Classifications Pharmacological (3)

8/6/2019 Classifications Pharmacological (3)

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A. Managing pain

1. Information common to analgesicsa. therapeutic class: analgesicsb. establish baseline data and frequently monitor

i. pain objective: pain scale subjective: characteristics, location, type of

painii. clinical indicators of pain

reluctance to move, ambulate, eat restlessness, splinting, muscle tension higher than normal blood pressure faster than normal heart rate or respiratory

rateiv. record response to therapy and analgesic at

indicated time according to administration route andagent used

2. collaborate with provider for comprehensive painmanagement

iii. provide non-pharmacological methods of pain reliefsuch as distraction, positioning, and guidedimagery with pharmacotherapy

iv. eliminate factors that decrease pain tolerance:fatigue, boredom, anxiety, stress, anger, fear

v. individualize pain management according to pain history context of therapy and available resources clients age, past experiences, values,

expectations, physical and mental healthvi. administer pharmacotherapy before severe pain

develops

vii. administer lowest dose of analgesic providingsatisfactory pain relief according to client report

viii. augment potential analgesic effect with adjuncttherapy (See also: III.A.6 adjunct therapy)

3. alcohol and CNS depressants potentiate analgesic effectiii. high risk behavior
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iv. associated with increased risk of adverse effectsincluding liver failure, respiratory depression,overdose, and death

4. opioids frequently combined with NSAIDS oracetaminophen

iii. moderate to severe pain, intractable pain

syndromesiv. combination allows lower dose of opioidv. benefit and adverse effects of both agents must be

consideredvi. keep track of total daily amount of each drug per

24-hour period when using a combination agent toprevent overdose of both drugs

5. administration methods (See also: administration routesI.D)

iii. oral contraindicated with nausea and vomiting assess response to therapy 1 hour after

administration slow-release preparations available: may

require additional analgesic at initiation oftherapy and forbreakthrough pain

iv. intramuscular assess response to therapy 30 minutes

after administration avoid these methods with hypothermia and

vasoconstrictionv. subcutaneous

assess response to therapy 30 minutes 1hour after initiating therapy

well-suited for clients with cancer requires ambulatory infusion pump easier to establish steady-state blood level

vi. epidural and intrathecal assess response to therapy 15-45 minutes

after initiating therapy itching can be severe risk of hematoma, infection, meningitis effective management of severe pain

without CNS depression agents: preservative-free opioids and local

anesthetics via PCA or implantable pump

vii. patient-controlled analgesia (PCA) assess response to therapy 15-30 minutes

after initiating therapy client controls dosing

1. client prevented from overdosingwith lock-out: establishesmaximum frequency of dosing

2. client and family teaching: intendedfor client only control

used with oral, IV, subcutaneous, andepidural administration

dose frequently includes a basal rate: client

activates PCA for on-demand dose1. typical basal rate of morphine

sulfate: of 2-5 mg/hour2. typical on-demand dose of morphine

sulfate: 0.5-2 mg every 10 minutes3. provides a steadier analgesic blood

level
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pump set-up requires specially trainedpersonnel; controls are behind a lockedpanel

may start equianalgesic oral opioids 30minutes to 1 hour before discontinuingdepending on the drugs involved

viii. transdermal assess response to therapy 1-2 hours after

initiating therapy difficult to adjust dosage agents: fentanyl and morphine increased absorption with febrile clients used in chouronic and severe pain

syndromes monitor for respiratory depression and skin

irritation remove old patch and cleanse area before

applying new patch

ix. intravenous assess response to therapy 15-30 minutes

after therapy given by direct bolus short-term pain management for moderate

to severe pain high risk of CNS depression especially

respiratory depressionx. other: sublingual, rectal

2. Therapeutic class: opioid analgesics (!high alert drugs)1. type: opioid agonists

iii. action: stimulate opioid receptors to cause

analgesia; vary according to side effects, route ofadministration, onset, peak, and duration

iv. examples


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iii. uses: moderate to severe acute and chouronicpain, acute MI, intraoperative analgesia, antitussive

iv. adverse effects respiratory depression, hypertension,

sedation, bradycardia, cough suppression euphoria, dizziness, hallucinations, miosis,

biliary spasm

nausea, pruritus, constipation, urinaryretention, allergyv. contraindications

respiratory failure, acute abdomen head injury (codeine is preferred agent) alcoholism, hypertension, hyperthermia,

hepatic dysfunctionvi. nursing care

(!high alert drugs) establish baseline data and monitor

respiratory rate, blood pressure, bowelpattern, platelets, neuro status, allergy

accurately time doses to prevent overdose;reverse effects with naloxone (Narcan) keep emergency equipment immediately

available counteract adverse effects

o administer antiemetic for nausea

o administer antipruritic for pruritus


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o prevent constipation with fluid, fiber,

ambulation stool softeners usually

ineffective transition client from IV, IM dosing to oral

dosing with equianalgesic doses (See also:

Opioid analgesic equianalgesic doses table)

client teachingo ask for help when getting up

o report rash, dyspnea,

inadequate painmanagement

o establish bowel habits, take

with food to avoid nauseao take only as directed, do not

exceed recommended doseo avoid

alcohol, CNSdepressants,antihistamines

herbal remediesincluding chamomileand kava

driving, makingimportant decisions,and dangerousactivity

b. type: opioid agonist-antagonistsiii. action: stimulate some opioid receptors and block

other opioid receptors; analgesic effect similar tomorphine

iv. examples nalbuphine (!high alert drug) (Nubain 10 mg

IM every 3-6 hours) buprenorphine (Buprenex 0.3 mg IM, IV

every 4-6 hours)v. uses: mild to moderate pain, adjunct intraoperative

analgesia, labor and delivery

iv. adverse effects (See also: III.A.1.iv) reverses other opioids in system psychotic episodes, dysrhythmias,

increased myocardial oxygen consumptionv. contraindications

physical dependence on opioids COPD, MI, CAD, HTN, hepatic dysfunction

vi. nursing care (See also: III.A.1.vi opioid agonists:nursing care)

screen clients for previous use of opioidsd. type: opioid antagonists

action: effectively block the action of opioidreceptors example: naloxone (Narcan 0.02-0.2 mg IV

every 2-3 minutes; may need to repeat in 1hour)

uses: reverse adverse effects of opioidsincluding respiratory depression andoverdose, fetal respiratory depression


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adverse effects1. ventricular tachycardia and

fibrillation, pulmonary edema

2. initiates acute withdrawal in clientsphysically dependent

3. duration of action is shorter than

action of opioids4. elimination of analgesic effect5. cramping, nausea, vomiting,

tachycardia, HTN, anxiety contraindications: opioid addiction nursing care

1. establish baseline data and monitorairway, respiratory rate, SaO2 bloodpressure, heart rate and rhythm,pain intensity

2. provide information to client3. administer with emergency

equipment nearby4. collaborate with provider for pain

management

d. type: synthetic diphenylheptane derivativei. action: depresses pain impulse transmission at

level of spinal cord

ii. example: methadone (!high alert drug) (Methadone20-120 mg by mouth, subcutaneously, IM daily)

iii. use: opiate withdrawal, severe painiv. adverse effects

seizures, cardiac arrest, shock, respiratorydepression, respiratory arrest

drowsiness, dizziness, headache, nausea,vomiting, anorexia, constipation

v. contraindications: opioid addictionvi. nursing care

establish baseline data and monitoro pain, vital signs, RFTs, LFTs,

airway, level of consciousness, pupilreaction to light

o opioid intoxication: lack of analgesic

effect, clinical indicators ofwithdrawal

o client teaching

report neuro changes,allergic reactions

avoid CNS depressants,alcohol for 24 hours afteradministration

change positions slowly, donot drive or engage indangerous activity

2. Type: non-opioid analgesicsd. sub-type: NSAIDs (See also: NSAIDs II.D.3)

i. action: anti-inflammatory, analgesic, antipyretic,antiplatelet

sub-type: cyclooxygenase-1 inhibitor (COX-1 inhibitor)

sub-type: cyclooxygenase-2 inhibitor (COX-2 inhibitor)

sub-type: aspirine. sub-type: acetaminophen


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i. action: blocks pain impulses that occur in responseto prostaglandin synthesis, antipyretic: without anti-inflammatory properties

ii. example: acetaminophen (Tylenol 1 gram by mouth3-4 times daily, not to exceed 1300 mg thoureetimes daily)

iii. uses: mild to moderate pain or fever, incombination with opioids

iv. adverse effects hepatotoxicity renal failure,

myelosuppression toxicity: nausea, vomiting, abdominal pain,

cyanosis, myelosuppression, delirium,seizures, coma

v. contraindications intolerance to tartrazine (yellow dye #5) liver or renal failure, alcoholism

vi. nursing care

establish baseline data and monitor pain,temperature, LFT, creatinine, CBC, urineoutput, neuro status

client teachingo avoid alcohol

o may crush or cut tablets

o do not exceed recommended dose

o avoid OTC containing

acetaminopheno report nausea, vomiting, abdominal

pain3. Type: anti-migraine headache agents

d. sub-type: triptani. action: cause cranial vasoconstriction and migraine

headache relief by binding to serotonin (5-HT1)receptor sites

ii. examples almotriptan (Axert 6.25-12.5 mg by mouth,

may repeat in 2 hours) naratriptan (Amerge 1 mg or 2.5 mg by

mouth, may repeat in 4 hours, do notexceed 5 mg/24 hours)

sumatriptan (Imitrex 25-50 mg by mouth,may repeat in 2 hours, do not exceed 300

mg/24 hours)iii. use: treatment but not prevention of acute migraine

headacheiv. adverse effects

hyper- and hypotension, coronary arteryvasospasm, ventricular tachycardia andfibrillation

dizziness, myalgia, weakness paresthesias, feeling hot, cold, or strange

v. contraindications CAD, clients with vascular disease,

hypertension older clients, hepatic or renal dysfunction concurrent use of ergotamine agents, MAO

inhibitorvi. nursing care

establish baseline data and monitor pain,associated findings, blood pressure, EKG,RFT, LFT, neuro status


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screen clients for cardiovascular orneurovascular history, drugs containingergotamine

client teachingo avoid triggers: foods containing

tyramine, sulfites, etc.o report chest pain, worsening

symptoms, paresthesias, flushingo avoid pregnancy

o do not crush tablets

o remain in calm environment, away

from noise, light

e. sub-type: ergot derivativesi. action: constricts vascular smooth muscle in

periphery, cranial vasculature, uterusii. examples

treatment: ergotamine, dihydroergotamine(Migranal 1-2 mg by mouth every 30minutes until attack subsides, up to 6 mg)

prophylaxis: methysergide (Sanserf 200 mgby mouth, IM, IV every 6-12 hours for 2-7days)

iii. uses: treatment of migraine headaches, pretermlabor

iv. adverse effects MI, hypo- and hypertension, tachycardia,

bradycardia, edema, claudication peripheral numbness, myalgia, nausea toxicity: nausea, weakness, myalgia,

intolerance to cold, paresthesiasv. contraindications: vascular, hepatic, renal, peptic

ulcer disease, hypertensionvi. nursing care

establish baseline data and monitor pain,associated findings, neuro status includingblurred vision, blood pressure, heart rate,RFT, LFT

treat overdose with vasodilators, heparin,and dextran

client teachingo do not swallow, crush, chew SL

tablets; do not drink, eat, or smoke

until tablet dissolveso use of inhaler

o avoid alcohol and OTC drugs

f. type: anticonvulsanti. example: topiramate (Topamax) (See also:

II.C.1.D.ii anticonvulsants)4. Other pain relief agents

d. type: local anestheticsi. example: lidocaine patch (Lidoderm)ii. example: lidocaine and prilocaine cream (EMLA)iii. nursing care: cream must be applied 1 hour before

paine. type: herbal remedy

i. example: capsaicin apply 3-4 times daily; more effective with

consistent use adverse effects: burning, extreme burning

on contact with mucous membranes or eyes nursing care
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o wear gloves to apply, rub into skin

until cream is transparento wash hands following application

o client teaching

apply with glove, wash handsfollowing application

burning increased by heat,sweating, humidity, clothing

5. Adjunct therapyd. type: antihistamines (See also: II.K.2 antihistamines)

i. examples: promethazine (Phenergan),hydrOXYzine (Vistaril)

ii. use: preoperative medication, sedation, enhanceanalgesic effect, nausea

e. type: anticonvulsants (See also: II.C.1 anticonvulsants)i. examples: gabapentin (Neurontin), carbamazepine

(Tegretal)ii. use: neuropathic pain

f. type: steroids (See also: II.K.1.b anti-inflammatory agents:glucocorticoids)

i. example: dexamethasone (Decadron), prednisoneii. use: severe bone pain, nerve compression

g. type: CNS stimulants (See also: III.D.6 stimulants)i. example: methylphenidate (Ritalin)ii. uses: counteract sedation and anorexia associated

with chemotherapyh. type: antihypertensive agent and centrally-acting

analgesic: alpha-adrenergic agonist (See also: II.A.4.ialpha-adrenergic agonists)

i. example: clonidine (Catapres)

ii. use: chronic pain syndromes2. Managing electrolyte imbalances

1. Type: sodium

d. action: the major extracellular cation: important in cellmembrane function and action potential, osmotic pressure,acid-base balance, and extracellular fluid volume; controlsfluid movement

e. examples: 0.9% NaCl (isotonic or normal saline), 0.45%NaCl, 3% NaCl

f. uses: hyponatremia, provide osmotic pressure, fluidvolume expander, maintain electroneutrality

g. nursing care

i. establish baseline data and monitor serum sodium,hypernatremia and hyponatremia, pH, fluid status,edema, weight, neuro status

ii. client teaching: read food labels for sodium content,weigh daily


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2. Type: potassiuma. action: the major intracellular ion; maintains intracellular

fluid volume and action potential of cell membranes;maintenance of myocardial contractility

b. example: potassium chloride (K-Dur)c. use: hypokalemia, concurrent diuretic therapy, ventricular

dysrhythmiasd. contraindications: renal failuree. nursing care

i. establish baseline data and monitor serumpotassium, RFT, EKG, urine output

ii. use large bore needle to draw blood specimen toprevent hemolysis

iii. administration never administer by IV push stop infusion with client complaints rapid infusion may cause cardiac standstill slowly infuse thourough central line or large

vein


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iv. client teaching take with full glass of water do not crush or chew tablets need for follow-up care and testing avoid OTC drugs and salt substitutes

4. type: calcium

a. action: neuromuscular function, bone strength anddensity, enzyme activation, blood clotting

b. examples (See also: II.F.2.c antacids: calcium)

calcium chloride and calcium gluconate calcium citrate (Citracal) calcium carbonate (Maalox, Tums)

b. uses: osteoporosis, hypocalcemia, hypersecretory(HCl) state, hyperphosphatemia, hypoparathyroidismc. nursing care

establish baseline data and monitor serum calcium,magnesium, phosphorous, and albumin; bonedensity, orientation, headache, blood pressure,EKG

provide adequate vitamin D

seizure precautions for hypocalcemia

administration

o IV: infuse slowly in large vein, stop infusion

with client complaints of burning, preventextravasation

o PO: give 1.5-2 hours after meals, avoid

giving with enteric-coated tablets

prevent constipation with fluid, fiber, and exercise


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client teaching

o do not change antacids

o limit vitamin D intake to 400 units daily

o

establish regular bowel habits with fluids,fiber, and exercise

1. Type: magnesium1. action: skeletal muscle contraction, energy production,

carbohydrate metabolism activation of B-complex vitamins,protein synthesis

2. example: magnesium sulfate (See also: II.F.1.d antacids:magnesium II.F.1.d)

3. uses: prevention and treatment ofhypomagnesemia,pregnancy induced hypertension, malabsorptionsyndromes

4. nursing care (See also: II.F.1.d)vi. establish baseline data and monitor serum

magnesium, potassium, and calcium; EKG, DTRs,blood pressure, respiratory rate, RFT

vii. IV administration slow IV push use infusion control device for continuous

infusion: stop for sudden hypotension,somnolence, or hyporeflexia


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5. Type: phosphorousa. action: vitamin B-complex activation, energy production,

cell division; carbohydrate, protein, and fat metabolism,acid-base balance

b. uses: hyperparathyroidism, osteomalacia, cirrhosis,hypokalemia, excess IV glucose, respiratory alkalosis

C. Managing pregnancy: classification of medications by health status (pregnancy)

1. Dietary supplementsa. therapeutic class: vitamins

i. type: folic acid action: normal growth, prevention of

macrocytic megaloblastic anemia recommended daily intake: 1-4 mg
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use: prevention of neural tube defects nursing care

o encourage minimum daily intake in

women of childbearing ageo collaborate with provider to provide 1

mg by mouth daily immediately after

conception: neural tube developsvery early

o increase dietary intake of folic acid

ii. type: multivitamin, prenatal formulaiii. type: vitamin K (See also: II.J.2.b hemostatic

agents) action: essential ingredient in clotting

cascade example: phytonadione (AquaMEPHYTON) use: prevention hemorrhagic disease of

newborn

2. therapeutic class: mineralsii. type: iron (See also: II.J.1.b antianemic agents)

recommended daily intake1. 27 mg by mouth daily2. 60-120 mg by mouth daily for iron

deficiency use: reduce risk of low-birth-weight infants,

increase oxygen-carrying capacity ofhemoglobin and number of erythourocytes

nursing care1. establish baseline data and monitor

Hct. and Hgb, serum ferritin, iron

binding capacity, exercise tolerance2. client teaching1. stool will be very dark, sticky2. take with food to avoid

nausea3. take with source of vitamin C

such as orange juice4. increase fiber, fluids, and

ambulation to preventconstipation; avoid laxativesand stool softeners

iii. type: calcium (See also: III.B.3 electrolytes:

calcium) recommended daily intake

1. pregnancy and lactation 1,000 mg2. adolescent pregnancy and lactation

1,300 mg use: fetal osteogenesis and tooth formation,

blood clotting2. Agents affecting uterine function


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1. therapeutic class: uterine stimulantsii. type: hormone

action: act directly on uterine myofibrils tocause contractions

example: oxytocin (Pitocin) use: increase strength and frequency of

uterine contractions, induce labor,incomplete abortion, postpartumhemorrhage

adverse effects

1. prolonged, tetanic contractions,abruptio placentae, decreaseduterine blood flow, seizures

2. fetal intracranial hemorrhage,asphyxia, fetal distress

contraindications: fetal distress, pregnancy-induced hypertension (PIH), cephalopelvicdisproportion (CPD), hypertonic uterus,

water intoxication nursing care

1. establish baseline data and monitor1. uterine contractions:

frequency, duration, andintensity and associated fetalresponse

2. maternal: blood pressure,heart rate, and SaO2, fluidbalance, urine output, neurostatus, vaginal bleeding

3. fetal: fetal heart tones (FHT)

2. administer with infusion controldevice

1. increase rate very slowly todesired effect: administerlowest effective dose

2. labor: 10 units per liter of IVsolution

3. postpartum hemorrhage: 10-40 units per liter

3. fetal distress or abnormaldeceleration patterns, maternalhypotension

1. priority: stop oxytocininfusion

2. position mother on left side,lower head if possible

3. infuse isotonic fluids4. administer supplemental

oxygen

4. client teaching: report vaginalbleeding. foul-smelling lochia

iii. prostaglandins action: stimulation uterine contractions and

soften cervix allowing forcervical dilatation

and effacement example: dinoprostone (Cervidil, Prepidil

vaginal insert) use: induce labor and stimulate initial

contractions, oxytocin may be started 30minutes after insertion

adverse effects
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1. uterine hyperstimulation, fetaldistress

2. increased risk of postpartumhemorrhage

3. fever, nausea, abdominal pain contraindications

1. fetal distress, vaginal bleeding,prolapsed umbilical cord

2. previous classical uterine incision3. suspicion of CPD, oxytocin infusion

already infusing, 6 or more previousterm pregnancies


1. maternal vital signs2. associated fetal response3. cervical dilatation and

effacement

4. uterine contractions:frequency, duration, andintensity

2. provide information3. remove vaginal insert with sustained

uterine contractions, fetal distress, oradverse maternal effects

4. administration1. gel-filled syringe: insert

applicator in cervical os2. suppository: place in

posterior fornix of vagina ,

leave in place for 30 minutes3. place rolled-up towel under

client hips to prevent escapeof gel

4. provide continuous maternaland fetal monitoring

5. client teaching1. remain on bedrest2. report vaginal bleeding,

sustained contraction,dypsnea

2. therapeutic class: tocolytics

ii. type: electrolytes action: depresses the CNS resulting in less

Ach, inhibited neuromuscular function,smooth muscle relaxation

example: magnesium sulfate IV uses: pre-term labor, anticonvulsant, PIH adverse effects

1. hypotension, respiratory failure,pulmonary edema

2. fetus: transient decrease invariability

3. flushing, nausea, constipation,

blurred vision, headache4. lethargy (may persist for 1-2 days

after discontinuing therapy)5. fewer side effects than beta-

adrenergic agonists nursing care

1. establish baseline data and monitor


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1. contractions: intensity,duration, frequency

2. blood pressure, respiratoryrate, DTRs, seizures

3. serum magnesium, level ofconsciousness, urine output

2. establish baseline data and monitorFHTs

3. maintain maternal Mg++ blood levelat 5.5-7.5 mg/dL

4. requires loading dose Mg++ sulfate4-6 grams IV over 15 minutes

1. maintain continuous infusionon infusion control device

2. infuse at lowest dose thatachieves tocolysis: usually 1-4 grams/hour titrated toDTRs and serum magnesium

5. keep calcium gluconate IV at thebedside (antidote)

iii. type: beta-adrenergic agonists (See also: II.B.1.bantihypertensives: beta-adrenergic agonists)

example1. ritodrine (do not confuse with Ritalin)

(Yutopar 50-100 mcg/min IV,increase 50 mcg every 10 minutesuntil desired outcome is achieved ormaternal heart rate is 130 bpm)

2. terbutaline (Brethine 10 mcg/minincrease by 5 mcg every 10 minutes

until contractions stop, do notexceed 80 mcg/min)

use: inhibit uterine contractions adverse effects

1. maternal myocardial ischemia,pulmonary edema, hypotension,dysrhythmias, tachycardia,palpitations

2. hyperglycemia, uterine atony contraindications fetal demise, PIH,

hemorrhage, abruptio placenta, acute fetaldistress


1. uterine contractions:frequency, duration, andintensity

2. back pain, bleeding, urineoutput

2. establish baseline data and monitorFHTs, fetal movement

3. provide information4. client teaching

1. report contractions occurring

< every 10 minutes, lowerabdominal cramps, rupture ofmembranes, increased pelvicpressure, decreased fetalmovement

2. report chest pain, insomnia,dysuria

iv. type: calcium channel blockers (See also: II.A.4.d)


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example: NIFEidipine (Procardia) use: used alone or in combination with

terbutaline to relax uterine smooth muscle adverse effects

1. hypotension, bradycardia, reflextachycardia, heart failure

nursing care establish baseline data andmonitor

1. uterine contractions: frequency,duration, and intensity; back pain,bleeding, urine output

2. establish baseline data and monitorFHTs, fetal movements

3. provide information4. client teaching

1. report contractions occurring< every 10 minutes, lowerabdominal cramps, rupture of

membranes, increased pelvicpressure, decreased fetalmovement

v. type: prostaglandin synthetase inhibitors (See also:II.D.3.b)

action: inhibits synthesis of prostaglandinsby decreasing the related enzyme,antipyretic, anti-inflammatory

example: celecoxib (Celebrex)3. Agents used with pre-term labor

1. therapeutic class: steroidsii. type: glucocorticoid (See also: II.K.1.b anti-

inflammatory agents: glucocorticoids) action: acceleration of fetal lung maturity examples

1. betamethasone, IM (CelestoneSoluspan)

2. dexamethosone, IV (Decadron) use: pre-term labor adverse effects

1. increased risk of infection2. neonate: lowered cortisol levels,

hypoglycemia, sepsis contraindications: labor, adequate L/S ratio,

maternal hemorrhage, infection, gestationalage >34 weeks


uterine contractions, L/S ratio, fetalmovement, maternal fluid andelectrolyte balance

2. dexamethosone: administer slow IVpush

3. betamethasone: administer by deepIM injection into gluteal muscle

4. Agents used with hypertensive disorders of pregnancy

1. therapeutic class: anticonvulsantsii. type: electrolyte

sub-type: magnesium sulfate (See also:III.C.2.b.i)

1. use

1. pre-eclampsia, eclampsia,pregnancy-inducedhypertension (PIH)


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2. continue infusion for 24hours after birth

2. nursing care: establish baseline dataand monitor breath sounds

sub-type: sodium (See also: III.B.1electrolytes: sodium)

1. use: hyponatremia associated withpre-eclampsia

iii. type: hydantoin (See also: II.C.1.b anticonvulsants:hydantoins)

example: phenytoin (Dilantin IV bolus 10mg/kg body weight infused at rate not toexceed 50 mg/minute; 2 hours later: IVbolus 5 mg/kg and then maintenance dosesevery 12 hours based on serum drug levels;may administer simultaneously withmagnesium)

use: after magnesium sulfate failure in the

treatment of eclampsia adverse effects

1. cerebral hemorrhage, fetalbradycardia, precipitous delivery,pulmonary edema


maternal1. blood pressure, heart rate,

EKG2. drug level: therapeutic range:

10-20 mg/ml

3. neuro status, level ofconsciousness, vision loss

4. vaginal bleeding,contractions, uterine rigidity,breath sounds, RFT

2. establish baseline data and monitorFHTs, fetal movement

3. postictal: monitor for combativenessand confusion, avoid bright lights,noise, frequent disturbance

4. maintain emergency equipmentimmediately available including

hydrALAZine, airway support, andadditional antihypertensive agents

2. therapeutic class: steroidsii. type: glucocorticoids (See also: II.K.1.b anti-

inflammatory agents: glucocorticoids)iii. use: prepare fetus for eminent birth to increase lung

maturation3. therapeutic class: antihypertensives

ii. type: alpha-adrenergic inhibitor action: stimulates central alpha2-adrenergic

receptors resulting in decreased peripheralvascular resistance

example: methyldopa (Aldomet 500-2000mg by mouth daily in divided doses, IV 250-500 mg every 6 hours)

use: safety and efficacy well-documentedfor fetus and mother

adverse effects1. myocarditis, heart failure, hepatic

dysfunction, myelosuppression


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2. CNS depression, psychosis,orthostatic hypotension

3. nasal congestion, rash, fluidretention


blood pressure, heart rate, EKG,RFT, LFT, CBC, edema, rash, levelof consciousness and mental status

2. establish baseline data and monitorFHTs and fetal movements

3. administration1. administer orally before

meals2. shake suspension before

dosing3. dilute IV solution in sodium

bicarbonate and infuse

slowly4. client teaching

1. maintain hydration2. do not abruptly discontinue

therapy3. avoid OTC drugs and

hazardous activities4. change positions slowly, ask

for help before getting upiii. type: centrally acting vasodilator (See also: II.A.4.j

antihypertensive agents: centrally actingvasodilator)

example: hydralazine

5. Diabetes mellitus, gestational and idiopathica. therapeutic class: antidiabetic agent

i. type: insulin (See also: antidiabetic agents: insulinII.G.1.c)

lispro, regular, and intermediate actinginsulin used in multiple injections

regular insulin used with continuous infusionii. type: oral hypoglycemic agents

contraindicated in pregnancy

5. Herbal agentsa. general principles

i. avoid essential oilsii. avoid herbs and tonic herbs during first trimesteriii. avoid standardized and highly concentrated forms

of herbsiv. avoid herbal stimulants and laxatives; agents used

as abortifacients and to induce menstruationb. avoid: aloe, fever few, kava, licorice, St. Johns Wort and

othersc. use with caution: garlic, ginger, turmeric

d. sources of vitamins and mineralsi. raspberry leaf: vitamin C and ironii. oat straw: calcium, magnesium, ironiii. dandelion root: vitamins A and C, beta carotene,

potassiume. lack of randomized-controlled trials to test safety and

efficacy in pregnancy6. Pain management in labor and childbirth


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a. information about obstetrical analgesiai. provide information to client: using anesthetics and

analgesics during labor and childbirth is a balanceof risk versus benefit

may slow or enhance the progress of labor may lead to serious adverse effects

1. maternal: circulatory collapse2. fetal distress or sedation

ii. use alternative comfort measures alone or incombination with anesthetic and analgesic agents

iii. assess mother and fetus before initiating painmanagement

iv. emergency equipment for mother and neonateshould be immediately available

v. client teaching: remain in bed, ask for help beforegetting up, empty bladder

c. analgesics used in labor and childbirth

type: opioid agonist-antagonist (See also:III.A.2.b opioid agonist-antagonist)

example: nalbuphine(Nubain 10 mg

subcutaneous injection, IM, IV every 3-6hours, not to exceed 160 mg/day)

adverse effectso sedation, respiratory depression

o reverses any opioid in the system

nursing careo establish baseline data and monitor

pain for type, location,intensity, respiratory rate

frequency, duration, andintensity of uterinecontractions

FHTs

type: opioid agonists (See also: III.A.2.a opioid agonist)

exampleso meperidine hydrochloride (Demerol

50 mg IM every 4 hours)


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o morphine sulfate (Morphine sulfate

2-10 mg IM, IV every 2-4 hours) adverse effects

o maternal and fetal respiratory

depression, sedationo pruritus, dizziness, nausea,

constipationo decreased intensity and frequency

of uterine contractions nursing care

o establish baseline data and monitor

pain for type, location,intensity, respiratory rate

uterine contractions forfrequency, duration, andintensity

FHTso monitor neonate for 4-6 hours

postpartum for residual respiratorydepression

o treatment of itching with

antihistamine usually increasessedation

vi. type: opioid antagonist (See also: III.A.2.C opioidantagonist)

example: naloxone (Narcan) use: reverse maternal or neonatal

respiratory depression, sedation, andhypotension caused by opioid agonists andagonist-antagonists

nursing care (neonate): establish baselinedata and monitor vital signs frequently for 4hours in special care area (respiratorydepression may recur after naloxone wearsoff)

d. anesthesia using local and regional methods

vi. local anesthetics (See also: II.B.4 local anesthetics) action: regional impairment of nerve impulse

transmission examples

o procaine hydrochloride (Novocaine)

o bupivacaine hydrochloride

(Marcaine) (longer acting) uses: local and regional pain management

during labor and delivery, alone or incombination with opioid analgesics

adverse effectso systemic toxic reaction, broad

ligament hematoma, perforation ofrectum

o trauma to sciatic nerve

contraindications: severe hypovolemia, CNSdisease, bleeding disorder nursing care

o maternal: establish baseline data

and monitor blood pressure and heart

rate


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pain for type, location,intensity

contractions for frequency,duration, and intensity

o neonatal: establish baseline data

and monitor FHTs, response to

injectionso provide information to client about

importance of not moving duringinjection and related transientdiscomfort

o remain at bedside during injections

lumbar epidural and spinal blocks


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ii. other anesthesia using local anesthetics pudendal block

o injection below pudendal plexus in

second stage of laboro low risk of maternal hypotension or

fetal depression

local infiltration: injection into soft tissue ofperineum, generally given for episiotomy

iii. general anesthetics: usually reserved for obstetricalemergencies when fetal demise is expected due tohigh risk of fetal depression (See also: generalanesthetics II.C.3)

adverse effectso maternal: postoperative nausea,

sedation, high risk of impairedairway

o fetal and neonatal: impaired

oxygenation

contraindications: high-risk fetus nursing care

o maternal

priority to protect airway untilgag reflex returns and clientis able to maintain airway;and maintain NPO

monitor vital signs frequently prevent postpartum

hemorrhageo neonatal

establish baseline data and

monitor vital signs, especiallyairway and respirations

provide warmth, quickly dryinfant

have emergency equipmentimmediately available

dedicate 1 neonatal nurse indelivery area


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provide initial maternal-newborn bonding whenmother awakens

2. adjunct therapies for obstetrical pain managementii. therapeutic classes

antihistamines (See also: II.K.2

antihistamines) antiemetics (See also: II.F.1 antiemetics) barbiturates (See also: II.C.1.b.i

barbiturates)iii. use in labor

anxiety, apprehension antiemetic (except barbiturates) pregnancy induced hypertension

iv. contraindications: active laborv. nursing care

establish baseline data and monitormaternal

o blood pressure and heart rateo pain for type, location, intensity

o contractions for frequency, duration,

and intensity establish baseline data and monitor FHTs,

response to injections client teaching: ask for help before getting

up, avoid driving or hazardous activities2. Agents for Rh incompatibility

1. therapeutic class: immune globulin

ii. type: Rh IgG immune globulin action

o prevents formation of maternalantibodies (sensitization) againstfetal cells that may enter herbloodstream during placentalseparation

o effective with subsequent

pregnancies in unsensitized womano provides passive immunity for

mother which prevents permanentactive immunity (antibody formation)

exampleso standard dose: Rh IgG immune

globulin (IM: RhoGAM, IV: WinRhoSDF)

o microdose: Rh IgG immune globulin

IM (MICRhoGAM) use:

o restricted to Rh negative mothers

with Rh positive fetus to reducerisk of antenatal sensitization inmother

at 28 weeks gestation withnegative antibody screen

within 72 hours of birth ifmaternal indirectCoombs'test and neonatal directCoombs tests are negative

o following amniocentesis,

spontaneous or elective abortion,ectopic pregnancy, chorionic villi,percutaneous umbilical bloodsampling, maternal trauma
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adverse effects: lethargy, irritation atinjection site, fever, myalgia

contraindications: Rh+ client, allergy toblood products


maternal indirect Coombs test,neonatal direct Coombs test, fetalintravascular hemolysis

o verify consent to treatment

o microdose generally not

administered after term pregnancyo do not use IM agents for IV

administration, do not confuse withGamulin Rh/MICRhoGAM

o IM dose administered by IM injection

into deltoid muscle or ventral glutealsite

o considered a blood product follow agency policy for

checking lot number of agentand cross-match

verify maternal Rh blood typeo client teaching for Rh- mothers: drug

must be administered aftersubsequent pregnancies if neonatesare Rh+

III. Classification of Medications Health StatusI. Information common to psychotropic agents

I. consider cultural perspective of clienta. impact on behavior

b. impact on psychotropic drug compliance: uniquesocial stigma about mental illness and psychotropicagents

II. establish baseline data and monitor using standardizedrating scales when available

a. negative and positive behavior associated with

conditionb. differentiation of psychiatric findings from adverseeffects

c. compliance with and adverse effects of therapeuticregimen

d. expected therapeutic effects ofpsychopharmacological therapy

III. client and familya. teaching take only as directedb. store away from heat, light, and moisturec. provide support, encouragement, and community

resourcesd. provide non-pharmological strategies to avoid

adverse effectse. identify barriers to compliance, develop

collaborative plan to eliminate or minimizef. psychopharmacological therapy most effective

when combined with psychotherapyg. expect drug titration

I. need for follow-up care and testing


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II. use of trial and error with choice ofmedication and dosing

II. Therapeutic class: antidepressantsI. information common to antidepressants

a. actions relate primarily to norepinephourine (NE),serotonin (5HT), dopamine to

I. inhibit the effects of monoamine oxidaseII. block reuptake of neurotransmitters at the

synaptic cleftIII. regulate receptor sites and neurotransmitter

breakdownb. uses

I. non-organic short term and chronicdepressive disorders

II. panic disorder, agoraphobia, generalizedanxiety disorder, post-traumatic stressdisorder

c. adverse effects

I. increased suicidal ideation especially inchildren

II. anticholinergic effects: dry mouth and eyes,constipation, urinary retention, sedation,insomnia

III. headache, tremors, fatigue, GI upsetIV. decreased libido and sexual performance,

weight gainV. increased risk of adverse effects in older

clients, especially sedation, dizziness, andhallucinations

d. nursing care

I. establish baseline data and monitor affect,weight, suicidal ideation, enjoyment,sleeping pattern, increased energy, andimplementation of daily activities

client teachingo report worsening depression,

suicidal ideation; seek immediatetreatment for well-developed suicideplans

o effective treatment usually consists

of taking 2 or more agents

concurrentlyo take as directed

do not abruptly discontinuetherapy

do not stop taking drug whenfeeling better

o avoid

alcohol, OTC drugs, kava,and SAMe

avoid driving and dangerousactivities until adverse effectsare well established

o take drug consistently initial improvement may not

be seen for 4 weeks take for 4-6 weeks before

abandoning agent due toadverse effects

many adverse effects willsubside with consistent use


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o strategies for adverse effects

take sedatingantidepressants at bedtime

use hard candy, gum, icechips, and sips of water fordry mouth

increase fluid intake, fiber indiet, and ambulation toprevent constipation

b. type: serotonin reuptake inhibitors (SSRIs)

i. action: inhibits 5HT reuptake in the CNSii. examples

fluoxetine hydrochloride (Prozac 20-80 mgby mouth once or twice daily)

sertraline (Zoloft 50-200 mg by mouth daily)


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citalopram (Celexa 20-60 mg by mouthdaily)

iii. uses major depressive disorders bulimia, citalopram post-traumatic stress disorder obsessive-compulsive disorders premenstrual dysphoric disorder

iv. adverse effects seizures, hemorrhage, dysrhythmias, MI,

thourombophlebitis vasomotor instability, palpitation, nasal

congestion, dypsnea sedation, activation, GI activation,

constipation nausea, headache, sexual dysfunction tolerance paroxetine increases levels of clozapine,

theophylline, warfarin fluoxetine potentiates tricyclic

antidepressants and some antidysrhythmics fluoxetine and sertraline increase levels of

benzodiazepines, clozapine, and warfarinv. contraindications: hepatic or renal dysfunction,

mania, concurrent administration of MAOIvi. nursing care

establish baseline data and monitoro CBC, platelets, LFT, urinary and

bowel patterno blood pressure, pulse; EKG for

flattened T wave, heart block may crush tablets administration

o may administer entire dose in AM

o older client may need to take twice a

day allow 5 weeks between administration of an

SSRI and an MAOI to prevent serotoninsyndrome

client teachingo report rash, mania, seizures, and

severe weight losso increase fluid intakeo use barrier contraception

o take weekly doses on same day

each weeko change positions slowly, ask for help

when getting up until adverse effectsof drug are well established

c. type: phenethylaminei. action: inhibit reuptake of NE and 5HT

ii. example: venlafaxine (Effexor 75-225 mg by mouthdaily)

iii. adverse effects vaginal and uterine hemorrhage usually dose related: HTN, nervousness,

anorexiaiv. nursing care: taper dose over 2-weeks before

discontinuing therapyd. type: tricyclic antidepressants (TCAs)
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i. action: reduce reuptake of NE and 5HT at thesynaptic clef resulting in increased stimulation ofpostsynaptic receptors

ii. examples imipramine hydrochloride (Tofranil 75-300

mg by mouth daily in 3-4 doses) amitriptyline hydrochloride (Elavil 75-150

mg by mouth daily)iii. uses

relief of depressive symptoms children: suppression of enuresis, ADHD

iv. adverse effects HTN, cardiac depression, EKG changes,

dysrhythmias paralytic ileus, hepatitis, hyperthermia,

acute renal failure, myelosuppression weakness, fatigue, drowsiness, blurred

vision, orthostatic hypotension

constipation, dry mouth, urinary retention,extrapyramidal symptoms

overdose: hyperthermia, seizures, delirium,coma

children: higher risk of seizures,cardiotoxicity, agitation, suicide

v. contraindications: recovery phase from MI, narrow-angle glaucoma, seizure disorders, BPH

vi. nursing care (See also: SSRI: III.D.2.b.vi nursingcare)

establish baseline data and monitorextrapyramidal symptoms, heart rate, EKG,

blood pressure, ambulation, level ofconsciousness

assist with ambulation avoid concurrent administration with SSRIs decreased protein-binding with phenytoin,

aspirin, phenothiazines client teaching

o wear sunscreen and protective

clothing in the suno change positions slowly

e. type: monoamine oxidase inhibitors (MAOI)i. action: irreversibly inhibits monoamine oxidase, the

enzyme responsible for terminating the actions of5HT, norepinephourine, and dopamine; thus,increasing the concentration of neurotransmitters atthe synaptic clef

ii. examples phenelzine sulfate (Nardil 60-90 mg by

mouth daily in divided doses) tranylcypromine (Parnate 30-60 mg by

mouth daily in 2 doses)iii. uses: depressive disorders in clients who are

unresponsive or intolerant of other therapiesiv. adverse effects

dysrhythmias, hypertensive crisis, SIADH-like syndrome, hepatic necrosis, intracranialbleeding(associated with more fataladverse effects than any otherantidepressant)

dizziness, drowsiness, orthostatichypotension, anorexia


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blurred vision, dry mouth, constipation,weight gain, change in libido

v. contraindications concurrent administration with TCA or SSRI HTN, heart failure, severe hepatic or renal

dysfunction, pheochouromocytoma, severe

cardiac disease, alcoholismvi. nursing care (See also: III.D.2.b.vi SSRIs: nursing

care) administer with food or milk, may crush

tablet and mix in food increased risk of

o serotonin syndrome when taken

within 5 weeks of SSRIso increased hypoglycemic effect when

taken with antidiabetic agents client teaching

o report

1. neck stiffness, chesttightness, headache

2. rash, changes in urinarypatterns, color of urine

3. palpitations, dizziness,insomnia, change in strength

o avoid

1. caffeine, CNS depressants,OTC cold medicine, coughsyrup, drugs for weight lossor allergic rhinitis

2. foods containing tyramine

3. beware of combination foodscontaining tyramine

3. Therapeutic class: anxiolytic and hypnotic agentsa. type: benzodiazepines


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i. action: enhances the action of gamma-aminobutryicacid (GABA) in the synaptic clef of limbic systemand reticular activating system; inhibits cell firing

ii. examples alprazolam (Xanax 0.25-0.5 mg by mouth

thouree times daily up to 4 mg/day) diazepam (Valium 2-10 mg by mouth daily

2-4 times daily, IV 5-10 mg at 2 mg/min) lorazepam (Ativan 2-6 mg by mouth daily in

divided doses) midazolam (Versed 0.7-0.8 mg/kg IV bolus

for sedation) chlorodiazepoxide (Librium 50-100 mg by

mouth, IM, IV four times daily) temazepam (Restoril 15-30 mg by mouth at

bedtime) flurazepam (Dalmane 15-30 mg by mouth)

iii. use: see Therapeutic class: anxiolytic agentstable

(below)

iv. adverse effects EKG changes, tachycardia, cardiac arrest,

laryngospasm, bronchospasm,myelosuppression

dizziness, drowsiness, confusion, blurredvision, daytime sedation

dose-dependent CNS depression aggravation of sleep-related breathing

disorders


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amnesia, orthostatic hypotension, nausea,vomiting, hangover (confusion)

older clients: accumulating drug levels withtherapeutic doses, half-life may increase 4times

v. contraindications use with alcohol or other CNS depressant shock, coma, acute narrow-angle glaucoma psychosis, history of substance abuse,

COPDvi. nursing care

establish baseline data and monitoro degree of anxiety and sedation,

mental status, mood, sleep pattern,tolerance, dependency

o blood pressure, heart rate,

respiratory rate, breath soundso CBC, LFT, seizure activity if

administered as anticonvulsant older clients: do not abruptly stop therapy;

very slowly withdraw drug administration

o oral: may crush tablets, may take

with food or milko IM: give by deep injection into large

muscle (discomfort)o IV: administer slowly in small

amounts over 30 seconds-2minutes, wait 15 minutes betweendoses

keep emergency equipmentimmediately available duringIV administration

antidote: flumazenil (Romazicon 0.2 mg IVover 15-30 seconds; repeat in 45 seconds ifconsciousness does not occur)

o administered IV push thourough IV

fluid infusiono peak action within 5-10 minutes,

lasts for about 1 houro may need to administer additional

doses after 1 hour

client teachingo report palpitations, worsening

symptoms, trouble breathing,shortness of breath

o use contraception while taking

benzodiazepineso do not use for everyday stress, take

only as directedo avoid driving, making important

decisions, and dangerous activityo

do not abruptly withdraw therapy;taper dose before discontinuingo avoid

grapefruit juice, alcohol OTC drugs, herbal remedies

especially kava and SAMe


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antihistamines, sedatingantidepressants other CNSdepressants

c. type: barbiturates (See also: II.C.1.b.ii anticonvulsants:barbiturates)

d. other anxiolytic agents

a. type: combined blocker action: inhibits the action of 5HT and

dopamine, increases NE levels example: busPIRone (BuSpar 20-30 mg by

mouth daily in 3 doses) use: anti-anxiety with little sedative,

anticonvulsant, or muscle relaxingproperties

adverse effectso CVA, MI, heart failure

o tachycardia, palpitations, dizziness,

headache, depression, stimulation,lightheadedness, paresthesias

o sore thouroat, tinnitus, blurred

vision, nasal congestiono nausea, dry mouth, diarrhea

constipation, sweating, pain,weakness

contraindications: children < 18 years-old nursing care (See also: III.D.2.b.vi SSRIs:

nursing care and III.D.3.a.vibenzodiazepines: nursing care)

o client teaching: therapeutic effect

may take 2-3 weeksc. type: pyrazolopyrimidine hypnotics

action: binds to the ?-1 receptor of GABAAto act as a sedative, hypnotic, musclerelaxatant, anticonvulsant, and anxiolyticagent

exampleso zaleplon (Sonata 5-20 mg by mouth

at bedtime, duration of action 2hours)

o zolpidem (Ambien, Ambien CR 10

mg at bedtime, duration of action 6-8hours)

use: insomnia adverse effects

o myelosuppression

o drowsiness, lethargy, daytime

sedationo chest pain, palpitations


mood, affect, sleeping patterns,drowsiness, suicidal ideation, CBC,heart rate and EKG, tolerance anddependency

o screen for previous drug

dependenceo period to induce hypnotic action is

limitedo client teaching

to induce sleep


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1. take 30 minutes to 1hour before desiredhour of sleep

2. establish bedtimeritual: implementsleep-promoting

behavior after takinghypnotic

3. avoid high-fat mealswithin 2 hours ofbedtime

do not abruptly withdrawtherapy after long-term use

avoid driving, dangerousactivity after taking hypnoticagent

avoid OTC drugs, alcohol,CNS depressants, and

herbal remedies: may lead torespiratory depression

2. Therapeutic class: antipsychotic agents, information common toantipsychotic agents

action

neuroleptic: suppression of psychoticbehavior without depressed level ofconsciousness

postsynaptic dopamine, serotonin, ordopamine receptor blockade of psychotic

behavior in the brain to lower incidence ofhallucinations, delusions, and paranoia

reticular activating system depression tolimit incoming stimuli

b. examples

typical antipsychotico traditional antipsychotics: affect

positive aspects of psychoticbehavior

o block non-selective neurotransmitter

receptors with high affinity fordopamine2-receptors
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ii. atypical antipsychotic agents newer antipsychotics: lower affinity for

dopamine2 receptors lower incidence of extrapyramidal

symptoms but some serious adverse effects


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c. usesi. schizophrenia, paranoid psychosis, manic

disorders, dementia, Alzheimers

ii. delusional thinking, motor agitation, motorretardation, and confusion associated withschizophrenia, severe anxiety, severe hiccups

iii. effective antiemeticiv. severe behavioral problems in childrenv. combativeness, agitation, uncooperativeness

d. adverse effectsi. hypotension, dysrhythmias, heart failure, prolonged

QTc intervalii. myelosuppression, pigment deposits on retina

iii. impaired thermoregulation, laryngospasm,neuroleptic malignant syndrome, tardive dyskinesia

iv. orthostatic hypotension, sedation, acute dystonia,perioral tremor (rabbit syndrome)

v. decreased threshold for seizures, weight gain,weakness, photosensitivity, may turn urine pink orreddish-brown, skin discoloration, bad taste
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e. contraindicationsi. severe hypertension, CAD, prolonged QTc intervalii. hepatic and renal disease, cerebral arteriosclerosis,

bleeding disorders, myelosuppressioniii. Parkinsonism, severe depression, narrow angle

glaucoma, during children < 12 years-old

iv. alcohol or barbiturate withdrawalf. nursing care

i. establish baseline data and monitor1. mood, affect, orientation, LOC, coordination,

extrapyramidal symptoms2. dizziness, heart rate, blood pressure, EKG,

LFT, RFT, CBC, urine outputii. provide client safety

1. prepare for sedation2. assist with changing positions and

ambulation

3. avoid other medication metabolized using

cytochrome P450iii. provide oral careiv. provide, support, encouragement, and community

resourcesv. administration

1. avoid contact with skin2. may give mixed in juice or carbonated

beverage3. give initially at very low dose at bedtime:

has long half-life4. make sure client is swallowing and not

hoarding medication

5. may administer fluphenazine andhaloperidol as depot injection (See also:I.D.2.b.iii intramuscular injection)

6. increased effect of both drugs withconcurrent administration of CNSdepressants beta-adrenergic blockers,quinidine, or procainamide

vi. neuroleptic malignant syndrome1. provide cooling and hydration2. discontinue all psychotropic medication

vii. client teaching1. report sore throat, fever, rash, tremors,

weakness, and vision changes2. wear MedicAlert tag3. do not abruptly withdraw therapy4. do not crush or chew sustained release

forms5. take only as directed, continue to take when

feeling good6. increase fluids, fiber, and ambulation to

prevent constipation7. remain supine for 30 minutes after IM

injection1. ask for help before getting up,

change positions slowly8. avoid

1. driving, making important decisions,dangerous activity

2. alcohol, CNS depressants, OTCdrugs, and herbal remedies,grapefruit juice
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3. hot baths and showers, excessiveclothing, hot sun, sunbathing,strenuous exercise

2. Therapeutic class: anti-manic agent (mood stabilizers)c. type: heavy metal

i. action: alters ion transport across cell membrane in

nerves and muscle cellsii. example: lithium chloride (Lithonate 300-900 mg by

mouth daily, based on serum lithium levels)

iii. uses: bipolar disorders, prevention ofmanic-depressive psychosis

iv. adverse effects1. seizures, dysrhythmias, circulatory collapse,

edema, renal dysfunction, nephourotoxicity,leukocytosis

2. tremor, nausea, thirst, polyuria3. acneiform rash, foliculitis, anticholinergic

effects

4. muscle weakness, depletes glycogen storesin liver

v. contraindications

1. brain trauma, obsessive-compulsivedisorder, schizophourenia

2. hepatic or renal disease, severe cardiacdisease, severe dehydration

vi. nursing care1. establish baseline data and monitor

1. weight, edema, sodium intake, urineoutput, neuro status

2. urine for albumin and glucose;

serum RFT, LFT3. lithium levels

1. therapeutic level 0.5-1.25mEq/L

2. monitor after each dosageincrease

3. monitor every 2-3 months orwith behavior episode

4. lithium toxicity1. blood level 2-3 mEq/L2. clinical findings: vomiting,

diarrhea, poor coordination,

tremors, extreme thirst,tinnitus, dilute urine

3. factors that increase lithiumlevels: dehydration, changesin other medications, fluidand electrolyte imbalance(especially sodium), NSAIDs,tetracycline

2. significant drug-drug interactions3. a void concurrent therapy with diuretics,

NSAIDs4. client teaching

1. may take with food, do not crush orchew capsules

2. report: tremors, impairedcoordination, vomiting, diarrhea,dilute urine

3. use contraception, eat 3 regularmeals daily
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4. if dose is missed, take within 2 hoursof next dose

5. avoid1. dehydration, sodium-free diet2. driving and dangerous

activity

3. alcohol, OTC drugs, herbalremedies

d. type: anticonvulsant (See also: II.C.1 anticonvulsants)i. action: impair normal neuronal dischargeii. examples

1. carbamazepine (Tegretol)2. gabapentin (Neurontin)3. lamotrigine (Lamictal)4. topiramate (Topamax)5. valproic acid (Depakote)

iii. uses: bipolar mood disorder, schizoaffectivedisorder

iv. adverse effects1. seizures, myelosuppression, hepatic failure,

hepatitis, pancreatitis2. sedation, GI disturbances, dizziness

v. nursing care1. client teaching: do not abruptly discontinue

therapy3. Therapeutic class: stimulants

c. information common to stimulantsi. action: increase release or decrease reuptake of

dopamine and NEii. uses

1. appetite control, depression, narcolepsy2. attention-deficit hyperactivity disorder

(ADHD) in childreniii. adverse effects

1. dysrhythmias, tachycardia2. palpitations, hyperactivity, insomnia,

restlessness3. children: associated with weight loss and

decreased rate of growth; approved for usein children generally > 6 years-old

iv. contraindications1. glaucoma, concurrent MAOI

2. anxiety, Tourette's syndrome, children < 6years-old

v. nursing care1. establish baseline data and monitor

1. blood pressure, heart rate, heightand weight

2. mood, affect, aggression, attentionspan, hyperactivity

3. sleeping pattern, appetite, tolerance;CBC, UA, blood glucose

2. client teaching1. take at least 6-12 hours before

bedtime2. do not crush, chew, or cut time

release tablets3. report tremors, insomnia,

palpitations, restlessness4. take only as directed, do not double

dose; taper dose to discontinue


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5. avoid caffeine, CNS stimulants, OTCdrugs, alcohol, and guarana, colanut, and yerba mat

d. type: piperadine derivativei. example: methylphenidate (Ritalin 5-20 mg by

mouth 2-3 times daily, Concerta 18-54 mg daily)

ii. use: ADHDiii. adverse effects

1. myelosuppression, exfoliative dermatitis,dysrhythmias

2. lowest side effect profile of all stimulantsiv. client teaching, Concerta: shell may appear in stool,

take 12 hours before bedtimee. type: methylphenidate derivative (amphetamine)

i. example: dexmethylphenidate (Focalin 5-10 mg bymouth twice daily)

ii. adverse effects: toxic psychosis, neurolepticmalignant syndrome

iii. use: ADHDiv. client teaching: take every 4 hours without regard to

mealsf. type: amphetamine

i. action: mimic brains most importantneurotransmitters, dopamine and NE

ii. example: dextroamphetamine (Dexedrine)iii. use: narcolepsy, ADHDiv. adverse effects

1. angina, hypertension, tachydysrhythmias

2. tolerance develops quickly, talkativeness,anorexia

v. contraindications1. anxiety, drug abuse, hyperthyroidism,

hypertension2. severe arteriosclerosis, cardiovascular

disease, glaucomavi. nursing care: inexpensive stimulant, manufactured

illegally in U.S., prolonged duration of actiong. type: xanthine (See also: II.B.1.b bronchodilators:

xanthines)i. action: stimulates the SNSii. example: caffeine

h. type: oxazolidinone derivative

i. action: stimulates CNS stimulation and paradoxicaleffect in the treatment of ADHD

ii. example: pemoline (Cylert 25-112.5 mg/day)iii. use: ADHD in children >6 years-oldiv. adverse effects

1. seizures, masking or aggravating Tourettessyndrome, hepatitis, hepatic failure

v. contraindications: hepatic dysfunctionvi. nursing care

1. administer in AM, give lowest effective dose2. client teaching: report tremors, jaundice,

bleeding, dark urine
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Total Parenteral Nutrition: Nursing Care of Clients

I. Nutritional supporta. Nutritional deficiency

1. clinical indications forhyperalimentation: clients whoa. cannot use GI tract for absorption of nutrientsb. require nutritional therapy to maintain or improve

nutritional statusc. have risk factors for malnutrition

1. body mass index for height and age belowaverage

2. admission to hospital, nursing home,rehabilitation facility

3. anorexia, nausea, vomiting from agent,event, or condition

4. inadequate nutritional intake, increasednutritional loss, or increased metabolic rateunsuitable for health maintenance

5. impaired ability to prepare, obtain, or eatfood

I. substance abuse, older clientsII. low socioeconomic status,

educational deficiencies

III. dysphagia, infection, multiple chronicillnesses, trauma

2. clinical indicators of malnutritiona. gold standard: pre-albumin below normal (protein

deficiency)

b. other labs: low hemoglobin, transferrin, cholesterol,

total lymphocytesc. physical findings1. gums and teeth in poor repair2. reddened and open areas, susceptibility to

infection3. dull, dry eyes, nails, skin, hair, inadequate

muscle bulk

b. Hyperalimentation

1. partial parenteral nutrition

a. indications: central line contraindicated,postoperative ileus prolonged

b. infusion

1. via large peripheral IV2. solutionsI. isotonic lipid emulsion: may be

administered with IV solutionII. hypertonic amino acid and dextrose

solution

2. total parenteral nutrition (TPN)

a. long-term intensive nutritional support for1. trauma, major surgery, hypermetabolic state2. GI impairment: inflammation, malabsorption,

obstruction, side effects of chemotherapyb. hyperalimentation solution

1. contains hypertonic dextrose and aminoacid solutions

I. 25%-35% dextroseII. 3%-5% amino acidsIII. 10%-20% lipids

2. infuses via central venous catheter insubclavian orinternal jugular vein
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3. includes electrolytes, minerals, traceelements, and insulin added by pharmacist

4. prepared under strict aseptic technique

c. benefit1. individualized according to client need2. provides protein-sparing action: calories3. supplies amino acids for tissue repair and

healing

4. delivers all nutrients with lower risk of fluidoverload than nutritional equivalent ofstandard IV therapy

3. complications from central venous catheter (See also:I.D.4.a.iii central venous intravenous line)

4. selected complications from TPN solutiona. infection: solution provides breeding ground for

microorganisms

b. fluid imbalance1. hypertonic solution infuses directly into

venous circulation

2. fluid shifts occur due toI. hyperosmolar nature of solutions

II. rapid infusion without sufficientinsulin, with hyponatremia orhypokalemia

II. Nursing care

a. Establish baseline data and monitor

1. vital signs, SaO2, right atrial pressure (right atrial pressure,CVP)

2. impairment of glucose metabolism

a. hyperglycemia: nausea, weakness, thirst,headache, tachypnea

b. hypoglycemia: diaphoresis, tachycardia, hunger,trembling, confusion

3. fluid volume status: daily weight, I & O, edema, breathsounds

4. nutritional status: skin, serum electrolytes, glucose,cholesterol, triglycerides

5. infection: temperature, WBC, insertion site6. other: pH, neuro status, BUN, creatinine, LFTs

7. refeeding syndrome (first 24-48 hours of therapy):bradypnea, lethargy, confusion, weakness

b. Prevent complications1. rebound hypoglycemia: withdraw TPN slowly2. microemboli: use 0.2 m-filter except with lipid emulsion3. injury: check expiration date of solution, verify TPN order4. hyperglycemia: verify insulin coverage, check blood

glucose frequently5. acidosis: maintain tight glycemic control, encourage

coughing and deep breathing6. infection

a. avoid contamination from oily skin or tracheostomyb. insert catheter with surgical asepsisc. refrigerate until 30 minutes before using, discard

after 24 hoursd. sterile dressing change, use aseptic technique,

change tubing daily

7. fluid shifts, hypervolemia, osmotic diuresisa. do not increase infusion rateb. maintain tight glycemic controlc. verify volume infused with time stripd. start infusion slowly and titrate to client tolerance


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e. administer 10% dextrose if TPN infusion isinterrupted

f. carefully control infusion rate, carefully programinfusion device

8. air embolia. use Luer-Lok connectionsb. cover site with occlusive dressing

c. clamp tubing when changing solution or tubing1. may need to position client in supine

position or ask client to perform Valsalvamaneuver

c. Client teaching for home therapy1. review purpose and procedure2. verify written instructions for all procedures,

troubleshooting, and complications, review procedures andequipment

a. record keepingb. infusing solutionc. ordering suppliesd. glucose monitoring

3. verify aseptic technique4. verify temperature in refrigerator

5. review clinical indicators of infection, hypo- andhyperglycemia, hypervolemia, air embolism

Blood Product Administration

A. Administration of blood and blood products1. Types

a. whole blood

Blood Composition


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b. blood productsi. red blood cells (RBCs)

washed RBCs: RBCs washed with sterilesaline before administration; removes some

immunoglobulins and proteins packed RBCs: blood cells are separated

from plasma and platelets, decreases risk offluid overload

autologous blood transfusion leukocyte-poor RBCs: removal of most

leukocytes, fewer RBCs than packed RBCsii. plasma

serum albumin immune serum globulin factor concentrates: factors VIII and IX fresh frozen plasma: contains coagulation

factors cryoprecipitate: clotting factors VII and VIII

iii. other blood components platelets RhoGAM (See also: III.C.8 agents to

prevent Rh incompatibility) granulocytes

2. Purpose and method(s)b. Restore blood volume

i. provide albumin normal serum albumin plasma protein fraction

ii. increase oncotic pressure serum albumin red blood cells

c. Increase oxygen-carrying capacityi. increase hematocrit: red blood cellsii. increase hemoglobin: red blood cells

d. Enhance immunologic defensei. provide immunological factors

immune serum globulin granulocytes

ii. prevent Rh-sensitization

e. Enhance hemostasisi. provide clotting factors

cryoprecipitate fresh frozen plasma

ii. provide platelets apheresis packs random donor packs

3. Risksb. Immunologic reactions: IgG or IgM immunoglobulin binding

to surface antigens of donor cells resulting in cell deathi. febrile nonhemolytic reaction

most common1. usually not serious2. usually begins within 30 minutes

after beginning transfusion chills, headache, flushing, muscle pain fever: increase greater than 1 degree

Centigrade or 2 degrees Fahrenheit1. acute hemolytic reaction

fever, chills, low back pain, flushing,bleeding
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i. vital signs, SaO2, skin every 15 minutes and 1 hourafter completion

ii. breath sounds, crackles, dypsnea, +JVDiii. Hgb and Hct, urine output; serum potassium,

calcium, and creatinine2. Prevention of complications

b. check before initiating transfusioni. carefully verifying documentation related to blood

products follow agency policy do not remove blood product tags or

identification verify data with another licensed

professional from sample collection to bloodadministration

1. blood type, lot number, expirationdate

2. identical client data on sample,

prescription, and blood productii. screen client for

hypocalcemia, hyperkalemia renal failure or dialysis (risk of

hyperkalemia) thyroid, parathyroid, or radical neck surgery

(risk of hypocalcemia) previous transfusion reaction:

immunological or non-immunologicalc. initiate transfusion slowly for 15-20 minutes

i. remain at bedsideii. question client about unusual feelings

iii. monitor vital signs every 5 minutes or follow agencypolicy

d. infuse transfusion at prescribed rate or follow agencypolicy

i. note volume of individual blood unitii. infuse via infusion control deviceiii. follow agency policy for safe disposal of empty

blood bag and tubinge. restrict use of refrigeration to that approved by blood bank

i. do not store blood in the refrigeratorii. initiate transfusion within 30 minutes of removal

from blood bank

iii. complete transfusion in 4 hours after removal fromblood bank

f. collaborate with provider toi. use autologous blood or autotransfusionii. premedicate with steroid or antihistamineiii. notify blood bank of transfusion reaction to increase

scrutiny of cross-match

iv. administer 10% calcium gluconate forhypocalcemia with continuous cardiac monitoring

v. consider use of washed, filtered, irradiated,apheresis separated, or leukocyte-poor bloodproducts after a transfusion reaction

f. screen blood donorsi. volunteer donors preferred: paid donors less likely

to report past or present diseaseii. screen for

infectious disease: hepatitis, HIV,tuberculosis, syphilis, malaria, international
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travel, residence in United Kingdombetween 1980-1996

blood diseases, abnormal bleeding hypotension, anemia, jaundice, fever high risk behavior: male homosexual or

bisexual malignancy, disease of heart, lungs, liver,

allergies recent pregnancy, surgery, blood

transfusion, vaccinations with attenuatedvirus

g. client teaching

i. ensure informed consent of clientii. provide information about contracting infections

from bloodiii. provide information about administration method,

monitoring, duration of transfusion, symptomrecognition and reporting

iv. add history of immunologic or non-immunologictransfusion reaction to client database

4. Nursing care for transfusion reaction

i. immediately stop transfusion clamp IV tubing and disconnect at hub of

catheter do not allow additional blood to enter clients

system, do not flush tubing with saline toclear

ii. collaborate with provider for supplemental oxygen diuretics and antibiotics antihistamines, glucocorticoids

iii. monitor Hgb and Hctiv. complete transfusion reaction formv. save entire administration set and blood bag, return

to blood bank or follow agency policy

Dosage Calculations

I. Proportion problemI. Equation description

I. each side of the equation represents the same proportion,percentage, or ratio

II. example: 75%

I. equal proportions:

II. equal percentages: 75% = 0.75

III. equal ratios: 3:4 = 7.5:10 = 75:100

III. both sides of the equation represent an equal relationshipbut are expressed with different quantities; the two sidesmatch

II. Use a proportion equation to solve

I. dosage calculations

II. metric to metric conversionI. involves multiples of 10, 100, or 1000II. grams mg mcg = 1 1000 1000

I. 1 gram 1000 = 1 mg

II. 1 mg 1000 = 1 mcg

III. 1 gram (1,000 x 1,000) = 1 mcgIII. mcg mg grams = mcg x 1,000 x 1,000


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I. 1 mcg x 1,000 = 1 mg

II. 1 mg x 1,000 = 1 gram

III. 1 mcg x 1,000,000 = 1 gram

IV. liters ml = 1 liter 1,000

I. 1 liter 1,000 = 1 ml

V.ml liters = 1 ml x 1,000 = 1 liter

III. applicable t

Documents

Classifications Pharmacological (3)