University of Perpetual Help System Dalta

Calamba Campus

EMERGENCY DRUGS

Submitted by:

Alcira, Jean ClarisseCamba, Hannah Yssabel

Dela Rosa, MichaelDevisfruto, Rica

Domingo, Jaime Jr.Maestro, Andri Faith

Tolentino, Miguel Angelo

Submitted to:

Amelia Almodovar, RN, MAN

Emergency Drugs

Table 1: Mandatory Emergency Drugs

Drugs Indications Preparations

OxygenFor use in all medical emergencies where hypoxemia may be present

Steel cylinders (green); E tanks, 690 L

EpinephrineAcute allergic reactions Acute asthma (not responding to adrenergic inhaler)

Ampules: 1 mg

Vials: 1 and 30 mg

Syringes: 0.3 and 1 mg

Nitroglycerin Angina pectoris, Acute myocardial infarction

Tablets (sublingual): 0.15, 0.3, 0.4, and 0.6 mg Spray: 0.4 mg/actuation

Oxygen can be delivered to the spontaneously breathing patient via full face mask, nasal cannulae, or nasal hood.

Epinephrine is mandatory for the treatment of cardiac arrest and overwhelming anaphylaxis. However, it must be emphasized that these extreme conditions are the only situations that would require its use in the dental office emergency. There are a few clinicians who maintain the mistaken belief that epinephrine is the drug of choice in shock or shocklike states. There are three principal reasons for disputing this belief.

First, in shock from almost any cause there is decreased venous return to the heart because of peripheral venous pooling. Because the peripheral action of epinephrine is primarily on the arterial side, there is little gain in promoting peripheral vasoconstrictions, which is already present because of the massive release of endogenous catecholamines (epinephrine and norepinephrine). At this point administration of epinephrine may further decrease venous return and tissue perfusion. Second, a possible deleterious effect is an increase in selective ischemia that takes place in certain viscera such as the kidney. Here, as in peripheral vessels, the blood supply is constricted in a compensatory effort to increase blood flow to the more vital brain and heart tissues. Perpetuation of this condition could be undesirable. Third, the possible precipitation of ventricular fibrillation in the ischemic and irritable myocardium is an important factor. This could be especially disastrous in the dental office where defibrillation equipment is usually not available. In early treatment of shock states the patient will benefit more from measures aimed at correction of the primary cause such as hypovolemia rather than misdirected attempts at pharmacologic correction.

Desirable properties of this agent include a rapid onset of action; potent action as a bronchial smooth muscle dilator (beta2

properties); antihistaminic actions; vasopressor actions; and its actions on the heart, which include an increased heart rate (21%), increased systolic blood pressure (5%), decreased diastolic blood pressure (14%), increased cardiac output (51%), and increased coronary blood flow. Undesirable actions include its tendency to predispose the heart to dysrhythmias and its relatively short duration of action.

Epinephrine is an important drug during cardiac arrest because no other drug is capable of maintaining coronary artery blood flow while CPR is in progress, which is essential for preserving the chances of survival from cardiac arrest. Epinephrine also preserves blood flow to the brain. In the absence of drug therapy, cerebral blood flow during CPR is minimal; most blood enters the common carotid artery and flows into the external carotid branch, not the internal carotid artery. Following administration of a drug with a-adrenergic properties, such as epinephrine, cerebral blood flow is significantly increased.

Because of its profound bronchodilating effects, epinephrine is also indicated for the treatment of acute asthmatic attacks unrelieved by b2-adrenergic sprays or aerosols.

Side effects, contraindications, and precautions: Tachydysrhythmias, both supraventricular and ventricular, may develop. Epinephrine should be used with caution in pregnant women because it decreases placental blood flow and may induce premature labor. When used, all vital signs must be monitored frequently.

Antihistamines will be of value in the treatment of the delayed allergic response and in the definitive management of the acute allergic reaction (administered after epinephrine has terminated the acute life-threatening phase of the reaction). Antihistamines act as competitive antagonists of histamine. They do not prevent the release of histamine from cells in response to injury, drugs, or antigens, but do prevent access of histamine to its receptor site in the cell and thereby block the response of the effector cell to histamine. Thus, antihistamines are more potent in preventing the actions of histamine than in reversing these actions once they develop.

Nitroglycerin Vasodilators are used in the immediate management of chest pain (such as may occur with angina pectoris or acute myocardial infarction). Two varieties of vasodilator are available: nitroglycerin (TNG) as a tablet and a spray, and an inhalant, amyl nitrite. A patient with a history of angina pectoris will usually carry a supply of nitroglycerin. Tablets remain the most popular form of TNG, although most patients prefer the translingual spray once they have used it. .

Amyl nitrite, another vasodilator, is available for use as an inhalant. It is supplied in a yellow vaporole or a gray cardboard vaporole with yellow printing in a dose of 0.3 mL, which when crushed between one's finger and held under the victim's nose will act in about 10 seconds to produce a profound vasodilation. The duration of action of amyl nitrite is shorter than that of TNG; however, the shelf life of the vaporole is considerably longer. Side effects occur with all vasodilators but they are more significant with amyl nitrite.

Side effects, contraindications, and precautions: Side effects of nitroglycerin include a transient pulsating headache, facial flushing, and a degree of hypotension (noted especially if the patient is in an upright position). Because of its mild hypotensive actions, nitroglycerin is contraindicated in patients who are hypotensive, but may be used with some degree of effectiveness in the management of acute hypertensive episodes. Side effects of amyl nitrite are similar to but more intense than those of nitroglycerin. These include facial flushing, pounding pulse, dizziness, intense headache, and hypotension. Amyl nitrite should not be administered to patients who are in an upright position because the patient may feel dizzy and suffer a fall.

Table 2: Emergency Support Drugs

Category Generic Proprietary Alternative

InjectableAnticonvulsant Midazolam Versed DiazepamAnalgesic Morphine MeperidineVasopressor Methoxamine Vasoxyl PhenylephrineAntihypoglycemic 50% Dextrose sol. Glucagon

CorticosteroidHydrocortisone Solu-Cortef sodium succinate

Dexamethasone

Antihypertensive Labetalol HCl NormodyneAnticholinergic Atropine

NoninjectablesRespiratory stimulant Aromatic Ammonia

Antihypoglycemic Carbohydrate Decorative icing Many

Bronchodilator Albuterol Ventolin, Proventil MetaproterenolAntihypertensive Nifedipine Procardia

Anticonvulsant Seizures that may require acute medical intervention may be associated with epilepsy, hyperventilation episodes, cerebrovascular accidents, hypoglycemic reactions, or vasodepressor syncope. Local anesthetic overdoses or accidental intravascular injection may also require the administration of an anticonvulsant. Current management of a seizure that interferes

with ventilation or persists for longer than 5 minutes includes the use of an intravenous benzodiazepine such as diazepam or midazolam.

With its introduction, diazepam became the preferred anticonvulsant. Because seizure disorders are characterized by a stimulation of the central nervous and cardiorespiratory and cardiovascular systems, followed by a period of depression of these same systems, drugs that depress the systems at therapeutic does are more likely to produce postseizure complications. When barbiturates are administered to terminate seizure activity, the degree of postseizure depression is accentuated and its duration prolonged because of the pharmcologic action of the barbiturate.

If the doctor is not adapt at recognizing and managing this situation, the patient may be worse off after the seizure than during it. The benzodiazepines, unlike barbiturates, will usually terminate seizure activity without the pronounced depression of the respiratory and cardiovascular systems.

Analgesic medications will be useful during emergency situations in which acute pain or anxiety is present. In most instances the presence of pain or anxiety will cause an increase in the workload of the heart (and an increased myocardial oxygen requirement) that may prove detrimental to the well-being of the patient. Two such circumstances are acute myocardial infarction and congestive heart failure. The choice of analgesic drugs includes the narcotic agonists morphine sulfate and meperidine (Demerol).

Side effects, contraindications, and precautions: Narcotic agonists are potent CNS and respiratory depressants. Vigilant monitoring of vital signs is mandatory whenever these agents are used. Use of narcotic agonists is contraindicated in victims of head injury and multiple trauma; they should be used with care in persons with compromised respiratory function.

Vasopressor In most emergency situations in which a vasopressor is indicated in the dental office, an agent such as epinephrine will not be the drug of choice. Epinephrine will be used primarily in the management of acute allergic reactions and is rarely employed in cases of clinically mild to moderate hypotension. One reason for this is that epinephrine elicits an extreme antihypotensive response. In addition to an increase in blood pressure, epinephrine causes an increase in the workload of the heart through its effect on heart rate and cardiac contraction; it also increases the irritability of the myocardium by sensitizing it to dysrhythmias.

Vasopressors such as methoxamine (Vasoxyl) and phenylephrine (Neo-Synephrine) are drugs that produce moderate blood pressure elevations through peripheral vasoconstriction.

Methoxamine is a clinically useful vasopressor with sustained action and little effect on the myocardium or central nervous system. Its vasopressor action is associated with a marked increase in peripheral resistance and no increase in cardiac output. A compensatory bradycardia accompanies the rise in blood pressure produced by methoxamine. The onset of the pressor action is almost immediate following IV administration and may persist for up to 60 minutes. After IM injection the response occurs within 15 minutes and persists for 90 minutes.

Phenylephrine acts in a similar fashion, with a 5-mg IM dose causing a 30-mm Hg elevation of systolic blood pressure and a 20-mm Hg elevation of diastolic blood pressure, with the response persisting for 50 minutes. As with methoxamine, a pronounced and persistent bradycardia will be noted (average decline in heart rate from 70 to 44 beats per minute).

Antihypoglycemic Glucose preparations are used to treat hypoglycemia that results either from fasting or insulin use in a patient with diabetes mellitus. If the patient is conscious, oral carbohydrates such as chocolate bar, cake icing, or cola drink will act rapidly to restore circulating blood sugar. On the other hand, if the patient is unconscious and acute hypoglycemia is suspected, intravenous administration of 50% dextrose solution is the treatment of choice.

Corticosteroids will be administered in the management of an acute allergic reaction, but only after the acute phase has been brought under control through the use of basic life support, epinephrine, and antihistamines. The primary value of the corticosteroids is in the prevention of recurrent episodes of anaphylaxis. Corticosteroids are also important in the management of acute adrenal insufficiency.

The onset of intravenous corticosteroids, such as hydrocortisone sodium succinate, is delayed, but the drugs can be useful in halting the progression of a major allergic or anaphylactoid reaction. There is also the potential for encountering what appears initially to be a syncopal episode but is in reality the more serious problem of acute adrenal insufficiency in a patient chronically taking systemic corticosteroids to treat a medical condition. For this life-threatening emergency, only the prompt diagnosis and infusion of corticosteroids will be curative.

Hydrocortisone sodium succinate is considered the drug of choice for the dental emergency kit. Corticosteroids are considered second-line drugs primarily because of their slow onset of action.

Antihypertensive The need to administer drugs to decrease excessive elevations in blood pressure is extremely uncommon. First, the incidence of extreme acute blood pressure elevation is quite rare and, second, there are other means of decreasing blood pressure without resorting to parenteral antihypertensive drugs.

Emergency Drugs Oral drugs, such as nifedipine or nitroglycerin, may be administered in most situations to provide a minor depression of blood pressure. The inclusion of a drug in this category is in response to state requirements for general anesthesia permits (and in a few states for parenteral sedation, too).

Anticholinergic Atropine, a parasympathetic blocking agent, is recommended for the management of symptomatic bradycardia (adult heart rate of <60 beats per minute). By enhancing discharge from the sinoatrial (SA) node, atropine may provoke tachycardia (adult heart rate>100 beats per minute). Atropine will be of benefit in situations in which the patient has an overload of parasympathetic activity on the heart. Extremely fearful patients are likely candidates for this response.

Atropine is also considered an essential drug in advanced cardiac life support (ACLS), in which it is employed in the management of bradydysrhythmias (hemodynamically significant heart block and asystole).

Side effects, contraindications, and precautions: Large doses of atropine (>2.0 mg) may produce clinical signs of overdosage, including: hot, dry skin; headache; blurred near vision; dryness of the mouth and throat; disorientation; and hallucination. Administration of atropine is contraindicated in patients with glaucoma or prostatic hypertrophy. However, in life-threatening situations the benefits of atropine administration usually outweigh the possible risks.

Respiratory stimulant After oxygen, aromatic ammonia is the most commonly used drug in the emergency situation. It is available in a silver-gray vaporole, which is crushed and placed under the victim's nose until respiratory stimulation is effected. Aromatic ammonia has a noxious odor and acts by irritating the mucous membrane of the upper respiratory tract, thereby stimulating the respiratory and vasomotor centers of the medulla; this in turn increases respiration and blood pressure. Movement of the arms and legs often occurs in response to inhalation of ammonia. This too acts to increase the return of blood from the periphery and aids in raising blood pressure, especially if the patient has been positioned properly.

Side effects, contraindications, and precautions: Ammonia should be employed with caution in persons with chronic obstructive pulmonary disease (COPD) or asthma because its irritating effects on the mucous membranes of the upper respiratory tract may precipitate bronchospasm.

Antihypoglycemic agents will be useful in the management of hypoglycemic reactions occurring in patients with diabetes mellitus or in the nondiabetic patient with hypoglycemia (low blood sugar). The diabetic patient will usually carry a ready source of carbohydrate such as a candy bar or hard candy. Such items should also be available in the dental office for use in the conscious patient with hypoglycemia.

Bronchodilator Asthmatic patients and patients with allergic reactions manifested primarily by respiratory difficulty will require the use of bronchodilator drugs. Although epinephrine remains the drug of choice in the management of bronchospasm, its wide ranging actions on systems other than the respiratory tract has resulted in the introduction of newer, more specific agents known as b2-adrenergic agonists. These agents, of which albuterol is an example, have specific bronchial smooth muscle-relaxing properties (b2) with little or no stimulatory effect on the cardiovascular and gastrointestinal systems (b1) . In the dental situation in which the patient's true cardiovascular status may be unknown, b2 agonists appear more attractive for management of the acute asthmatic episode than agents that have both b1 and b2 agonist properties, such as epinephrine and isoproterenol.

Bronchodilators must be administered precisely as directed. One to two inhalations every 4 to 6 hours is the recommended dosage for albuterol. Nebulized epinephrine (e.g., Primatene-Mist â ) should be administered one to two inhalations per hour. In situations in which these nebulized agents fail to terminate the attack, other bronchodilators (e.g., epinephrine, aminophylline, isoproterenol) must be administered parenterally (intramuscularly or subcutaneously).

Side effects, contraindications, and precautions: Albuterol, like other b2 agonists, may have a clinically significant cardiac effect in some patients. This response is less likely to develop with albuterol than with other bronchodilators, thus its selection for the emergency kit. Metaproterenol, epinephrine, and isoproterenol mistometers are more likely to produce cardiovascular side effects, including tachycardia and ventricular dysrhythmias.

Table 3: Advanced Cardiac Life Support Drugs

Drug IndicationAntiarrhythmics

Lidocaine Ventricular tachycardia, pulseless, ventricular tachycardia, or ventricular fibrillation

Procainamide Ventricular tachycardia, pulseless ventricular tachycardia or ventricular fibrillation

Bretylium Ventricular tachycardia, pulseless ventricular tachycardia or ventricular fibrillation

Verapamil, diltiazem Atrial flutter or atrial fibrillation, paroxysmal supraventricular tachycardia

Adenosine Paroxysmal supraventricular tachycardia

AtropineBradycardia, asystole, first-degree and Mobitz type I atrioventricular block, Mobitz type II and third-degree block

Magnesium Torsades de pointes, ventricular fibrillation

ß blockers (e.g., propranolol)Atrial flutter or atrial fibrillation, refractory ventricular tachycardia or ventricular fibrillation

Inotropes

Epinephrine Ventricular fibrillation, asystole, pulseless, electrical activity, bradycardia

Norepinephrine Refractory hypotensionDopamine Bradycardia, hypotensionDobutamine Congestive heart failureIsoproterenol Refractory bradycardiaDigitalis Atrial flutter, fibrillationAmrinone Refractory congestive heart failureVasodilators/Antihypertensives

Nitroprusside Hypertension, acute heart failure

NitroglycerinHypertension, acte heart failure, anginal pain

Others

Sodium bicarbonate Hyperkalemia, metabolic acidosis with bicarbonate loss, hypoxic lactic acidosis

Furosemide Acute pulmonary edemaMorphine Acute pulmonary edema, pain and anxietyThrombolytic agents (e.g., anistreplase) Acute myocardial thrombosis

Table 4: Antidotal Drugs

Category Generic Proprietary AlternativeNarcotic antagonist Naloxone Narcan NalbuphineBenzodiazepine antagonist Flumazenil Mazicon

Antiemergence delirium Physostigmine Antilirium

Vasodilator Procaine Novocain

Table 5: Emergency Drug Kit

Drug Indications Adult Dosage and Route of Administration

Epinephrine (Adrenalin)-1:1000 anaphylaxis, cardiac arrest 0.5 ml intravenously

Methylprednisolone sodium succinate (Solu-Medrol)-125 mg Monovile

cardiac arrest, anaphylaxis, acute adrenocortical insufficiency

125 mg intravenously, given slowly

Sodium bicarbonate–7.5% cardiac arrest1 mEq/kg intravenously initially, then half this every 10 minutes

Diphenhydramine (Benadryl) 10 mg/ml

acute allergic reaction, extrapyramidal reaction to

5 ml intravenously

phenothiazineAromatic spirits of ammonia- crush ampules syncope one ampule, by inhalation

Glyceryl trinitrate–0.6 mg tablet angina pectoris one tablet sublingually

Morphine sulfate–15mg/ml myocardial infarction 1 ml subcutaneously or intravenously

Phenylephrine hydrochloride (Neo-Synephrine Hydrochloride) – 1:500

toxic reaction to local anesthetic 1 to 2 ml intravenously

Dextrose in water–5% hypovolemia, IV route for drug administration 1000 ml IV drip

Diazepam– 5 mg/mlsevere or prolonged convulsion as in toxic reaction to local anesthetic

1 to 8 ml intravenously (titrated)

Naloxone hydrochloride(Narcan) –0.4 mg/ml

narcotic depression 1 ml intravenously or intramuscularly

Isoproterenol hydrochloride aerosol–0.25% bronchospasm one or two inhalations

Physostigmine salicylate – 1mg/ml

CNS depression following diazepam administration

0.5 to 2 ml intravenously (slow titration)

Atropine sulphate–0.1 mg/ml bradycardia with hypotension 0.5 - 1.0 mg IV

EMERGENCY DRUGS: A Drug Study

1) AMINOPHYLLINE

Brand Names: Phil Pharmawealth/Atlantic Aminophylline amp Theofil amp

Classification: Antiasthmatic & COPD Preparations

Dosage: Initial: 225-450 mg twice daily, increased if needed. IV Acute severe bronchospasm. Loading dose: 5 mg/kg (ideal body wt). Maintenance: 0.5 mg/kg/hr. Rate should not exceed 25 mg/min.

Indication: PO Chronic bronchospasm as hydrate

Action: Increases the level of cAMP resulting in bronchodilation

Adverse Reactions: Nausea, vomiting, abdominal pain, diarrhea, headache, insomnia, dizziness, anxiety, restlessness; tremor, palpitations. Potentially Fatal: Convulsions, cardiac arrhythmias, hypotension and sudden death after too rapid IV injection.

Nursing Measures:

Administer to pregnant patients only when clearly needed - neonatal tachycardia, jitteriness, and withdrawal apnea observed when mothers received xanthines up until delivery.

Caution patient not to chew or crush enteric-coated timed-release forms. Give immediate-release, liquid dosage forms with food if GI effects occur. Do not give timed-release forms with food; these should be given on an empty stomach 1

hr before or 2 hr after meals. Maintain adequate hydration. Monitor results of serum theophylline levels carefully, and arrange for reduced dosage if

serum levels exceed therapeutic range of 10-20 mcg/mL. Take serum samples to determine peak theophylline concentration drawn 15–30 min

after an IV loading dose. Monitor for clinical signs of adverse effects, particularly if serum theophylline levels are

not available. Ensure that diazepam is readily available to treat seizures.

Take this drug exactly as prescribed; if a timed-release product is prescribed, take this drug on an empty stomach, 1 hr before or 2 hr after meals.

Do not to chew or crush timed-release preparations. Administer rectal solution or suppositories after emptying the rectum. It may be necessary to take this drug around the clock for adequate control of asthma

attacks. Avoid excessive intake of coffee, tea, cocoa, cola beverages, chocolate. Smoking cigarettes or other tobacco products impacts the drug's effectiveness. Try not to

smoke. Notify the care provider if smoking habits change while taking this drug. Frequent blood tests may be necessary to monitor the effect of this drug and to ensure

safe and effective dosage; keep all appointments for blood tests and other monitoring. These side effects may occur: Nausea, loss of appetite (taking this drug with food may

help if taking the immediate-release or liquid dosage forms); difficulty sleeping, depression, emotional lability (reversible).

Report nausea, vomiting, severe GI pain, restlessness, seizures, irregular heartbeat

2) AMIODARONE HYDROCHLORIDE

Brand Names: Anoion tab Cordarone Cordarone inj Sandoz Amiodarone HCl tab

Classification: Cardiac Drugs

Dosage: PO Initial: 200 mg 3 times/day for 1 wk, reduce to 200 mg twice daily for a further wk. Maintenance: 200 mg/day or lowest effective dose. IV Initial: 5 mg/kg infusion via central venous catheter. Max: 1.2 g/24 hr.

Indication: Ventricular and supraventricular arrhythmias.

Action: Blocks potassium chloride leading to prolongation of action potential duration.

Adverse Reactions: Blue-grey discoloration of skin, photosensitivity, peripheral neuropathy, paraesthesia, myopathy, ataxia, tremor, nausea, vomiting, metallic taste, hypothyroidism, hyperthyroidism, alopecia, sleep disturbances, corneal microdeposits, hot flushes, sweating. Heart block, bradycardia, sinus arrest, hepatotoxicity, heart failure. Potentially Fatal: Pulmonary toxicity including pulmonary fibrosis and interstitial pneumonitis, hepatotoxicity, thyrotoxicity. Ventricular arrhythmias, pulmonary alveolitis, exacerbation of arrhythmias and rare serious liver injury. Generally in patients with high doses and having preexisting abnormalities of diffusion capacity.

Nursing Measures:

Monitor cardiac rhythm continuously. Monitor for an extended period when dosage adjustments are made.

Monitor for safe and effective serum levels (0.5–2.5 mcg/mL). Doses of digoxin, quinidine, procainamide, phenytoin, and warfarin may need to be

reduced one-third to one-half when amiodarone is started. Give drug with meals to decrease GI problems. Arrange for ophthalmologic exams; reevaluate at any sign of optic neuropathy. Arrange for periodic chest x-ray to evaluate pulmonary status (every 3–6 mo). Arrange for regular periodic blood tests for liver enzymes, thyroid hormone levels. Drug dosage will be changed in relation to response of arrhythmias; you will need to be

hospitalized during initiation of drug therapy; you will be closely monitored when dosage is changed.

Have regular medical follow-up, monitoring of cardiac rhythm, chest x-ray, eye exam, blood tests.

These side effects may occur: Changes in vision (halos, dry eyes, sensitivity to light; wear sunglasses, monitor light exposure); nausea, vomiting, loss of appetite (take with meals; eat small, frequent meals); sensitivity to the sun (use a sunscreen or protective clothing when outdoors); constipation (a laxative may be ordered); tremors, twitching, dizziness, loss of coordination (do not drive, operate dangerous machinery, or undertake tasks that require coordination until drug effects stabilize and your body adjusts to it).

Report unusual bleeding or bruising; fever, chills; intolerance to heat or cold; shortness of breath, difficulty breathing, cough; swelling of ankles or fingers; palpitations; difficulty with vision.

3) ATROPINE SULFATE

Brand Names: Anespin amp Atropol amp Euro-Med Atropine Sulfate amp Isopto Atropine eye drops Phil Pharmawealth/Atlantic Atropine amp

Classification: Other Cardiovascular Drugs, Muscle Relaxants, Mydriatic Drugs, Antidotes, Detoxifying Agents & Drugs Used in Substance Dependence

Indication/Dosage: IV Bradycardia 500 mcg every 3-5 mins. Total: 3 mg. IV/IM Organophosphorus poisoning 2 mg every 10-30 mins until muscarinic effects disappear or atropine toxicity appears. IM/SC Premed in anesth 300-600 mcg 30-60 mins before anesth. IV/IM/SC Overdosage w/ other compd having muscarinic actions 0.6-1 mg, repeat 2 hrly. Ophth Inflammatory eye disorders As 0.5-1% soln: 1-2 drops 4 times/day. Eye refraction As 1% soln: 1 drop twice daily for 1-2 days before procedure.

Action: An anti-cholinergic that inhibits acetylcholine at the parasympathetic neuroeffector junction, enhances the conduction of AV node and increases heart rate

Adverse Reactions: Dry mouth, dysphagia, constipation, flushing and dryness of skin, tachycardia, palpitations, arrhythmias, mydriasis, photophobia, cycloplegia, raised intraocular

pressure. Toxic doses cause tachycardia, hyperpyrexia, restlessness, confusion, excitement, hallucinations, delirium and may progress to circulatory failure and respiratory depression. Eye drops: Systemic toxicity especially in children, on prolonged use may lead to irritation, hyperemia, edema and conjunctivitis. Increased intraocular pressure. Inhalation: Dryness of mouth, throat. Potentially Fatal: Atrial arrhythmias, AV dissociation, multiple ventricular ectopics.

Nursing Measures:

Ensure adequate hydration; provide environmental control (temperature) to prevent hyperpyrexia.

Have patient void before taking medication if urinary retention is a problem. When used preoperatively or in other acute situations, incorporate teaching about the

drug with teaching about the procedure; the ophthalmic solution is used mainly acutely and will not be self-administered by the patient; the following apply to oral medication for outpatients:

Take as prescribed, 30 min before meals; avoid excessive dosage. Avoid hot environments; you will be heat intolerant, and dangerous reactions may occur. These side effects may occur: Dizziness, confusion (use caution driving or performing

hazardous tasks); constipation (ensure adequate fluid intake, proper diet); dry mouth (suck sugarless lozenges; perform frequent mouth care; may be transient); blurred vision, sensitivity to light (reversible; avoid tasks that require acute vision; wear sunglasses in bright light); impotence (reversible); difficulty in urination (empty the bladder prior to taking drug).

Report rash; flushing; eye pain; difficulty breathing; tremors, loss of coordination; irregular heartbeat, palpitations; headache; abdominal distention; hallucinations; severe or persistent dry mouth; difficulty swallowing; difficulty in urination; constipation; sensitivity to light.

4) BUMETANIDE

Brand Names: Burinex amp Burinex tab

Classification: Sulfonamide Diuretics

Indication/Dosage: PO edema 1 mg once daily, 2nd dose 6-8 hr later if needed. Refractory edema Initial: 5 mg/day, may increase dose depending on response. Max: 10 mg/day. HTN 0.5-1 mg/day. Max: 5 mg/day. IV Pulmonary edema 1-2 mg, repeat 20 mins. later if needed. IV/IM Emergency edema 0.5-1 mg, then adjust according to response.

Action: inhibits Sodium and Chloride reabsorption at the ascending loop of Henle

Adverse Reactions: Muscle cramps, dizziness, hypotension, headache, nausea, impaired hearing, pruritus, ECG changes, musculoskeletal pain, rash, chest discomfort, renal failure, premature ejaculation, thrombocytopenia, hypokalemia, hypomagnesaemia, hyponatremia, hyperuricemia, hyperglycemia, hypocalcaemia.

Nursing Measures:

Give with food or milk to prevent GI upset. Mark calendars or use reminders if intermittent therapy is best for treating edema. Give single dose early in day so increased urination will not disturb sleep. Avoid IV use if oral use is possible. Arrange to monitor serum electrolytes, hydration, liver function during long-term

therapy. Provide diet rich in potassium or supplemental potassium. Record alternate day or intermittent therapy on a calendar or dated envelopes. Take the drug early in day so increased urination will not disturb sleep; take with food or

meals to prevent GI upset. Weigh yourself on a regular basis, at the same time, and in the same clothing; record the

weight on your calendar. These side effects may occur: Increased volume and frequency of urination; dizziness,

feeling faint on arising, drowsiness (avoid rapid position changes; hazardous activities, such as driving; and alcohol consumption); sensitivity to sunlight (use sunglasses, sunscreen, wear protective clothing); increased thirst (suck sugarless lozenges; use frequent mouth care); loss of body potassium (a potassium-rich diet, or supplement will be needed).

Report weight change of more than 3 lb in 1 day; swelling in ankles or fingers; unusual bleeding or bruising; nausea, dizziness, trembling, numbness, fatigue; muscle weakness or cramps.

5) CALCIUM GLUCONATE

Brand Names: Phil Pharmawealth/Harson Calcium Gluconate amp

Classification: Electrolytes

Indication/Dosage: PO Hypocalcaemia 10-50 mmol/day. IV Hypocalcaemic tetany 2.25 mmol via slow inj, then 58-77 mL of 10% soln diluted and administered as a continuous IV infusion. Antidote in severe hypermagnesaemia; Severe hyperkalaemia 10 mL of 10% soln, repeat every 10 mins if needed.

Action: replaces Calcium and maintains Calcium level

Adverse Reactions: GI irritation; soft-tissue calcification, skin sloughing or necrosis after IM/SC inj. Hypercalcaemia characterised by anorexia, nausea, vomiting, constipation, abdominal pain, muscle weakness, mental disturbances, polydipsia, polyuria, nephrocalcinosis, renal calculi; chalky taste, hot flushes and peripheral vasodilation. Potentially Fatal: Cardiac arrhythmias and coma.

Nursing Measures:

Make sure prescriber specifies form of calcium to be given; crash carts may contain both calcium gluconate and calcium chloride.

Tell patient to take oral calcium 1 to 11/2 hours after meals if GI upset occurs. Give I.M. injection in gluteal region in adults and in lateral thigh in infants. Use I.M.

route only in emergencies when no I.V. route is available bec. of irritation of tissue by calcium salts.

Tell patient to take oral calcium with a full glass of water. Monitor calcium levels frequently. Hypercalcemia may result after large doses in chronic

renal failure. Report abnormalities.

6) CAPTOPRIL

Brand Names: Ace-Bloc tab Capomed tab Capotec tab Capoten tab Captor tab Captril tab Cardiovaz tab Conamid tab Hartylox tab Normil tab Phil Pharmawealth/Panion & BF Captopril tab Prelat tab Primace tab Retensin tab Spec-Ace tab Tensoril tab Unihype tab Vasostad tab

Classification: ACE Inhibitors

Indication/Dosage: 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. HTN in diabetic nephropathy 75-100 mg/day in divided doses.

Action: inhibits ACE, reduces Sodium and water retention, lowers blood pressure

Adverse Reactions: Hypotension, tachycardia, chest pain, palpitations, pruritus, hyperkalaemia. Proteinuria; angioedema, skin rashes; taste disturbance, nonproductive cough, headache. Potentially Fatal: Neutropenia, usually occurs within 3 mth of starting therapy especially in patients with renal dysfunction or collagen diseases. Hyperkalaemia. Anaphylactic reactions.

Nursing Measures:

Administer 1 hr before or 2 hr after meals. Alert surgeon and mark patient's chart with notice that captopril is being taken; the

angiotensin II formation subsequent to compensatory renin release during surgery will be blocked; hypotension may be reversed with volume expansion.

Monitor patient closely for fall in BP secondary to reduction in fluid volume (excessive perspiration and dehydration, vomiting, diarrhea); excessive hypotension may occur.

Reduce dosage in patients with impaired renal function. Take drug 1 hr before or 2 hr after meals; do not take with food. Do not stop without

consulting your health care provider. Be careful of drop in blood pressure (occurs most often with diarrhea, sweating,

vomiting, dehydration); if light-headedness or dizziness occurs, consult your health care provider.

Avoid over-the-counter medications, especially cough, cold, allergy medications that may contain ingredients that will interact with ACE inhibitors. Consult your health care provider.

These side effects may occur: GI upset, loss of appetite, change in taste perception (limited effects, will pass); mouth sores (perform frequent mouth care); rash; fast heart rate; dizziness, light-headedness (usually passes after the first few days; change position slowly, and limit your activities to those that do not require alertness and precision).

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

7) CLONIDINE

Brand Names: Catapin amp Catapres amp Catapres tab

Classification: Other Antihypertensives

Indication/Dosage: PO HTN Initial: 50-100 mcg 3 times/day. Max: 2,400 mcg/day. Menopausal flushing; Migraine prophylaxis 50 mcg twice daily, up to 75 mg twice daily. IV Hypertensive crisis 150-300 mcg via slow inj. Max: 750 mcg over 24 hr. Epidural Severe cancer pain Initial: 30 mcg/hr as continuous infusion in combination w/ an opioid. Transdermal HTN As patch releasing 100-300 mcg clonidine base/day at constant rate: Apply once wkly.

Action: stimulates alpha 2 receptors and inhibits central vasomotor centers, lowers peripheral vascular resistance, blood pressure, and heart rate

Adverse Reactions: Dry mouth, drowsiness, dizziness, headache, constipation, impotence, vivid dreams, urinary retention; dry, itching, burning sensation in the eye; fluid or electrolyte imbalance, GI upset, paralytic ileus, orthostatic hypotension, weakness, sedation, pruritus, myalgia, urticaria, nausea, insomnia, arrhythmias, agitation. Reduced GI motility at times may

cause paralytic ileus. Potentially Fatal: Transient hypertension or profound hypotension, respiratory depression, convulsion. Clonidine withdrawal syndrome could be life threatening. Bradycardia, coma and disturbances in conduction (in individuals with preexisting diseases of SA/AV nodes, overdose or on digitalis).

Nursing Measures:

Take drug 1 hr before or 2 hr after meals; do not take with food. Do not stop without consulting your health care provider.

Be careful of drop in blood pressure (occurs most often with diarrhea, sweating, vomiting, dehydration); if light-headedness or dizziness occurs, consult your health care provider.

Avoid over-the-counter medications, especially cough, cold, allergy medications that may contain ingredients that will interact with ACE inhibitors. Consult your health care provider.

These side effects may occur: GI upset, loss of appetite, change in taste perception (limited effects, will pass); mouth sores (perform frequent mouth care); rash; fast heart rate; dizziness, light-headedness (usually passes after the first few days; change position slowly, and limit your activities to those that do not require alertness and precision).

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

Take this drug exactly as prescribed. Do not miss doses. Do not discontinue the drug unless so instructed. Do not discontinue abruptly; life-threatening adverse effects may occur. If you travel, take an adequate supply of drug.

Use the transdermal system as prescribed; refer to directions in package insert, or contact your health care provider with questions. Be sure to remove old systems before applying new ones.

Attempt lifestyle changes that will reduce your BP: stop smoking and using alcohol; lose weight; restrict intake of sodium (salt); exercise regularly.

Use caution with alcohol. Your sensitivity may increase while using this drug. These side effects may occur: Drowsiness, dizziness, light-headedness, headache,

weakness (often transient; observe caution driving or performing other tasks that require alertness or physical dexterity); dry mouth (suck on sugarless lozenges or ice chips); GI upset (eat small, frequent meals); dreams, nightmares (reversible); dizziness, light-headedness when you change position (get up slowly; use caution climbing stairs); impotence, other sexual dysfunction, decreased libido (discuss with care providers); breast enlargement, sore breasts; palpitations.

Report urinary retention, changes in vision, blanching of fingers, rash.

8) DIAZEPAM

Brand name: Valium

Classification: Anxiolytics

Dosage: 10mg/2ml

Indication: relief of anxiety, agitation & tension due to psychoneurotic states & transient situational disturbances

Action: a benzodiazepine that probably potentiates the effects of GABA, depresses the CNS & suppresses the spread of seizure activity

Adverse Reaction: drowsiness,dysarthria, slurred speech, tremor, transient amnesia, fatigue, ataxia, headache, insomnia, paradoxical anxiety, hallucination

Nursing Measures:

Do not administer intra-arterially; may produce arteriospasm, gangrene. Change from IV therapy to oral therapy as soon as possible. Do not use small veins (dorsum of hand or wrist) for IV injection. Reduce dose of narcotic analgesics with IV diazepam; dose should be reduced by at least

one-third or eliminated. Carefully monitor P, BP, respiration during IV administration. Maintain patients receiving parenteral benzodiazepines in bed for 3 hr; do not permit

ambulatory patients to operate a vehicle following an injection. Monitor EEG in patients treated for status epilepticus; seizures may recur after initial

control, presumably because of short duration of drug effect. Monitor liver and kidney function, CBC during long-term therapy. Taper dosage gradually after long-term therapy, especially in epileptic patients. Arrange for epileptic patients to wear medical alert ID indicating that they are epileptics

taking this medication. Discuss risk of fetal abnormalities with patients desiring to become pregnant.

9) DIGOXIN

Brand name: Digitek, Lanoxicaps, Lanoxin, Novo-Digoxin (CAN)

Classification: Inotropics

Dosage: 5mg/2ml

Indication: Cardiac failure accompanied by atrial fibrillation; management of chronic cardiac failure where systolic dysfunction or ventricular dilatation is dominant; management of certain supraventricular arrhythmias, particularly chronic atrial flutter & fibrillation.

Action: inhibits sodium-potassium activated adenosine triphosphate, promoting movement of calcium from extracellular to intra-cytoplasm and strengthening myocardial contraction, also acts on CNS to enhance vagal tone

Adverse Reaction: nausea, vomiting, anorexia, headache, facial pain, fatigue, weakness, dizziness, drowsiness, disorientation, mental confusion, bad dreams, convulsions

Nursing Measures:

Monitor apical pulse for 1 min before administering; hold dose if pulse < 60 in adult or < 90 in infant; retake pulse in 1 hr. If adult pulse remains < 60 or infant < 90, hold drug and notify prescriber. Note any change from baseline rhythm or rate.

Check dosage and preparation carefully. Avoid IM injections, which may be very painful. Follow diluting instructions carefully, and use diluted solution promptly. Avoid giving with meals; this will delay absorption. Have emergency equipment ready; have K+ salts, lidocaine, phenytoin, atropine, cardiac

monitor on standby in case toxicity develops. Monitor for therapeutic drug levels: 0.5–2 ng/mL.

10) DIPENHYDRAMINE

Brand name: Benadryl

Classification: antihistamine

Dosage: 50mg/ml

Indication: Hay fever, urticaria, vasomotor rhinitis, angioneurotic edema, drug sensitization, serum & penicillin reaction, contact dermatitis, atopic eczema, other allergic dermatoses, pruritus, food sensitivity, parkinsonism, motion sickness.

Action: prevents histamine mediated responses, drug provides local anesthesia and suppresses cough reflex

Adverse Reaction: CV and CNS effects, blood disorders, GI disturbances, anti-muscarinic effects and allergic reactions.

Nursing Measures:

Monitor carefully, assess for confusion, delirium, other anticholinergic side effects and fall risk. Institute measures to prevent falls.

Assess movement disorder before and after administration.

Caution patient not to use oral OTC diphenhydramine products with any other product containing diphenhydramine, including products used topically.

It can cause excitation in children. Caution parents or caregivers about proper dose calculation; overdosage, especially in infants and children, can cause hallucinations, seizures or death Inform patient that this drug may cause dry mouth. Frequent oral rinses, good oral hygiene, and sugarless gum or candy may minimize this effect. Notify dentist if dry mouth persists for more than 2 weeks.

11) EPINEPHRINE

Brand name: Epinephrine Bitartrate Aerosols: Primatene Mist Epinephrine Borate Ophthalmic solution: Epinal Epinephrine Hydrochloride Injection, OTC nasal solution: Adrenalin Chloride Ophthalmic solution: Epifrin, Glaucon Insect sting emergencies: EpiPen Auto-Injector (delivers 0.3 mg IM adult dose), EpiPen Jr. Auto-Injector (delivers 0.15 mg IM for children) OTC solutions for nebulization: AsthmaNefrin, microNefrin, Nephron, S2

Classification: Sympathomimetic, Alpha-adrenergic agonist, Beta1 and beta2-adrenergic agonist, Cardiac stimulant, Vasopressor, Bronchodilator, Antasthmatic drug, Nasal decongestant, Mydriatic, Antiglaucoma drug

Dosage: 1mg/ml

Indication: Acute asthmatic attacks, Advanced cardiac life support

Action: Naturally occurring neurotransmitter, the effects of which are mediated by alpha or beta receptors in target organs. Effects on alpha receptors include vasoconstriction, contraction of dilator muscles of iris. Effects on beta receptors include positive chronotropic and inotropic effects on the heart (beta1 receptors); bronchodilation, vasodilation, and uterine relaxation (beta 2 receptors); decreased production of aqueous humor.

Adverse Reaction: drowsiness, headache, nervousness, tremors, cerebral hemorrhage, dizziness, weakness, vertigo, pain

Nursing Measures:

Monitor heart rate. Use extreme caution when calculating and preparing doses; epinephrine is a very potent

drug; small errors in dosage can cause serious adverse effects. Double-check pediatric dosage.

Use minimal doses for minimal periods of time; "epinephrine-fastness" (a form of drug tolerance) can occur with prolonged use.

Protect drug solutions from light, extreme heat, and freezing; do not use pink or brown solutions. Drug solutions should be clear and colorless (does not apply to suspension for injection).

Shake the suspension for injection well before withdrawing the dose. Rotate SC injection sites to prevent necrosis; monitor injection sites frequently. Keep a rapidly acting alpha-adrenergic blocker (phentolamine) or a vasodilator (a nitrate)

readily available in case of excessive hypertensive reaction. Have an alpha-adrenergic blocker or facilities for intermittent positive pressure breathing

readily available in case pulmonary edema occurs. Keep a beta-adrenergic blocker (propranolol; a cardioselective beta-blocker, such as

atenolol, should be used in patients with respiratory distress) readily available in case cardiac arrhythmias occur.

Do not exceed recommended dosage of inhalation products; administer pressurized inhalation drug forms during second half of inspiration, because the airways are open wider and the aerosol distribution is more extensive. If a second inhalation is needed, administer at peak effect of previous dose, 3–5 min.

Use topical nasal solutions only for acute states; do not use for longer than 3–5 days, and do not exceed recommended dosage. Rebound nasal congestion can occur after vasoconstriction subsides.

Do not exceed recommended dosage; adverse effects or loss of effectiveness may result. Read the instructions that come with respiratory inhalant products, and consult your health care provider or pharmacist if you have any questions.

To give eye drops: Lie down or tilt head backward, and look up. Hold dropper above eye; drop medicine inside lower lid while looking up. Do not touch dropper to eye, fingers, or any surface. Release lower lid; keep eye open, and do not blink for at least 30 sec. Apply gentle pressure with fingers to inside corner of the eye for about 1 min; wait at least 5 min before using other eye drops.

These side effects may occur: Dizziness, drowsiness, fatigue, apprehension (use caution if driving or performing tasks that require alertness); anxiety, emotional changes; nausea, vomiting, change in taste (eat frequent small meals); fast heart rate. Nasal solution may cause burning or stinging when first used (transient). Ophthalmic solution may cause slight stinging when first used (transient); headache or brow ache (only during the first few days).

Report chest pain, dizziness, insomnia, weakness, tremor or irregular heart beat (respiratory inhalant, nasal solution), difficulty breathing, productive cough, failure to respond to usual dosage (respiratory inhalant), decrease in visual acuity (ophthalmic).

12) FUROSEMIDE

Brand name: Apo-Furosemide (CAN), Furoside (CAN), Lasix, Myrosemide (CAN)

Classification: loop diuretics

Dosage: 20mg/2ml

Indication: edema, hypertension

Action: inhibits Sodium and Chloride reabsorption at the proximal and distal tubules and the ascending loop of Henle

Adverse Reaction: vertigo, headache, dizziness, paresthesia, weakness, restlessness, fever, nocturia, oliguria, polyguria

Nursing Measures:

Monitor BP after administration Administer with food or milk to prevent GI upset. Reduce dosage if given with other antihypertensives; readjust dosage gradually as BP

responds. Give early in the day so that increased urination will not disturb sleep. Avoid IV use if oral use is at all possible. Do not mix parenteral solution with highly acidic solutions with pH below 3.5. Do not expose to light, may discolor tablets or solution; do not use discolored drug or

solutions. Discard diluted solution after 24 hr. Refrigerate oral solution. Measure and record weight to monitor fluid changes. Arrange to monitor serum electrolytes, hydration, liver function. Arrange for potassium-rich diet or supplemental potassium as needed.

13) HYDRALAZINE HYDROCHLORIDE

Brand name: Supres

Classification: antihypertension

Dosage: 20mg/ml

Indication: For hypertensive patient

Action: a direct acting peripheral vasodilator that relaxes arteriolar smooth muscles

Adverse Reaction: tachycardia, palpitation, angina pectoris, severe headache, dizziness, weight gain, GI disturbances, pruritus, rashes, nausea and vomiting

Nursing Measures:

Give oral drug with food to increase bioavailability(drug should be given in a consistent relationship ti ingestion of food for consistent response to therapy).

Drug may cause a syndrome resembling systemic lupus erythematosus (SLE). Arrange for CBC, LE cell preparations, and ANA titers before and periodically during prolonged therapy, even in the asymptomatic patient. Discontinue if blood dyscrasias occur. Reevaluate therapy if ANA or LE tests are positive.

Arrange for pyridoxine if patient develops symptoms of peripheral neuritis. Monitor patient for orthostatic hypotension which is most marked in the morning and in

hot weather, and with alcohol or exercise.

14) HYDROCORTISONE SODIUM SUCCINATE

Brand name: A-hydroCort, Solu-Cortef

Classification: corticosteroid hormones

Stock Dose:100 mg/ 2 mL, 250 mg/ 2 mL

Indication: endocrine, hematologic, rheumatic & collagen disorders, dermatologic, ophth, GI, resp & neoplastic diseases, edematous states, control of severe incapacitating allergic conditions, TB meningitis w/ subarachnoid block or impending block when used concurrently with appropriate anti-TB chemotherapy, shock secondary to adrenocortical insufficiency or shock unresponsive to conventional therapy when adrenocortical insufficiency may be present

Action: Decreases inflammation, mainly by stabilizing leukocyte lysosomal membranes, suppresses immune response, stimulates bone marrow and influences protein, fat, and carbohydrate metabolism

Adverse Reactions: fluid and electrolyte disturbances, decreased carbohydrate tolerance, impaired wound healing, thin fragile skin, muscle weakness, steroid myopathy, osteoporosis, aseptic necrosis, peptic ulceration w/ possible perforation, cataracts, increased intraocular and intracranial pressure, growth retardation, Cushingoid state, protein catabolism, psychic derangements, exophthalmos, masking of infections, gasping syndrome, seizures, menstrual irregularities.

Nursing Measures:

Give daily before 9 AM to mimic normal peak diurnal corticosteroid levels and minimize HPA suppression.

Space multiple doses evenly throughout the day. Do not give IM injections if patient has thrombocytopenic purpura.

Rotate sites of IM repository injections to avoid local atrophy. Use minimal doses for minimal duration to minimize adverse effects. Taper doses when discontinuing high-dose or long-term therapy. Arrange for increased dosage when patient is subject to unusual stress. Use alternate-day maintenance therapy with short-acting corticosteroids whenever

possible. Do not give live virus vaccines with immunosuppressive doses of hydrocortisone. Provide antacids between meals to help avoid peptic ulcer.

15) ISOSORBIDE-5- MONONITRATE

Brand name: Imdur

Classification: anti- anginal drug

Stock Dose: SL: 5 mg/mL ; Oral: 30 mg, 60 mg

Indication: prophylactic treatment of angina pectoris

Action: Thought to reduce cardiac oxygen demand by decreasing preload and afterload. Drug also may increase blood flow through the collateral coronary vessels

Adverse Reactions: headache, hypotension w/ dizziness and nausea, tachycardia

Nursing Measures:

Monitor BP and heart rate. Assess location, duration, intensity, and precipitating factors of anginal pain.

16) ISOSORBIDE DINITRATE

Brand name: Isoket IV

Classification: anti – anginal drug

Stock: IV amp 10 mg/ 10 mL

Dose: 10 mg/10mL

Indication: unresponsive left ventricular failure secondary to acute MI, severe or unstable angina pectoris

Action: Isosorbide dinitrate is a smooth muscle relaxant. It is particularly effective on vascular and bronchial smooth muscle. Its systemic cardiovascular effects are mainly due to a decrease in venous return (pooling of blood in the peripheral venous system). Consequently, ventricular end-diastolic pressure and volume are diminished, thus reducing cardiac work and implicitly myocardial oxygen requirements. The arterial vessels are dilated as well, though to a lesser degree. This results in a slight drop in aortic and systemic blood pressure relieving the myocardium from a part of its afterload. These nitrate-induced changes account for both the antianginal effects of isosorbide dinitrate and for its beneficial effects in the treatment of congestive heart failure. Side effects/ adverse reactions: severe cerebral flow deficiency and decreased coronary perfusion may develop, nitrate headache and nausea.

Nursing Measures:

Monitor BP and heart rate. Assess location, duration, intensity, and precipitating factors of anginal pain.

17) MAGNESIUM SULFATE

Brand name: Elin Magnesium Sulfate

Classification: anticonvulsant

Dosage: 250 mg/10 mL

Indication: treatment of hypomagnesemia accompanied by signs of tetany, control of HTN, encephalophathy & convulsions, prevention & control of convulsions in patients w/ preeclampsia or eclampsia, prevention of hypomagnesemia in patients receiving TPN

Action: may decrease acetylcholine released by nerve impulses, but its anticonvulsant mechanism is unknown

Adverse Reactions: flushing, sweating, hypotension, muscular weakness, sedation & confusion; decreased deep tendon reflexes; resp. paralysis

Nursing Measures:

Monitor the following: I.V.: Rapid administration: ECG monitoring, vital signs, deep tendon reflexes; magnesium, calcium, and potassium levels; renal function during administration. Obstetrics: Patient status including vital signs, oxygen saturation, deep tendon reflexes, level of consciousness, fetal heart rate, maternal uterine activity. Oral: Renal function; magnesium levels; bowel movements.

18) MEPERIDINE HYDROCHLORIDE

Brand name: Demerol

Classification: antivertigo drug

Dosage: 100 mg/ 2mL

Indication: relief of moderate to severe pain, pre-op medication, support of anesth & obstet analgesia

Action: binds with opiate receptors in the CNS, altering perception of and emotional response to pain

Adverse Reactions: resp. depression, circulatory depression, resp arrest, shock, cardiac arrest, GI disturbance, light headedness, dizziness, sedation, nausea, vomiting, sweating, euphoria, dysphoria, weakness, headache, tremor, agitation, uncoordinated muscle movements, severe convulsions, transient hallucinations & disorientation, visual disturbance, flushing, tachycardia, bradycardia, palpitation, hypotension, syncope, phlebitis, urinary retention, allergic reactions, pain at injection site and local tissue irritation.

Nursing Measures:

Make position changes slowly and in stages particularly from recumbent to upright posture. Lie down immediately if light-headedness or dizziness occurs.

Lie down when feeling nauseated and to notify physician if this symptom persists. Nausea appears to worsen with ambulation.

Avoid driving and other potentially hazardous activities until reaction to drug is known. Codeine may impair ability to perform tasks requiring mental alertness and therefore to.

Do not take alcohol or other CNS depressants unless approved by physician. Hyperactive cough may be lessened by avoiding irritants such as smoking, dust, fumes

and other air pollutants. Humidification of ambient air may provide some relief. Do not breast feed while taking this drug.

19) METOCLOPRAMIDE

Brand name: Apo-Metoclop (CAN), Maxeran (CAN), Maxolon, Nu-Metoclopramide (CAN), Octamide PFS, Reglan

Classification: antiemetic & anti-spasmodic

Dosage: 10 mg/ 2mL

Indication: disturbances of GI motility, nausea & vomiting of central & peripheral origin associated w/ surgery, metabolic diseases, infectious & drug induced diseases, facilitate small bowel intubation & radiological procedures of GIT

Action: stimulates motility of upper GI tract, increases lower esophageal sphincter tone, and blocks dopamine receptors at the chemoreceptor trigger zone

Adverse Reactions: extrapyramidal reactions, drowsiness, fatigue & lassitude, anxiety, less frequently, insomnia, headache, dizziness, nausea, galactorrhea, gynecomastia, bowel disturbances.

Nursing Measures:

Monitor BP carefully during IV administration. Monitor for extrapyramidal reactions, and consult physician if they occur. Monitor diabetic patients, arrange for alteration in insulin dose or timing if diabetic

control is compromised by alterations in timing of food absorption. Keep diphenhydramine injection readily available in case extrapyramidal reactions occur

(50 mg IM). Have phentolamine readily available in case of hypertensive crisis (most likely to occur

with undiagnosed pheochromocytoma).

20) MIDAZOLAM HYDROCHLORIDE

Brand name: Dormicum

Classification: hypnotics & sedatives

Dosage: 5mg/5mL

Indication: tab: disturbances of sleep rhythm, insomnia esp difficulty in falling asleep either initially or after premature awakening, tab/inj: sedation in premed before surgical or diagnostic procedures, induction & maintenance of anesth.

Action: may potentiate the effects of GABA, depress the CNS, and suppress the spread of seizure activity

Adverse Reactions: rarely cardioresp adverse events, nausea, vomiting, headache, hiccoughs, laryngospasm, dyspnoea, hallucination, oversedation, drowsiness, ataxia, rash, paradoxical reactions, amnesic episodes.

Nursing Measures:

Do not administer intra-arterially, which may produce arteriospasm or gangrene. Do not use small veins (dorsum of hand or wrist) for IV injection. Administer IM injections deep into muscle. Monitor IV injection site for extravasation. Arrange to reduce dose of midazolam if patient is also being given opioid analgesics;

reduce dosage by at least 50% and monitor patient closely. Monitor level of consciousness prior to, during, and for at least 2–6 hr after

administration of midazolam. Carefully monitor P, BP, and respirations carefully during administration. Keep resuscitative facilities readily available; have flumazenil available as antidote if

overdose should occur. Keep patients in bed for 3 hr; do not permit ambulatory patients to operate a vehicle

following an injection. Arrange to monitor liver and kidney function and CBC at intervals during long-term

therapy. Establish safety precautions if CNS changes occur (use side rails, accompany ambulating

patient). Provide comfort measures and reassurance for patients receiving diazepam for tetanus. Arrange to taper dosage gradually after long-term therapy. Provide patient with written information regarding recovery and follow-up care.

Midazolam is a potent amnesiac and memory may be altered.

21) MORPHINE SULFATE

Brand name: Morin

Classification: Analgesics (Opioid)

Dosage: Adult 5-20 mg IM/SC 4 hrly. Severe or chronic pain Childn 10 mg IM/SC 4 hrly, range: 5-20 mg; 6-12 yr 5-10 mg, 1-5 yr 2.5-5 mg, 1-12 mth 200 mcg/kg, <1 mth 150 mcg/kg 4 hrly. Max: 15 mg. Analgesic effect Ped 100-200 mcg/kg SC 4 hrly, max: 15 mg/dose; or 50-100 mcg/kg slow IV. Pre-op 50-100 mcg/kg IM, max: 10 mg/dose.

Indication: Relief of moderate to severe pain not responsive to non-narcotic analgesics. Premed. Analgesic adjunct in general anesth esp in pain associated w/ cancer, MI & surgery. Alleviates anxiety associated w/ severe pain. Hypnotic for pain-related sleeplessness.

Action: alters perception and emotional response to pain

Adverse Reactions: Lightheadedness, dizziness, sedation, nausea, vomiting, constipation & sweating.

Nursing Measures:

Caution patient not to chew or crush controlled-release preparations. Dilute and administer slowly IV to minimize likelihood of adverse effects. Tell patient to lie down during IV administration. Keep opioid antagonist and facilities for assisted or controlled respiration readily

available during IV administration. Use caution when injecting SC or IM into chilled areas or in patients with hypotension or

in shock; impaired perfusion may delay absorption; with repeated doses, an excessive amount may be absorbed when circulation is restored.

Reassure patients that they are unlikely to become addicted; most patients who receive opioids for medical reasons do not develop dependence syndromes.

22) NICARDIPINE HYDROCHLORIDE

Brand name: Cardepine

Classification: Calcium Antagonists

Dosage: IV infusion Dilute to 10-20 mg/100 mL (conc of 1.01-0.02%). Initial infusion rate: 5 mg/hr; titrate dose up to 15 mg/hr until desired therapeutic response is achieved (DBP <95 mmHg, SBP <140 mmHg). Maintenance rate: Can be tapered down to ≤10mg/hr. IV bolus inj 2-7 mg w/out dilution given over 1-2 min.

Indication: Hypertensive emergencies or urgencies, peri-op & post-op HTN, hypertensive states of NPO patients.

Action: a Calcium channel blocker that inhibits Calcium ion influx across cardiac and smooth muscle cells, also dilates coronary arteries and arterioles

Adverse Reactions: Peripheral edema, headache, tachycardia, palpitations, localized thrombophlebitis & hypotension.

Nursing Measures:

Patients with hepatic impairment should receive lower dose. Monitor blood pressure.Allow atleast 3 days between dosage adjustment to achieve

steady plasma levels. Advise patient to report immediately if experiencing chest pain

23) NTG PATCH

Brand name: Deponit, Minitran, Nitrek, Nitro-Dur, Nitrodisc, Transderm-Nitro

Classification: Anti-Anginal Drugs

Dosage: Starting dose: 0.2-0.4 mg/hr. Dosing schedule: Daily patch-on period of 12-14 hr & daily patch-off period of 10-12 hr.

Indication: Prevention of angina pectoris due to coronary artery disease

Action: a nitrate that reduces cardiac oxygen demand by decreasing left ventricular end diastolic pressure and to a lesser extent, systemic vascular resistance, also increases blood flow through collateral coronary vessels

Adverse Reactions: Headache. Transient episodes of lightheadedness. Infrequently, hypotension. Syncope, crescendo angina, rebound HTN, allergic & anaphylactoid reactions. Rarely severe, application site irritation.

Nursing Measures:

Administer transdermal systems to skin site free of hair and not subject to much movement. Shave areas that have a lot of hair. Do not apply to distal extremities. Change sites slightly to decrease the chance of local irritation and sensitization. Remove transdermal system before attempting defibrillation or cardioversion.

To use transdermal systems, you may need to shave an area for application. Apply to a slightly different area each day. Use care if changing brands; each system has a different concentration.

24) PARACETAMOL

Brand name: Aeknil

Classification: Analgesics (Non-Opioid) & Antipyretics

Dosage: Adult & childn ≥10 yr 2-3 mL, ≤10 yr 1-2 mL. Depending on severity of case, dose may be repeated 4 hrly. In severe cases, dose may be administered by IV very slowly

Indication: Pyrexia of unknown origin. Fever & pain associated w/ common childhood disorders, tonsillitis, upper resp tract infections post-immunization reactions, after tonsillectomy & other conditions. Prevention of febrile convulsion. Headache, cold, sinusitis, muscle pain, arthritis & toothache Action: produce analgesia by blocking pain impulses by inhibiting synthesis of prostaglandin in CNS, relieves fever

Adverse Reactions: Hematological, skin & other allergic reactions

Nursing Measures:

Use liquid form for children and patients who have difficulty swallowing. In children, don’t exceed five doses in 24 hours. Advise patient that drug is only for short term use and to consult the physician if giving

to children for longer than 5 days or adults for longer than 10 days. Advise patient or caregiver that many over the counter products contain acetaminophen;

be aware of this when calculating total dailydose. Warn patient that high doses or unsupervised long term use can cause liver damage.

25) PHENYTOIN

Brand name: Dilantin

Classification: Anticonvulsants

Dosage: Adult Initially 100 mg tid. Maintenance: 300-400 mg daily. Childn ≥6 yr Initially 100 mg tid, subsequent dosage should be adjusted according to therapeutic response, <6 yr 30 mg bid, may be increased to 30 mg tid or qid. Pedia 5 mg/kg/day Initially in 2-3 equally divided doses. Max: 300 mg daily. Maintenance: 4-8 mg/kg/day

Indication: Tonic-clonic & complex partial (psychomotor, temporal lobe), prevention & treatment of seizures occurring during or following neurosurgery

Action: may stabilize neuronal membranes and limit seizure activity by either by increasing efflux or decreasing influx of Na ions across cell membrane in the motor cortex during generation of nerve impulses

Adverse Reactions: GI disturbances; ataxia, slurred speech; diplopia, nystagmus & mental confusion w/ headache, dizziness, gingival hyperplasia, hirsutism, hyperglycemia, osteomalacia

Nursing Measures:

Assess location, duration, frequency, and characteristics of seizure activity. EEG may be onitored periodically throughout therapy, Assess oral hygiene. Vigorous oral cleaning beginning within 10 days of initiation of phenytoin therapy may help control gingival hyperplasia

26) TERBUTALINE

Brand name: Bricalin

Classification: Antiasthmatic & COPD Preparations

Dosage: Antiasthmatic & COPD Preparations

Indication: For reversible airways obstruction, in asthma, COPD. Decreases uterine contractility & may be used to arrest premature labor

Action: relaxes bronchial smooth muscles by stimulating beta-2 receptors

Adverse Reaction: Fine tremor of skeletal muscle esp hands, palpitations, tachycardia, nervous tension, headache, peripheral vasodilation.

Nursing Measures:

Use minimal periods of time; drug tolerance can occur with prolonged use. Keep beta-adrenergic blocker readily available in case cardiac arrhythmias occur. Do not recommended dosage.

27) VERAPAMIL HYDROCHLORIDE

Brand name: Calan, Calan SR, Covera-HS, Isoptin, Isoptin SR, Verelan, Verelan PM

Classification: Calcium Antagonists

Dosage: Isoptin tab Adult 40-80 mg tid-qid. Max: 480 mg daily. Childn >6 yr 40-120 mg bid-tid, up to 360 mg daily, childn ≤6 yr 40 mg bid-tid. Isoptin SR 180 Coronary insufficiency 1 tab bid. Usual daily dose: 40-480 mg. Hypertension 1 tab in the morning. Isoptin SR 240 1 tab in the morning. If required after 2 wk, increase dose to 2 tab daily. Isoptin amp 5 mg slow IV, if required, 5 mg after 5-10 min. Then, if required, continuous drip infusion of 5-10 mg/hr up to 100 mg/day. Angina pectoris & rapid elimination of tachyarrhythmias 1-2 amp IV, if required bid-tid

Indication: Isoptin/Isoptin SR 180 Essential hypertension, chronic coronary insufficiency, angina pectoris, paroxysmal supraventricular tachycardia, tachyarrhythmias, long-term treatment after MI. Isoptin SR 240 Essential hypertension

Action: decreases myocardial contractility and oxygen demand, it also dilates coronary arteries and arterioles

Adverse Reactions: Constipation, dizziness, nausea. Rarely, vertigo, headache, hypotension, ankle edema, flushing, fatigue, nervousness, erythromelalgia, paraesthesia, neuropathy; bradycardiac arrhythmias, CHF. Dyspnea

Nursing Measures:

Monitor patient carefully (BP, cardiac rhythm, and output) while drug is being titrated to therapeutic dose. Dosage may be increased more rapidly in hospitalized patients under close supervision.

Ensure that patient swallows SR tablets whole: do not cut, crush, or chew them. Monitor BP very carefully with concurrent doses of antihypertensives. Monitor cardiac rhythm regularly during stabilization of dosage and periodically during

long-term therapy. Administer sustained-release form in the morning with food to decrease GI upset. Protect IV solution from light. Monitor patients with renal or hepatic impairment carefully for possible drug

accumulation and adverse reactions.

28) IPRATROPIUM INHALATION

Brand name: Atrovent

Classification: Antiasthmatic & COPD Preparations, anticholinergics or antimuscarinics

Stock: 0.5 mg/2 mL

Dosage: Adult (including elderly) & adolescent >12 yr Acute attacks 1 vial, may repeat doses until patient is stable. Maintenance: 1 vial tid-qid.

Indication: Bronchodilator for treatment of bronchospasm associated w/ COPD, including chronic bronchitis, emphysema and asthma

Action: it works by binding to specific receptors (called muscarinic receptors) in the airway, helping to relax the smooth muscle of the airway. When used to treat a runny nose, it works by decreasing the production of fluid in the glands that line the nasal passages

Adverse Reaction: Headache, nausea, dry mouth, increased heart rate & palpitations, ocular accommodation disturbances, GI motility disturbances, urinary retention, ocular side effects, cough, local irritation, bronchoconstriction, skin rash, angioedema, urticaria, laryngospasm, anaphylactic reactions.

Nursing Measures:

Protect solution for inhalation from light. Store unused vials in foil pouch. Use nebulizer mouthpiece instead of face mask to avoid blurred vision or aggravation of

narrow-angle glaucoma. Can mix albuterol in nebulizer for up to 1 hr. Ensure adequate hydration, control environmental temperature to prevent hyperpyrexia. Have patient void before taking medication to avoid urinary retention.

Teach patient proper use of inhalator.

29) FENOTEROL/IPRATROPIUM BROMIDE

Brand name: Berodual

Classification: Antiasthmatic & COPD Preparations

Dosage: Berodual inhalation soln Adult (including elderly) & adolescent >12 yr Treatment of 1 mL for immediate symptom relief. Intermittent & long-term treatment 1-2 mL for each administration, up to qid. Moderate bronchospasm or w/ assisted ventilation 0.5 mL. Childn 6-12 yr Treatment of attacks 0.5-1 mL. Intermittent & long-term treatment 0.5-1 mL for each administration, up to qid. Moderate bronchospasm or w/ assisted ventilation 0.5 mL. Childn <6 yr (<22 kg body wt) Up to 0.5 mL up to tid. Berodual F UDV Adult & childn >12 yr Acute asthma episodes 1 vial, in very severe cases, 2 vials are needed. Intermittent & long-term treatment 1 vial up to qid.

Indication: prevention and treatment of symptoms in chronic obstructive airway disorders with reversible bronchospasm

Action: for the prevention and treatment of reversible bronchospasm associated with bronchial asthma and especially chronic bronchitis with or without emphysema

Adverse Reactions: Fine tremor of skeletal muscles, nervousness, restlessness, palpitations; less frequently tachycardia, dizziness or headache. Dry mouth, throat irritation or allergic reactions, cough, paradoxical bronchoconstriction (rare). Urinary retention may occur in particular, in patients w/ preexisting outflow tract obstruction.

Nursing Measures:

Protect solution for inhalation from light. Store unused vials in foil pouch. Use nebulizer mouthpiece instead of face mask to avoid blurred vision or aggravation of

narrow-angle glaucoma. Can mix albuterol in nebulizer for up to 1 hr. Ensure adequate hydration, control environmental temperature to prevent hyperpyrexia. Have patient void before taking medication to avoid urinary retention. Teach patient proper use of inhalator.

30) BUDESONIDE

Brand name: Symbicort

Classification: Corticosteroids

Dosage: 80/4.5 mcg x 60 doses; 160/4.5 mcg x 60 doses; 320/9 mcg x 60 doses

Indication: regular treatment of asthma where use of a combination (inhaled corticosteroid and long acting beta 2 agonist) is appropriate

Action: work by reducing inflammation, which helps with several conditions ranging from asthma to allergies to Crohn’s disease

Adverse Reactions: Abdominal pain, conjunctivitis (pinkeye), cough, diarrhea, ear infection or inflammation, fever, fungal infection in mouth, headache, nasal or sinus inflammation, nosebleed, pain, rash, respiratory infection, stomach or intestinal inflammation, throat inflammation, viral infection, vomiting, wheezing

Nursing Measures:

Taper systemic steroids carefully during transfer to inhalational steroids; deaths from adrenal insufficiency have occurred.

Arrange for use of decongestant nose drops to facilitate penetration if edema, excessive secretions are present.

Prime unit before use for Pulmicort Turbuhaler; have patient rinse mouth after each use. Use aerosol within 6 mo of opening. Shake well before each use. Store Respules upright and protected from light; gently shake before use; open envelopes

should be discarded after 2 wk.

31) ALBUTEROL AND IPRATROPIUM INHALATION

Brand name: Combivent

Classification: Bronchodilators

Stock: 2.5 mL

Dose: MDI Adult 2 puffs tid-qid. Max 12 puffs/day. Unit dose vial Adult & childn >12 yr 1 vial every 6-8 hr. Childn 2-12 yr 3 drops/kg/dose (max: 2500 mcg of salbutamol) every 6-8 hr.

Indication: management of reversible bronchospasm associated with obstructive airway diseases in patients who require more than a single bronchodilator

Action: muscles in the airways and increase air flow to the lungs

Adverse Reactions: Fine tremor of skeletal muscle; palpitations; headache, dizziness, nervousness; dryness of mouth, throat irritation; urinary retention

Nursing Measures:

Use nebulizer mouthpiece instead of face mask to avoid blurred vision or aggravation of narrow-angle glaucoma.

Can mix albuterol in nebulizer for up to 1 hr. Ensure adequate hydration, control environmental temperature to prevent hyperpyrexia. Have patient void before taking medication to avoid urinary retention. Teach patient proper use of inhalator.

32) SALBUTAMOL

Brand name: Aero-Vent

Classification: bronchodilator

Stock: 1 mg/1 mL

Dose: Adult & childn 2.5-5 mg. May repeat qid by hlebitis. Delivery of aerosol may be by face mask of ”T” piece. Use undiluted. For prolonged delivery time, dilute w/ sterile water or normal saline for inj.

Indication: treatment of acute, severe asthma and in routine management of chronic bronchospasm unresponsive to conventional therapy

Action: used with anti-inflammatory medication to prevent asthma attacks, Some of these medicines are used to treat the symptoms of asthma, chronic bronchitis, emphysema, and other lung diseases, while others are used to prevent the symptoms

Adverse Reactions: Dizziness, severe; feeling of choking, irritation, or swelling in throat; flushing or redness of skin; hives; increased shortness of breath; skin rash; swelling of face, lips, or eyelids; tightness in chest or wheezing, troubled breathing

Nursing Measures:

Assess lung sounds, pulse, and blood pressure before administration and during peak of medication. Note amount, color, and character of sputum produced.

Monitor pulmonary function tests before initiating therapy and periodically throughout course to determine effectiveness of medication.

Observe for paradoxical bronchospasm (wheezing). If condition occurs, withhold medication and notify physician or other health care professional immediately.

Instruct mother to take missed dose as soon as remembered, spacing remaining doses at regular intervals. Do not double doses or increase the dose or frequency of doses.

Inform the mother not to smoke near the child and to avoid respiratory irritants. Advise the mother to rinse the child’s mouth with water after each inhalation dose to

minimize dry mouth.

33) TERBUTALINE SULFATE

Brand name: Pulmonyl

Classification: Antiasthmatic/ Brochodilator

Stock: 2.5 mg/ml

Dose: Adult 5-10 mg, Children 2-5mg

Indication: relief of bronchospasm in obstructive airway diseases

Action: It works by dilating (opening) the bronchioles of the lungs by relaxing the muscles around them. This allows for easier airflow into and out of the lungs

Adverse Reactions: Headache, nausea, vomiting, palpitations, tachycardia, sweating & drowsiness

Nursing Measures:

Use minimal periods of time; drug tolerance can occur with prolonged use. Keep beta-adrenergic blocker readily available in case cardiac arrhythmias occur. Do not recommended dosage.

34) HEPARIN SODIUM

Brand name: Britton Heparin Na

Classification: Anticoagulants, Antiplatelets & Fibrinolytics (Thrombolytics)

Dosage: 5000 iu/1 mL; 25000 iu/1 mL

Indication: treatment and prophylaxis of thromboembolic disorders

Action: Accelerates formation of antithrombin III-thrombin complex and deactivates thrombin, preventing conversion of fibrinogen to fibrin

Adverse Reactions: Slight fever, headache, chills, nausea, vomiting, constipation, epistaxis, bruising, slight haematuria, skin necrosis (SC inj), osteoporosis, alopecia. Hypersensitivity reactions include urticaria, conjunctivitis, rhinitis, asthma, angioedema and anaphylactic shock. Priapism. Potentially Fatal: Heparin-induced thrombocytopenia with or without thrombosis; bleeding

Nursing Measures:

Baseline blood coagulation tests, Hct, Hgb, RBC and platelet counts prior to initiation or therapy and at regular intervals throughout therapy

Monitor APTT levels closely Draw blood for coagulation tests 30 min before each scheduled SC or intermittent IV

dose and approximately q4h for pts receiving continuous IV heparin during dosage adjustments period. After dosage is established, tests may be done once daily

Pts vary widely in their reaction to heparin; risk of hemorrhage appears greatest in women, all patients > 60 y, and patients with liver disease or renal insufficiency.

Monitor vitals, report fever, drop in BP, rapid pulse and other S&S of hemorrhage Observe all needle sites daily for hematoma and signs of inflammation Have on hand protamine sulfate, specific heparin antagonist

35) ESMOLOL HYDROCHLORIDE

Brand name: Brevibloc

Classification: Beta blockers

Dosage: 100mg/10ml

Indication: supraventricular tachycardia; post-operative tachycardia or hypertension; non-compensatory sinus tachycardias; intra-operative tachycardia or hypertension; unstable angina, non ST segment elevation MI

Action: A Class II antiarrythmic and ultra-short-acting selective beta blocker that decreases heart rate, contractility and blood pressure

Adverse Reactions: Hypotension, bradycardia, heart failure, local irritation, diaphoresis, peripheral ischaemia, dizziness, somnolence, confusion, fatigue, paraesthesia, peripheral neuropathy, headache, weakness, irritability, dyspnoea, nausea, vomiting, blurred vision, urinary retention, fever, rigor, muscular pain.

Potentially Fatal: Profound bradycardia, AV block, cardiogenic shock, asystole, bronchospasm.

Nursing Measures:

Monitor patient carefully (BP, cardiac rhythm, and output) while drug is being titrated to therapeutic dose. Dosage may be increased more rapidly in hospitalized patients under close supervision.

Monitor cardiac rhythm regularly during stabilization of dosage and periodically during long-term therapy.

36) D 50-50

Brand name: Phil Pharmawealth/Atlantic 50% Dextrose

Classification: Intravenous & Other Sterile Solutions

Dosage: 50ml/vial

Indication: for hypoglycemia

Action: A simple water soluble sugar that minimizes glyconeogenesis and promotes anabolism in patients whose oral caloric intake is limited

Adverse Reactions: Local pain, vein irritation, thrombophlebitis & tissue necrosis in the event of extravasation. Fluid & electrolyte imbalance eg hypokalemia, hypomagnesemia & hypophosphatemia; edema or water intoxication

Nursing Measures:

Monitor infusion rate frequently; if signs of fluid overload, turn off IV drip. Infusion may result in fluid overload.

Check IV site frequently and if infiltration is noted, turn off IV drip. Watch out for signs of fluid overload (distended neck veins (JVD), rapid respirations,

shallow tidal volume, fine auscultatory crackles, dyspnea, and peripheral edema) Watch out for signs of infiltration (swelling and pain around IV site).

37) POTASSIUM CHLORIDE

Brand name: Phil Pharmawealth/Atlantic Potassium Chloride

Classification: Electrolytes

Dosage: 40 meqs/20 ml

Indication: for hypokalemia, acute MI

Action: Replaces potassium and maintains potassium level

Adverse Reactions: GI ulceration (sometimes with haemorrhage and perforation or with late formation of strictures) following the use of enteric-coated K chloride preparation; hyperkalaemia. Oral: Nausea, vomiting, phlebitis and abdominal cramps. IV: Pain or phlebitis; cardiac toxicity.

Nursing Measures:

Monitor serum potassium levels, renal function, and serum bicarbonate. 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 doseschedule. 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. Some extended-release tablets are contained in a wax matrix that may be expelled in the stool. This occurrence is not significant.

Instruct patient to avoid salt substitutes or low-salt milk or food unless approved by health care professional.

Patient should be advised to read all labels to prevent excess potassium intake. Advise patient regarding sources of dietary potassium. Encourage compliance with recommended diet. Instruct patient to report dark, tarry, or bloody stools; weakness; unusual fatigue; or

tingling of extremities. Notify health care professional if nausea, vomiting, diarrhea, or stomach discomfort

persists. Dosage may require adjustment. Emphasize the importance of regular follow-up exams

to monitor serum levels and progress.

38) LIDOCAINE HYDROCHLORIDE

Brand name: Abbott Lidocaine

Classification: Anaesthetics - Local & General

Dosage: 50 ml/vial

Indication: local or regional anesthesia

Action: A class IB antiarrythmic that decreases the depolarization, automaticity, and excitability in the ventricles during the diastolic phase by direct action on the tissues especially the Purkinje network

Adverse Reactions: Restlessness, nervousness, dizziness, tinnitus, blurred vision; GI upsets; muscle twitching, convulsions; numbness of the tongue; hypotension, bradycardia; methemoglobinaemia; fetal intoxication.

Nursing Measures:

Check drug concentration carefully; many concentrations are available. Reduce dosage with hepatic or renal failure. Continuously monitor response when used as antiarrhythmic or injected as local

anesthetic. Keep life-support equipment and vasopressors readily available in case severe adverse

reaction (CNS, CV, or respiratory) occurs when lidocaine is injected. Establish safety precautions if CNS changes occur; have IV diazepam or short-acting

barbiturate (thiopental, thiamylal) readily available in case of seizures. Monitor for malignant hyperthermia (jaw muscle spasm, rigidity); have life-support

equipment and IV dantrolene on standby. Titrate dose to minimum needed for cardiac stability, when using lidocaine as

antiarrhythmic. Reduce dosage when treating arrhythmias in CHF, digitalis toxicity with AV block, and

geriatric patients. Monitor fluid load carefully; more concentrated solutions can be used to treat arrhythmias

in patients on fluid restrictions. Have patients who have received lidocaine as a spinal anesthetic remain lying flat for 6–

12 hr afterward, and ensure that they are adequately hydrated to minimize risk of headache.

Check lidocaine preparation carefully; epinephrine is added to solutions of lidocaine to retard the absorption of the local anesthetic from the injection site.

Be sure that such solutions are used only to produce local anesthesia. These solutions should be injected cautiously in body areas supplied by end arteries and used cautiously in patients with peripheral vascular disease, hypertension, thyrotoxicosis, or diabetes.

Use caution to prevent choking. Patient may have difficulty swallowing following use of oral topical anesthetic. Do not give food or drink for 1 hr after use of oral anesthetic.

Treat methemoglobinemia with 1% methylene blue, 0.1 mg/kg, IV over 10 min. Apply lidocaine ointments or creams to a gauze or bandage before applying to the skin.

Monitor for safe and effective serum drug concentrations (antiarrhythmic use: 1–5 mcg/mL). Doses > 6–10 mcg/mL are usually toxic

39) SODIUM BICARBONATE

Brand name: Hospira Sodium Bicarbonate

Classification: Alkalinizers

Dosage: 10mEq/10ml; 50mEq/50ml

Indication: metabolic acidosis, systemic or urinary alkalinization, antacid, cardiac arrest

Action: Restores buffering capacity of the body and neutralizes excess acid

Adverse Reaction: Tetany, edema, gastric distention, belching, flatulence, hypokalemia, metabolic alkalosis, hypernatremia, chemical cellulitis because of alkalinity, pain, irritation, tissue necrosis, ulceration or sloughing at the site of infiltration

Nursing Measures:

do not take drug with milk to avoid hypercalcemia, abnormally high alkalinity in tissues and fluids, or kidney stones.

do not give to patients with metabolic or respiratory alkalosis, and in those with hypocalcemia in which alkalosis may produce tetany, hypertension, seizures, or heart failure.

monitor for alkalosis by obtaining blood pH, PaO2, PCO2, and electrolyte levels

40) DOPAMINE

Brand name: Intropin

Classification: Adrenergics (Sympathomimetics)

Dosage: 40 mg/Ml; 80 mg/mL; 160 mg/mL

Indication: shock and hemodynamic imbalances, hypotension

Action: Stimulates dopaminergic and alpha beta receptors for the sympathetic nervous system resulting in a positive inotropic effect and increased cardiac output. Action is dose-related; large doses cause mainly alpha stimulation

Adverse Reaction: ectopic beats, tachycardia, anginal pain, palpitation, hypotension, vasoconstriction, ventricular arrhythmias, hypertension, headache, anxiety, dilated pupils, nausea, vomiting, decreased urine output, dyspnea

Nursing Measures:

Monitor vital signs and ECG closely throughout therapy. Monitor I&O regularly; note decreases in urine output. Monitor central venous pressure or pulmonary wedge pressure if possible during

infusion. Note significant changes in vital signs, ECG changes, deterioration of peripheral pulses,

and/or cold, mottled extremities

41) DOBUTAMINE

Brand name: Dobatrey

Classification: Adrenergics

Dosage: 12.5 mg/mL

Indication: increased cardiac output in short term treatment of cardiac decompensation caused by epressed contractility

Action: Stimulates heart’s beta1 receptors to increase myocardial contractility and stroke volume. Increases cardiac output by decreasing peripheral vascular resistance, reducing ventricular filling pressure, and facilitating AV node conduction

Adverse Reaction: increased systolic BP, increased heart rate, chest pain, increased number of premature ventricular beats, headache, tingling sensations, paresthesia. nausea, vomiting, dyspnea, phlebitis, local inflammation after infiltration, leg cramps

Nursing Measures:

Monitor vital signs, ECG, cardiac output, pulmonary capillary wedge pressure, central venous pressure and urinary output carefully throughout infusion.

Monitor patency and placement of IV catheter to reduce risk of extravasation and phlebitis.

Watch out for symptoms of overdosage such as excessive hypertension, tachycardia, nausea, vomiting, tremor, headache, chest pain

42) LIDOCAINE PREMIXED

Brand name: Xylocaine

Classification: Antiarrhythmic agent, Local anesthetic

Dosage: 0.2% (2mg/ml); 0.4% (4g/ml); 0.8% (8g/ml)

Indication: ventricular arrhythmias caused by MI, cardiac manipulation or cardiac glycosides

Action: Acts as an anesthetic by stabilizing the neuronal membrane by inhibiting the ionic fluxes required for the initiation and conduction of impulses, thereby effecting local anesthetic action. Also acts as an antiarrhythmic by decreasing the depolarization, automaticity, and excitability in the ventricles during the diastolic phase by a direct action on the tissues, especially the Purkinje network, without involvement of the autonomic system. Neither contractility, systolic arterial blood pressure, atrioventricular (AV) conduction velocity, nor absolute refractory period is altered by usual therapeutic doses

Adverse Reaction: bradycardia, cardiac arrest, CV collapse, hypotension, apprehension, confusion, dizziness, drowsiness, hallucinations, headache, light-headedness, mood changes, nervousness, tremors, conjunctival hyperemia, corneal epithelial changes, diplopia, tinnitus, visual disturbances, nausea, vomiting, erythema, petechiae, edema, injection-site reactions, including bruising, burning, contusion, hemorrhage, local reactions, including soreness at IM injection site, venous thrombosis or phlebitis, extravasation, burning, stinging, sloughing, respiratory depression or arrest, hypersensitivity reactions

Nursing Measures:

Explain that adverse reactions related to the CNS (eg, drowsiness, confusion, paresthesias, convulsions, respiratory arrest) can occur and are a result of CNS toxicity.

Advise patient that drug may cause dizziness or drowsiness and to avoid getting out of bed or walking without assistance.

Advise patients that skin reactions, including erythema, petechiae, and edema, may occur with intradermal injection.

Systemic effects can occur following topical use; use lowest possible dose to avoid serious toxicity, shock, or heart block.

Do not use in patients with congenital or idiopathic methemoglobinemia or in infants younger than 12 mo of age who are receiving methemoglobin-inducing drugs.

Use with caution and in lower doses in patients with CHF, reduced cardiac output, digitalis toxicity, and in elderly patients

43) MANNITOL

Brand name: Osmitrol

Classification: osmotic diuretic

Dosage: 5% , 10%, 15%, 20%, 25% in 500cc/1,000cc

Indication: test dose for marked oliguria or suspected inadequate renal function, oliguria, to reduce intraocular or intracranial pressure, diuresis in drug intoxication

Action: Increases osmotic pressure of glomerular filtrate; drug elevates plasma osmolality

Adverse Reaction: Increased urination, nausea, runny nose, vomiting, severe allergic reactions (rash, hives, itching, difficulty breathing, tightness in the chest, swelling of the mouth, face, lips, or tongue), blurred vision, chest pain, chills or fever, confusion, decreased alertness, difficulty urinating, extreme dizziness, extreme thirst or dry mouth, fast or irregular heartbeat, headache, muscle cramps, pain, redness, or swelling at the injection site, weakness

Nursing Measures:

Monitor vital signs, including CVP, and fluid intake and output. Monitor weight, renal function, and serum sodium and potassium levels daily Watch out for symptoms of overdosage such as excessive hypertension, tachycardia,

nausea, vomiting, tremor, headache, chest pain To relieve thirst, give frequent mouth care and fluids

44) DEXTROSE 5% IN WATER (D5W) SOLUTION

Brand name: None

Classification: Isotonic/Hypotonic Solution

Dosage: 250ml bottles (5g dextrose/100ml water)

Indication: fluid replacement and caloric supplementation in patients who can’t maintain adequate oral intake or are restricted from doing so

Action: Provides some sugar for cellular metabolism and supplies body water

Adverse Reaction: Increases free water and may cause intracellular edema, fluid overload, infiltration (swelling and pain at infusion site)

Nursing Measures:

Monitor infusion rate frequently; if signs of fluid overload, turn off IV drip. Infusion may result in fluid overload.

Check IV site frequently and if infiltration is noted, turn off IV drip. Watch out for signs of fluid overload (distended neck veins (JVD), rapid respirations,

shallow tidal volume, fine auscultatory crackles, dyspnea, and peripheral edema)

Watch out for signs of infiltration (swelling and pain around IV site).