Bsn2 Final Fall13

Front 1

ADVIL (Ibuprofen) - PO
*400mg q 4-6hrs PR pain
*Safe dose: Yes
*Give 30min before or 2hr after meals. May give with food, milk or antacids to decrease GI upset. May crush tab and mix with food or fluid.

Back 1

Drug Class: Nonopioid analgesic - NSAID (pain relief), Antipyretic (fever reducer)

Mech. of action: Inhibits prostaglandin synthesis

Indications: Mild-moderate pain, lowering fever, inflammatory disorders like rheumatoid arthritis

Onset:
Peak:
Duration:

Contraindications: Hypersensitivity, use with other NSAIDs, GI bleed, renal impairment or disease, pregnant patients

Suggested dose for Pain/Fever - Adults PO/Rect: 325-1000mg q 4-6 hr (not to exceed 4g/day). Extended-release tablets - 650mg q 8 hr or 800mg q 12 hr.

Side effects: Headache, anaphylaxis, GI bleed, Steven-johnson’s syndrome

Nursing Implications: Assess respiratory, s/s of GI bleeding and pain; Monitor temp

Drug-drug interactions: Use with aspirin may lower effectiveness of ibuprofen; Adverse GI effects with aspirin, oral potassium, and other NSAIDs, corticosteroids or alcohol; Increased risk of renal reactions when used with acetaminophen; May lower effects of diuretics or antihypertensives; May increase hypoglycemic effects of insulin or oral hypoglycemics; May slightly increase serum digoxin levels; May increase serum lithium levels and toxicity risk; Increased risk of toxicity from methotrexate; Probenecid increases risk of toxicity from ibuprofen; Increased bleed risk when used with valproic acid, thrombolytics, warfarin, (and other drugs we don't have on our med list)

Patient teaching: Take w/ full glass of water, remain upright for 15-30 mins after. May cause drowsiness so avoid driving. Avoid aspirin, acetaminophen, alcohol and other OTC or herbal products. Taking with alcohol may increase risk of GI bleed. Don’t take for more than 10 days for pain or for more 3 days for fever. Take missed meds ASAP but do not double doses.

Special notes from Prof. Rose: This drug is nephotoxic (and probably ototoxic with prolonged use). Check BUN and creatinine to assess liver function.

Front 2

AMOXICILLIN (Practice Amoxi) - PO
*500mg BID x 3 weeks
*Safe dose: Yes
*Give with or without meals at any time of day. Capsules may be opened and emptied into a liquid. Don't crush ER tabs

Back 2

Drug Class: Antibiotic, penicillin

Mech. of action: Destroys bacterial cell wall causing cell death

Indications: Skin infections, Otitis media, Sinusitis, Respiratory infections, Genitourinary infections

Onset:
Peak:
Duration:

Contraindications: Penicillin allergy, patients with phenlyketonuria

Suggested dose for Adults - PO 250-500mg q 8 hr OR 500-875mg q 12 hr (not to exceed 2-3 g/day).

Suggested dose Adults and Children >12 - Extended-release tablets for strep throat: 775mg once daily for 10 days.

Side effects: Seizures, pseudomembranous colitis, diarrhea, rash

Nursing Implications: Assess infected site for infection or healing; Observe for s/s of anaphylaxis; Obtain specimens for culture and sensitivity prior to therapy; Monitor bowel function.

Patient Teaching: Take med and finish drug completely as directed, even if feeling better. Sharing med may be dangerous. Report signs of superinfection. Notify if symptoms do not improve. Female patients taking oral contraceptives need to use an alternative method.

Front 3

CARDIZEM/Diltiazem (Practi-Carzem) - PO
*180mg Q daily
*Safe dose: Yes
*Give with or without meals. Crush and mix with food or fluid for pts who can't swallow but don't open, break or crush SR tabs or caps.

Back 3

Drug Class: Antianginals, antiarrhythmics (class IV), antihypertensives

Indications: Hypertension, Angina pectoris and vasospastic (Prinzmetal's) angina, Supraventricular tachyarrhythmias atrial fibrillation.

Action: Calcium channel blocker, Systemic vasodilation resulting in decreased BP; Coronary vasodilation resulting in decreased frequency and severity of attacks of angina; Reduction of ventricular rate in atrial fibrillation

Onset:
Peak:
Duration:

Contraindications: Hypersensitivity, Systolic BP <90 mmHg; Recent MI or pulmonary congestion; Concurrent use of Rifampin.

Suggested dose for Adults - PO 30-120 mg 3-4 times daily or 60-120 mg once dailt as CD or XR capsules or LA tablets (up to 360mg/day); Concurrent simvastatin therapy - Diltiazem dose should not exceed 10 mg/day.

Side effects: confusion, dizziness, drowsiness, headache, ARRHYTHMIAS, HF, peripheral edema, bradycardia, chest pain, hypotension, palpitations, tachycardia, ↑ liver enzymes, constipation, diarrhea

Drug-drug interactions: May increase digoxin levels

Nursing Implications: May ↑ digoxin levels; Limit Grapefruit juice because it ↑ levels and effects of drug; Monitor BP, pulse and ECG periodically; Monitor I&O and daily weight. Assess for signs of HF; Assess pain

Patient Teaching: Take med as directed at the same time each day, even if feeling well. Take missed meds ASAP but do not double doses. Avoid large amounts of grapefruit juice. Maintain good dental hygiene to prevent gingival hyperplasia. Minimize orthostatic hypotension by changing positions slowly. Teach patient correct technique to monitor their pulse and seek help if heart rate is <50bpm. Notify HCP of all Rx. OTC or herbal meds they are taking.

Prof. Rose's Notes: Check BP and pulse before and after administering

Front 4

COLACE (Colac) - PO
*50mg Q daily
*Safe dose: Yes
*Give with a full glass of water/juice. May give on empty stomach for rapid absorption.
*Don't give within 2hrs of other laxatives.

Back 4

Class: Laxative, stool softener

Mech. of Action: Promotes incorporation of water into stool; May also promote electrolyte and water secretion into the colon.

Indications: Prevention of constipation

Onset:
Peak:
Duration:

Contraindications: Hypersensitivity, GI upset

Suggested dose for Docusate Calcium - Adults: 240mg once daily

Suggested dose for Docusate Sodium- Adults: 50 - 400 mg in 1-4 divided doses.

Side effects: throat irritation, mild cramps, diarrhea, rashes

Drug-drug interactions: None

Nursing implications: Assess for abdominal distention, bowel sounds; Assess color, consistency, and amount of stool produced.

Patient Teaching: Increase fluid intake, for short-term therapy only. Long-term therapy may cause electrolyte imbalance and dependence. Encourage patients to also incorporate bulk in the diet and increase fluid intake to 6-8 glasses/day. Advise patient not to use other laxatives with docusate. Instruct patients with cardiac disease to avoid straining during bowel movements.

Prof. Rose's Notes: Hold if patient has diarrhea.

Front 5

COUMADIN (Practi-Couma/Coumadn) - PO
*10mg Q daily
*Safe dose: Yes, dose has been titrated for this patient
*CHECK DOSE WITH A SECOND NURSE
*Give at same time each day
*Check PT and INR
*Antidote is Vitamin K

Back 5

Drug class: Anticoagulants

Mech. of Action: Interferes with hepatic synthesis of vitamin K-dependent clotting factors (II, VII, IX, and X).

Indications: Prevention and treatment of venous thrombosis, pulmonary embolism, Afib with embolization, Management of MI, decreases risk of subsequent MI, Prevention of thrombus formation and embolization

Onset:
Peak:
Duration:

Contraindications: Uncontrolled bleeding (hemophilia), pregnant women, Uncontrolled HTN

Suggested dose PO/IV for Adults: 2-5 mg/day for 2-4 days; then adjust daily dose by results of INR. Initiate therapy in lower doses in geriatric or debilitated patients or in Asian patients.

Side effects: Cramps, nausea, BLEEDING

Drug-drug interactions: Thrombolytics, sulfonamides, NSAIDs, valproates, aspirin and chronic use of acetaminophen may increase risk of bleeding; Chronic alcohol ingestion may decrease action of warfarin: If patient has liver damage due to chronic alcohol use action of warfarin may be increased due to reduce production of clotting factor; Contraceptives containing estrogen as well as St. John's wort may decrease anticoagulant effects of warfariin

Nursing Considerations: Monitor PT and INR; Assess for signs of bleeding and hemorrhage (i.e. bruising, bleeding gums, bloody stools). Patients > 60 years old exhibit a greater than expected PT/INR response so monitor for side effects at lower therapeutic ranges. INR for patients on Coumadin should be 2.5-3.5.

Patient Teaching: Limit foods high in vitamin K, Use soft toothbrush and electric razor, avoid cranberry juice, report unusual bleeding or bruising, not ETOH aspirin or NSAIDs, Must have labs drawn frequently

Front 6

DEPAKENE/Valproate (Depakene) - PO
*500mg BID
*Safe dose: TBD-This dose is based on patient's weight
*Give with or immediately after food. Don't give with milk or carbonated beverages. Sprinkle capsules may be opened and mixed with soft, cold food like pudding.

Back 6

Drug class: Anticonvulsants, vascular headache suppressants (Migraines), for Bipolar

Mech. of Action: Increase levels of GABA, Suppression of seizure activity, decreased freq. of migraines and manic episodes

Indications: For simple and complex absence seizures

Onset:
Peak:
Duration:

Contraindications: Hypersensitivity, Hepatic (Liver) impairment, Urea cycle disorders.

Suggested dose for PO Adults: Single-agent therapy (complex partial seizures) - Initial dose of 10-15 mg/kg/day in 1-4 divided doses; Increase by 5-10 mg/kg/day weekly until therapeutic response achieved (not to exceed 60 mg/kg/day); when daily dose exceeds 250mg, give in divided doses. Polytherapy (complex partial seizures) Initial dose of 10-15 mg/kg/day; Increase by 5-10 mg/kg/day weekly until therapeutic response achieved (not to exceed 60 mg/kg/day); when daily dose exceeds 250mg, give in divided doses.

Side effects: Suicidal thoughts, agitation, dizziness, headache, insomnia, sedation, confusion, peripheral edema, visual disturbances, hepatotoxicity, pancreatitis, abdominal pain, anorexia, diarrhea, indigestion, GI upset, weight gain, alopecia, rash, leukopenia, thrombocytopenia, hyperammonemia, hypothermia, tremor, ataxia

Drug-drug interactions: MAOIs and other antidepressants may reduce seizure threshold and lower effectiveness of valproate.

Nursing Implications: Assess location, duration and characteristics of seizures; assess mood, ideation, and behavior frequently; monitor for frequency of migraines; assess for suicidal tendencies; Assess geriatric patients for excessive somnolence.

Patient teaching: Take med as directed, abrupt withdrawal may lead to status epilepticus; may cause drowsiness so don't drive until given clearance by physician; no alcohol or CNS depressants; Patient and family should notify professional if they have thoughts about suicide or dying

Prof. Rose's Notes: VERY dangerous drug; hepatotoxic; causes hyperammoniasm

Front 7

DIGOXIN (Digo) - PO
125mcg q Daily (0.125mg)
*Safe Dose: Yes
*CHECK DOSE WITH A SECOND NURSE
*Take apical pulse for 1 min.
*Tablets can be crushed

Back 7

Drug class: Antiarrhythmics, inotropics

Mech. of action: Increases force of myocardial contraction, prolongs refractory period of the AV node, decreases conduction through the SA and AV nodes

Indications: CHF, Afib, Atrial tachycardia

Onset:
Peak:
Duration:

Contraindications: Hypersensitivity, ventricular dysrrhythmias, AV block, known ETOH intolerance, Constrictive pericarditis, Ididopathic hypertrophic subaortic stenosis

Suggested dose for PO Adults: Digitalizing dose - 0.75-1.5mg given as 50% of the dose initially and 25% of the initial dose in each of 2 subsequent doses at 6-12 hr intervals. Maintenance dose - 0.125-0.5 mg/day depending on patient's lean body weight, renal function, and serum level.

Side effects: fatigue, headache, weakness, blurred or yellow/green vision, dysrrythmias, bradycardia, SA or AV blocks, anorexia, GI upset, ECG changes, thrombocytopenia, electrolyte imbalances with actute digoxin toxicity

Drug-drug interactions: Thiazide and loop diuretics as well as corticosteroids and excessive laxative use may cause hypokalemia and increases risk of toxicity; Some benzodiazepines may increase digoxin levels and lead to toxicity; Additive bradycardia may occur with beta blockers, Cardiazem, and other antiarrhythmics; thyroid hormones may decrease therapeutic effects.

Nursing Implications: Monitor apical pulse for 1 minute before administering, don't give med if pulse is <60bpm in an adult or >100bpm; monitor BP and ECG

Patient teaching: Take med as directed, teach pt to take pulse for a full minute, notify doctor if they see symptoms of digtoxicity; Pt cannot share meds, nor should they mix this med in another pill bottle; pt can't take antacids or antidiarrheals within 2 hours of taking digoxin

Prof. Rose's Notes: give digibind for digtox, pt may see yellow halos

Front 8

DYAZIDE (Dyaz) - PO
*Hydrochlorothiazide 25mg
*Safe dose: Yes
*Give in AM with food or milk to minimize GI upset. May crush tabs and mix with fluid.

Back 8

Drug class: Antihypertensives/diuretics

Mech. of action: Increases sodium and water excretion by inhibiting sodium excretion in the distal tube.

Indications: Management of mild to moderate HTN; Treatment of edema associated with HF, renal dysfunction, cirrhosis, glucocorticoid therapy, estrogen therapy

Onset:
Peak:
Duration:

Contraindications: Hypersensitivity, lactation, anuria, products containing tartrazine intolerance

Suggested dose for PO Adults: 12.5-100 mg/day in 1-2 doses (up to 200mg/day; not to exceed 50mg/day for hypertension; doses above 25mg are associated with greater likelihood of electrolyte abnormalities).

Side effects: dizziness, drowsiness, lethargy, weakness, hypotension, anorexia, cramping, hepatitis, nausea, vomiting, STEVEN-JOHNSON SYNDROME, photosensitivity, rash, acute angle glaucoma, acute myopia, hyperglycemia, hypokalemia, dehydration, hypercalcemia, hypochloremic alkalosis, hypomagnesemia, hyponatremia, hypophosphatemia, hypovolemia, blood dyscrasias, hyperuricemia, hypercholesterolemia, muscle cramps, pancreatitis

Drug-Drug interactions: Cholestyramine or colestipol lowers absorption; Hypokalemia increases risk of digoxin toxicity

Nursing Implications: Monitor BP, I/O and daily weight, assess feet and legs and sacral area for edema; Assess patient taking digoxin for nausea, vomiting, muscle cramps; Notify PCP of signs of electrolyte imbalance; Pts taking digitalis glycosides are at risk of digitalis toxicity b/c of the POTASSIUM-DEPLETING effect of the diuretic; if hypokalemia occurs consider giving a potassium supplement or decreasing dose of diuretic. Assess patient for allergy to sulfonamides. Assess patient for skin rash frequently. Discontinue diuretic at first sign of rash as it may be Steven-Johnson syndrome which is life-threatening.

Patient teaching: Pt must take med at the same time everyday and take missed doses asap but do not double doses; change positions slowly to prevent Orthostatic hypertension; instruct pt to discuss dietary potassium requirements with HCP, use sunscreen to prevent photosensitivity reactions; Notify HCP of med regimen before surgery; Report rash muscle weakness, cramps, nausea vomiting, diarrhea, or dizziness to HCP; Emphasize the importance of follow-up exams. Advise patient to continue meds even if feeling better. Encourage smoking cessation, low-sodium diet, weight loss, exercise, moderate alcohol use, and stress management.

Prof. Rose's Notes: Monitor electrolytes for K+ levels

Front 9

DYAZIDE (Dyaz) - PO
*Triamterene 37.5mg
*Safe dose: Yes
*Give in AM b/c its a diuretic. Give at same time everyday.

Back 9

Drug class: Potassium-sparing diuretics

Mech. of action: Inhibits sodium resorption in the kidney while saving potassium and hydrogen ions.

Indications: Counteracts potassium loss of other diuretics (like hydrchlorothiazide). Used with other agents to treat edema or HTN.

Onset:
Peak:
Duration:

Contraindications: Hypersensitivity, hyperkalemia,concurrent use of potassium supplements or other potassium-sparing agents. Use cautiously in hepatic dysfunction, pts with diabetes mellitus, renal insufficiency, Hx of gout or kidney stones, pregnancy/lactation or children.

Suggested dose for PO Adults: 25-100 mg/day (120mg/m2/day) in divided doses given daily or every other day (not to exceed 6mg/kg/day or 300mg/day).

Side effects: Dizziness, arrhythmias, nausea, vomitting, erectile dysfunctions, bluish urine, nephrolithiasis (kidney stones), photosensitivity, hyperkalemia, hyponatremia, blood dyscrasias, muscle cramps, allergic reactions.

Drug-Drug interactions: Use with ACE inhibitors, ARBs ("sartans"), potassium supplements, or cyclosporine increase the risk of hyperkalemia; This drug decreases lithium excretion as well as the effects of folic acid (leucovorin should be used).

Nursing Implications: Monitor I/O and daily weight; evaluate BP before administering; monitor for s/s of hypokalemia (fatigue, muscle weakness, arrhythmias, polyuria, polydipsia, ECG changes) and assess patient for development of hyperkalemia (fatigue, muscle weakness, arrhythmias, confusion et.al.) Patients with diabetes mellitus or kidney disease are at increased risk of developing these symptoms; Monitor BUN and Creatinine, Potassium and urinary calcium excretion levels. Discontinue potassium-sparing diuretis 3 days prior to a glucose tolerance test because of risk of severe hyperkalemia; Monitor platelet count and total differential leukocyte count before and during therapy.

Patient teaching: Continue meds even if feeling well. Take at same time everyday and take missed dose ASAP but don't double doses. Avoid salt substitutes and high levels of potassium or sodium. may cause dizziness so avoid driving. Use sunscreen. Notify patient that it may cause blue urine. Report muscle weakness, fatigue, severe nausea, vomiting and diarrhea. Encourage smoking cessation, low-sodium diet, weight loss, exercise, moderate alcohol use, and stress management.

Front 10

GENTAMICIN SULFATE (Gentamicin) - IV
200mg q6h IV
*Safe dose: (Calculate dose - 1-2mg/kg q8h, upto 6 mg/kg/day in 3 div doses)
*Watch patient w/in 15mins
*Remember - Assess IV site & clean, flush IV site.
Maintain STERILITY. Prime your line.

Back 10

Drug class: Antibiotics, aminoglycosides

Mech. of action: inhibits bacteria's protein synthesis; Rapid onset, peak is 15-30mins, duration 8-24hours.

Indications: Rx of SERIOUS gram negative staphylococci or enterococcal; prevention of endocarditis

Contraindications: Hypersensitivity and intolerance

Onset: rapid
Peak: 30-90 min
Duration: 8-24 hrs

Suggested dose for IV Adults: 1-2mg/kg q8h, upto 6 mg/kg/day in 3 div doses

Drug-drug interactions: Inactivated by penicillins and cephalosporins when given to patients with renal insuff.

Side effects: ataxia, vertigo, ototox & nephrotox., muscle paralysis, hypersensitivity reactions

Nursing Implications: Monitor for ototoxicity, nephrotoxicity; Monitor I/O, daily weight to assess renal fxn & hydration status; Assess for signs of superinfection: fever, UTI, vaginal itching, increasing malaise, diarrhea; Infuse slowly over 30mins - 2hrs

How to prepare: Intermittent infusion: Diluent: Dilute each dose in 50-200mL of D5W or 0.9% NaCl. Concentration not to exceed 10mg/mL. Do not use solutions that are discolored or contains a precipitate. RATE: Infuse slowly over 30mins-2hrs. For peds patients, the volume of diluents may be reduced but should be sufficient to permit infusion over 30mins -1hr.

Labs: BUN, Cr, AST, ALT, bilirubin, creatinine, LDH

Patient teaching: Do not manipulate IV flow rate & don’t lie on tubing; report ringing in ears

Front 11

GLUCOPHAGE (Glucphge-XR) - PO
500mg QD PO
Safe dose: Yes
*Take at same time daily with meals to minimize GI upset

Back 11

Drug class: Antidiabetics, Biguanides

Mech. of Action: increases sensitivity to insulin in Type 2 diabetes, maintains blood glucose, decreases hepatic glucose production, intestinal glucose absorption

Indications: Mgmt of type 2 diabetes in combo with diet, insulin and other oral hypoglycemics;

Onset:
Peak: unk
Duration: 12hrs

Contraindications: RADIOGRAPHIC STUDIES requiring contrast media, hypersensitivity, metabolic acidosis, excessive ETOH use, dehydration, asepsis, hypoxemia, renal dysfunction, patients undergoing stress

Suggested dose for PO Adults: 500mg bid, can be given up to 2000mg/day, If doses <2000mg/day are required, give in 3 doses

Side effects: GI upset/bloating, hypoglycemia, lactic acidosis (deadly), decreases vitamin B12 levels

Drug-drug interactions: ETOH, digoxin, triamterene, vancomycin, FUROSEMIDE (Lasix) may increase effects of Metformin

Nursing Implications: Assess for signs of hypoglycemia (abd pain, sweating, hunger, weak, dizziness, headache, tremor, tachycardia, anxiety), check blood glucose; DISCONTINUE temporarily in patients requiring surgery; Assess renal function before initiating and during therapy

Patient teaching: Instruct pt to carry sugar packet or candy in case of hypoglycemia, how to check blood sugar, take med at same time daily with food and do not double doses if missed, teach s/s of hypoglycemia and risk of lactic acidosis (low pH in body)

Front 12

HEPARIN (Practi-heparin) - SQ
8000 Units q12h SQ
Safe Dose: Yes
*Rotate injection sites
*Protamine sulfate is the antidote
*Check aPTT, check dose w/ 2 nurses

Back 12

Drug class: Anticoagulants, antithrombotics

Mech. of Action: Used for prophylaxis & tx of various thromboembolic disorders; Acts on factor Xa & thrombin; Neutralizes thrombin, prevention of conversion fibrinogen to fibrin

Indications:

Onset 20-60min, Peak 2 hours, duration is 8-12hrs

Contraindications: uncontrolled bleeding, liver or kidney disease, untreated HTN, ulcers, spinal cord or brain injury, ulcers, open wounds, severe thrombocytopenia

Suggested dose for SQ Adults: 5,000 units IV followed by initial subcutaneous dose of 10,000-20,000 units then 8-10,000 units q8hrs or 15,000-20,000 units q12 hrs.

Side effects: drug induced hepatitis, alopecia, rashes, urticarial, local pain at injection site, osteoporosis, fever, hypersensitivity. MORTALITY: bleeding, heparin induced thrombocytopenia (HIT) with or without thrombosis & anemia.

Drug-drug interactions: digoxin, tetracyclines, nicotine, antihistamines can decrease anticoagulant effect of heparin (AKA: could increase risk of throwing a clot), risk of bleeding increases with arnica, anise, chamomile, dong quai, fever few, garlic, ginger, panax ginseng.

Nursing Implications: Prolonged PTT of 1.5-2.5 times control without signs of hemorrhage is DESIRED outcome.
Monitor: aPTT (activated partial thromboplastin time), PLT & HCT; S/S of hemorrhage (bleeding gums, nosebleeds, bruising, black/tarry stools, hematuria, HCT or BP lowering, guiaic positive stools); observe injection sites for hematomas, bruising & inflammation; CHECK AST, ALT levels as heparin can cause increase in AST, ALT and hyperkalemia.

Patient teaching: Advise pts to report unusual bleeding; Instruct pt not to take meds containing aspirin or NSAIDs; Use soft toothbrush, electric razor during heparin therapy; wear medic alert bracelet; AVOID IM INJECTIONS and activities leading to injury.

Prof. Rose's Notes: Inject at 45-degree angle

Front 13

HEPARIN (Practi-heparin) - SQ
1200 Units q12h SQ
Safe Dose: NO, not enough
*Rotate injection sites
*Protamine sulfate is the antidote
*Check aPTT, check dose w/ 2 nurses

Back 13

Drug class: Anticoagulants, antithrombotics

Mech. of Action: Used for prophylaxis & tx of various thromboembolic disorders; Acts on factor Xa & thrombin; Neutralizes thrombin, prevention of conversion fibrinogen to fibrin

Indications:

Onset: 20-60min
Peak: 2 hours:
Duration: 8-12hrs

Contraindications: uncontrolled bleeding, liver or kidney disease, untreated HTN, ulcers, spinal cord or brain injury, ulcers, open wounds, severe thrombocytopenia

Suggested dose for SQ Adults: 5,000 units IV followed by initial subcutaneous dose of 10,000-20,000 units then 8-10,000 units q8hrs or 15,000-20,000 units q12 hrs.

Side effects: drug induced hepatitis, alopecia, rashes, urticarial, local pain at injection site, osteoporosis, fever, hypersensitivity. MORTALITY: bleeding, heparin induced thrombocytopenia (HIT) with or without thrombosis & anemia.

Drug-drug interactions: digoxin, tetracyclines, nicotine, antihistamines can decrease anticoagulant effect of heparin (AKA: could increase risk of throwing a clot), risk of bleeding increases with arnica, anise, chamomile, dong quai, fever few, garlic, ginger, panax ginseng.

Nursing Implications: Prolonged PTT of 1.5-2.5 times control without signs of hemorrhage is DESIRED outcome.
Monitor: aPTT (activated partial thromboplastin time), PLT & HCT; S/S of hemorrhage (bleeding gums, nosebleeds, bruising, black/tarry stools, hematuria, HCT or BP lowering, guiaic positive stools); observe injection sites for hematomas, bruising & inflammation; CHECK AST, ALT levels as heparin can cause increase in AST, ALT and hyperkalemia.

Patient teaching: Advise pts to report unusual bleeding; Instruct pt not to take meds containing aspirin or NSAIDs; Use soft toothbrush, electric razor during heparin therapy; wear medic alert bracelet; AVOID IM INJECTIONS and activities leading to injury.

Prof. Rose's Notes: Inject at 45-degree angle

Front 14

IMODIUM (Loperamide) - PO
2mg after each loose stool
Safe Dose: Yes
*This is a PRN med, may/may not be needed
* Pt must take with water to avoid dehydration

Back 14

Drug class: Antidiarrheals

Mech. of Action: Inhibits peristalsis & prolongs transit time by effect on nerves in intestinal muscle wall. Reduces of fecal volume, increases fecal viscosity & bulk, diminishes fluid loss & electrolyte loss.

Indications: Adjunctive therapy of acute diarrhea, chronic diarrhea associated w/ IBS, increases volume of ileostomy drainage.

Onset: 1hr
Peak: 2.5-5hrs
Duration:

Contraindications: Contraindicated in pts that can’t tolerate constipation, abd pain associated with fever, ETOH intolerance. Use cautionsly with hepatic dysfunction. USUALLY compatible with breast feeding.

Suggested dose for PO Adults: 4mg initially, then 2mg after each loose stool. Maintenance dose is usually 4-8mg/day, not to exceed 8mg/day OTC or 16mg/day RX use.

Side effects: drowsiness, dizziness, constipation, abd pain/distention/discomfort, dry mouth, nausea, vomiting.

Drug-drug interactions: Hops, chamomile, valerian, kava-kava cause + CNS depression.

Nursing Implications: Assess bowel sounds prior to & during therapy, monitor fluid & electrolytes, check skin turgor for dehydration

Patient teaching: May cause drowsiness so don’t drive. Frequent oral care: may cause dry mouth. If diarrhea, fever, abd pain/distention persists, call the doctor.
Discontinue IF DIARRHEA PERSISTS more than 48 hours.
In chronic diarrhea, if no improvement in 10 days of max dose - “ineffective”

Front 15

LANTUS U100 INSULIN (Demo Dose Lantus U100) - SQ
6 Units qAM
Safe Dose: Yes
*Rotate injection sites
*Food w/in 15 mins
*Give bedtime snack, protein + carb
*Need food q4h

Back 15

Drug class: Hormones, pancreatics

Mech. of Action: Lowers blood glucose by 1) stimulating glucose uptake

Indications: Control of hyperglycemia in Type 1 & 2 Diabetics.

Onset: 3-4
Peak: none
Duration:

Contraindications: Hypoglycemia, allergy. Use cautiously in stress, infection which increases insulin requirement

Suggested dose for SQ Adults: in patients with type 2 diabetes already being treated with an oral antidiabetic, 10 Units once daily then adjusted based on the patient's needs (range 2-100 units/day)

Side effects: Hypoglycemia, anaphylaxis

Drug-drug interactions: Beta blockers mask s/s of hypoglycemia; Corticosteroids, thyroid supplements, estrogens, isoniazid, niacin, phenothiazine, rifampin increase insulin requirements; ETOH, ACE inhibitors, MAO & oral hypoglycemic agents may decrease insulin requirements.

Nursing Implications: Assess for hypoglycemia; Monitor blood glucose q6h, and in times of stress more frequently; Monitor for ketoacidosis (DKA)

Patient teaching: Proper technique for insulin administration, rotation of sites, glucose testing, importance of maintaining nutritional guidelines and exercise regimen, teach s/s of hypo-/hyperglycemia, keep candy or sugar on them

Front 16

LASIX (Lasi) - PO
30mg bid PO
Safe Dose: Yes
*Give in AM
*Potassium-depleting
*May be taken with food or milk to minimize GI upset *Tabs can be crushed.

Back 16

Drug class: Loop diuretics

Mech. of Action: : Inhibits re-absorption of sodium & chloride from Loop of Henle & distal renal tubule. Increases renal excretion of water, sodium, chloride, magnesium, potassium, calcium. Effectiveness persists in impaired renal function.

Indications: Edema d/t heart failure, Hepatic impairment or renal disease, HTN

Onset: 30 - 60min
Peak: 1-2hrs
Duration: 6-8hrs

Contraindications: Cross sensitivity: Thiazides & sulfonamides, hepatic coma, anuria, avoid with ETOH intolerance. Use caution: liver disease, concurrent use with K+ sparing diuretics may become necessary; electrolyte depletion, diabetes, hypoprotenemia, severe renal impairment.

Suggested dose for PO Adults: 20-80mg/day as single dose initially. May repeat in 6-8 hrs, may increase dose by 20-40mg q6-8hrs until desired response. Maintenance dosing may be given once or twice daily in pts with HF or renal disease. Hypertension: 40mg BID, doses up to 2.5g have been used in pts with HF or renal disease.

Side effects: dehydration, hypocalcemia, hypochloremia, hypokalemia, hypomagnesemia, hyponatremia, hypovolemia, metabolic alkalosis. MORTALITY: stevens-johnsons syndrome, toxic epidermal necrolysis, aplastic anemia, agranulocytosis.
Can also cause: elevated BUN, excessive urination, neprhcalcinosis, thrombocytopenia, muscle cramps, fever, paresthesia, hearing loss, tinnitus, vertigo, blurred vision, hypotension, constipation, NVD, dry mouth

Drug-drug interactions: Hypokalemia increases risk of Digoxin toxicity and lithium toxicity, NSAIDs decrease effects, increases risk of methotrexate or salicylate toxicity, concurrent use with cyclosporine may increase risk of gouty arthritis

Nursing Implications: Monitor fluids, daily weight, I&O; Assess for edema, amount of edema; Check lung sounds, skin turgor, mucous membranes for dehydration; Monitor BP, pulse before & during administration. Increased fall risk for GERI pts; Assess pt for tinnitus, hearing loss. Assess for skin rash frequently; discontinue furosemide at first sign of rash. (stevens-johnsons disease & epidermal necrolysis).

Labs: Monitor electrolytes, renal & hepatic function, serum glucose, uric acid levels.
Commonly decreases serum potassium, can cause lower serum sodium, calcium and magnesium concentration. Can elevate BUN, serum glucose, creatinine & uric acid levels.

Patient teaching: Take Lasix as directed, don’t miss doses. Don’t double doses; Change positions slowly to minimize orthostatic HTN. Caution that use of ETOH, exercise or standing for long periods of time may enhance orthostatic HTN; Weight gain of >3lbs/day is not normal; Diabetic pts should monitor blood sugar as Lasix can increase blood glucose; Controls but doesn’t cure HTN; Restrict sodium intake and don’t smoke.

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LIPITOR (Practi-Lipit or Lipitr) - PO
20mg QD PO
Safe Dose: Yes
*Give w/ or w/o food at night
*Check ALT & AST
*No grapefruit juice

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Drug class: Lipid-Lowering Agent; HMG CoA Reductase Inhibitors (Statins)

Mech. of Action: Inhibits HMG CoA , an enzyme responsible for catalyzing an early step in the synthesis of cholesterol

Indications: Primary Hypercholesterolemia; Mixed Dyslipidemia; Primary prevention of coronary heart disease (myocardial infarction, stroke, angina, and coronary revascularization)

Onset: unk
Peak: unk
Duration: 20-30 hrs

Contraindications: Hypersensitivity, active liver disease or unexplained persistent elevations in AST and ALT, alcoholism, renal impairment
Concurrent use of gemfibrozil, azole antifungals, erythromycin, clarithromycin, protease inhibitors, niacin, or cyclosporin

Suggested dose for PO Adults: 1020mg once daily; Dose should not exceed 80mg/day

Side effects: Confusion, dizziness, headache, chest pain, peripheral edema, constipation, diarrhea, increase of liver enzymes, hyperglycemia, myalgia, arthritis, abdominal cramps, dyspepsia

Drug-drug interactions: Increases risk of myopathy with concurrent use of cyclosporine, gemfibrozil, itraconazole, colchicine, erythromycin, clarithromycin, nelfinavir, ritonavir/saquinavir, lopinavir/ritonavir, tipranavir/ritonavir, saquinavir/ritonavir, darunavir/ritonavir, fosamprenavir, fosamprenavir/ritonavir, telaprevir, and large doses of niacin, gemfibrozil, cyclosporine, tipranavir/ritonavir, or telaprevir should be avoided; use lowest dose with lopinavir/ritonavir; use ↓ doses nelfinavir, clarithromycin, itraconazole, saquinavir/ritonavir, darunavir/ritonavir, fosamprenavir, or fosamprenavir/ritonavir); May slightly increase serum digoxin levels; Grapefruit juice increases levels and risk of rhabdomyolysis.

Nursing Implications: Obtain a diet history, especially with regard to fat consumption.
Lab Test Considerations:
Evaluate serum cholesterol and triglyceride levels before initiating, after 2–4 wk of therapy, and periodically thereafter; Monitor LFTs prior to initiation of therapy and as clinically indicated. If symptoms of serious liver injury, hyperbilirubinemia, or jaundice occurs discontinue atorvastatin and do not restart. May also cause ↑ alkaline phosphatase and bilirubin levels.
If patient develops muscle tenderness during therapy, CPK levels should be monitored. If CPK levels are >10 times the upper limit of normal or myopathy occurs, therapy should be discontinued.

Patient teaching: Instruct patient to take medication exactly as directed, not to skip doses or double doses. Advise patient to avoid grapefruit juice during therapy. Medication helps control but does not cure elevated serum cholesterol levels. Use med in conjunction with diet restrictions (fat, cholesterol, carbohydrates, alcohol), exercise, and cessation of smoking. Instruct patient to notify health care professional if unexplained muscle pain, tenderness, or weakness occurs, especially if accompanied by fever or malaise.

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LOPRESSOR (Lopre) - PO
50mg QD PO
Safe Dose: Yes
*Check BP when sitting or standing
*Patient must be weaned off

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Drug class: Antianginals, antihypertensives, beta blockers

Mech. of Action: Blocks stimulation of beta-1 (myocardial) adrenergic receptors

Indications: Hypertension, angina pectoris, prevention of MI and decreased mortality in patients with recent MI
Management of stable, symptomatic (class II or III) heart failure due to ischemic, hypertensive or cardiomyopathc origin (may be used with ACE inhibitors, diuretics and/or digoxin; Toprol XL only)
Unlabeled use: Ventricular arrhythmias/tachycardia, Migraine prophylaxis, Tremors, Aggressive behavior, Drug-induced akathisia, Anxiety

Onset: 15mins
Peak: unk
Duration: 6-12hr

Contraindications: Uncompensated HF; Pulmonary edema; Cardiogenic shock; Bradycardia, heart block, or sick sinus syndrome (in absence of a pacemaker).
Use Cautiously in: Renal and hepatic impairment; Diabetes mellitus (may mask signs of hypoglycemia); Thyrotoxicosis (may mask symptoms)

Suggested dose for PO Adults: Antihypertensive/antianginal–25–100 mg/day as a single dose initially or 2 divided doses; may be ↑ q 7 days as needed up to 450 mg/day (immediate-release) or 400 mg/day (extended-release) (for angina, give in divided doses). Extended-release products are given once daily. MI–25–50 mg (starting 15 min after last IV dose) q 6 hr for 48 hr, then 100 mg twice daily. Heart failure–12.5–25 mg once daily (of extended-release), can be doubled every 2 wk up to 200 mg/day. Migraine prevention–50–100 mg 2–4 times daily (unlabeled).

Side effects: Bronchospasm, wheezing, bradycardia, HF, pulmonary edema, hypotension, peripheral vasoconstriction, constipation, diarrhea, ED, hyperglycemia, hypoglycemia, joint pain, drug induced lupus

Drug-drug interactions: General anesthesia, phenytoin, and verapamil may cause an increase in myocardial depression; Concurrent use with amphetamines, cocaine, ephedrine, epinephrine, norepinephrine, phenylephrine, pseudoephedrine may result in unopposed alpha-adrenergic stimulation (excessive hypertension, bradycardia); Concurrent administration of thyroid administration may lower effectiveness; May alter the effectiveness of insulins or oral hypoglycemic agents (dose adjustments may be necessary); Use cautiously within 14 days of MAO inhibitor therapy (may result in hypertension).

Nursing Implications: Monitor BP, ECG, and pulse frequently during dose adjustment and periodically during therapy; Monitor vital signs and ECG every 5–15 min during and for several hours after parenteral administration. If heart rate <40 bpm, especially if cardiac output is also decreased, administer atropine 0.25–0.5 mg IV; Monitor I&Os and daily weights. Assess routinely for signs and symptoms of HF (dyspnea, rales/crackles, weight gain, peripheral edema, jugular venous distention). Angina: Assess frequency and characteristics of anginal attacks periodically during therapy.

Lab Test Considerations: May cause ↑ BUN, serum lipoprotein, potassium, triglyceride, and uric acid levels; May cause ↑ ANA titers; May cause ↑ in blood glucose levels; May cause ↑ serum alkaline phosphatase, LDH, AST, and ALT levels.

Patient teaching: Instruct patient to take medication as directed, at the same time each day, even if feeling well; do not skip or double up on missed doses. Take missed doses as soon as possible up to 8 hr before next dose. Abrupt withdrawal may precipitate life-threatening arrhythmias, hypertension, or myocardial ischemia; Teach patient and family how to check pulse daily and BP biweekly and to report significant changes to health care professional; May cause drowsiness. Caution patient to avoid driving or other activities that require alertness until response to the drug is known; Advise patient to change positions slowly to minimize orthostatic hypotension; Caution patient that this medication may increase sensitivity to cold.

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MORPHINE (Morphine) - IV or IM
4mg q4h IV or IM
Safe Dose: Yes, both routes safe for adults >50kg
*Check resp status, BP, Pulse
*Give colace for constipation
*SLOW IV PUSH - 1mg per minute
*Have NARCAN closeby

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Drug class: Opioid Agonists

Mech. of Action: Binds to receptors in the CNS and alters perception of pain

Indications: Severe pain (the 20 mg/mL oral solution concentration should only be used in opioid-tolerant patients); Pulmonary edema, Pain associated with MI

IV Onset: rapid
IV Peak: 20 mins
IV Duration: 4-5 hrs
IM Onset: 10-30 mins
IM Peak: 30-60 mins
IMDuration: 4-5 hrs
Contraindications:

Suggested dose for IV/IM Adults: (Adults ≥50 kg): Usual starting dose for moderate to severe pain in opioid-naive patients–4–10 mg q 3–4 hr. MI–8–15 mg, for very severe pain additional smaller doses may be given every 3–4 hr.
IM: IV: SC: (Adults and Children <50 kg): Usual starting dose for moderate to severe pain in opioid-naive patients–0.05–0.2 mg/kg q 3–4 hr, maximum: 15 mg/dose.

Side effects: Respiratory depression, confusion, dizziness, sedation, hypotension, bradycardia, constipation, urinary retention, nausea, vomiting

Drug-drug interactions: Use with extreme caution in patients receiving MAO inhibitors within 14 days prior (may result in unpredictable, severe reactions–↓ initial dose of morphine to 25% of usual dose).
Administration of partial-antagonist opioid analgesics may precipitate opioid withdrawal in physically dependent patients.
Buprenorphine, nalbuphine, butorphanol, or pentazocine may lower analgesia.
Cimetidine lower metabolism and may increase effects. Use of liposomal injection after bupivacaine may ↑ levels of morphine (↑ dosing interval between 2 drugs to >30 min).
Drug-Natural Products:
Concomitant use of kava-kava, valerian, or chamomile can increase CNS depression.

Nursing Implications: Assess type, location, and intensity of pain prior to and 1 hr following PO, SQ, IM, and 20 min (peak) following IV administration. Assess level of consciousness, BP, pulse, and respirations before and periodically during administration. If respiratory rate is <10/min, assess level of sedation. Physical stimulation may be sufficient to prevent significant hypoventilation. Subsequent doses may need to be decreased by 25–50%. Initial drowsiness will diminish with continued use.

How to prepare: Direct IV: Diluent: Dilute with at least 5 mL of sterile water or 0.9% NaCl for injection. Concentration 0.5–5 mg/mL.
Rate: High Alert: Administer 2.5–15 mg over 5 min. Rapid administration may lead to increased respiratory depression, hypotension, and circulatory collapse.
~~~~
Continuous Infusion: Diluent: May be added to D5W, D10W, 0.9% NaCl, 0.45% NaCl, Ringer's or LR, dextrose/saline solution, or dextrose/Ringer's or LR. Concentration 0.1–1 mg/mL or greater for continuous infusion.
Rate: Administer via infusion pump to control the rate. Dose should be titrated to ensure adequate pain relief without excessive sedation, respiratory depression, or hypotension. May be administered via patient-controlled analgesia (PCA) pump.

Flow rate: volume (mL)/time (min) X drop factor (gtt/mL)= IV flow rate (gtt/min)

mL/hr: volume (mL)/time(min) X 60min/1 hr = IV flow rate (mL/hr)

IM: SC: Use IM route for repeated doses, because morphine is irritating to subcut tissues.
IM sites: ventrogluteal, vastus lateralis, dorsogluteal, rectus femoris, deltoid
~~~~~

Patient teaching:May cause drowsiness or dizziness. Caution patient to call for assistance when ambulating or smoking and to avoid driving or other activities requiring alertness until response to medication is known. Advise patient to change positions slowly to minimize orthostatic hypotension. Encourage patients who are immobilized or on prolonged bedrest to turn, cough, and breathe deeply every 2 hr to prevent atelectasis.

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NITRO DERM PATCH (Nitr Derm) - Derm
0.3mg/hr QD
Safe Dose: Yes
*Cleanse skin w/ alcohol first
*Wear gloves to protect YOUR skin
*Assess for HypoTN
*Causes headaches

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Drug class: Nitrates, antianginals

Mech. of Action: Increases coronary blood flow by dilating coronary arteries and improving collateral flow to ischemic regions; Produces vasodilation (venous greater than arterial); Decreases left ventricular end-diastolic pressure and left ventricular end-diastolic volume (preload); Reduces myocardial oxygen consumption

Indications: Management of angina pectoris; acute and long term prophylatic

Onset: 40-60 mins
Peak: unk
Duration: 8-12 hrs

Contraindications: Hypersensitivity, Severe anemia, Pericardial tamponade, Constrictive pericarditis, Alcohol intolerance (large IV doses only), Concurrent use of PDE-5 inhibitor (sildenafil, tadalafil, vardenafil).

Suggested dose for Transderm Adults: Transdermal patch–0.2–0.4 mg/hr initially; may titrate up to 0.4–0.8 mg/hr. Patch should be worn 12–14 hr/day and then taken off for 10–12 hr/day.

Side effects: Dizziness, headache, restlessness, weakness, hypotension, tachycardia, syncope, contact dermatitis, abdominal pain, nausea, vomiting

Drug-drug interactions: Concurrent use of nitrates in any form sildenafil, tadalafil, and vardenafil increase risk of serious and potentially fatal hypotension; concurrent use is contraindicated; Agents having anticholinergic properties (tricyclic antidepressants, antihistamines, phenothiazines) may lower absorption of translingual or sublingual nitroglycerin.

How to use: Transdermal patches may be applied to any hairless site (avoid distal extremities or areas with cuts or calluses). Apply firm pressure over patch to ensure contact with skin, especially around edges. Apply a new dose unit if the first one becomes loose or falls off. Units are waterproof and not affected by showering or bathing. Do not cut or trim system to adjust dosage. Do not alternate between brands of transdermal products; dose may not be equivalent. Remove patches before MRI, cardioversion or defibrillation to prevent patient burns. Patch may be worn for 12–14 hr and removed for 10–12 hr at night to prevent development of tolerance.

Lab Test Considerations: May cause falsely elevate serum cholesterol levels.

Nursing Implications: Assess location, duration, intensity, and precipitating factors of patient's anginal pain; Monitor BP and pulse before and after administration. Patients receiving IV nitroglycerin require continuous ECG and BP monitoring.

Patient teaching: Instruct patient to take medication as directed, even if feeling better. Take missed doses as soon as remembered unless next dose is scheduled within 2 hr (6 hr with extended-release preparations). Do not double doses. Do not discontinue abruptly; gradual dose reduction may be necessary to prevent rebound angina. Caution patient to change positions slowly to minimize orthostatic hypotension. First dose should be taken while in a sitting or reclining position, especially in geriatric patients.
Inform patient that headache is a common side effect that should decrease with continuing therapy. Aspirin or acetaminophen may be ordered to treat headache. Notify health care professional if headache is persistent or severe. Advise patient to notify health care professional if dry mouth or blurred vision occurs

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NORVASC (Amlodipine Besylate) - PO
2.5mg QD PO
Safe Dose: Yes, this must be a small or fragile patient
*Give w/ or w/o food but NO GRAPEFRUIT JUICE
*Check BP before and after giving

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Drug class: Antihypertensives, Calcium Channel Blockers

Mech. of Action: Inhibits the transport of calcium into myocardial and vascular smooth muscle cells resulting in inhibition of excitation contraction coupling and subsequent contraction.

Indications: Alone or with other agents in the management of hypertension, angina pectoris, and vasospastic (Prinzmetal's) angina.

Onset: unk
Peak: 6-9 (I'm guessing hours)
Duration: 24hrs

Contraindications: Hypersensitivity; systolic BP < 90mm Hg; Severe hepatic impairment (dosage reduction recommended); Aortic stenosis; History of HF

Suggested dose for PO Adults: 5–10 mg once daily; antihypertensive in fragile or small patients or patients already receiving other antihypertensives–initiate at 2.5 mg/day, ↑ as required/tolerated (up to 10 mg/day) as an antihypertensive therapy with 2.5 mg/day in patients with hepatic insufficiency.

Side effects: Headache, dizziness, fatigue, peripheral edema, angina, bradycardia, hypotension, palpitations, gingival hyperplasia, nausea

Drug-drug interactions: Strong CYP3A4 inhibitors, including ketoconazole, itraconazole, and ritonavir may increase levels. Increased risk of myopathy with simvastatin (do not exceed 20 mg/day of simvastatin). Drug-Food: Grapefruit juice increase serum levels and effect.

Nursing Implications: Monitor BP and pulse before therapy, during dose titration, and periodically during therapy. Monitor ECG periodically during prolonged therapy. Monitor I&Os and daily weight. Assess for signs of HF (peripheral edema, rales/crackles, dyspnea, weight gain, jugular venous distention).
Angina: Assess location, duration, intensity, and precipitating factors of patient's anginal pain.
Lab Test Considerations: Total serum calcium concentrations are not affected by calcium channel blockers.

Patient teaching: Advise patient to take medication as directed, even if feeling well. Take missed doses as soon as possible unless almost time for next dose; do not double doses. May need to be discontinued gradually.
Advise patient to avoid large amounts (6–8 glasses of grapefruit juice/day) during therapy.
Instruct patient on correct technique for monitoring pulse. Instruct patient to contact health care professional if heart rate is <50 bpm.
Caution patient to change positions slowly to minimize orthostatic hypotension.
Instruct patient on importance of maintaining good dental hygiene and seeing dentist frequently for teeth cleaning to prevent tenderness, bleeding, and gingival hyperplasia (gum enlargement).
Instruct patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products being taken, to avoid alcohol, and to consult health care professional before taking any new medications, especially cold preparations.
Advise patient to notify health care professional if irregular heartbeats, dyspnea, swelling of hands and feet, pronounced dizziness, nausea, constipation, or hypotension occurs or if headache is severe or persistent.
Angina:
Instruct patient on concurrent nitrate or beta-blocker therapy to continue taking both medications as directed and to use SL nitroglycerin as needed for anginal attacks.
Advise patient to contact health care professional if chest pain does not improve or worsens after therapy, if it occurs with diaphoresis, if shortness of breath occurs, or if severe, persistent headache occurs.
Caution patient to discuss exercise restrictions with health care professional before exertion.
Hypertension:
Encourage patient to comply with other interventions for hypertension (weight reduction, low-sodium diet, smoking cessation, moderation of alcohol consumption, regular exercise, and stress management). Medication controls but does not cure hypertension.
Instruct patient and family in proper technique for monitoring BP. Advise patient to take BP weekly and to report significant changes to health care professional.

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NPH INSULIN (Practi-NPH U100 Insulin) - SQ
15Units qAM SQ -
Safe Dose: Check glucose first (Accucheck)
*Administer w/in 30–60 min before a meal
*Meal should be on the floor
*Long-acting
*Rotate sites.
*HS snack

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Drug class: Antidiabetics, hormones

Mech. of Action: Lowers blood glucose by stimulating glucose uptake in skeletal muscle and fat and inhibiting hepatic glucose production; Inhibits lipolysis and proteolysis, enhances protein synthesis

Indications: Controls hyperglycemia in pts wit diabetes mellitus

Onset: 2-4hrs
Peak: 4-10hrs
Duration: 10-16hrs

Contraindications: Hypoglycemia
Allergy or hypersensitivity to a particular type of insulin, preservatives, or other additives.

Suggested dose for SQ Adults: Dose depends on blood glucose, response, and many other factors
SC: (Adults and Children) 0.5–1 unit total insulin/kg/day. Adolescents during rapid growth–0.8–1.2 units total insulin/kg/day.

Side effects: HYPOGLYCEMIA, lipodystrophy, pruritus, erythema, swelling

Drug-drug interactions: Beta blockers, clonidine, and reserpine may mask some of the signs and symptoms of hypoglycemia.
Corticosteroids, thyroid supplements, estrogens, isoniazid, niacin, phenothiazines, and rifampin may increase insulin requirements. Alcohol, ACE inhibitors, MAO inhibitors, octreotide, oral hypoglycemic agents, and salicylates, may lower insulin requirements.
Drug-Natural Products:
Glucosamine may worsen blood glucose control.
Fenugreek, chromium, and coenzyme Q-10 may produce additive hypoglycemic effects.

Nursing Implications: Assess patient periodically for symptoms of hypoglycemia (anxiety; restlessness; tingling in hands, feet, lips, or tongue; chills; cold sweats; confusion; cool, pale skin; difficulty in concentration; drowsiness; nightmares or trouble sleeping; excessive hunger; headache; irritability; nausea; nervousness; tachycardia; tremor; weakness; unsteady gait) and hyperglycemia (confusion, drowsiness; flushed, dry skin; fruit-like breath odor; rapid, deep breathing, polyuria; loss of appetite; unusual thirst) during therapy.
Monitor body weight periodically. Changes in weight may necessitate changes in insulin dose.
Lab Test Considerations:
Monitor blood glucose every 6 hr during therapy, more frequently in ketoacidosis and times of stress. A1C may be monitored every 3–6 mo to determine effectiveness.
Toxicity Overdose:
Severe hypoglycemia is a life-threatening emergency; treatment consists of IV glucose, glucagon, or epinephrine.

Patient teaching: Instruct patient on proper technique for administration. Include type of insulin, equipment (syringe, cartridge pens, alcohol swabs), storage, and place to discard syringes. Discuss the importance of not changing brands of insulin or syringes, selection and rotation of injection sites, and compliance with therapeutic regimen. Caution patient that insulin pens should not be shared with others, even if clean needles are used.

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PERCOCET (Practi-Perco) - PO
5mg/375mg q 4h PRN pain 3-6
10mg/375mg q4h PRN pain 7-10
*Safe dose: Yes
*Waste it with another RN if you have extra
*Have NARCAN closeby
*Give with food or milk, full glass of water.

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Drug class: Opioid analgesic

Mech. of action: Binds to opiate receptors in the brain and alters perception of pain

Indications: Moderate to severe pain

Contraindications: Hypersensitivity to oxycodone/acetominophen/aspirin/ibuprofen; pts with bleeding disorders/thrombocytopenia, renal or hepatic disease; avoid chronic use in lactating patients

Side effects: confusion, sedation, dizziness, dysphoria and euphoria, floating, hallucinations, unusual dreams, diplopia, blurred vision, RESPIRATORY DEPRESSION, O-hypotension, constipation, dry mouth, GI upset, urinary retention, flushing/sweating, dependence, tolerance

Nursing Implications: Assess pain, BP, pulse, respirations before and during administration, assess for dependence and tolerance, assess bowel function; prevent constipation with + fluids, bulk, lax. Stimulant laxatives admin if opioid use exceeds 2-3 days; Watch patient swallow meds

Patient teaching: Instruct pt on how and when to take med; protect med from theft; may cause drowsiness or dizziness so get help ambulating and avoid driving; empty matrix tabs may appear in stool; Avoid ETOH and CNS depressants; encourage deep breathing every 2 hours to prevent atelectasis. Teach: how/when to ask for pain meds; turn – cough – breathe deeply q2h

Prof. Rose's Notes: Remember that it contains tylenol; check pt 30 mins after administering; causes constipation so push pt to take fiber and fluid; makes pt "loopy" so they are a fall risk

Front 24

POTASSIUM CHLORIDE (Potassm) - PO
40mEq bid PO
Safe Dose: Yes
*Give w/ or after meals to prevent GI upset
*Patient cannot chew/crush enteric coated meds

Back 24

Drug class: Mineral and electrolyte replacements/supplements

Mech. of Action: Maintain acid-base balance, isotonicity, and electrophysiologic balance of the cell; Activator in many enzymatic reactions; essential to transmission of nerve impulses; contraction of cardiac, skeletal and smooth muscle; gastric secretion; renal function; tissue synthesis; and carb metabolism

Indications: Treatment/prevention of potassium depletion

Onset: unk
Peak: 1-2hrs
Duration: unk

Contraindications: Hyperkalemia, Severe renal impairment, Untreated Addison's disease, Some products may contain tartrazine (FDC yellow dye #5) or alcohol; avoid using in patients with known hypersensitivity or intolerance; Hyperkalemic familial periodic paralysis.

Suggested dose for PO Adults: 40–80 mEq/day
Prevention of hypokalemia during Diuretic Therapy
PO: (Adults) 20–40 mEq/day in 1–2 divided doses; single dose should not exceed 20 mEq.
Treatment of Hypokalemia
PO: (Adults) 40–100 mEq/day in divided doses

Side effects: confusion, restlessness, weakness, ECG changes, abdominal pain, diarrhea, flatulence, nausea, vomiting, ulceration, stenotic lesions, paralysis, paresthesia

Drug-drug interactions: Use with potassium-sparing diuretics or ACE inhibitors or angiotensin II receptor antagonists may lead to hyperkalemia; Anticholinergics may increase GI mucosal lesions in patients taking wax-matrix potassium chloride preparations

Nursing Implications: Assess for signs and symptoms of hypokalemia (weakness, fatigue, U wave on ECG, arrhythmias, polyuria, polydipsia) and hyperkalemia

Lab Test Considerations: Monitor serum potassium before and periodically during therapy. Monitor renal function, serum bicarbonate, and pH. Determine serum magnesium level if patient has refractory hypokalemia; hypomagnesemia should be corrected to facilitate effectiveness of potassium replacement. Monitor serum chloride because hypochloremia may occur if replacing potassium without concurrent chloride.

Patient teaching: Explain to patient purpose of the medication and the need to take as directed, especially when concurrent digoxin or diuretics are taken. A missed dose should be taken as soon as remembered within 2 hr; if not, return to regular dose schedule. Do not double dose. Emphasize correct method of administration. GI irritation or ulceration may result from chewing enteric-coated tablets or insufficient dilution of liquid or powder forms.

Front 25

PREDNISONE (Practi-Pred) - PO
60mg QD x 2 days PO
Safe Dose: Yes
*Give in AM with meals to minimize GI irritation.
*Tablets may be crushed and administered with food or fluids

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Drug class: Steroidal anti-inflammatories (intermediate acting) 
immune modifiers

Mech. of Action: Supresses inflammation and the normal immune response; numerous intense metabolic effects; suppresses adrenal function at chronic doses of 5 mg/day; Replaces endogenous cortisol in deficiency states; Has minimal mineralocorticoid activity.

Indications: Used systemically and locally in a wide variety of chronic diseases including: Inflammatory, Allergic, Hematologic, Neoplastic, Autoimmune disorders. Suitable for alternate-day dosing in the management of chronic illness.
Unlabeled Use(s): Adjunctive therapy of hypercalcemia.
Adjunctive management of nausea and vomiting from chemotherapy.

Onset: Hours
Peak: unk
Duration: 1.25 - 1.5 days

Contraindications: Active untreated infections (may be used in patients being treated for tuberculous meningitis)
Some products contain alcohol and should be avoided in patients with known intolerance
Lactation: Avoid chronic use.

Suggested dose for PO Adults: Most uses–5–60 mg/day as a single dose or in divided doses. Multiple sclerosis–200 mg/day for 1 wk, then 80 mg every other day for 1 mo. Adjunctive therapy of Pneumocystis jirovecii pneumonia in AIDS patients–40 mg twice daily for 5 days, then 40 mg once daily for 5 days, then 20 mg once daily for 10 days.

Side effects: common with high-dose/long-term therapy
depression, euphoria, headache, ↑ intracranial pressure (children only), personality changes, psychoses, restlessness, cataracts, ↑ intraocular pressure, hypertension, PEPTIC ULCERATION, anorexia, nausea, vomiting, acne, ↓ wound healing, ecchymoses, fragility, hirsutism, petechiae, adrenal suppression, hyperglycemia, fluid retention (long-term high doses), hypokalemia, hypokalemic alkalosis THROMBOEMBOLISM, thrombophlebitis, weight gain, weight loss, muscle wasting, osteoporosis, avascular necrosis of joints, muscle pain, cushingoid appearance (moon face, buffalo hump), ↑ susceptibility to infection

Drug-drug interactions: Hypokalemia may ↑ risk of digoxin toxicity. Phenytoin, phenobarbital, and rifampin stimulate metabolism; may ↓ effectiveness; Oral contraceptives may ↓ metabolism; ↑ risk of adverse GI effects with NSAIDs (including aspirin).

Nursing Implications: Indicated for many conditions. Assess involved systems before and periodically during therapy.
Assess patient for signs of adrenal insufficiency (hypotension, weight loss, weakness, nausea, vomiting, anorexia, lethargy, confusion, restlessness) before and periodically during therapy. Monitor intake and output ratios and daily weights. Observe patient for peripheral edema, steady weight gain, rales/crackles, or dyspnea. Notify health care professional if these occur.

Lab Test Considerations:
Monitor serum electrolytes and glucose. May cause hyperglycemia, especially in persons with diabetes. May cause hypokalemia. May decrease WBC counts. May ↓ serum potassium and calcium and ↑ serum sodium concentrations.

Patient teaching: Caution patient to avoid vaccinations without first consulting health care professional. Glucocorticoids cause immunosuppression and may mask symptoms of infection. Instruct patient on correct technique of medication administration. Advise patient to take medication as directed. Take missed doses as soon as remembered unless almost time for next dose. Do not double doses. Stopping the medication suddenly may result in adrenal insufficiency (anorexia, nausea, weakness, fatigue, dyspnea, hypotension, hypoglycemia). If these signs appear, notify health care professional immediately. This can be life-threatening.

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PRILOSEC (Practi-Prilo) - PO
40mg QD PO
Safe Dose: Yes
*Give before meals, in the AM
*Pt must swallow whole, not crushed or chewed.
*May be given with antacids

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Drug class: Antiulcer agents, proton pump inhibitors

Mech. of Action: Binds to enzyme on gastric parietal cells in the presence of acidic gastric pH, preventing the final transport of hydrogen ions into the gastric lumen.

Indications: May be used to treat GERD, for the maintenance of healing in erosive esophagitis, for Duodenal ulcers (with or without H. pylori infection), for short-term treatment of active benign gastric ulcer, for pathologic hypersecretory disorders, and for reduction of risk of GI bleeding in critically ill patients. It can also be purchased OTC for heartburn

Onset: 1hr
Peak: 2hr
Duration: 72-96 hrs

Contraindications: hypersensitivity or lactation

Suggested dose for PO Adults: GERD/erosive esophagitis–20 mg once daily. Duodenal ulcers associated with H. pylori–40 mg once daily in the morning with clarithromycin for 2 wk, then 20 mg once daily for 2 wk or 20 mg twice daily with clarithromycin 500 mg twice daily and amoxicillin 1000 mg twice daily for 10 days (if ulcer is present at beginning of therapy, continue omeprazole 20 mg daily for 18 more days); has also been used with clarithromycin and metronidazole.Gastric ulcer–40 mg once daily for 4–6 wk. Reduction of the risk of GI bleeding in critically ill patients–40 mg initially, then another 40 mg 6–8 hr later, followed by 40 mg once daily for up to 14 days. Gastric hypersecretory conditions–60 mg once daily initially; may be increased up to 120 mg 3 times daily (doses >80 mg/day should be given in divided doses);OTC–20 mg once daily for up to 14 days.

Side effects: dizziness, drowsiness, fatigue, headache, weakness, chest pain, abdominal pain, acid regurgitation, constipation, diarrhea, flatulence, nausea, vomiting, hypomagnesemia, itching, rash, bone fracture, allergic reactions

Drug-drug interactions: May increase risk of bleeding with warfarin (Coumadin)--monitor PT and INR for these patients, hypomagnesemia (side effect) my increase risk of Digoxin toxicity. Also should not be used with St. John's wort, it may decrease levels and response.

Nursing Implications: assess routinely for epigastric or abdominal pain and for frank or occult blood in the stool, emesis, or gastric aspirate.

Labs: CBC with diff should be monitored periodically and AST, ALT, alkaline phosphatase and bilirubin may increase.

Patient teaching: The client should take the med as directed for the full course of therapy, even if feeling better. Do not double doses. Avoid activities requiring alertness until response to medication is known because of possible CNS side effects. The patient's provider should be aware of all prescription of OTC meds, vitamins, or herbal products the patient is taking. The patient should avoid alcohol, products containing aspirin or NSAIDS (****ADVIL/IBUPROFEN****), and foods that may cause an increase in GI irritation. The patient should report the onset of black, tarry stools, diarrhea, abdominal pain, or persistent headache to the healthcare professional promptly. Female patients should notify the health care professional if pregnancy is planned or suspected or if breastfeeding.

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REGULAR U100 INSULIN (Practi-Regular Insulin) - SQ
Per scale AC an HS SQ
Safe Dose: Depends on Blood glucose check
*Make sure food is right there, need to eat w/in 15 mins

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Drug class: Pancreatics, anti diabetics

Mech. of Action: Lowers blood glucose by stimulating glucose uptake in skeletal muscle and fat, and inhibiting hepatic glucose production. Also enhances protein synthesis and inhibits lipolysis and proteolysis.

Indications: Control of hyperglycemia in patients with diabetes mellitus.

Onset: 30-60 minutes
Peak: 2-4hrs
Duration: 5-7hrs

Contraindications: Hypoglycemia, allergy or hypersensitivity to a particular type of insulin, preservatives, or other additives

Suggested dose for PO Adults: 0.5-1 unit/kg/day in divided doses

Side effects: hypoglycemia (and local lipodystrophy, pruritus, erythema, and swelling)

Drug-drug interactions: Beta-blockers, clonidine, and reserpine may mask some signs and symptoms of hypoglycemia. Corticosteroids (***PREDNISONE***), thyroid supplements (***SYNTHROID***), isoniazid, niacin, phenothiazines, and rifampin may increase insulin requirements. Alcohol, ACE inhibitors, MAO inhibitors, octreotide, oral hypoglycemic agents (****GLUCOPHAGE****) and salicylates may decrease insulin requirements.

Nursing Implications: Patient should be assessed routinely for signs of hypoglycemia and hyperglycemia. Body weight should also be monitored periodically. Blood glucose should be taken before every administration of insulin in order to determine sliding scale dosing.

Patient teaching: Families should be taught about testing of blood glucose and ketones, the types of insulin, the equipment, storage, rotation of injection sites, and general compliance with the therapeutic regimen; insulin therapy is a treatment, but not a cure for diabetes. S/s of hyperglycemia and hypoglycemia and what to do in either circumstance. The patient should notify their health care provider if nausea, vomiting, or fever develops or if unable to eat regular diet or if blood glucose levels are not controlled. Carry a source of sugar and ID describing their disease and treatment regimen at all times.

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ROCEPHIN (Practi-Ceftrixne) - IM
500mg QD x 3 doses IM
Safe Dose: Yes
*Tissue toxic, give deep IM, Z-track

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Drug class: Third generation cephalosporins, Anti-infectives)

Mech. of Action: Binds to the bacterial cell wall membrane, causing cell death.

Indications: Treats numerous kinds of infections, and is used preoperatively prophylactically.

Onset: rapid
Peak: 1-2hrs
Duration: 12-24 hrs

Contraindications: Hypersensitivity to cephalosporins (***May have crossover sensitivity with penicillin.)

Suggested dose for IM Adults: Most infections–1–2 g every 12–24 hr Gonorrhea–250 mg IM (single dose). Meningitis–2 g every 12 hr.Perioperative prophylaxis-1 g 0.5–2 hr before surgery (single dose).

How to prepare: Reconstitute IM doses with sterile water for injection, or 0.9% NaCl for injection. May be diluted with Lidocaine to minimize injection discomfort; Inject deep into well developed muscle mass; massage well

Side effects: Most common are pain at the IM site. Life-threatening are anaphylactic allergic reactions, seizures, and pseudomembranous colitis.
Other possibilities include diarrhea, cholelithiasis, gallbladder slugging, rashes, uticaria, bleeding, eosinophilia, hemolytic anemia, leukopenia, thrombocytosis, superinfection.

Drug-drug interactions: Should not be administered concurrently with any calcium-containing solutions.

Nursing Implications: Assess for signs of infection throughout therapy to ensure that they are receding. Observe for anaphylaxis if they have never taken a penicillin or cephalosporin; epinephrine, an antihistamine, and resuscitation equipment should be kept nearby. Specimens for C&S should be obtained before initiating therapy. Bowel function should also be monitored for signs of pseudomembranous colitis (diarrhea, abdominal cramping, fever, and bloody stools).

Patient teaching: Patient should report signs of super infection (vaginal itching or discharge; loose or foul smelling stools). The should also report any diarrhea containing blood, mucus, or pus.

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SYNTHROID (Synthrd) - PO
100 micrograms QD PO
Safe Dose: Yes
*Take before meals with water
*Can be crushed

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Drug class: Thyroid preparations, Hormones)

Mech. of Action: Replacement of or supplementation to endogenous thyroid hormones. Principal effect is increasing metabolic rate of body tissues.

Indications: Hypothyroidism, treatment or suppression of euthyroid goiters, adjunctive treatment for some kinds of thyroid cancer.

Onset: unk
Peak: 1-3 wks
Duration: 1-3 wks

Contraindications: Hypersensitivity, recent MI, hyperthyroidism

Suggested dose for PO Adults: Hypothyroidism - 50mcg as a single dose initially; may be increased to q 2-3 weeks by 25 mcg/day; usual maintenence dose is 75-125 mcg/day (1.5 mcg/kg/day).

Side effects: (usually only seen when excessive doses cause secondary hyperthyroidism). They may include headache, insomnia, irritability, angina pectoris, arrhythmias, tachycardia, abdominal cramps, diarrhea, vomiting, sweating, hyperthyroidism, menstrual irregularities, heat intolerance, and weight loss.

Drug-drug interactions: May increase requirements for insulin or oral hyperglycemic agents in diabetics. increases cardiovascular effects with adrenergics (Sympathomimmetics). Drug-food interactions: Food or supplements containing calcium, iron, magnesium, or zinc may bind with Synthroid and prevent complete absorption.

Nursing Implications: Assess apical pulse and BP prior to and during therapy (paying attention for tachyarrhythmias) , ask patient about chest pain. Thyroid function studies should also be monitored before and during drug therapy. Administer as a single dose with a full glass of water, preferably before breakfast (to prevent insomnia). Can be crushed and placed in water if necessary for patients who have difficulty swallowing, but should not be stored in suspension.

Patient teaching: Notify their provider if they experience headache, nervousness, diarrhea, excessive sweating, heat intolerance, cheats pain, increased pulse rate, palpitations, weight loss of greater than 2 lbs per week, or other unusual symptoms. Patient should know that this medication is a treatment, not a cure. They should know not to discontinue this med without consulting a health care professional. Emphasize the importance of continued thyroid function monitoring and not adding new drugs or herbals to their regimen without consulting their provider.

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TORADOL (Toradl) - IM
30mg q6h PRN IM
Safe dose:

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Drug class: Pyrroziline carboxylic acid, NSAID, nonopiod analgesics

Mech. of Action: Inhibits prostaglandin synthesis, producing peripherally mediated analgesia, also has anti-pyretic and anti-inflammatory properties.

Indications: Short-term pain management (no more than 5 days for all routes combined).

Onset: 10 mins
Peak: 1-2hrs
Duration: 6+ hrs

Contraindications: hypersensitivity (cross-sensitivity may exist with other NSAIDS), preoperative use, active or history of peptic ulcer disease or GI bleeding, known alcohol intolerance, preoperative pain from coronary artery bypass graft surgery, cerebrovascular bleeding, advanced renal impairment or at risk for renal failure due to volume depletion, concurrent use of pentoxifylline or probenecid, pregnancy, lactation.

Suggested dose for IM Adults: Adults <65yrs - Single dose is 60mg, Multiple dosing is 30mg q6h (not to exceed 120 mg/day)
Adults >65 or renal impairment - Single dose is 30mg, Multiple dosing is 15mg q6h (not to exceed 60 mg/day)

Side effects: Most common are drowsiness, or anaphylactic allergic reaction. Life-threatening include stroke, MI, GI bleeding, exfoliative dermatitis, Stevens-Johnson syndrome, or toxic epidermal necrolysis. Other possible side effects include abnormal thinking, dizziness, euphoria, headache, asthma, dyspnea, edema, pallor, vasodilation, abnormal taste, diarrhea, dry mouth, dyspepsia, GI pain, increased liver enzymes, nausea, oliguria, renal toxicity, urinary frequency, pruritus, purpura, sweating, uticaria, prolonged bleeding time, injection site pain, parasthesia.

Drug-drug interactions: Probenecid increases levels and risk of adverse reactions, pentoxyfylline increases risk of bleeding; therefore both of these drugs are contraindicated for concurrent use with Toradol. Use with aspirin may decrease effectiveness, may increase serum lithium levels and increase risk of toxicity.
Also increases bleeding risk with the following natural products: arnica, chamomile, clove, dong quay, feverfew, garlic, ginger, ginkgo, Panax ginseng.

Nursing Implications: Assess pain (type, location, intensity) prior to and 1-2hrs following administration. Patients with asthma, aspirin allergy, or nasal polyps are at increased risk for hypersensitivity, watch for rhinitis,asthma, and uticaria. Also assess for rash periodically during therapy as Toradol may cause Stevens Johnson syndrome or toxic epidermal necrolysis.

Labs: Liver function tests should be monitored an may be increased. Bleeding time may be prolonged, and it may cause increased BUN, creatinine, or potassium concentrations.

Patient teaching: Patient should avoid driving or other activities that require mental alertness as Toradol may cause drowsiness. The patient should also avoid concurrent use of aspirin, alcohol, NSAIDs, acetaminophen, or other OTC meds without consulting the provider. Patient should also consult health care professional if rash, itching, visual disturbances, tinnitus, weight gain, edema, black stools, persistent headaches, or influenza-like syndrome (chills, fever, muscle aches, pain) occurs.

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TRIVALENT INACTIVATED INFLUENZA VACCINE (TIV-IM) - IM
0.5mL One time IM
Safe Dose:
*Do NOT aspirate

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Drug class: Immunizations

Mech. of Action: Prompts the immune system to produce antibodies to fight the influenza virus before the person has been exposed to it.

Onset: a few days
Peak: a few weeks for full immunity

Contraindications: Egg allergies! People who are immunocompromised also should not receive the vaccine, but should wait until their immune system is fully functioning and can produce the expected antibodies.

Suggested dose for PO Adults: 0.5mL, one time

Side effects: Brief fainting spells and related symptoms (such as jerking movements) can happen after any medical procedure, including vaccination. soreness, redness, or swelling at injection site, hoarseness; sore, red or itchy eyes; cough, fever, aches, headache, itching, fatigue. If these problems occur, they usually begin soon after the shot and last 1 or 2 days. A severe allergic reaction could occur after any vaccine. There is a small possibility that inactivated flu vaccine could be associated with Guillain-Barré Syndrome (GBS)

Patient teaching: Advise patient to sit or lie down for about 15 minutes after a vaccination to help prevent fainting and injuries caused by falls. Report dizziness or light-headed, or have vision changes or ringing in the ears.

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VANCOMYCIN (Practi-Vancomycin) - IV
500mg q12h IV
Safe Dose: Yes
*Check urine blood, sputum before administering

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Drug class: Anti-Infectives

Mech. of Action: Binds to bacterial cell wall, resulting in cell death.

Indications: Treatment of potentially life-threatening infections when less toxic antifectives are contraindicated. Particularly useful in staphylococcal infections, including: Endocarditis, meningitis, osteomyelitis, pneumonia, septicemia, soft-tissue infections in patients who have allergies to penicillin or its derivatives or when sensitivity testing demonstrates resistance to methicillin.

How to prepare: IV administration: To reconstitute, add 10mL of sterile water for injection to 500mg vial, or 20mL to a 1g vial for a concentration of 50mg/mL. Should then be diluted further with at least 100mL of 0.9% NaCl, D5W, D5/0.9%NaCl or LR for every 500mg of vancomycin being administered. Final concentration should be less than or equal to 5mg/mL. It should be infused over at least 60 minutes, faster infusion could cause red-man syndrome, slower infusion of 1.5-2hrs is recommendable. NOT Y-site compatible with ***ZITHROMAX (azithromycin)***!!!

Onset: rapid
Peak: end of infusion
Duration: 12-24 hrs

Contraindications: Hypersensitivity.

Suggested dose for IV Adults: 500mg q6h or 1g q12h

Side effects: Most common are nephrotoxicity and phlebitis. Only life-threatening are hypersensitivity reactions that may include anaphylaxis. Other possible side-effects include: ototoxicity, hypertension, nausea, vomiting, rashes, eosinophilia, leaukopenia, back and neck pain, chills, fever, "red man" syndrome (with rapid infusion) and superinfection.

Drug-drug interactions: May cause additive ototoxicity and nephrotoxicity with other drugs that may cause such side effects such as aspirin, aminoglycosides, cyclosporine, cisplatin, or loop diuretics.

Nursing Implications: Signs of infection should be assessed continually throughout therapy to ensure that they are receding. Should be observed for anaphylaxis if they have never taken a penicillin or cephalosporin; epinephrine, an antihistamine, and resuscitation equipment should be kept nearby if such a reaction is a possibility. Specimens for culture and sensitivity should be obtained before initiating therapy. IV site must be monitored closely because vancomycin is irritating to tissues and causes necrosis and severe pain with extravasation. BP should be monitored throughout the IV infusion. Evaluate the functioning of CN 8 by audiometry and serum levels of vancomycin prior to and throughout therapy for patients with borderline renal function or those who are over 60 yrs old. Prompt recognition of ototoxic symptoms are essential in preventing permanent damage. Monitor I&O and daily weight as measures of potential nephrotoxicity, which may be indicated by cloudy or pink urine. Should also monitor CBC and watch for for casts, albumin, or cells in the urine or decreased specific gravity during therapy. Increased BUN levels may also occur.

Patient teaching: Patient should report signs of hypersensitivity, tinnitus, vertigo, or hearing loss immediately. Additionally, if symptoms of the infection are not improving within a few days, the patient should notify their provider.

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ZITHROMAX (Practi-Zithromy) - IV
500mg q24h IV
Safe Dose: Yes
*Assess allergy

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Drug class: Macrolides, Agents for atypical mycobacterium, anti-infectives

Mech. of Action: Inhibits protein synthesis at the level of the 50S bacterial ribosome.

Indications: Treatment of upper respiratory tract infections, chronic bronchitis, pneumonia, otitis media, skin infections, and gonorrhea.

Onset: Rapid
Peak: End of infusion
Duration: 24hrs

Contraindications: Hypersensitivity to this drug or other macrolides, history of hepatic dysfunction with prior use, QT interval prolongation, hypokalemia, hypomagnesemia, bradycardia, concurrent use of quinidine, procainamide, dofetilide, amiodarone, or sotalol.

Suggested dose for IV Adults: 500mg on 1st day, then 250mg/day for 4 more days (total dose of 1.5g); Acute bacterial sinusitis - 500mg once daily for 3 days or single 2-g dose of ER suspension (Zmax).

Side effects: Most frequent are abdominal pain, diarrhea, and nausea. Life-threatening are torsades de points, hepatotoxicity, psuedomembranous colitis, Stevens-Johnson syndrome, toxic epidermal necrolysis, and angioedema. Other side effects include: dizziness, seizures, drowsiness, fatigue, headache, chest pain, hypotension, palpitations, QT interval prolongation (rare), cholestatic jaundice, increased liver enzymes, dyspepsia, flatulence, melena, oral candidiasis, pyloric stenosis, nephritis, vaginitis, anemia, leukopenia, thrombocytopenia, photosensitivity, rash, ototoxicity, and hyperkalemia.

Drug-drug interactions: Quinidine, procainamide, dofetiliide, sotalol, and amiodarone may increase risk of QT interval prolongation, so concurrent use should be avoided. Aluminum and magnesium containing antacids decrease peak levels. This and other macrolide anti-infectives have been known to increase levels and effects of digoxin, theophylline, ergotalmine, dihydroergotamine, triazolam, carbamazepine, cyclosporine, tacrolimus, and phenytoin; therefore careful monitoring of concurrent use is recommended. Nelfinavir and efavirenz also have interactions to be concerned with.

Nursing Implications: Signs of infection should be assessed continually throughout therapy to ensure that they are receding. Should be observed for anaphylaxis (rash, pruritus, laryngeal edema, wheezing) and treated accordingly. Specimens for culture and sensitivity should be obtained before initiating therapy. Assess patient for skin rash frequently during therapy. Discontinue at first sign of a rash, Stevens-Johnson syndrome or toxic epidermal necrolysis my develop. May cause increase in serum bilirubin, AST, ALT, LDH, and alkaline phosphatase concentrations. May also cause an increase in creatinine phosphokinase, potassium, prothrombin time, BUN, and blood glucose concentrations. May occasionally cause decreased WBC and platelet count.

Patient teaching: Patient should report any of the following symptoms: chest pain, palpitations, yellowing of skin or eyes, or signs of superinfection (black, furry growth on the tongue, vaginal itching or unusual discharge, loose or foul smelling stool) or rash. Fever or loose stools (especially if they contain blood, pus, or mucus) should also be reported. Warn the patient that this med may cause dizziness and drowsiness so they should avoid activities requiring alertness until the response to the medication is known. Patient should use sunscreen and protective clothing to prevent possible photosensitivity reactions if spending time outside. PO form should not be taken with food or antacids