e! <$A+=
hearin s!#ium an# 0@DE s!#ium chl!ri#e
hearin s!#ium l!c. flush s!luti!n
6ealean>'!. <$A+=, 6earin '!c. ;lush,
6e>'!c., 6e>'!c. &?(
Pregnancy Category C
Drug class
Anticoagulant
Theraeutic acti!ns
Beparin inactivates factor KA, therefore
inhi%iting throm%us and clot formation %y
%locing the conversion of prothrom%in to
throm%in and fi%rinogen to fi%rin, the final
steps in the clotting process. Beparin also
inhi%its the activation of factor K555, throm%in-
induced activation of factors 9 and 9555.
"n#icati!ns
6revention and treatment of venous
throm%osis and pulmonary em%olism
!reatment of atrial fi%rillation with
em%oli(ation
=iagnosis and treatment of =5&
6revention of clotting in %lood
samples and heparin loc sets and
during dialysis procedures
'nla%eled uses" Adjunct in therapy
of coronary occlusion with acute #5,
prevention of left ventricular throm%i
and &9A post-#5, prevention of
cere%ral throm%osis in the evolving
stroe
$!ntrain#icati!ns an# cauti!ns
&ontraindicated with hypersensitivity
to heparin) severe
throm%ocytopenia) uncontrolled
%leeding) any patient who cannot %e
monitored regularly with %lood
coagulation tests) la%or and
immediate postpartum period)
women older than /- yr are at high
ris for hemorrhaging.
'se cautiously with pregnancy)
women older than /- yr are at high
ris for hemorrhaging)
dys%etalipoproteinemia) recent
surgery or injury.
A%ailable f!rms
5njection+1,---, ,,---, ,,2--, 2,---, 3,2--,
1-,---, 1,,2--, ,-,---, .-,--- units4m*)
also single-dose and unit-dose forms. *oc
flush solution+1-, 1-- units4m*.
Dosages
Adjust dosage according to coagulation
tests. =osage is ade$uate when ?@&! L
211
,.278 times control+or a6!! L 1.278 times
control value. !he following are guidelines to
dosage"
AD&'TS
:u%cutaneous (deep su%cutaneous injection)
6or general anticoagulation: 59
loading dose of 2,--- units and then
1-,---7,-,--- units su%cutaneously
followed %y 0,---71-,--- units $ 0
hr or 12,---7,-,--- units $ 1, hr.
Prophylaxis of postoperative
throm(oem(olism: 2,--- units %y
deep su%cutaneous injection , hr
%efore surgery and $ 071, hr
thereafter for 3 days or until patient
is fully am%ulatory.
59
Intermittent IV: 5nitial dose of
1-,--- units and then 2,---7
1-,--- units $ .7/ hr.
$ontinuous IV infusion: *oading
dose of 2,--- units and then
,-,---7.-,--- units4day.
Surgery of heart and (lood vessels
for patients undergoing total (ody
perfusion: <ot less than
12- units4g) guideline often used is
8-- units4g for procedures less than
/- min, .-- units4g for longer
procedures.
$lot prevention in (lood samples:
3-712- units41-7,- m* of whole
%lood.
&eparin loc2 and extracorporeal
dialysis: :ee manufacturerHs
instructions.
()D"AT*"$ (AT")+TS
5nitial 59 %olus of 2- units4g and then 1--
units4g 59 $ . hr, or ,-,--- units4m
,
per ,.
hr %y continuous 59 infusion.
(harmac!.inetics
;oute Onset 6ea =uration
59 5mmediate #inutes ,7/ hr
:& ,-7/- min ,7. hr 071, hr
/etab!lism0 !
14,
" 8-710- min
Distributi!n0 =oes not cross placenta, does
not enter %reast mil) %roen down in liver
)1creti!n0 'rine
IV facts
$!ntinu!us infusi!n0 &an %e mixed in
normal saline, =
2
?, ;ingerHs) mix well) invert
%ottle numerous times to ensure ade$uate
mixing. #onitor patient closely) infusion
pump is recommended.
Single #!se0 =irect, undiluted 59 injection of
up to 2,--- units (adult) or 2- units4g
(pediatric), given over /- seconds.
/!nit!ring0 @lood should %e drawn for
coagulation testing 8- min %efore each
intermittent 59 dose or $ .7/ hr if patient is
on continuous infusion pump.
"nc!matibilities0 Beparin should not %e
mixed in solution with any other drug unless
specifically ordered) direct incompati%ilities in
solution and at D-site seen with amiacin,
codeine, chlorproma(ine, cytara%ine,
dia(epam, do%utamine, doxoru%icin,
droperidol, ergotamine, erythromycin,
gentamicin, haloperidol, hydrocortisone,
anamycin, levorphanol, meperidine,
methadone, methicillin, methotrimepra(ine,
morphine, netilimicin, penta(ocine,
phenytoin, polymyxin @, prometha(ine,
streptomycin, tetracycline, to%ramycin,
trifluproma(ine, vancomycin.
A#%erse effects
Dermat!l!gic0 *oss of hair
6emat!l!gic0 6em!rrhage;
(ruising, throm%ocytopenia) elevated
A:!, A*! levels, hyperalemia
6yersensiti%ity0 &hills, fever,
urticaria, asthma
4ther0 Osteoporosis, suppression of
renal function (long-term, high-dose
therapy)
"nteracti!ns
212
Drug-drug
5ncreased %leeding tendencies with
oral anticoagulants, salicylates,
penicillins, cephalosporins) low-
moleculer-weight heparins
=ecreased anticoagulation effects if
taen concurrently with nitroglycerin
Drug-lab test
5ncreased A:!, A*! levels
5ncreased thyroid function tests
Altered %lood gas analyses,
especially levels of car%on dioxide,
%icar%onate concentration, and %ase
excess
Drug-alternatie thera"y
5ncreased ris of %leeding if
com%ined with chamomile, garlic,
ginger, gingo, and ginseng therapy)
high-dose vitamin A
Nursing considerations
Assessment
6ist!ry0 ;ecent surgery or injury)
sensitivity to heparin) hyperlipidemia)
pregnancy
(hysical0 6eripheral perfusion, ;,
stool guaiac test, 6!! or other tests
of %lood coagulation, platelet count,
renal function tests
Interentions
Adjust dose according to coagulation
test results performed just %efore
injection (8- min %efore each
intermittent dose or $ .7/ hr if
continuous 59 dose). !herapeutic
range a6!!" 1.27,.2 times control.
Always chec compata%ilities with
other 59 solutions.
'se heparin loc needle to avoid
repeated injections.
>ive deep su%cutaneous injections)
do not give heparin %y 5# injection.
=o not give 5# injections to patients
on heparin therapy (heparin
predisposes to hematoma
formation).
7A*+"+30 Apply pressure to all
injection sites after needle is
withdrawn) inspect injection sites for
signs of hematoma) do not massage
injection sites.
#ix well when adding heparin to 59
infusion.
=o not add heparin to infusion lines
of other drugs, and do not piggy%ac
other drugs into heparin line. 5f this
must %e done, ensure drug
compati%ility.
6rovide for safety measures (electric
ra(or, soft tooth%rush) to prevent
injury from %leeding.
&hec for signs of %leeding) monitor
%lood tests.
Alert all health care providers of
heparin use.
7A*+"+30 Bave protamine sulfate
(heparin antidote) readily availa%le in
case of overdose) each mg
neutrali(es 1-- units of heparin.
7A*+"+30 !reatment of overdose"
6rotamine sulfate (1F solution).
Aach mg of protamine neutrali(es
1-- ':6 heparin units. >ive very
slowly 59 over 1- min, not to exceed
2- mg. Asta%lish dose %ased on
%lood coagulation studies.
!eaching "oints
!his drug must %e given %y a
parenteral route (cannot %e taen
orally).
Fre$uent %lood tests are necessary
to determine %lood clotting time is
within the correct range.
@e careful to avoid injury" 'se an
electric ra(or, avoid contact sports
and other activities that might lead to
injury.
Dou may experience loss of hair.
213
;eport nose %leed, %leeding of the
gums, unusual %ruising, %lac or
tarry stools, cloudy or dar urine,
a%dominal or lower %ac pain,
severe headache.
Adverse effects in Italic are most common)
those in 8!l# are life-threatening.
hy#r!chl!r!thiazi#e
(hye droe lor oh thye' a (ide)
A!>6y#r! <$A+=, )si#ri1, )zi#e,
6y#r!D"&*"', /icr!zi#e $asules, 4retic
Pregnancy Category /
Drug class
!hia(ide diuretic
Theraeutic acti!ns
5nhi%its rea%sorption of sodium and chloride
in distal renal tu%ule, increasing the excretion
of sodium, chloride, and water %y the idney.
"n#icati!ns
Adjunctive therapy in edema
associated with &BF, cirrhosis,
corticosteroid, and estrogen therapy)
renal dysfunction
Bypertension as sole therapy or in
com%ination with other
antihypertensives
'nla%eled uses" &alcium
nephrolithiasis alone or with
amiloride or allopurinol to prevent
recurrences in hypercalciuric or
normal calciuric patients) dia%etes
insipidus, especially nephrogenic
dia%etes insipidus) osteoporosis
$!ntrain#icati!ns an# cauti!ns
&ontraindicated with allergy to
thia(ides, sulfonamides) fluid or
electrolyte im%alance) renal disease
(can lead to a(otemia)) liver disease
(ris of hepatic coma)) anuria.
'se cautiously with gout (ris of
attac)) :*A) glucose tolerance
a%normalities, dia%etes mellitus)
hyperparathyroidism) manic-
depressive disorder (aggravated %y
hypercalcemia)) pregnancy)
lactation, elevated triglyceride levels.
A%ailable f!rms
!a%lets+,2, 2-, 1-- mg) solution+2- mg42
m*) capsules+1,.2 mg
Dosages
AD&'TS
*dema: ,27,-- mg daily 6O until
dry weight is attained. !hen, ,27
1-- mg daily 6O or intermittently, up
to ,-- mg4day.
&ypertension: 1,.272- mg 6O.
$alcium nephrolithiasis: 2- mg daily
or %id 6O.
()D"AT*"$ (AT")+TS
7897 yr: 83.271--.- mg4day in , doses.
4eneral guidelines: ,., mg4g4day 6O in ,
doses.
: mo87 yr: 1,.2783.2 mg4day in , doses.
. : mo: 'p to 8.8 mg4g4day in , doses.
(harmac!.inetics
;oute Onset 6ea =uration
Oral , hr .7/ hr /71, hr
/etab!lism0 Bepatic) !
14,
" 2./71..0 hr
Distributi!n0 &rosses placenta) enters
%reast mil
)1creti!n0 'rine
A#%erse effects
$+S0 +i!!iness, vertigo,
paresthesias, weaness, headache,
drowsiness, fatigue
$20 Orthostatic hypotension, venous
throm%osis, volume depletion,
cardiac arrhythmias, chest pain
214
Dermat!l!gic0 6hotosensitivity,
rash, purpura, exfoliative dermatitis,
hives, alopecia
3"0 #ausea, anorexia, vomiting, dry
mouth, diarrhea, constipation,
jaundice, hepatitis, pancreatitis
3&0 Polyuria, nocturia, impotence,
loss of li%ido
6emat!l!gic0 *euopenia,
throm%ocytopenia, agranulocytosis,
aplastic anemia, neutropenia
4ther0 #uscle cramps and muscle
spasms, fever, gouty attacs,
flushing, weight loss, rhinorrhea,
electrolyte im%alances,
hyperglycemia
"nteracti!ns
Drug-drug
Altered electrolytes with loop
diueretics, amphotericin @,
corticosteroids
5ncreased neuromuscular %locing
effects and respiratory depression
with nondepolari(ing muscle
relaxants
=ecreased a%sorption with
cholestyramine, colestipol
5ncreased ris of cardiac glycoside
toxicity if hypoalemia occurs
5ncreased ris of lithium toxicity
=ecreased effectiveness of
antidia%etic drugs
Drug-lab test
=ecreased 6@5 levels without clinical
signs of thyroid distur%ance
Nursing considerations
Assessment
6ist!ry0 Allergy to thia(ides,
sulfonamides) fluid or electrolyte
im%alance) renal or liver disease)
gout) :*A) glucose tolerance
a%normalities, dia%etes mellitus)
hyperparathyroidism) manic-
depressive disorders) lactation,
pregnancy
(hysical0 :in color, lesions,
edema) orientation, reflexes, muscle
strength) pulses, %aseline A&>, @6,
orthostatic @6, perfusion) ;, pattern,
adventitious sounds) liver evaluation,
%owel sounds, urinary output
patterns) &@&, serum electrolytes,
%lood glucose, *F!s, renal function
tests, serum uric acid, urinalysis
Interentions
>ive with food or mil if >5 upset
occurs.
#ar calendars or provide other
reminders of drug for alternate day
or 872 days4w therapy.
;educe dosage of other
antihypertensives %y at least 2-F if
given with thia(ides) readjust
dosages gradually as @6 responds.
Administer early in the day so
increased urination will not distur%
sleep.
#easure and record weights to
monitor fluid changes.
!eaching "oints
;ecord intermittent therapy on a
calendar, or use prepared, dated
envelopes. !ae drug early so
increased urination will not distur%
sleep. =rug may %e taen with food
or meals if >5 upset occurs.
?eigh yourself on a regular %asis, at
the same time and in the same
clothing) record weight on your
calendar.
Dou may experience these side
effects" 5ncreased volume and
fre$uency of urination) di((iness,
feeling faint on arising, drowsiness
(avoid rapid position changes)
ha(ardous activities, lie driving) and
215
alcohol)) sensitivity to sunlight (use
sunglasses, wear protective clothing,
or use a sunscreen)) decrease in
sexual function) increased thirst
(sucing on sugarless lo(enges and
fre$uent mouth care may help)) gout
attac (report any sudden joint pain).
;eport weight change of more than 8
pounds in 1 day, swelling in your
anles or fingers, unusual %leeding
or %ruising, di((iness, trem%ling,
num%ness, fatigue, muscle
weaness or cramps.
Adverse effects in Italic are most common)
those in 8!l# are life-threatening.
hy#r!c!rtis!ne
(hye droe .!r' ti (one)
hy#r!c!rtis!ne acetate
Dermatologic cream( ointment)
$!rtai# Fith Al!e, $!rtef ;eminine "tch,
$!rticaine, 3ynec!rt ;emale $reme,
'anac!rt>5, 'anac!rt>10, /a1imum
Strength $al#ec!rt, /a1imum Strength
$!rtai#
hy#r!c!rtis!ne butyrate
Dermatologic ointment and cream)
'!c!i#
hy#r!c!rtis!ne cyi!nate
*ral sus"ension)
$!rtate <$A+=, $!rtef
hy#r!c!rtis!ne s!#ium h!shate
I1( I,( or subcutaneous in.ection)
6y#r!c!rt!ne h!shate
hy#r!c!rtis!ne s!#ium succinate
I1( I, in.ection)
S!lu>$!rtef
hy#r!c!rtis!ne %alerate
Dermatologic cream( ointment( lotion)
7estc!rt
Pregnancy Category C
Drug classes
&orticosteroid, short acting
>lucocorticoid
Adrenal cortical steroid
Bormone
Theraeutic acti!ns
Anters target cells and %inds to cytoplasmic
receptors) initiates many complex reactions
that are responsi%le for its anti-inflammatory,
immunosuppressive (glucocorticoid), and
salt-retaining (mineralocorticoid) actions.
:ome actions may %e undesira%le,
depending on drug use.
"n#icati!ns
;eplacement therapy in adrenal
cortical insufficiency
Allergic states+severe or
incapacitating allergic conditions
Bypercalcemia associated with
cancer
:hort-term inflammatory and allergic
disorders, such as rheumatoid
arthritis, collagen diseases (:*A),
dermatologic diseases (pemphigus),
status asthmaticus, and autoimmune
disorders
Bematologic disorders+
throm%ocytopenic purpura,
erythro%lastopenia
!richinosis with neurologic or
myocardial involvement
'lcerative colitis, acute
exacer%ations of #:, and palliation
in some leuemias and lymphomas
5ntra-articular or soft-tissue
administration" Arthritis, psoriatic
pla$ues
;etention enema" For ulcerative
colitis, proctitis
216
=ermatologic preparations" !o
relieve inflammatory and pruritic
manifestations of dermatoses that
are steroid responsive
Anorectal cream, suppositories" !o
relieve discomfort of hemorrhoids
and perianal itching or irritation
$!ntrain#icati!ns an# cauti!ns
:ystemic administration
&ontraindicated with fungal
infections, ame%iasis, hepatitis @,
vaccinia, or varicella, and anti%iotic-
resistant infections.
'se cautiously with idney disease
(ris to edema)) liver disease,
cirrhosis, hypothyroidism) ulcerative
colitis with impending perforation)
diverticulitis) recent >5 surgery)
active or latent peptic ulcer)
inflammatory %owel disease (riss
exacer%ations or %owel perforation))
hypertension, &BF)
throm%oem%olitic tendencies,
throm%ophle%itis, osteoporosis,
sei(ure disorders, metastatic
carcinoma, dia%etes mellitus) !@)
lactation.
;etention enemas, intrarectal foam
&ontraindicated with systemic fungal
infections, recent intestinal surgery,
extensive fistulas.
'se cautiously with pregnancy.
!opical dermatologic administration
&ontraindicated with fungal,
tu%ercular, herpes simplex sin
infections) vaccinia, varicella) ear
application when eardrum is
perforated.
'se cautiously with pregnancy,
lactation.
A%ailable f!rms
!a%lets+2, 1-, ,- mg) oral suspension+
1- mg42 m*, ,2, 2- mg4m*) injection+,2, 2-
mg4m*, 1--, ,2-, 2--, 1,--- mg4vial) topical
lotion+-.,2F, -.2F, 1F, ,F, ,.2F) topical
li$uid+1F) topical oil+1F) topical solution
+1F) topical spray+1F) cream+-.,F,
-.2F, 1F, ,.2F) ointment+-.2F, 1F, ,.2F)
topical gel+1F, ,F
Dosages
AD&'TS
5ndividuali(e dosage, %ased on severity and
response. >ive daily dose %efore I A# to
minimi(e adrenal suppression. 5f long-term
therapy is needed, alternate-day therapy
should %e considered. After long-term
therapy, withdraw drug slowly to avoid
adrenal insufficiency. For maintenance
therapy, reduce initial dose in small
increments at intervals until lowest clinically
satisfactory dose is reached.
5#, 59 (hydrocortisone sodium succinate)
1--72-- mg initially and $ ,71- hr, %ased on
condition and response.
Acute adrenal insufficiency
;hydrocortisone sodium phosphate<:
1-- mg 59 followed %y 1-- mg $ 0 hr
in 59 fluids.
()D"AT*"$ (AT")+TS
5ndividuali(e dosage %ased on severity and
response rather than on formulae that correct
adult doses for age or weight. &arefully
o%serve growth and development in infants
and children on prolonged therapy.
Oral (hydrocortisone and cypionate)
,-7,.- mg4day in single or divided doses.
AD&'TS A+D ()D"AT*"$ (AT")+TS
59, 5# or su%cutaneous (hydrocortisone and
hydrocortisone sodium phosphate)
,-7,.- mg4day usually in divided doses $ 1,
hr.
5#, 59 (hydrocortisone sodium succinate)
;educe dose, %ased on condition and
response, %ut give no less than ,2 mg4day.
=etention enema ;hydrocortisone<:
1-- mg nightly for ,1 days.
5ntrarectal foam (hydrocortisone acetate)
217
1 applicator daily or %id for , w and every
second day thereafter.
5ntra-articular, intralesional (hydrocortisone
acetate)
27,2 mg, depending on joint or soft-tissue
injection site.
!opical dermatologic preparations
Apply sparingly to affected area %id7$id.
(harmac!.inetics
;oute Onset 6ea =uration
Oral 17, hr 17, hr 171.2
days
5# ;apid .70 hr 171.2
days
59 5mmediate 'nnown 171.2
days
6; :low 872 days .7/ days
/etab!lism0 Bepatic) !
14,
" 0-71,- min
Distributi!n0 &rosses placenta) enters
%reast mil
)1creti!n0 'rine
IV facts
(rearati!n0 >ive directly or dilute in normal
saline or =
2
?. Administer within ,. hr of
diluting
"nfusi!n0 5nject slowly, directly or dilute, and
infuse hydrocortisone phosphate at a rate of
,2 mg4min) hydrocortisone sodium succinate
at rate of each 2-- mg over 8-7/- sec.
"nc!matibilities0 =o not mix or inject at D-
site with amo%ar%ital, ampicillin, %leomycin,
dimenhydrinate, doxapram, doxoru%icin,
ephedrine, ergotamine, heparin, hydrala(ine,
metaraminol, methicillin, nafcillin,
pento%ar%ital, pheno%ar%ital, phenytoin,
prochlopera(ine, prometha(ine, seco%ar%ital,
tetracyclines.
A#%erse effects
:ystemic
$+S0 Vertigo, headache,
paresthesias, insomnia, sei(ures,
psychosis
$20 &ypotension, shoc2,
hypertension and &BF secondary to
fluid retention, throm%oem%olism,
throm%ophle%itis, fat em%olism,
cardiac arrhythmias secondary to
electrolyte distur%ances
Dermat!l!gic0 -hin, fragile s2in,
petechiae, ecchymoses, purpura)
striae) su%cutaneous fat atrophy
))+T0 &ataracts, glaucoma (long-
term therapy), increased 5O6
)n#!crine0 Amenorrhea, irregular
menses, growth retardation,
decreased car%ohydrate tolerance
and dia%etes mellitus, cushingoid
state (long-term therapy), B6A
suppression systemic with therapy
longer than 2 days
3"0 Peptic or esophageal ulcer,
pancreatitis, a%dominal distention,
nausea, vomiting, increased appetite
and weight gain (long-term therapy)
6emat!l!gic0 #a
>
and fluid
retention, hypo2alemia,
hypocalcemia, increased %lood
sugar, increased serum cholesterol,
decreased serum !
8
and !
.
levels
6yersensiti%ity0 Anaphylactoid or
hypersensitivity reactions
/uscul!s.eletal0 'uscle
ea2ness, steroid myopathy and
loss of muscle mass, osteoporosis,
spontaneous fractures (long-term
therapy)
4ther0 Immunosuppression,
aggravation or mas2ing of infections,
impaired ound healing
Adverse effects related to specific routes of
administration
"/ re!sit!ry inCecti!ns0 Atrophy at
injection site
"ntra>articular0 Osteonecrosis,
tendon rupture, infection
"ntralesi!nal theray, hea# an#
nec.0 @lindness (rare)
218
"ntrasinal0 #eningitis, adhesive
arachnoiditis, conus medullaris
syndrome
"ntrathecal a#ministrati!n0
Arachnoiditis
*etenti!n enema0 *ocal pain,
%urning) rectal %leeding) systemic
a%sorption and adverse effects (see
:ystemic Adverse Affects)
T!ical #ermat!l!gic !intments,
creams, srays0 *ocal %urning,
irritation, acneiform lesions, striae,
sin atrophy
"nteracti!ns
Drug-drug
5ncreased steroid %lood levels with
hormonal contraceptives,
troleandomycin, etocona(ole,
estrogen
=ecreased steroid %lood levels with
phenytoin, pheno%ar%ital, rifampin,
cholestyramine
=ecreased serum level of salicylates
=ecreased effectiveness of
anticholinesterases (am%enonium,
edrophonium, neostigmine,
pyridostigmine), etocona(ole,
estrogen
Drug-lab test
False-negative nitro%lue-tetra(olium
test for %acterial infection (with
systemic a%sorption)
:uppression of sin test reactions
#ay decrease serum potassium
levels, !
8
, and !
.
levels
Nursing considerations
Assessment
6ist!ry0 5nfections) idney disease)
liver disease, hypothyroidism)
ulcerative colitis with impending
perforation) diverticulitis) recent >5
surgery) active or latent peptic ulcer)
inflammatory %owel disease)
hypertension, &BF)
throm%oem%olitic tendencies,
throm%ophle%itis, osteoporosis,
sei(ure disorders, metastatic
carcinoma, dia%etes mellitus)
lactation. =etention enemas,
intrarectal foam: :ystemic fungal
infections) recent intestinal surgery,
extensive fistulas. -opical
dermatologic administration: Fungal,
tu%ercular, herpes simplex sin
infections) vaccinia, varicella) ear
application when eardrum is
perforated
(hysical0 Systemic administration:
?eight, !) reflexes, affect, %ilateral
grip strength, ophthalmologic
examination) @6, 6, auscultation,
peripheral perfusion, discoloration,
pain or prominence of superficial
vessels) ;, adventitious sounds,
chest x-ray) upper >5 x-ray (history
or symptoms of peptic ulcer), liver
palpation) &@&, serum electrolytes,
,-hr postprandial %lood glucose,
urinalysis, thyroid function tests,
serum cholesterol. -opical,
dermatologic preparations: Affected
area, integrity of sin
Interentions
:ystemic administration
7A*+"+30 >ive daily %efore I A#
to mimic normal pea diurnal
corticosteroid levels and minimi(e
B6A suppression.
:pace multiple doses evenly
throughout the day.
=o not give 5# injections if patient
has throm%ocytopenic purpura.
;otate sites of 5# repository
injections to avoid local atrophy.
'se minimal doses for minimal
duration to minimi(e adverse effects.
!aper doses when discontinuing
high-dose or long-term therapy.
219
Arrange for increased dosage when
patient is su%ject to unusual stress.
Ansure that ade$uate amount of
&a
,M
is taen if prolonged
administration of steroids.
'se alternate-day maintenance
therapy with short-acting
corticosteroids whenever possi%le.
7A*+"+30 =o not give live virus
vaccines with immunosuppressive
doses of hydrocortisone.
6rovide antacids %etween meals to
help avoid peptic ulcer.
!opical dermatologic administration
'se caution with occlusive
dressings) tight or plastic diapers
over affected area can increase
systemic a%sorption.
Avoid prolonged use, especially near
eyes, in genital and rectal areas, on
face, and in sin creases.
!eaching "oints
:ystemic administration
!ae this drug exactly as prescri%ed.
=o not stop taing this drug without
notifying your health care provider)
slowly taper dosage to avoid
pro%lems.
=osage reductions may create
adrenal insufficiency. ;eport any
fatigue, muscle and joint pains,
anorexia, nausea, vomiting, diarrhea,
weight loss, weaness, di((iness, or
low %lood sugar (if you monitor %lood
sugar).
!ae with meals or snacs if >5
upset occurs.
!ae single daily or alternate-day
doses %efore I A#) mar calendar or
use other measures as reminder of
treatment days.
=o not overuse joint after intra-
articular injections, even if pain is
gone.
Fre$uent follow-up visits to your
health care provider are needed to
monitor drug response and adjust
dosage.
?ear a medical alert 5= (long-term
therapy) so that any emergency
medical personnel will now that you
are taing this drug.
Dou may experience these side
effects" 5ncrease in appetite, weight
gain (some of gain may %e fluid
retention) monitor intae)) heart%urn,
indigestion (eat fre$uent small
meals) use of antacids may help))
increased suscepti%ility to infection
(avoid crowds during pea cold or flu
seasons, and avoid anyone with a
nown infection)) poor wound
healing (if injured or wounded,
consult health care provider)) muscle
weaness, fatigue (fre$uent rest
periods may help).
;eport unusual weight gain, swelling
of lower extremities, muscle
weaness, %lac or tarry stools,
vomiting of %lood, epigastric %urning,
puffing of face, menstrual
irregularities, fever, prolonged sore
throat, cold or other infection,
worsening of symptoms.
5ntra-articular, intralesional administration
=o not overuse the injected joint
even if the pain is gone. Adhere to
rules of proper rest and exercise.
!opical dermatologic administration
Apply sparingly, and ru% in lightly
Avoid contacting your eye with the
medication.
;eport %urning, irritation, or infection
of the site, worsening of the
condition.
Avoid prolonged use.
Anorectal preparations
220
#aintain normal %owel function with
proper diet, ade$uate fluid intae,
and regular exercise.
'se stool softeners or %ul laxatives
if needed.
<otify your health care provider if
symptoms do not improve in 3 days
or if %leeding, protrusion, or seepage
occurs.
Adverse effects in Italic are most common)
those in 8!l# are life-threatening.
hy#r!1yzine
(hye #r!1H i (een)
hy#r!1yzine hy#r!chl!ri#e
*ral "re"arations)
A!>6y#r!1yzine <$A+=, +!%!>
6y#r!1yzine <$A+=, 2istaril
Parenteral "re"arations)
2istaril
hy#r!1yzine am!ate
*ral "re"arations)
2istaril
Pregnancy Category C
Drug classes
Anxiolytic
Antihistamine
Antiemetic
Theraeutic acti!ns
#echanisms of action not understood)
actions may %e due to suppression of
su%cortical areas of the &<:) has clinically
demonstrated antihistaminic, analgesic,
antispasmodic, antiemetic, mild antisecretory,
and %ronchodilator activity
"n#icati!ns
:ymptomatic relief of anxiety and
tension associated with
psychoneurosis) adjunct in organic
disease states in which anxiety is
manifested) alcoholism and asthma)
%efore dental procedures
#anagement of pruritus due to
allergic conditions, such as chronic
urticaria, atopic and contact
dermatosis, and in histamine-
mediated pruritus
:edation when used as
premedication and following general
anesthesia
&ontrol of nausea and vomiting and
as adjunct to analgesia
preoperatively and postoperatively
(parenteral) to allow decreased
opioid dosage
5# administration" #anagement of
the acutely distur%ed or hysterical
patient) the acute or chronic
alcoholic with anxiety withdrawal
symptoms or delirium tremens) as
preoperative and postoperative and
prepartum and postpartum
adjunctive medication to permit
reduction in narcotic dosage, allay
anxiety, and control emesis
$!ntrain#icati!ns an# cauti!ns
&ontraindicated with allergy to
hydroxy(ine, pregnancy, lactation.
'se cautiously with uncomplicated
vomiting in children (may contri%ute
to ;eyeHs syndrome or unfavora%ly
influence its outcome)
extrapyramidal effects may o%scure
diagnosis of ;eyeHs syndrome).
A%ailable f!rms
!a%lets+1-, ,2, 2-, 1-- mg) syrup+
1- mg42 m*) capsules+,2, 2-, 1-- mg) oral
suspension+,2 mg42 m*) injection+,2,
2- mg4m*
Dosages
221
:tart patients on 5# therapy when indicated)
use oral therapy for maintenance. Adjust
dosage to patientHs response.
AD&'TS
Oral
Symptomatic relief of anxiety: 2-7
1-- mg $id.
'anagement of pruritus: ,2 mg tid7
$id.
Sedative ;preoperative and
postoperative<: 2-71-- mg.
5#
Psychiatric and emotional
emergencies, including alcoholism:
2-71-- mg immediately and $ .7/
hr as needed.
#ausea and vomiting: ,271-- mg.
Preoperative and postoperative,
prepartum and postpartum: ,27
1-- mg.
()D"AT*"$ (AT")+TS
Oral
Anxiety, pruritus:
. : yr: 2- mg4day in divided doses.
0 : yr: 2-71-- mg4day in divided
doses.
Sedative: -./ mg4g.
5#
#ausea, preoperative and
postoperative: 1.1 mg4g (-.2 mg4l%).
(harmac!.inetics
;oute Onset 6ea =uration
Oral,
5#
1278-
min
8 hr .7/ hr
/etab!lism0 Bepatic) !
14,
" 8 hr
Distributi!n0 &rosses placenta) may enter
%reast mil
)1creti!n0 'rine
A#%erse effects
$+S0 +rosiness, involuntary motor
activity, including tremor and
sei(ures
3"0 +ry mouth, reflux, constipation
3&0 'rinary retention
6yersensiti%ity0 ?hee(ing,
dyspnea, chest tightness
"nteracti!ns
Drug-drug
6otentiating action when used
concomitantly with &<: depressants
(opioids, %ar%iturates)
Nursing considerations
Assessment
6ist!ry0 Allergy to hydroxy(ine or
cetiri(ine, uncomplicated vomiting in
children, lactation, pregnancy
(hysical0 :in color, lesions,
texture) orientation, reflexes, affect)
;, adventitious sounds
Interentions
7A*+"+30 =etermine and treat
underlying cause of vomiting. =rug
may mas signs and symptoms of
serious conditions, such as %rain
tumor, intestinal o%struction,
appendicitis.
=o not administer parenteral solution
su%cutaneously, 59, or intra-arterially)
tissue necrosis has occurred with
su%cutaneous and intra-arterial
injection, and hemolysis with 59
injection.
>ive 5# injections deep into a large
muscle. 5n adults, use upper outer
$uadrant of %uttocs or midlateral
thigh) in children use midlateral thigh
muscles) use deltoid area only if well
developed.
!eaching "oints
!ae this drug as prescri%ed. Avoid
excessive dosage.
Dou may experience these side
effects" =i((iness, sedation,
drowsiness (use caution if driving or
222
performing tass that re$uire
alertness)) avoid alcohol, sedatives,
sleep aids (serious overdosage
could result)) dry mouth (fre$uent
mouth care, sucing on sugarless
lo(enges may help).
;eport difficulty %reathing, tremors,
loss of coordination, sore muscles,
or muscle spasms.
Adverse effects in Italic are most common)
those in 8!l# are life-threatening.
ibur!fen
(eye by!!' proe fen)
A#%il, A#%il 'iqui>3els, A#%il /igraine,
A!>"bur!fen <$A+=, $hil#ren's A#%il,
$hil#ren's /!trin, 3enril, "nfants' /!trin,
Guni!r Strength A#%il, Guni!r Strength
/!trin, /ena#!l, /i#!l, /i#!l /a1imum
Strength $ram ;!rmula, /!trin, /!trin
"8, /!trin /igraine (ain, +!%!>(r!fen
<$A+=, +urin, (e#ia$are ;e%er, (e#iatric
A#%il Dr!s
Pregnancy Category /
Pregnancy Category D $third trimester%
Drug classes
<:A5=
Analgesic (nonopioid)
6ropionic acid derivative
Theraeutic acti!ns
Anti-inflammatory, analgesic, and antipyretic
activities largely related to inhi%ition of
prostaglandin synthesis) exact mechanisms
of action are not nown. 5nhi%its %oth
cyclooxygenase (&OK) 1 and ,. 5%uprofen is
slightly more selective for &OK-1.
"n#icati!ns
;elief of signs and symptoms of
rheumatoid arthritis and
osteoarthritis
;elief of mild to moderate pain
!reatment of primary dysmenorrhea
Fever reduction
'nla%eled uses" 6rophylactic for
migraine) a%ortive treatment for
migraine
$!ntrain#icati!ns an# cauti!ns
&ontraindicated with allergy to
i%uprofen, salicylates, or other
<:A5=s (more common in patients
with rhinitis, asthma, chronic
urticaria, nasal polyps).
'se cautiously with &9 dysfunction,
hypertension) peptic ulceration, >5
%leeding) pregnancy) lactation)
impaired hepatic or renal function.
A%ailable f!rms
!a%lets+1--, ,--, .--, /--, 0-- mg)
chewa%le ta%lets+2-, 1-- mg) capsules+
,-- mg) suspension+1-- mg4,.2 m*, 1--
mg42 m*) oral drops+.- mg4m*
Dosages
AD&'TS
=o not exceed 8,,-- mg4day.
'ild to moderate pain: .-- mg $ .7/
hr 6O.
)steoarthritis or rheumatoid arthritis:
1,,--78,,-- mg4day 6O (8-- mg $id
or .--, /--, 0-- mg tid or $id)
individuali(e dosage. !herapeutic
response may occur in a few days,
%ut often taes , w).
Primary dysmenorrhea: .-- mg $ .
hr 6O.
)-$ use: ,--7.-- mg $ .7/ hr 6O
while symptoms persist) do not
exceed 1,,-- mg4day. =o not tae
for more than 1- days for pain or 8
days for fever, unless so directed %y
health care provider.
()D"AT*"$ (AT")+TS
?uvenile arthritis: 8-7.- mg4g4day
6O in three to four divided doses)
,- mg4g4day for milder disease.
223
6ever ;: mo897 yr<: 271- mg4g 6O
$ /70 hr) do not exceed
.- mg4g4day.
(harmac!.inetics
;oute Onset 6ea =uration
Oral 8- min 17, hr .7/ hr
/etab!lism0 Bepatic) !
14,
" 1.07,.2 hr
Distributi!n0 &rosses placenta) may enter
%reast mil
)1creti!n0 'rine
A#%erse effects
$+S0 &eadache, di!!iness,
somnolence, insomnia, fatigue,
tiredness, di((iness, tinnitus,
ophthalmologic effects
$20 Bypertension, palpitations,
arrhythmia
Dermat!l!gic0 =ash, pruritus,
sweating, dry mucous mem%ranes,
stomatitis
3"0 #ausea, dyspepsia, 4I pain,
diarrhea, vomiting, constipation,
flatulence, 3" blee#ing
3&0 =ysuria, renal impairment,
menorrhagia
6emat!l!gic0 @leeding, platelet
inhi%ition with higher doses,
neutropenia, eosinophilia,
leuopenia, pancytopenia,
throm%ocytopenia, agranulocytosis,
granulocytopenia, aplastic anemia,
decreased Bg% or Bct, %one marrow
depression
*esirat!ry0 =yspnea, hemoptysis,
pharyngitis, br!nch!sasm, rhinitis
4ther0 6eripheral edema,
anahylact!i# reacti!ns t!
anahylactic sh!c.
"nteracti!ns
Drug-drug
5ncreased toxic effects of lithium with
i%uprofen
=ecreased diuretic effect with loop
diuretics+%umetanide, furosemide,
ethacrynic acid
6otential decrease in
antihypertensive effect of %eta-
adrenergic %locing agents and A&A
inhi%itors
5ncreased ris of gastric ulceration
with %isphosphates
5ncreased ris of %leeding with
anticoagulants
Nursing considerations
Assessment
6ist!ry0 Allergy to i%uprofen,
salicylates or other <:A5=s) &9
dysfunction, hypertension) peptic
ulceration, >5 %leeding) impaired
hepatic or renal function) pregnancy)
lactation
(hysical0 :in color, lesions) !)
orientation, reflexes, ophthalmologic
evaluation, audiometric evaluation,
peripheral sensation) 6, @6, edema)
;, adventitious sounds) liver
evaluation, %owel sounds) &@&,
clotting times, urinalysis, *F!s, renal
function tests, serum electrolytes,
stool guaiac
Interentions
Administer drug with food or after
meals if >5 upset occurs.
Arrange for periodic ophthalmologic
examination during long-term
therapy.
=iscontinue drug if eye changes,
symptoms of liver dysfunction, or
renal impairment occur.
7A*+"+30 5nstitute emergency
procedures if overdose occurs"
224
>astric lavage, induction of emesis,
supportive therapy.
!eaching "oints
'se drug only as suggested) avoid
overdose. !ae the drug with food or
after meals if >5 upset occurs. =o
not exceed the prescri%ed dosage.
Avoid over-the-counter drugs. #any
of these drugs contain similar
medications, and serious
overdosage can occur.
Dou may experience these side
effects" <ausea, >5 upset, dyspepsia
(tae drug with food)) diarrhea or
constipation) drowsiness, di((iness,
vertigo, insomnia (use caution when
driving or operating dangerous
machinery).
;eport sore throat, fever, rash,
itching, weight gain, swelling in
anles or fingers, changes in vision,
%lac or tarry stools.
Adverse effects in Italic are most common)
those in 8!l# are life-threatening.
ibutili#e fumarate
(eye byu' ti lyed)
$!r%ert
Pregnancy Category C
Drug class
Antiarrhythmic (predominately class 555)
Theraeutic acti!ns
6rolongs cardiac action potential, increases
atrial and ventricular refractoriness) produces
mild slowing of sinus rate and A9 conduction.
"n#icati!ns
;apid conversion of atrial fi%rillation
or flutter of recent onset to sinus
rhythm) most effective in arrhythmias
of J I- daysH duration
$!ntrain#icati!ns an# cauti!ns
&ontraindicated with hypersensitivity
to i%utilide) second- or third-degree
A9 heart %loc, prolonged N!c
intervals.
'se cautiously with ventricular
arrhythmias, pregnancy, lactation,
renal and hepatic impairment.
A%ailable f!rms
:olution+-.1 mg4m*
Dosages
AD&'TS 9 :0 H3 <1A2 '8=
1 vial (1 mg) infused over 1- min) may %e
repeated after 1- min if arrhythmia is not
terminated.
AD&'TS I :0 H3
-.1 m*4g (-.-1 mg4g) infused over 1- min)
may %e repeated after 1- min if arrhythmia is
not terminated.
()D"AT*"$ (AT")+TS
<ot recommended.
(harmac!.inetics
;oute Onset 6ea
59 5mmediate 1- min
/etab!lism0 Bepatic) !
14,
" / hr
Distributi!n0 &rosses placenta, may enter
%reast mil
)1creti!n0 Feces, urine
IV facts
(rearati!n0 #ay %e diluted in 2- m* of
diluent, -.IF sodium chloride, or 2F
dextrose injection) one 1--m* vial added to
2- m* of diluent yields a concentration of
-.-13 mg4m*) may also %e infused undiluted)
diluted solution is sta%le for ,. hr at room
temperature or for .0 hr refrigerated.
"nfusi!n0 5nfuse slowly over 1- min.
$!matibilities0 &ompati%le with 2F
dextrose injection, -.IF sodium chloride
injection.
225
"nc!matibilities0 =o not mix in solution with
any other drugs.
A#%erse effects
$+S0 Beadache, light-headedness,
di((iness, tingling in arms,
num%ness
$20 2entricular arrhythmias,
hypotension, hypertension
3"0 #ausea
"nteracti!ns
Drug-drug
5ncreased ris of serious to life-
threatening arrhythmias with
disopyramide, $uinidine,
procainamide, amiodarone, sotalol)
do not give together
5ncreased ris of proarrhythmias with
phenothia(ines, !&As,
antihistamines
'se cautiously with digoxin %ecause
i%utilide may mas digoxin
cardiotoxicity
Nursing considerations
Assessment
6ist!ry0 Bypersensitivity to i%utilide)
second- or third-degree A9 heart
%loc, time of onset of atrial
arrhythmia) prolonged N!c intervals)
pregnancy, lactation) ventricular
arrhythmias
(hysical0 Orientation) @6, 6,
auscultation, A&>) ;, adventitious
sounds
Interentions
=etermine time of onset of
arrhythmia and potential %enefit
%efore %eginning therapy.
&onversion is more liely in patients
with arrhythmias of short (J I- daysH)
duration.
7A*+"+30 Ansure that patient is
ade$uately anticoagulated, generally
for at least , w, if atrial fi%rillation
lasts E ,78 days.
#onitor A&> continually during and
for at least . hr after administration.
@e alert for possi%le arrhythmias,
including 69&s, sinus tachycardia,
sinus %radycardia, varying degrees
of %loc at time of conversion.
7A*+"+30 Ceep emergency
e$uipment readily availa%le during
and for at least . hr after
administration.
6rovide appointments for continued
follow-up, including A&> monitoring)
tendency to revert to atrial
arrhythmia after conversion
increases with length of time patient
was in a%normal rhythm.
!eaching "oints
!his drug can only %e given %y 59
infusion. Dou will need
electrocardiogram monitoring during
and for . hours after administration.
Arrange for follow-up medical
evaluation, including an
electrocardiogram, which is
important to monitor the effect of the
drug on your heart.
Dou may experience these side
effects" ;apid or irregular heart%eat
(usually passes shortly), headache.
;eport chest pain, difficulty
%reathing, num%ness or tingling.
Adverse effects in Italic are most common)
those in 8!l# are life-threatening.
insulin
(in' su lin)
Insulin in.ection)
226
6umulin *, 6umulin * *egular &>500
<c!ncentrate#=, +!%!lin ge T!r!nt! <$A+=,
+!%!lin *, +!%!lin * (en;ill, 2el!sulin
6uman 8*
Insulin lis"ro)
6umal!g
Iso"hane insulin sus"ension $NP2%)
6umulin +, +!%!lin ge <$A+=, +!%!lin +,
+!%!lin + (en;ill, +!%!lin ge +(6 <$A+=
Insulin 3inc sus"ension $-ente%)
6umulin>', 'ente "lentin "", +!%!lin ge
lente <$A+=
Protamine 3inc sus"ension $P0I%)
"letin (J" <$A+=
Insulin 3inc sus"ension( extended
$4ltralente%)
6umulin & <$A+=
Insulin As"art)
+!%!l!g
Insulin Detemir)
'e%emir
Insulin +largine)
'antus
Insulin +lulisine)
Ai#ra
Combination insulins)
6umal!g 75?25; 6umulin 70?A0; 6umulin
50?50; +!%!lin 70?A0; +!%!lin ge 10?D0,
20?K0, A0?70, L0?:0, 50?50 <$A+=; +!%!l!g
70?A0
Pregnancy Category /
Pregnancy Category C $insulin glargine(
insulin as"art( insulin glulisine%
Drug classes
Antidia%etic
Bormone
Theraeutic acti!ns
5nsulin is a hormone secreted %y the %eta
cells of the pancreas that, %y receptor-
mediated effects, promotes the storage of the
%odyHs fuels, facilitating the transport of
meta%olites and ions (potassium) through
cell mem%ranes and stimulating the
synthesis of glycogen from glucose, of fats
from lipids, and proteins from amino acids.
"n#icati!ns
!reatment of type 1 (insulin-
dependent) dia%etes mellitus
!reatment of type , (non7insulin-
dependent) dia%etes mellitus that
cannot %e controlled %y diet or oral
drugs
;egular insulin injection" !reatment
of severe etoacidosis or dia%etic
coma
!reatment of hyperalemia with
infusion of glucose to produce a shift
of potassium into the cells
Bighly purified and human insulins
promoted for short courses of
therapy (surgery, intercurrent
disease), newly diagnosed patients,
patients with poor meta%olic control,
and patients with gestational
dia%etes
5nsulin injection concentrated"
!reatment of dia%etic patients with
mared insulin resistance
(re$uirements of E ,-- units4day)
>largine (3antus)" !reatment of adult
patients with type , dia%etes mellitus
who re$uire %asal insulin control of
hyperglycemia
!reatment of adults and children E /
yr who re$uire %aseline insulin
control
=etermir (3evemir)" !reatment of
adults with dia%etes who re$uire
%asal insulin for the control of
hyperglycemia
$!ntrain#icati!ns an# cauti!ns
&ontraindicated with allergy to por
products (varies with preparations)
human insulin not contraindicated
with por allergy).
227
'se cautiously with pregnancy (eep
patients under close supervision)
rigid control is desired) following
delivery, re$uirements may drop for
,.73, hr, rising to normal levels
during next / w)) lactation (monitor
mother carefully) insulin
re$uirements may decrease during
lactation).
A%ailable f!rms
5njection+1-- units4m*, 2-- units4m*
(concentrated)) prefilled cartridges and pens
+1-- units4m*
Dosages
AD&'TS A+D ()D"AT*"$ (AT")+TS
>eneral guidelines, -.271 unit4g4day. !he
num%er and si(e of daily doses, times of
administration, and type of insulin
preparation are determined after close
medical scrutiny of the patientHs %lood and
urine glucose, diet, exercise, and intercurrent
infections and other stresses. 'sually given
su%cutaneously. ;egular insulin may %e
given 59 or 5# in dia%etic coma or
etoacidosis. 5nsulin injection concentrated
may %e given su%cutaneoulsy or 5#, %ut do
not administer 59.
AD&'TS 7"T6 T-() 2 D"A8)T)S
*)M&"*"+3 8ASA' "+S&'"+ $4+T*4'
1- units4day su%cutaneously, given at the
same time each day. ;ange, ,71-- units4day
(3antus) or -.17-., units4g su%cutaneously
in the evening or 1- units once or twice a day
(3evemir).
(harmac!.inetics
!ype Onset 6ea =uration
;egular 8-7/-
min
,78 hr /71, hr
:emilente 171.2
hr
271-
hr
1,71/ hr
<6B 171.2
hr
.71,
hr
,. hr
*ente 17,.2
hr
3712
hr
,. hr
6O5 .70 hr 1.7,.
hr
8/ hr
'ltralente .70 hr 1-78-
hr
E 8/ hr
*ispro J 12
min
8-7I-
min
/70 hr
Aspart 1-7,-
min
178 hr 872 hr
=etemir :low 87/ hr /711 hr
>largine /- min <one ,. hr
>lulisine ,72
min
8-7/-
min
, hr
&om%ination
insulins
8-7/-
min,
then 17
, hr
,7.
hr,
then
/71,
hr
/70 hr,
then 107
,. hr
/etab!lism0 &ellular) !
14,
" 9aries with
preparation
Distributi!n0 &rosses placenta) does not
enter %reast mil
)1creti!n0 'nnown
IV facts
(rearati!n0 #ay %e mixed with standard 59
solutions) use of plastic tu%ing or %ag will
change the amount of insulin delivered.
"nfusi!n0 'se of a monitored delivery system
is suggested. ;ate should %e determined %y
patient response and glucose levels.
"nc!matibilities0 =o not add to
aminophylline, amo%ar%ital, chlorothia(ide,
cytara%ine, do%utamine, methylprednisolone,
pento%ar%ital, pheno%ar%ital, phenytoin,
seco%ar%ital, sodium %icar%onate, thiopental.
A#%erse effects
6yersensiti%ity0 ;ash,
anahyla1is !r angi!e#ema
'!cal0 Allergy+local reactions at
injection site+redness, swelling,
itching) usually resolves in a few
days to a few wees) a change in
type or species source of insulin may
%e tried) lipodystrophy) pruritus
228
/etab!lic0 Bypoglycemia)
etoacidosis
Interactions
Drug-drug
5ncreased hypoglycemic effects of
insulin with #AO5s, %eta %locers,
salicylates, or alcohol
=elayed recovery from hypoglycemic
episodes and mased signs and
symptoms of hypoglycemia if taen
with %eta-adrenergic %locing drugs
Drug-alternatie thera"y
5ncreased ris of hypoglycemia if
taen with juniper %erries, ginseng,
garlic, fenugree, coriander,
dandelion root, celery
Nursing considerations
$'"+"$A' A')*T5
Name confusion may occur between
-antus and -ente insulin; use e1treme
caution.
Assessment
6ist!ry0 Allergy to por products)
pregnancy) lactation
(hysical0 :in color, lesions) eye%all
turgor) orientation, reflexes,
peripheral sensation) 6, @6,
adventitious sounds) ;) urinalysis,
%lood glucose
Interentions
Ansure uniform dispersion of insulin
suspensions %y rolling the vial gently
%etween hands) avoid vigorous
shaing.
>ive maintenance doses
su%cutaneously, rotating injection
sites regularly to decrease incidence
of lipodystrophy) give regular insulin
59 or 5# in severe etoacidosis or
dia%etic coma.
#onitor patients receiving insulin 59
carefully) plastic 59 infusion sets
have %een reported to remove ,-F7
0-F of the insulin) dosage delivered
to the patient will vary.
=o not give insulin injection
concentrated 59) severe anaphylactic
reactions can occur.
'se caution when mixing two types
of insulin) always draw the regular
insulin into the syringe first) if mixing
with insulin lispro, draw the lispro
first) use mixtures of regular and
<6B or regular and *ente insulins
within 2712 min of com%ining them)
3antus insulin (insulin glargine) and
3evemir (insulin detemir) cannot %e
mixed in solution with any other
drug, including other insulins.
7A*+"+30 =ou%le-chec, or have a
colleague chec, the dosage drawn
up for pediatric patients, for patients
receiving concentrated insulin
injection, or patients receiving very
small doses) even small errors in
dosage can cause serious pro%lems.
&arefully monitor patients %eing
switched from one type of insulin to
another carefully) dosage
adjustments are often needed.
Buman insulins often re$uire smaller
doses than %eef or por insulin)
monitor cautiously if patients are
switched) lispro insulin is given 12
min %efore a meal. 3evemir is given
in the evening.
:tore insulin in a cool place away
from direct sunlight. ;efrigeration is
preferred. =o not free(e insulin.
5nsulin prefilled in glass or plastic
syringes is sta%le for 1 w
refrigerated) this is a safe way of
ensuring proper dosage for patients
with limited vision or who have
pro%lems with drawing up insulin.
229
#onitor urine or serum glucose
levels fre$uently to determine
effectiveness of drug and dosage.
6atients can learn to adjust insulin
dosage on a sliding scale %ased on
test results.
#onitor insulin needs during times of
trauma or severe stress) dosage
adjustments may %e needed.
7A*+"+30 Ceep life support
e$uipment and glucose readily
availa%le to deal with etoacidosis or
hypoglycemic reactions.
!eaching "oints
'se the same type and %rand of
syringe) use the same type and
%rand of insulin to avoid dosage
errors.
=o not change the order of mixing
insulins. ;otate injection sites
regularly (eep a chart of sites used)
to prevent %readown at injection
sites.
=osage may vary with activities,
stress, diet. #onitor %lood or urine
glucose levels, and consult physician
if pro%lems arise.
:tore drug in the refrigerator or in a
cool place out of direct sunlight) do
not free(e insulin.
5f refrigeration is not possi%le, drug is
sta%le at controlled room
temperature and out of direct
sunlight for up to 1 month.
#onitor your urine or %lood for
glucose and etones as prescri%ed.
?ear a medical alert tag stating that
you have dia%etes and are taing
insulin so that emergency medical
personnel will tae proper care of
you.
Avoid alcohol) serious reactions can
occur.
;eport fever, sore throat, vomiting,
hypoglycemic or hyperglycemic
reactions, rash.
Adverse effects in Italic are most common)
those in 8!l# are life-threatening.
iratr!ium br!mi#e
(i pra tr!e' pee um)
A!>"ra%ent <$A+=, Atr!%ent, +!%!>
"rami#e <$A+=
Pregnancy Category /
Drug classes
Anticholinergic
Antimuscarinic drug
6arasympatholytic
Theraeutic acti!ns
Anticholinergic, chemically related to
atropine, which %locs vagally mediated
reflexes %y antagoni(ing the action of
acetylcholine. &auses %ronchodilation and
inhi%its secretion from serous and
seromucous glands lining the nasal mucosa.
"n#icati!ns
@ronchodilator for maintenance
treatment of %ronchospasm
associated with &O6= (solution,
aerosol), chronic %ronchitis, and
emphysema
<asal spray" :ymptomatic relief of
rhinorrhea associated with perennial
rhinitis, common cold
$!ntrain#icati!ns an# cauti!ns
&ontraindicated with hypersensitivity
to atropine or its derivatives, soy
%ean or peanut allergies (aerosol).
'se cautiously with narrow-angle
glaucoma, prostatic hypertrophy,
%ladder nec o%struction, pregnancy,
lactation.
230
A%ailable f!rms
Aerosol+10 mcg4actuation) solution for
inhalation+-.-,F (2-- mcg4vial) nasal spray
+-.-8F (,1 mcg4spray), -.-/F
(., mcg4spray)
Dosages
Aerosol
AD&'TS A+D ()D"AT*"$ (AT")+TS 9 12
-*
!he usual dosage is , inhalations (8/ mcg)
$id. 6atients may tae additional inhalations
as re$uired. =o not exceed 1, inhalations4,.
hr.
:olution for inhalation
AD&'TS A+D ()D"AT*"$ (AT")+TS 9 12
-*
2-- mcg tid7$id with doses /70 hr apart.
<asal spray
AD&'TS A+D ()D"AT*"$ (AT")+TS 9 12
-*
, sprays -.-/F per nostril tid7$id for relief
with common cold.
()D"AT*"$ (AT")+TS 5>11 -*
, sprays -.-/F per nostril tid for relief with
common cold.
AD&'TS A+D ()D"AT*"$ (AT")+TS 9 :
-*
, sprays -.-8F per nostril %id-tid for rhinitis.
(harmac!.inetics
;oute Onset 6ea =uration
5nhalation 12 min 17, hr 87. hr
/etab!lism0 Bepatic, !
14,
" 1./ hr
Distributi!n0 #ay cross placenta, may enter
%reast mil
)1creti!n0 'nnown
A#%erse effects
$+S0 #ervousness, di!!iness,
headache, fatigue, insomnia, (lurred
vision
3"0 #ausea, >5 distress, dry mouth
*esirat!ry0 =yspnea, %ronchitis,
%ronchospasms, ';5, cough,
exacer%ation of symptoms,
hoarseness
4ther0 @ac pain, chest pain,
allergic-type reactions, palpitations,
rash
Nursing considerations
Assessment
6ist!ry0 Bypersensitivity to atropine,
soy%eans, peanuts (aerosol
preparation)) acute %ronchospasm,
narrow-angle glaucoma, prostatic
hypertrophy, %ladder nec
o%struction, pregnancy, lactation
(hysical0 :in color, lesions,
texture) !) orientation, reflexes,
%ilateral grip strength) affect)
ophthalmic examination) 6, @6) ;,
adventitious sounds) %owel sounds,
normal output) normal urinary output,
prostate palpation
Interentions
6rotect solution for inhalation from
light. :tore unused vials in foil
pouch.
'se ne%uli(er mouthpiece instead of
face mas to avoid %lurred vision or
aggravation of narrow-angle
glaucoma.
&an mix al%uterol in ne%uli(er for up
to 1 hr.
Ansure ade$uate hydration, control
environmental temperature to
prevent hyperpyrexia.
Bave patient void %efore taing
medication to avoid urinary retention.
!each patient proper use of inhalator.
!eaching "oints
'se this drug as an inhalation
product. ;eview the proper use of
inhalator) for nasal spray, initiation of
pump re$uires 3 actuations) if not
used for ,. hours, , actuations will
231
%e needed %efore use. 6rotect from
light) do not free(e.
Dou may experience these side
effects" =i((iness, headache, %lurred
vision (avoid driving or performing
ha(ardous tass)) nausea, vomiting,
>5 upset (proper nutrition is
important) consult with your dietitian
to maintain nutrition)) cough.
;eport rash, eye pain, difficulty
voiding, palpitations, vision changes.
Adverse effects in Italic are most common)
those in 8!l# are life-threatening.
irbesartan
(er %ah sar' tan)
A%ar!
Pregnancy Category C $first trimester%
Pregnancy Category D $second and third
trimesters%
Drug classes
Angiotensin 55 receptor antagonist (A;@)
Antihypertensive
Theraeutic acti!ns
:electively %locs the %inding of angiotensin
55 to specific tissue receptors found in the
vascular smooth muscle and adrenal gland)
this action %locs the vasoconstriction effect
of the renin-angiotensin system as well as
the release of aldosterone, leading to
decreased @6.
"n#icati!ns
!reatment of hypertension as
monotherapy or in com%ination with
other antihypertensives
:lowing of the progression of
nephropathy in patients with
hypertension and type , (non7
insulin-dependent) dia%etes
'nla%eled use" &BF
$!ntrain#icati!ns an# cauti!ns
&ontraindicated with hypersensitivity
to ir%esartan, pregnancy (use during
the second or third trimester can
cause injury or even death to the
fetus).
'se cautiously with hepatic or renal
dysfunction, hypovolemia, lactation,
pregnancy.
A%ailable f!rms
!a%lets+32, 12-, 8-- mg
Dosages
AD&'TS
+ia(etic neuropathy: 8-- mg4day 6O
as a single dose.
&ypertension: 12- mg 6O daily as
one dose) adjust slowly to determine
effective dose) maximum daily dose
+8-- mg.
()D"AT*"$ (AT")+TS 1A>1: -*
12- mg4day 6O) maximum dose, 8-- mg.
()D"AT*"$ (AT")+TS :,12 -*
32 mg4day 6O, titrate to a maximum of
12- mg4day.
()D"AT*"$ (AT")+TS I : -*
<ot recommended.
24'&/)> 4* SA'T>D)(')T)D (AT")+TS
32 mg4day 6O.
(harmac!.inetics
;oute Onset 6ea
Oral 9aries 178 hr
/etab!lism0 Bepatic) !
14,
" 11712 hr
Distributi!n0 &rosses placenta) enters
%reast mil
)1creti!n0 Feces, urine
A#%erse effects
$+S0 &eadache, di!!iness,
syncope, muscle weaness, sleep
distur%ance
$20 Bypotension, orthostatic
hypotension, flushing
232
Dermat!l!gic0 ;ash, inflammation,
urticaria, pruritus, alopecia, dry sin
3"0 +iarrhea, a(dominal pain,
nausea, constipation, dry mouth,
dental pain
*esirat!ry0 @=I symptoms, cough,
sinus disorders
4ther0 &ancer in preclinical studies,
%ac pain, fever, gout, fatigue,
neutropenia, angioedema
Interactions
Drug-drug
'se caution with drugs meta%oli(ed
%y &D6,&I) anticipated effects may
%e altered.
Nursing considerations
Assessment
6ist!ry0 Bypersensitivity to
ir%esartan, pregnancy, lactation,
hepatic or renal dysfunction,
hypovolemia
(hysical0 :in lesions, turgor) !)
reflexes, affect) @6) ;, respiratory
auscultation) *F!s, renal function
tests
Interentions
Administer without regard to meals.
7A*+"+30 Ansure that patient is
not pregnant %efore %eginning
therapy) suggest using %arrier %irth
control while using ir%esartan) fetal
injury and deaths have %een
reported.
Find an alternative method of
feeding the %a%y if giving drug to a
nursing mother. =epression of the
renin-angiotensin system in infants is
potentially very dangerous.
7A*+"+30 Alert surgeon and mar
patientHs chart with notice that
ir%esartan is %eing taen. !he
%locage of the renin-angiotensin
system following surgery can
produce pro%lems. Bypotension may
%e reversed with volume expansion.
#onitor patient closely in any
situation that may lead to a decrease
in @6 secondary to reduction in fluid
volume (excessive perspiration,
dehydration, vomiting, diarrhea))
excessive hypotension can occur.
!eaching "oints
!ae this drug without regard to
meals. =o not stop taing this drug
without consulting your health care
provider.
'se a %arrier method of %irth control
while using this drug) if you %ecome
pregnant or desire to %ecome
pregnant, consult your health care
provider.
Dou may experience these side
effects" =i((iness (more liely to
occur in any situation where you may
%e fluid depleted Pextreme heat,
exertionQ) avoid driving or performing
ha(ardous tass)) headache
(medications may %e availa%le to
help)) nausea, vomiting, diarrhea
(proper nutrition is important) consult
a dietitian)) symptoms of upper
respiratory tract infection, cough (do
not self-medicate) consult your
health care provider if this %ecomes
uncomforta%le).
;eport fever, chills, di((iness,
pregnancy.
Adverse effects in Italic are most common)
those in 8!l# are life-threatening.
233
is!s!rbi#e nitrates
(eye soe s!r' %ide)
is!s!rbi#e #initrate
A!>"SD+ <$A+=, Dilatrate S*, "s!r#il,
"s!r#il Titra#!se
is!s!rbi#e m!n!nitrate
"m#ur, "S/4, "s!trate )*, /!n!.et
Pregnancy Category C
Drug classes
Antianginal
<itrate
9asodilator
Theraeutic acti!ns
;elaxes vascular smooth muscle with a
resultant decrease in venous return and
decrease in arterial @6, which reduces left
ventricular worload and decreases
myocardial oxygen consumption.
"n#icati!ns
=initrate" !reatment and prevention
of angina pectoris
#ononitrate" 6revention of angina
pectoris
$!ntrain#icati!ns an# cauti!ns
&ontraindicated with allergy to
nitrates, severe anemia, head
trauma, cere%ral hemorrhage,
hypertrophic cardiomyopathy,
narrow-angle glaucoma, postdural
hypotension
'se cautiously with pregnancy,
lactation, acute #5, &BF.
A%ailable f!rms
+initrate: ta%lets+2, 1-, ,-, 8-, .- mg) :;
ta%lets+.- mg) :; capsules+.- mg) :*
ta%lets+,.2, 2, 1- mg) chewa%le ta%lets+2,
1- mg
'ononitrate: !a%lets+1-, ,- mg) A; ta%lets
+8-, /-, 1,- mg
Dosages
AD&'TS
!o avoid tolerance to drug, tae short-acting
products %id or tid with last dose no later
than 3 6# and :; products once daily or %id
at 0 6# and , 6#. !his creates a nitrate-free
period.
5sosor%ide dinitrate
Angina pectoris: :tarting dose, ,.27
2 mg su%lingual, 2-mg chewa%le
ta%lets, 2- to ,--mg oral ta%lets. For
maintenance, 1-7.- mg $ / hr oral
ta%lets or capsules) :;, initially
.- mg, then .-70- mg 6O $ 071, hr.
Acute prophylaxis: 5nitial dosage, 27
1- mg su%lingual or chewa%le ta%lets
$ ,78 hr.
5sosor%ide mononitrate
Prevention of angina: ,- mg 6O %id
given at least 3 hr apart) A; ta%lets
+8-7/- mg4day 6O may %e
increased to 1,- mg4day if needed.
5n smaller patients, start with 2 mg
(one-half of 1--mg ta%let) %ut then
increase to at least 1- mg %y day ,
or 8 of therapy. >ive first dose when
waing and second dose 3 hr later.
!his creates a nitrate-free period and
minimi(es tolerance to drug.
()D"AT*"$ (AT")+TS
:afety and efficacy not esta%lished.
(harmac!.inetics
;oute Onset =uration
Oral 127.2 min .7/ hr
Oral :; 'p to . hr /70 hr
:* ,72 min 17, hr
/etab!lism0 Bepatic) !
14,
" 2 min, then ,72 hr
Distributi!n0 #ay cross placenta) may enter
%reast mil
)1creti!n0 'rine
234
A#%erse effects
$+S0 &eadache, apprehension,
restlessness, ea2ness, vertigo,
di((iness, faintness
$20 -achycardia, retrosternal
discomfort, palpitations,
hypotension, sync!e, collapse,
orthostatic hypotension, angina,
re(ound hypertension, atrial
fi%rillation, postdural hypertension
Dermat!l!gic0 ;ash, exfoliative
dermatitis, cutaneous vasodilation
with flushing
3"0 #ausea, vomiting, incontinence
of urine and feces, a%dominal pain,
diarrhea
3&0 =ysuria, impotence, urinary
fre$uency
4ther0 #uscle twitching, pallor,
perspiration, cold sweat, arthralgia,
%ronchitis
"nteracti!ns
Drug-drug
5ncreased systolic @6 and decreased
antianginal effect if taen
concurrently with ergot alaloids
Drug-lab test
False report of decreased serum
cholesterol if done %y the Olatis-Oa
color reaction
Nursing considerations
$'"+"$A' A')*T5
Name confusion has occurred between
Isordil $isosorbide% and Plendil
$felodi"ine%; use caution.
Assessment
6ist!ry0 Allergy to nitrates, severe
anemia, >5 hypermo%ility, head
trauma, cere%ral hemorrhage,
hypertrophic cardiomyopathy,
pregnancy, lactation
(hysical0 :in color, temperature,
lesions) orientation, reflexes, affect)
6, @6, orthostatic @6, %aseline A&>,
peripheral perfusion) ;, adventitious
sounds) liver evaluation, normal
output) &@&, Bg%
Interentions
>ive su%lingual preparations under
the tongue or in the %uccal pouch)
discourage the patient from
swallowing.
&reate a nitrate-free period to
minimi(e tolerance.
7A*+"+30 >ive chewa%le ta%lets
slowly, only 2 mg initially, %ecause
severe hypotension can occur)
ensure that patient does not chew or
crush :; preparations.
>ive oral preparations on an empty
stomach, 1 hr %efore or , hr after
meals) tae with meals if severe,
uncontrolled headache occurs.
7A*+"+30 Ceep life support
e$uipment readily availa%le if
overdose occurs or cardiac condition
worsens.
7A*+"+30 >radually reduce dose if
anginal treatment is %eing
terminated) rapid discontinuation can
lead to pro%lems of withdrawal.
!eaching "oints
6lace su%lingual ta%lets under your
tongue or in your chee) do not chew
or swallow the ta%let. !ae the
isosor%ide %efore chest pain %egins,
when activities or situation may
precipitate an attac. !ae oral
isosor%ide dinitrate on an empty
stomach, 1 hour %efore or , hours
after meals) do not chew or crush
sustained-release preparations) do
not tae isosor%ide mononitrate to
relieve acute anginal episodes.
235
Dou may experience these side
effects" =i((iness, light-headedness
(may %e transient) use care to
change positions slowly)) headache
(lie down in a cool environment, rest)
over-the-counter preparations may
not help) tae drug with meals))
flushing of the nec or face
(reversi%le).
;eport %lurred vision, persistent or
severe headache, rash, more
fre$uent or more severe angina
attacs, fainting.
Adverse effects in Italic are most common)
those in 8!l# are life-threatening.
236