Isosorbide Dinitrate (Isordil or Isoket) is an antianginal and a nitrate

drug. Isordil relaxes vascular smooth muscle with a resultant decrease in

Pregnancy Category C

Dosage & Route

venous return and decrease in arterial BP, which reduces left ventricular
workload and decreases myocardial oxygen consumption.
Adults
Contents [show]

To avoid tolerance to drug, take short-acting products bid or tid with last

Generic Names

dose no later than 7 PM and SR products once daily or bid at 8 PM and 2

PM. This creates a nitrate-free period.

isosorbide nitrates , isosorbide dinitrate , isosorbide mononitrate

Isosorbide dinitrate

Brand Names

Angina pectoris: Starting dose, 2.55 mg sublingual, 5-mg chewable

tablets, 5- to 20-mg oral tablets. For maintenance, 1040 mg q 6 hr oral

Isordil,

Isordil Titradose ,

Imdur,

ISMO,

Isotrate ER,

Monoket

Classifications

tablets or capsules; SR, initially 40 mg, then 4080 mg PO q 812 hr.

Acute prophylaxis: Initial dosage, 510 mg sublingual or chewable

tablets q 23 hr.

Isosorbide mononitrate

Prevention of angina: 20 mg PO bid given 7 hr apart; ER tablets30

60 mg/day PO may be increased to 120 mg/day if needed. In smaller
patients, start with 5 mg (one-half of 10-mg tablet) but then increase to

Antianginal,

at least 10 mg by day 2 or 3 of therapy. Give first dose when waking

Nitrate,

and second dose 7 hr later. This creates a nitrate-free period and

Vasodilator

minimizes tolerance to drug.

Pediatric patients

GI: Nausea, vomiting, incontinence of urine and feces, abdominal pain,

diarrhea

Safety and efficacy not established.

GU: Dysuria, impotence, urinary frequency

Other: Muscle twitching, pallor, perspiration, cold sweat, arthralgia,

bronchitis

Therapeutic actions

Contraindications
Isordil relaxes vascular smooth muscle with a resultant decrease in venous
return and decrease in arterial BP, which reduces left ventricular workload

Contraindicated with allergy to nitrates, severe anemia, head trauma,

cerebral hemorrhage, hypertrophic cardiomyopathy, narrow-angle

and decreases myocardial oxygen consumption.

glaucoma, postdural hypotension

Indications

Use cautiously with pregnancy, lactation, acute MI, CHF.

Nursing considerations

Dinitrate: Treatment and prevention of angina pectoris

Mononitrate: Prevention of angina pectoris

Unlabeled use (dinitrate): Used with hydralazine in patients with

[box type="alert"]Name confusion has occurred between Isordil (isosorbide)

advanced CHF

and Plendil (felodipine); use caution.[/box]

Adverse effects

Assessment

CNS: Headache, apprehension, restlessness, weakness, vertigo,

dizziness, faintness

trauma, cerebral hemorrhage, hypertrophic cardiomyopathy, pregnancy,

CV: Tachycardia, retrosternal discomfort, palpitations, hypotension,

lactation

syncope, collapse, orthostatic hypotension, angina, rebound

History: Allergy to nitrates, severe anemia, GI hypermobility, head

Physical: Skin color, T, lesions; orientation, reflexes, affect; P, BP,

hypertension, atrial fibrillation, postural hypertension

orthostatic BP, baseline ECG, peripheral perfusion; R, adventitious

Dermatologic: Rash, exfoliative dermatitis, cutaneous vasodilation with

sounds; liver evaluation, normal output; CBC, Hgb

flushing

Interventions

meals; do not chew or crush sustained-release preparations; do not

take isosorbide mononitrate to relieve acute anginal episodes.

Give sublingual preparations under the tongue or in the buccal pouch;

(may be transient; use care to change positions slowly); headache (lie

discourage the patient from swallowing.

You may experience these side effects: Dizziness, lightheadedness

down in a cool environment, rest; over-the-counter preparations may

Create a nitrate-free period to minimize tolerance.

not help; take drug with meals); flushing of the neck or face (reversible).

[box type="alert"]WARNING: Give chewable tablets slowly, only 5 mg

Report blurred vision, persistent or severe headache, rash, more

frequent or more severe angina attacks, fainting.

initially, because severe hypotension can occur; ensure that patient does not
chew or crush sustained-release preparations.[/box]

Give oral preparations on an empty stomach, 1 hr before or 2 hr after

meals; take with meals if severe, uncontrolled headache occurs.

[box type="alert"]WARNING: Keep life support equipment readily available if

overdose occurs or cardiac condition worsens.[/box]
[box type="alert"]WARNING: Gradually reduce dose if anginal treatment is
being terminated; rapid discontinuation can lead to problems of
withdrawal.[/box]

Generic Names

Teaching Points
budesonide

Place sublingual tablets under your tongue or in your cheek; do not

chew or swallow the tablet. Take the isosorbide before chest pain

(bue des oh nide)

begins, when activities or situation may precipitate an attack. Take oral

isosorbide dinitrate on an empty stomach, 1 hour before or 2 hours after

Brand Names

Inhalation:

Entocort (CAN), Pulmicort Respules, Pulmicort Turbuhaler, Rhinocort Aqua,

Turbuhaler

Maintenance treatment of asthma as prophylactic therapy in adults and

children > 6 yr and for patients requiring corticosteroids for asthma

Rhinocort Turbuhaler (CAN)

Inhalation suspension
Oral:

12 mo8 yr

Entocort EC

Drug class

Oral

Corticosteroid

Pregnancy Category B

Therapeutic actions

Maintenance treatment and prophylaxis therapy of asthma in children

Treatment of mild to moderate active Crohns disease involving the

ileum or ascending colon

Contraindications and cautions

Inhalation

Anti-inflammatory effect; local administration into nasal passages maximizes

beneficial effects on these tissues, while decreasing the likelihood of

Contraindicated with hypersensitivity to drug or for relief of acute

asthma or bronchospasm.

adverse effects from systemic absorption.

Use cautiously with TB, systemic infections, lactation.

Indications
Oral

Management of symptoms of seasonal or perennial allergic rhinitis in

adults and children; nonallergic perennial rhinitis in adults

Contraindicated with hypersensitivity to drug, lactation.

Use cautiously with TB, hypertension, diabetes mellitus, osteoporosis,

dose possible to maintain the control of symptoms. Generally takes 37

peptic ulcer disease, glaucoma, cataracts, family history of diabetes or

glaucoma, other conditions in which glucocorticosteroids may have

days to achieve maximum clinical effect.

unwanted effects.

Pulmicort Turbuhaler
Nasal
ADULTS

Contraindicated with hypersensitivity to drug, nasal infections, nasal

trauma, nasal septal ulcers, recent nasal surgery.

Use cautiously with lactation, TB, systemic infection.

Previously on inhaled corticosteroids: Initially, 200400 mcg twice daily,

maximum dose, 800 mcg bid (4 inhalations).

Available forms
Previously on bronchodilators alone: 200400 mcg bid.
Aerosol32 mcg/actuation; dry powder for inhalation200 mcg (each
Previously on oral corticosteroids: 400800 mcg bid.
actuation delivers 160 mcg); inhalation suspension0.25 mg/2 mL,
0.5 mg/2 mL; capsules3 mg
PEDIATRIC PATIENTS

Dosages
Children > 6 yr previously on inhaled corticosteroids: 200 mcg bid.

Nasal inhalation
Children > 6 yr previously on bronchodilators alone: 200 mcg bid.

ADULTS AND PATIENTS > 6 YR

Initial dose, 64 mcg/day given as 1 spray in each nostril morning and

evening. After desired clinical effect is achieved, reduce dose to the smallest

Children > 6 yr previously on oral corticosteroids: 400 mcg bid.

Respules

PEDIATRIC PATIENTS 12 MO8 YR

Route

Onset

Peak

Duration

Intranasal, inhaled

Immediate

Rapid

812 hr

Oral

Slow

0.510 hr

Unknown

0.251 mg once daily or in two divided doses

of Respules, using jet nebulizer.

Oral

ADULTS
Metabolism: Hepatic; T1/2: 23.6 hr (oral); T1/2: 2.8 hr (inhalation)
9 mg/day PO taken in the morning for up to 8 wk. Recurrent episodes may
Distribution: Crosses placenta; may enter breast milk
be retreated for 8-wk periods.
Excretion: Urine
PEDIATRIC PATIENTS

Adverse effects
Safety and efficacy not established.

PATIENTS WITH HEPATIC IMPAIRMENT

Monitor patients very closely for signs of hypercorticism; reduced dosage

should be considered with these patients.

Pharmacokinetics

CNS: Headache, dizziness, lethargy, fatigue, paresthesias,

nervousness

Dermatologic: Rash, edema, pruritus, alopecia

Endocrine: HPA suppression, Cushings syndrome

with overdosage and systemic absorption

GI: Nausea, dyspepsia, dry mouth

Local: Nasal irritation, fungal infection

Respiratory: Epistaxis, rebound congestion, pharyngitis, cough

Other: Chest pain, asthenia, moon face, acne, bruising, back pain

Interactions
Oral use

Inhalation

WARNING: Taper systemic steroids carefully during transfer

to inhalational steroids; deaths from adrenal insufficiency have
occurred.

Drug-drug

Arrange for use of decongestant nose drops to facilitate penetration if

edema, excessive secretions are present.

Increased risk of corticosteroid toxic effects if combined

with ketoconazole, itraconazole, ritonavir, indinavir, saquinavir,

Prime unit before use for Pulmicort Turbuhaler; have patient rinse
mouth after each use.

erythromycin, or other known CYP3A4 inhibitors; if drugs must be used

Use aerosol within 6 mo of opening. Shake well before each use.

together, decrease dosage of budesonide and monitor patient closely

Store Respules upright and protected from light; gently shake before
use; open envelopes should be discarded after 2 wk.

Drug-food

Oral

Risk of increased toxic effects if combined with grapefruit juice; avoid

this combination.

Make sure patient does not cut, crush, or chew capsules; they must be
swallowed whole.

Nursing considerations

Administer the drug once each day, in the morning; do not administer
with grapefruit juice.

Assessment

Encourage patient to complete full 8 wk of drug therapy.

WARNING: Monitor patient for signs of hypercorticismacne, bruising,

moon face, swollen ankles, hirsutism, skin striae, buffalo humpwhich

History: Untreated local nasal infections, nasal trauma, septal ulcers,

could indicate need to decrease dosage.

recent nasal surgery, lactation

Physical: BP, P, auscultation; R, adventitious sounds; examination of

nares

Interventions

Teaching points
Inhalation

Do not use more often than prescribed; do not stop without consulting

nausea, flatulence (frequent small meals may help; try to maintain your

your health care provider.

fluid and food intake).

It may take several days to achieve good effects; do not stop if effects
are not immediate.

Use decongestant nose drops first if nasal passages are blocked.

Prime unit before use for Pulmicort Turbuhaler; rinse mouth after each

Report chest pain, ankle swelling, respiratory infections, increased

bruising.

ALBUTEROL SULFATE

use.

Store Respules upright, protect from light; discard open envelopes after

GENERIC NAME: albuterol sulfate

2 wk; gently shake before use.

You may experience these side effects: Local irritation (use your device
correctly), dry mouth (suck sugarless lozenges).

Report sore mouth, sore throat, worsening of symptoms, severe

BRAND NAME: AccuNeb, Novo-Salmol, Proventil, Proventil HFA, Salbutamol, Ventodisk,

Ventolin HFA

sneezing, exposure to chickenpox or measles, eye infections.

DRUG CLASSES: Beta2-selective adrenergic agonist, Bronchodilator, Antasthmatic

Oral

Pregnancy Category C

Take the drug once a day in the morning. Do not cut, crush, or chew the
capsules, they must be swallowed whole.

If you miss a day, take the capsules as soon as you remember them.
Take the next days capsules at the regular time. Do not take more than

THERAPEUTIC ACTIONS

three capsules in a day.

Take the full course of the drug therapy (8 wk in most cases).

Do not take this drug with grapefruit juice; avoid grapefruit juice entirely
while using this drug.

Store Respules upright, protected from light; discard open envelopes

after 2 wk. Shake before use.

In low doses, acts relatively selectively at beta2-adrenergic receptors to cause

bronchodilation and vasodilation; at higher doses, beta2 selectivity is lost, and the drug acts
at beta2 receptors to cause typical sympathomimetic cardiac effects.

You may experience these side effects: Dizziness, headache (avoid

driving or operating dangerous machinery if these effects occur);

INDICATIONS

1. Relief and prevention of bronchospasm in patients with reversible obstructive airway

disease;

GU: Increased incidence of leiomyomas of uterus when given in higher than human doses in
preclinical studies

2. Inhalation: Treatment of acute attacks of bronchospasm;

Respiratory: Respiratory difficulties, pulmonary edema, coughing, bronchospasm, paradoxical

airway resistance with repeated, excessive use of inhalation preparations

3. Prevention of exercise-induced bronchospasm;

INTERACTIONS
CONTRAINDICATIONS

Drug-drug
1. Contraindicated with hypersensitivity to albuterol; tachyarrhythmias, tachycardia caused
by digitalis intoxication; general anesthesia with halogenated hydrocarbons or cyclopropane
(these sensitize the myocardium to catecholamines); unstable vasomotor system disorders;
hypertension; coronary insufficiency, CAD; history of stroke; COPD patients with degenerative
heart disease.

1. Increased sympathomimetic effects with other sympathomimetic drugs;

2. Increased risk of toxicity, especially cardiac, when used with theophylline, aminophylline,
oxtriphylline;

2. Use cautiously with diabetes mellitus (large IV doses can aggravate diabetes and
ketoacidosis); hyperthyroidism; history of seizure disorders; psychoneurotic individuals; labor
and delivery (oral use has delayed second stage of labor; parenteral use of beta2-adrenergic
agonists can accelerate fetal heart beat and cause hypoglycemia, hypokalemia, pulmonary
edema in the mother and hypoglycemia in the neonate); lactation; the elderly (more sensitive
to CNS effects).

3. Decreased bronchodilating effects with beta-adrenergic blockers (eg, propranolol);

4. Decreased effectiveness of insulin, oral hypoglycemic drugs; and
5. Decreased serum levels and therapeutic effects of digoxin

NURSING CONSIDERATIONS
ADVERSE EFFECTS
Assessment
CNS: Restlessness, apprehension, anxiety, fear, CNS stimulation, hyperkinesia, insomnia,
tremor, drowsiness, irritability, weakness, vertigo, headache
CV: Cardiac arrhythmias, tachycardia, palpitations, PVCs (rare), anginal pain
Dermatologic: Sweating, pallor, flushing
GI: Nausea, vomiting, heartburn, unusual or bad taste in mouth

History: Hypersensitivity to albuterol; tachyarrhythmias, tachycardia caused by digitalis

intoxication; general anesthesia with halogenated hydrocarbons or cyclopropane; unstable
vasomotor system disorders; hypertension; coronary insufficiency, CAD; history of stroke;
COPD patients who have developed degenerative heart disease; diabetes mellitus;
hyperthyroidism; history of seizure disorders; psychoneurotic individuals; lactation

captopril
Physical: Weight; skin color, T, turgor; orientation, reflexes, affect; P, BP; R, adventitious
sounds; blood and urine glucose, serum electrolytes, thyroid function tests, ECG

Brand Names
Interventions1. Use minimal doses for minimal periods; drug tolerance can occur with
prolonged use.
2. Maintain a beta-adrenergic blocker (cardioselective beta-blocker, such as atenolol, should
be used with respiratory distress) on standby in case cardiac arrhythmias occur.
3. Prepare solution for inhalation by diluting 0.5 mL 0.5% solution with 2.5 mL normal saline;
deliver over 515 min by nebulization.
4. Do not exceed recommended dosage; administer pressurized inhalation drug forms during
second half of inspiration, because the airways are open wider and the aerosol distribution is
more extensive.

Apo-Capto (CAN),

Capoten,

Gen-Captopril (CAN),

Novo-Captopril (CAN),

Nu-Capto (CAN)

Classification
ACE inhibitor, Antihypertensive

Teaching points

1. Do not exceed recommended dosage; adverse effects or loss of effectiveness may result.
Read the instructions that come with respiratory inhalant.
2. You may experience these side effects: Dizziness, drowsiness, fatigue, headache (use
caution if driving or performing tasks that require alertness); nausea, vomiting, change in
taste (eat frequent small meals); rapid heart rate, anxiety, sweating, flushing, insomnia.
3. Report chest pain, dizziness, insomnia, weakness, tremors or irregular heart beat, difficulty
breathing, productive cough, failure to respond to usual dosage.

Pregnancy Category C (first trimester)

Pregnancy Category D (second and third trimesters)

Dosage & Route

Generic Name

PO HTN Initial: 12.5 mg twice daily.

Maintenance: 25-50 mg twice daily.

Max: 50 mg 3 times/day.

Heart failure Initial: 6.25-12.5 mg 2-3 times/day.

Max: 50 mg 3 times/day.

Post MI Start 3 days after MI.

Initial: 6.25 mg/day, may increase after several wk to 150 mg/day

in divided doses if needed and tolerated.

Diabetic nephropathy 25 mg 3 times/day.

Treatment of hypertension alone or in combination with thiazide-type

diuretics

Treatment of CHF in patients unresponsive to conventional therapy;

used with diuretics and digitalis

Therapeutic actions

Treatment of diabetic nephropathy

Treatment of left ventricular dysfunction after MI

Unlabeled uses: Management of hypertensive crises; treatment of

Captopril competitively inhibits the conversion of angiotensin I (ATI) to

rheumatoid arthritis; diagnosis of anatomic renal artery stenosis,

angiotensin II (ATII), thus resulting in reduced ATII levels and

hypertension related to scleroderma renal crisis; diagnosis of primary

aldosterone secretion. It also increases plasma renin activity and

aldosteronism, idiopathic edema; Bartters syndrome; Raynauds

bradykinin levels. Reduction of ATII leads to decreased sodium and

syndrome

water retention. By these mechanisms, captopril produces a

hypotensive effect and a beneficial effect in congestive heart failure.

Pharmacokinetics

Hypotension, tachycardia, chest pain, palpitations, pruritus,

hyperkalemia. Proteinuria; angioedema, skin rashes; taste disturbance,

Absorption: 60-75% absorbed from the GI tract (oral); peak plasma

concentrations after 1 hr. Absorption may be reduced in the presence of

Adverse effects

nonproductive cough, headache.

Potentially Fatal: Neutropenia, usually occurs within 3 mth of starting

food.

therapy especially in patients with renal dysfunction or collagen

Distribution: Protein-binding: 30%; crosses the placenta and enters

diseases. Hyperkalaemia. Anaphylactic reactions.

breast milk at about 1% of maternal blood concentrations.

Excretion: Via urine (40-50% as unchanged, the rest as disulfide and

other metabolites); 2-3 hr (elimination half-life), may be increased in

Contraindications

renal impairment. Removed by hemodialysis.

Indications

Known hypersensitivity to the drug.

Bilateral renal artery stenosis,

hereditary angioedema;

renal impairment;

pregnancy.

Nursing Considerations

Monitor patient closely for fall in BP secondary to reduction in fluid

volume (due to excessive perspiration, and dehydration, vomiting, or

Assessment

History: Allergy to captopril, history of angioedema, impaired renal

diarrhea); excessive hypotension may occur.

Reduce dosage in patients with impaired renal function.

Teaching points

function, CHF, salt or volume depletion, pregnancy, lactation

Physical: Skin color, lesions, turgor; T; P, BP, peripheral perfusion;

mucous membranes, bowel sounds, liver evaluation; urinalysis, LFTs,
renal function tests, CBC and differential

without consulting your healthcare provider.

Be careful of drop in blood pressure (occurs most often with diarrhea,

sweating, vomiting, or dehydration); if lightheadedness or dizziness

Interventions

occurs, consult your healthcare provider.

Take drug 1 hour before meals; do not take with food. Do not stop

Administer 1 hr before meals.

Severe fetal damage can occur if captopril is taken during pregnancy.

Use of contraceptives is advised; if pregnancy should occur, stop drug
and notify health care provider.

[box type="note"]WARNING: Ensure that patient is not pregnant before

Avoid over-the-counter medications, especially cough, cold, allergy

medications that may contain ingredients that will interact with ACE

beginning treatment. Encourage use of contraceptives; if pregnancy is

inhibitors. Consult your healthcare provider.

detected, stop drug.[/box]

You may experience these side effects: Cough, GI upset, loss of

appetite, change in taste perception (limited effects, will pass); mouth
sores (frequent mouth care may help); rash; fast heart rate; dizziness,

[box type="note"]WARNING: Alert surgeon and mark patients chart with

light-headedness (usually passes after the first few days; change

notice that captopril is being taken; the angiotensin II formation subsequent

position slowly, and limit your activities to those that do not require

to compensatory renin release during surgery will be blocked; hypotension

may be reversed with volume expansion.[/box]

alertness and precision).

Report mouth sores; sore throat, fever, chills; swelling of the hands or
feet; irregular heartbeat, chest pains; swelling of the face, eyes, lips or
tongue; difficulty breathing.

Generic Name

Initially, 2080 mg/day PO as a single dose. If needed, a second dose

may be given in 68 hr.

furosemide

Brand Name

If response is unsatisfactory, dose may be increased in 20- to 40-mg

increments at 6- to 8-hr intervals.

Up to 600 mg/day may be given.

Intermittent dosage schedule (24 consecutive days/wk) is preferred for

maintenance, or 2040 mg IM or IV (slow IV injection over 12 min).

Apo-Furosemide (CAN),

Furosemide Special (CAN),

Lasix

May increase dose in increments of 20 mg in 2 hr. High-dose therapy

should be given as infusion at rate not exceeding 4 mg/min.

Acute pulmonary edema:

Classification

Loop diuretic

Pregnancy Category C

Dosage & Route

40 mg IV over 12 min. M

ay be increased to 80 mg IV given over 12 min if response is

unsatisfactory after 1 hr.

Hypertension:

Available forms :Tablets20, 40, 80 mg; oral solution10 mg/mL, 40 mg/5

mL; injection10 mg/mL

40 mg bid PO. If needed, additional antihypertensive agents may be

added.

Pediatric Patients

Adults
Avoid use in premature infants: stimulates prostaglandin E2 synthesis and
may increase incidence of patent ductus arteriosus and complicate
Edema:
respiratory distress syndrome.

Edema:

Indications

Initially, 2 mg/kg/day PO. If needed, increase by 12 mg/kg in 68 hr.

Oral, IV: Edema associated with CHF, cirrhosis, renal disease

Do not exceed 6 mg/kg.

IV: Acute pulmonary edema

Adjust maintenance dose to lowest effective level.

Oral: Hypertension

Pulmonary edema:

1 mg/kg IV or IM. May increase by 1 mg/kg in 2 hr until the desired

effect is seen. Do not exceed 6 mg/kg.

Adverse Effects

Fluid and electrolyte imbalance.

Rashes, photosensitivity, nausea, diarrhoea, blurred vision, dizziness,

headache, hypotension. Bone marrow depression (rare), hepatic

Patients with Renal Impairment

Up to 4 g/day has been tolerated.

IV bolus injection should not exceed 1 g/day given over 30 min.

dysfunction.

Hyperglycaemia, glycosuria, ototoxicity.

Potentially Fatal: Rarely, sudden death and cardiac arrest.

Hypokalaemia and magnesium depletion can cause cardiac
arrhythmias.

Therapeutic actions
Contraindications
Furosemide inhibits reabsorption of Na and chloride mainly in the medullary

portion of the ascending Loop of Henle. Excretion of potassium and

and furosemide, hypokalaemia, hyponatraemia, precomatose states

associated with liver cirrhosis, anuria or renal failure.

ammonia is also increased while uric acid excretion is reduced. It increases

plasma-renin levels and secondary hyperaldosteronism may result.
Furosemide reduces BP in hypertensives as well as in normotensives. It also
reduces pulmonary oedema before diuresis has set in.

Severe sodium and water depletion, hypersensitivity to sulphonamides

Addisons disease.

Nursing considerations

Name confusion has occurred between furosemide and torsemide; use

Do not expose to light, may discolor tablets or solution; do not use

discolored drug or solutions.

extreme caution.

Assessment

Discard diluted solution after 24 hr.

Refrigerate oral solution.

Measure and record weight to monitor fluid changes.

Arrange to monitor serum electrolytes, hydration, liver and renal

function.

History: Allergy to furosemide, sulfonamides, tartrazine; electrolyte

depletion anuria, severe renal failure; hepatic coma; SLE; gout;

Arrange for potassium-rich diet or supplemental potassium as needed.

diabetes mellitus; lactation, pregnancy

Physical: Skin color, lesions, edema; orientation, reflexes, hearing;

Teaching points

pulses, baseline ECG, BP, orthostatic BP, perfusion; R, pattern,

adventitious sounds; liver evaluation, bowel sounds; urinary output

patterns; CBC, serum electrolytes (including calcium), blood sugar,

possible, take the drug early so increased urination will not disturb

LFTs, renal function tests, uric acid, urinalysis, weight

sleep. Take with food or meals to prevent GI upset.

Interventions

Weigh yourself on a regular basis, at the same time and in the same
clothing, and record the weight on your calendar.

BLACK BOX WARNING: Profound diuresis with water and electrolyte

Record intermittent therapy on a calendar or dated envelopes. When

Blood glucose levels may become temporarily elevated in patients with

diabetes after starting this drug.

depletion can occur; careful medical supervision is required.

You may experience these side effects: Increased volume and

frequency of urination; dizziness, feeling faint on arising, drowsiness
(avoid rapid position changes; hazardous activities, like driving; and

Reduce dosage if given with other antihypertensives; readjust dosage

consumption of alcohol); sensitivity to sunlight (use sunglasses, wear

gradually as BP responds.

protective clothing, or use a sunscreen); increased thirst (suck on

Administer with food or milk to prevent GI upset.

sugarless lozenges; use frequent mouth care); loss of body potassium

Give early in the day so that increased urination will not disturb sleep.

Avoid IV use if oral use is at all possible.

WARNING: Do not mix parenteral solution with highly acidic solutions

ankles or fingers, unusual bleeding or bruising, dizziness, trembling,

with pH below 3.5.

numbness, fatigue, muscle weakness or cramps.

(a potassium-rich diet or potassium supplement will be needed).

Report loss or gain of more than 3 pounds in 1 day, swelling in your

Generic Name

PO: 1 to 1.5 grams two or three times a day.

Tranexamic Acid

Tranexamic Acid Oral Solution

Brand Names

A 5% oral rinse is prepared by diluting 5 mL of 10% tranexamic acid injection with 5 mL of sterile water

Lysteda
Cyklokapron
Classification
Therapeutic: hemostatic agents
Pharmacologic: fibrinolysis inhibitors
Indications and Usage

Patients with hemophilia for short-term use (two to eight days)

To reduce or prevent hemorrhage during and following tooth extraction.
Treatment of severe localized bleeding secondary to hyperfibrinolysis, including epistaxis, hyphema, or
hypermenorrhea (menorrhagia) and hemorrhage following certain surgical procedures

Treatment of hereditary angioedema

Mode of Action
Tranexamic acid competitively inhibits activation of plasminogen thereby reducing conversion of plasminogen to
plasmin (fibrinolysin), an enzyme that degrades fibrin clots, fibrinogen, and other plasma proteins, including the
procoagulant factors V and VIII.
In patients with hereditary angioedema, inhibition of the formation and activity of plasmin by tranexamic acid may
prevent attacks of angioedema by decreasing plasmin-induced activation of the first complement protein (C1).
Dosage and Administration

Prevention and treatment of oral hemorrhage, including hemorrhage following dental surgery, in
hemophilic patients

PO: Presurgical: 25 mg per kg of body weight every six to eight hours, beginning one day before the dental
procedure.
Postsurgical: 25 mg per kg of body weight every six to eight hours for two to eight days after surgery
IV: Presurgical: 10 mg per kg of body weight, administered immediately prior to surgery.Postsurgical (for patients
unable to take medication orally): 10 mg per kg of body weight every six to eight hours for seven to ten days

Preparation of dosage form

Tranexamic acid injection may be mixed with intravenous infusion solutions, including solutions containing
electrolytes, carbohydrates, amino acids, or dextran. Heparin may be added to the tranexamic acid injection, if
necessary.
Tranexamic acid should not be added to any solution containing penicillin or mixed with blood.
Pharmacokinetics
Absorption:
Oral:30 to 50% of a dose is absorbed from the gastrointestinal tract.
Bioavailability:
Not altered by food intake
Protein binding:
Very low (<3%), primarily to plasminogen, at therapeutic plasma concentrations, tranexamic acid does not bind to
serum albumin.
Biotransformation:
Less than 5% of a dose is metabolized
Time to peak concentration:
Oral: Approximately 3 hours
Elimination:
Renal, via glomerular filtration: > 95% of a dose is excreted as unchanged tranexamic acid
Oral: 39% of a dose (about 78% of the quantity absorbed) is excreted within 24 hours after administration of 10 to
15 mg/kg
Intravenous: 90% of a dose is excreted within 24 hours after administration of 10 mg/kg
Drug Interactions
Anti-inhibitor coagulant complex or Factor IX complex:
Concurrent use may increase the risk of thrombotic complications

Hemorrhage, hyperfibrinolysis-inducedepistaxis

PO: 1 to 1.5 grams three or four times a day for 10 days

Contraceptives, estrogen-containing, oral or Estrogens:

Concurrent use with tranexamic acid may increase the potential for thrombus formation

IV: 15 mg per kg of body weight or 1 gram every six to eight hours

Thrombolytic agents:

Angioedema, hereditary

The actions of tranexamic acid and of thrombolytic agents are mutually antagonistic; although controlled studies to

demonstrate its efficacy have not been done in humans, tranexamic acid may be useful in treating severe
hemorrhage caused by a thrombolytic agent
Side Effects

Nausea

Diarrhea
Hypotension
Thromboembolic, e.g., arterial, venous, embolic;
Neurologic, e.g., visual impairment, convulsions, headache, mental status changes; myoclonus;
Rash

Tranexamic acid is contraindicated in patients with:

hypersensitivity to tranexamic acid or any of the ingredients
acquired defective color vision, since this prohibits measuring one endpoint that should be followed as a
measure of toxicity

subarachnoid hemorrhage
active intravascular clotting

Precautions

Pregnancy
Tranexamic acid crosses the placenta.
Breast-feeding
Tranexamic acid is distributed into breast milk; concentrations reach approximately 1% of the maternal
plasma concentration

Nursing Responsibilities
Before:

Monitor for overt bleeding every 1530 min.

Monitor neurologic status (pupils, level of consciousness, motor activity) in patients with subarachnoid

Assess for thromboembolic complications.(especially in patients with history). Notify physician of positive
Homans sign, leg pain hemorrhage, edema, hemoptysis, dyspnea, or chest pain.

Monitor platelet count and clotting factors prior to and periodically throughout therapy in patients with
systemic fibrinolysis.

During:

Instruct patient to notify the nurse immediately if bleeding recurs or if thromboembolic symptoms develop.
Caution patient to make position changes slowly to avoid orthostatic hypotension.

Generic Name:Metoclopramide
Brand Name:Clopra, Emex , Maxeran , Maxolon, Reglan
Classifications:gastrointestinal agent; prokinetic agent (gi stimulant); autonomic nervous system agent; directacting cholinergic (parasympathomimetic); antiemetic
Pregnancy Category:B
Availability
5 mg, 10 mg tablets; 5 mg/5 mL solution; 5 mg/mL injection
Actions
Potent central dopamine receptor antagonist. Structurally related to procainamide but has little antiarrhythmic or
anesthetic activity. Exact mechanism of action not clear but appears to sensitize GI smooth muscle to effects of
acetylcholine by direct action.
Therapeutic effects
Increases resting tone of esophageal sphincter, and tone and amplitude of upper GI contractions. As a result,
gastric emptying and intestinal transit are accelerated with little effect, if any, on gastric, biliary, or pancreatic
secretions. Antiemetic action results from drug-induced elevation of CTZ threshold and enhanced gastric
emptying. In diabetic gastroparesis, indicated by relief of anorexia, nausea, vomiting, persistent fullness after
meals.
Uses
Management of diabetic gastric stasis (gastroparesis); to prevent nausea and vomiting associated with emetogenic
cancer chemotherapy (e.g., cisplatin, dacarbazine); to facilitate intubation of small bowel; symptomatic treatment of

Monitor blood pressure, pulse, and respiratory status as indicated by severity of bleeding.

hemorrhage.

Stabilize IV catheter to minimize thrombophlebitis. Monitor site closely.

Vomiting

Contraindications

After:

gastroesophageal reflux.
Contraindicatons
Sensitivity or intolerance to metoclopramide; allergy to sulfiting agents; history of seizure disorders; concurrent use
of drugs that can cause extrapyramidal symptoms; pheochromocytoma; mechanical GI obstruction or perforation;
history of breast cancer. Safety during pregnancy (category B) or lactation is not established.
Cautious Use
CHF; hypokalemia; kidney dysfunction; GI hemorrhage; history of intermittent porphyria.
Route & Dosage

Gastroesophageal Reflux

AGONIST-ANTAGONIST

adult:PO 1015 mg q.i.d. a.c. and h.s.

Prototype: Pentazocine
Pregnancy Category: C

child:PO/IV/IM 0.40.8 mg/kg/d in 4 divided doses

Diabetic Gastroparesis
adult:PO 10 mg q.i.d. a.c. and h.s. for 28 wk

Availability

geriatric:PO 5 mg a.c and h.s.

Small-bowel Intubation, Radiologic Examination

10 mg/mL, 20 mg/mL injection

adult:IM/IV 10 mg administered over 12 min

child:IM/IV <6 y, 0.1 mg/kg over 12 min; 614 y, 2.55 mg over 12 min
Chemotherapy-induced Emesis
adultchild:PO 2 mg/kg 1 h before antineoplastic administration, may repeat q2h for 3 more doses if needed
IM/IV 2 mg/kg 30 min before antineoplastic administration, may repeat q2h for 2 doses, then q3h for 3 doses if
needed
Adverse effects:
CNS:restlessness,drowsiness,fatigue,insomia,dizziness,anxiety

Actions
Synthetic narcotic analgesic with agonist and weak antagonist properties. Analgesic
potency is about 3 or 4 times greater than that of pentazocine and approximately
equal to that produced by equivalent doses of morphine. On a weight basis, produces
respiratory depression about equal to that of morphine; however, in contrast to
morphine, doses >30 mg produce no further respiratory depression. Antagonistic
potency is approximately one fourth that of naloxone and about 10 times greater
than that of pentazocine.

CV:tansient hypertension
GI:nausea and diarrhea

Therapeutic Effects

Nursing Implications

Analgesic action that relieves moderate to severe pain with apparently low potential
for dependence.
Assessment & Drug Effects

Report immediately the onset of restlessness, involuntary movements, facial grimacing, rigidity, or

Uses

tremors. Extrapyramidal symptoms are most likely to occur in children, young adults, and the older adult
and with high-dose treatment of vomiting associated with cancer chemotherapy. Symptoms can take
months to regress.

Be aware that during early treatment period, serum aldosterone may be elevated; after prolonged
administration periods, it returns to pretreatment level.

Symptomatic relief of moderate to severe pain. Also preoperative sedation analgesia

and as a supplement to surgical anesthesia.

Contraindications

Lab tests: Periodic serum electrolyte.

Monitor for possible hypernatremia and hypokalemia, especially if patient has CHF or cirrhosis.
Adverse reactions associated with increased serum prolactin concentration (galactorrhea, menstrual

History of hypersensitivity to drug. Safety during pregnancy (category C) or

lactation is not established. Prolonged use during pregnancy could result in neonatal
withdrawal.

disorders, gynecomastia) usually disappear within a few weeks or months after drug treatment is stopped.

NALBUPHINE HYDROCHLORIDE
(nal'byoo-feen)
Nubain
Classifications: CENTRAL NERVOUS SYSTEM AGENT; ANALGESIC; NARCOTIC (OPIATE)

Cautious Use
History of emotional instability or drug abuse; head injury, increased intracranial
pressure; impaired respirations; impaired kidney or liver function; MI; biliary tract
surgery.

Route & Dosage

Moderate to Severe Pain

Adult: IV/IM/SC 1020 mg q36h prn (max: 160 mg/d)

Child: IV/IM/SC 0.10.15 mg/kg q36h prn

Administration

Interactions
Drug: Alcohol and other CNS DEPRESSANTS add to CNS depression.

Pharmacokinetics
Onset: 23 min IV; 15 min IM. Peak: 30 min IV. Duration: 36
h. Distribution: Crosses placenta. Metabolism: Metabolized in
liver. Elimination: Eliminated in urine. Half-Life: 5 h.

Intramuscular/Subcutaneous

Nursing Implications

Inject undiluted.

Intravenous

Note: Verify correct rate of IV injection in infants, children with

physician.

PREPARE: Direct: Give undiluted.

ADMINISTER: Direct: Give at a rate of 10 mg or fraction thereof over 35 min.

Assessment & Drug Effects

INCOMPATIBILITIES Solution/additive: Diazepam, pentobarbital, promethazine, t

Assess respiratory rate before drug administration. Withhold drug and

notify physician if respiratory rate falls below 12.
Watch for allergic response in persons with sulfite sensitivity.
Administer with caution to patients with hepatic or renal impairment.
Monitor ambulatory patients; nalbuphine may produce drowsiness.
Watch for respiratory depression of newborn if drug is used during labor
and delivery.
Avoid abrupt termination of nalbuphine following prolonged use, which
may result in symptoms similar to narcotic withdrawal: nausea, vomiting,
abdominal cramps, lacrimation, nasal congestion, piloerection, fever,
restlessness, anxiety.

hiethylperazine. Y-site: Nafcillin.

Patient & Family Education

Store at 1530C (5986F), avoid freezing.

Adverse Effects ( 1%)

CV: Hypertension, hypotension, bradycardia, tachycardia, flushing. GI: Abdominal
cramps, bitter taste, nausea, vomiting, dry mouth. CNS: Sedation,

dizziness, nervousness, depression, restlessness, crying, euphoria, dysphoria,

distortion of body image, unusual dreams, confusion, hallucinations; numbness and
tingling sensations, headache, vertigo. Respiratory: Dyspnea, asthma, respiratory
depression. Skin:Pruritus, urticaria, burning sensation, sweaty, clammy skin. Special
Senses: Miosis, blurred vision, speech difficulty. Urogenital: Urinary urgency.

Do not drive or engage in potentially hazardous activities until response to

drug is known.
Avoid alcohol and other CNS depressants.
Do not breast feed while taking this drug without consulting physician.

Drug Name
Generic Name: aspirin

Brand Name:Apo-ASA (CAN), Aspergum, Bayer, Easprin, Ecotrin, Empirin, Entrophen

(CAN), Genprin, Halfprin 81, 1/2 Halfprin, Heartline, Norwich, Novasen (CAN), PMSASA (CAN), ZORprin, Alka-Seltzer, Ascriptin, Asprimox, Bufferin, Buffex, Magnaprin

Classification: Antipyretic, Analgesic (nonopioid), Anti-inflammatory, Antirheumatic,

Antiplatelet, Salicylate, NSAID
Pregnancy Category D

Juvenile rheumatoid arthritis: 60110 mg/kg per 24 hr in divided doses at

6- to 8-hr intervals. Maintain a serum level of 150300 mcg/mL.

Acute rheumatic fever: Initially, 100 mg/kg/day, then decrease to 75

mg/kg/day for 46 wk. Therapeutic serum salicylate level is 150300
mg/dL.

Dosage & Route

Kawasaki disease: 80180 mg/kg/day; very high doses may be needed

during acute febrile period; after fever resolves, dosage may be adjusted to
10 mg/kg/day.

Available in oral and suppository forms. Also available as chewable tablets,

gum; enteric coated, SR, and buffered preparations (SR aspirin is not
recommended for antipyresis, short-term analgesia, or children < 12 yr.)

ADULTS

Therapeutic actions

Analgesic and antirheumatic effects are attributable to aspirin's ability to

inhibit the synthesis of prostaglandins, important mediators of

inflammation. Antipyretic effects are not fully understood, but aspirin

Minor aches and pains: 325650 mg q 4 hr.

probably acts in the thermoregulatory center of the hypothalamus to block

Arthritis and rheumatic conditions: 3.26 g/day in divided doses.

effects of endogenous pyrogen by inhibiting synthesis of the prostaglandin

Acute rheumatic fever: 58 g/day; modify to maintain serum salicylate

intermediary. Inhibition of platelet aggregation is attributable to the

level of 1530 mg/dL.

inhibition of platelet synthesis of thromboxane A2, a potent vasoconstrictor

TIAs in men:1,300 mg/day in divided doses (650 mg bid or 325 mg qid).

and inducer of platelet aggregation. This effect occurs at low doses and

MI prophylaxis: 75325 mg/day.

lasts for the life of the platelet (8 days). Higher doses inhibit the synthesis
of prostacyclin, a potent vasodilator and inhibitor of platelet aggregation.

PEDIATRIC PATIENTS

Analgesic and antipyretic: 65 mg/kg per 24 hr in four to six divided doses,

Indications

not to exceed 3.6 g/day. Dosage recommendations by age:

Age (yr)

Dosage(mg q 4 hr)

23

162

45

243

68

324

910

405

11

486

12

648

Mild to moderate pain

Fever
Inflammatory conditionsrheumatic fever, rheumatoid arthritis,
osteoarthritis

Reduction of risk of recurrent TIAs or stroke in males with history of TIA

due to fibrin platelet emboli

Reduction of risk of death or nonfatal MI in patients with history of

infarction or unstable angina pectoris

MI prophylaxis
Unlabeled use: Prophylaxis against cataract formation with long-term use

Adverse effects

Acute aspirin toxicity: Respiratory alkalosis, hyperpnea, tachypnea,

Assessment

bleeding ulcers, hemorrhagic states, blood coagulation defects,

tetany, metabolic acidosis, fever, coma, CV collapse, renal and respiratory

hypoprothrombinemia, vitamin K deficiency; impaired hepatic function;

failure (dose related, 2025 g in adults, 4 g in children)

impaired renal function; chickenpox, influenza; children with fever

Aspirin intolerance: Exacerbation of bronchospasm, rhinitis (with nasal

accompanied by dehydration; surgery scheduled within 1 wk; pregnancy;

polyps, asthma, rhinitis)

History: Allergy to salicylates or NSAIDs; allergy to tartrazine; hemophilia,

hemorrhage, excitement, confusion, asterixis, pulmonary edema, seizures,

GI: Nausea, dyspepsia, heartburn, epigastric discomfort, anorexia,

lactation

Physical: Skin color, lesions; T; eighth cranial nerve function, orientation,

hepatotoxicity

reflexes, affect; P, BP, perfusion; R, adventitious sounds; liver evaluation,

Hematologic: Occult blood loss, hemostatic defects

bowel sounds; CBC, clotting times, urinalysis, stool guaiac, LFTs, renal

Hypersensitivity: Anaphylactoid reactions to anaphylactic shock

function tests

Salicylism: Dizziness, tinnitus, difficulty hearing, nausea, vomiting,

diarrhea, mental confusion, lassitude (dose related)

Contraindications

Interventions

BLACK BOX WARNING: Do not use in children and teenagers to treat

chickenpox or flu symptoms without review for Reyes syndrome, a rare but
fatal disorder.

Contraindicated with allergy to salicylates or NSAIDs (more common with

nasal polyps, asthma, chronic urticaria); allergy to tartrazine (cross-

sensitivity to aspirin is common); hemophilia, bleeding ulcers, hemorrhagic

states, blood coagulation defects, hypoprothrombinemia, vitamin K
deficiency (increased risk of bleeding)

Use cautiously with impaired renal function; chickenpox, influenza (risk of

Give drug with food or after meals if GI upset occurs.

Give drug with full glass of water to reduce risk of tablet or capsule lodging
in the esophagus.

Do not crush, and ensure that patient does not chew SR preparations.
Do not use aspirin that has a strong vinegar-like odor.
WARNING: Institute emergency procedures if overdose occurs: Gastric
lavage, induction of emesis, activated charcoal, supportive therapy.

Reye's syndrome in children and teenagers); children with fever

accompanied by dehydration; surgery scheduled within 1 wk; pregnancy
(maternal anemia, antepartal and postpartal hemorrhage, prolonged

Teaching points

gestation, and prolonged labor have been reported; readily crosses the
placenta; possibly teratogenic; maternal ingestion of aspirin during late

pregnancy has been associated with the following adverse fetal effects: low
birth weight, increased intracranial hemorrhage, stillbirths, neonatal death);

Take extra precautions to keep this drug out of the reach of children; this
drug can be very dangerous for children.

lactation.

Use the drug only as suggested; avoid overdose. Avoid the use of other
over-the-counter drugs while taking this drug. Many of these drugs contain
aspirin, and serious overdose can occur.

Nursing considerations

Take the drug with food or after meals if GI upset occurs.

Do not cut, crush, or chew sustained-release products.

Over-the-counter aspirins are equivalent. Price does not reflect

6.

Headache

effectiveness.

7.

Anorexia

You may experience these side effects: Nausea, GI upset, heartburn (take

8.

N&V

9.

Anxiety

10.

GI upset

11.

Asthenia

drug with food); easy bruising, gum bleeding (related to aspirin's effects on
blood clotting).

Report ringing in the ears; dizziness, confusion; abdominal pain; rapid or

difficult breathing; nausea, vomiting, bloody stools.

Dosage:
Per Orem: 25-50 mg TID- QID
Generic Name: Diphenhydramine hydrochloride
Brand Name: Benadryl
Classification: Antihistamine, second generation, ethanolamine

IV: 10-50mg up to 100mg/IV

Uses:
1.

Treatment of hypersensitivity reactions

2.

Treatment of motion sickness

1.

Give full prophylactic dose 30min. prior to travel if used as a prophylaxis for motion sickness

3.

Treatment of Parkinsonism

2.

Take similar doses with meals and at bedtime

4.

Nighttime sleep aid

3.

Do not use more than 2 weeks to treat insomnia

5.

Antitussive

4.

For IV, may give undiluted

Actions:

Nursing Considerations:

5.

Do not exceed IV rate of 25mg/minute

1.

Has high sedative, anticholinergic and antiemetic effects

6.

Drug causes drowsiness. Avoid activities requiring mental alertness

2.

Blocks the action of acetylcholine

7.

Use sun protection as it may cause photosensitivity

3.

Blocks H-1 receptors on effector cells of the GI tract, blood vessels, and respiratory tract

8.

Use sugarless candy/gum to diminish dry mouth effects

9.

Avoid alcohol and other CNS depressants

10.

Stop therapy 72-96 hr. prior to skin testing. Report adverse effect and lack of response

Contraindications:
1.

Use with other products containing diphenhydramine

2.

Hypersensitivity to antihistamines

Special Concerns:
1.

Increases the risk of cognitive decline in the elderly

2.

Use with caution in clients suffering from the following: Increased Pressure in the Eye, Closed Angle
Glaucoma, Chronic Difficulty having a Bowel Movement, High Blood Pressure, Stenosing Peptic Ulcer,
Blockage of Urinary Bladder, Enlarged Prostate, Cannot Empty Bladder, Overactive Thyroid Gland

Side-Effects:
1.

Drowsiness

2.

Constipation

3.

Diarrhea

4.

Dizziness

5.

Dry mouth/nose/throat