LPN IV Push Medications

Part 2April 2010

Additional IV Push Medications

Ativan Decadron Digoxin Phenergan

Robinul Solumedrol Valium

Ativan (Lorazepam) Class: Benzodiazepine, Anxiolytic Action: Thought to depress CNS at

limbic system and disrupt neurotransmission in reticular activating system

Availability: Injection- 2 mg/ml, 4 mg/ml; Tablets- 0.5 mg, 1 mg, 2 mg

Ativan, cont. Indications & dosage

Anxiety- 2-3 mg PO daily in two or three divided doses. Maximum dosage is 10 mg daily.

Insomnia- 2-4 mg PO at bedtime

Pre-Op- 0.05 mg/kg not to exceed 4 mg deep IM 2 hours prior to surgery OR 0.044 mg/kg not to exceed 2 mg IV 15-20 min. prior to surgery

Status epilepticus- 4 mg IV given slowly- no faster than 2 mg per min., Can repeat if seizures recur after 10-15 min. Don’t exceed 8 mg in 12 hours.

Ativan, cont. Dosage adjustment required in elderly or

debilitated patients Off label uses: acute alcohol withdrawal

syndrome Contraindications: hypersensitivity to

drug, other benzodiazepines, polyethylene or propylene glycol, or benzyl alcohol, acute angle glaucoma, coma, CNS depression, hepatic or renal failure

Ativan, cont. Precautions: Use cautiously in renal or

hepatic impairment, history of suicide attempt, drug abuse, depressive disorder, or psychosis, elderly patients, pregnant or breastfeeding patients

Administration: Dilute IV doses with equal volume of diluent such as NS or D5W. Give each 2 mg dose IV slow push over 2-5 minutes. Don’t exceed rate of 2 mg/min.

Ativan, cont.

Adverse Reactions: amnesia, agitation, ataxia, depression, disorientation, dizziness, drowsiness, headache, incoordination, asthenia, hypotension with too rapid administration IV, bradycardia, tachycardia, apnea, cardiac arrest, blurred vision, diplopia, nystagmus, nausea, abdominal discomfort

Ativan, cont. Interactions:

Drug to drug: additive effects with other benzodiazepinesContraceptives: increased ativan clearanceDrug to Herbs: increased CNS depression with chamomile, hops, kava, skullcap, valerianDrug-behaviors: increased CNS depression with alcohol, increased metabolism and decreased efficacy of ativan with smoking

Ativan, cont. Patient monitoring:

During IV administration, monitor EKG/cardiovascular and respiratory statusMonitor V.S. closelyEvaluate for amnesiaWatch closely for CNS depression, signs & symptoms of overdoseMonitor LFTs & CBC

Decadron (Dexamethasone) Class: Glucocorticoid, anti-inflammatory Action: reduces inflammation by

suppressing polymorphonuclear leukocyte migration, reversing increased capillary permeability, and stabilizing leukocyte lysosomal membranes. Also suppresses immune response (by lymphatic activity), stimulate bone marrow, and promotes protein, fat, and carbohydrate metabolism

Decadron, cont. Availability:

Elixir: 0.5mg/5 ml

Oral solution: 0.5 mg/5 ml, 1 mg/ml

IV: 4 mg/ml, 10 mg/ml, 20 mg/ml, 24 mg/ml

Tablets: 0.25 mg, 0.5 mg, 0.75 mg, 1 mg, 1.5 mg, 2 mg, 4 mg, 6 mg

Decadron, cont. Indications & Dosages:

Allergic and inflammatory conditions-0.75- 9 mg/day PO as a single dose or in divided doses, in severe cases much higher doses may be required

Cerebral edema-initially 10 mg IV followed by 4 mg IM every 6 hours, then reduce dosage gradually over 5-7 days

Cushing’s syndrome-1 mg PO at 11 pm or 0.5 mg PO every 6 hours for 48 hours (with urine collection testing as ordered)

Decadron, cont. Off-label uses:

-acute altitude sickness-bacterial meningitis-bronchopulmonary dysplasia in

preterm infants-hirsutism-suppression test for detection, diagnosis,

or management of depression

Decadron, cont.

Contraindications:

Hypersensitivity to drug, benzyl alcohol, bisulfites, EDTA, creatinine, polysorbate 80, or methylparaben

Systemic fungal infections

Decadron, cont. Precautions:

Use cautiously in:renal insufficiency, cirrhosis, diabetes, diverticulitis, GI disease, cardiovascular disease, hypoprothrombinemia, hypothyroidism, myasthenia gravis, glaucoma, osteoporosis, infections, underlying immunosuppression, psychotic tendencies, pregnant or breastfeeding patients, children

Decadron, cont.

Administration:Give PO dose with food or milkWhen giving IM, inject deep into gluteal muscle, rotate sites as neededFor IV use may give undiluted as single dose over 1 minute

Decadron, cont. Adverse reactions:

headache, malaise, vertigo, psychiatric disturbances, increased ICP, seizures, hypotension, thrombophlebitis, myocardial rupture after recent MI, thromboembolism, cataracts, nausea, vomiting, abdominal distetion, dry mouth, anorexia, peptic ulcer, bowel perforation, pancreatitis, ulcerative esophagitis, hyperglycemia, cushingoid appearance, fluid retention, adrenal suppression, hypokalemic alkalosis, muscle wasting, muscle pain, osteoporosis, tendon rupture, long bone fractures, diaphoresis, angioedema, erythema, rash, pruritis, acne, decreased wound healing, bruising, fragile skin, weight gain or loss, increased susceptability to infections

Decadron, cont. Interactions:

Drug to drug: barbiturates, phenytoin, rifampin- decreaseddecadron effects

Digoxin- increases risk of dig toxicityEphedrine- increased decadron clearanceContraceptives- block decadron absorptionFluoroquinolones- increased risk of tendon ruptureKetoconazole, itraconazole- increased decadron level

and effectsLive-virus vaccines- decreased antibody response to

vaccineLoop & thiazide diuretics- additive hypokalemiaNSAIDs- increased risk of GI effectsSomatrem, somatropin- decreased response to these

drugs

Decadron, cont. Drug-Diagnostic tests- calcium &

potassium- levels decreased, cholesterol & glucose- levels increased

Drug-Herbs- echinacea- increased immune-stimulating effect, ginseng= potentiation of immune-modulating response

Drug-behaviors – alcohol use- increased gastric irritation & GI ulcers

Digoxin (lanoxin) Class: cardiac glycoside, inotrope,

antiarrhythmic Action: increases force and velocity

of myocardial contraction and prolongs refractory period of AV node by increasing calcium entry into myocardial cells. Slows conduction through SA and AV nodes and produces antiarrhythmic effects

Digoxin, cont. Availability:

Capsules: 0.05 mg, 0.1 mg, 0.2 mg

Tablets: 0.125 mg. 0.25 mg, 0.5 mg

Elixir (pediatric): 0.05 mg/ml

IV: 0.05 mg/ml, 0.1 mg/ml, 0.25 mg/ml

Digoxin, cont. Indications and dosage:

Heart failure, tachyarrhythmias, atrial fib/flutter, PSAT

LPNs will only be giving this drug for maintenance dosing. LPNs will NOT be pushing this drug for initial digitializing of the patient.

Digoxin, cont. Dosage adjustment: renal impairment,

hyperthyroidism, elderly patients

Off-label uses: SVT, intrauterine tachycardias

Contraindications: hypersensitivity to drug, uncontrolled ventricular tachycardias, AV block, idiopathic hypertrophic subaortic stenosis, constrictive pericarditis

Precautions: renal or hepatic impairment, electrolyte imbalances, myocardial infarction, thyroid disorders, obesity, elderly patients, pregnant or breastfeeding patients

Digoxin, cont. Administration:

Measure apical pulse for one full minute before administering. If rate is below 60 bpm, withhold dose and notify provider.

Drug has narrow therapeutic index, monitor patient carefully for toxicity

Digoxin, cont.

Adverse reactions: fatigue, headache, asthenia, bradycardia, EKG changes, arrhythmias, blurred or yellow vision, nausea, vomiting, diarrhea, gynecomastia, thrombocytopenia, decreased appetite.

Digoxin, cont. Interactions:

Drug-drug: many drugs result in changes in digoxin blood level possibly leading to toxicity, check nursing drug resources for a complete list; partial list includes amiodarone, cyclosporine, diclofenac, diltiazem, propafenone, quinidine, quinine, verapamil, amphotericin B, corticosteroids, mezlocillin, pipercillin, thiazide and loop diuretics, ticarfillin, antacids, cholestyramine, colestipol, kaolin/pectin, beta blockers, laxatives, spironalactone, thyroid hormones

Drug-herb: cocoa seed, coffee seed, cola seed, guarana seed, horsetail, licorice, aloe, yerba mate, may lead to toxicity

Digoxin, cont.

Therapeutic range for digoxin blood levels is 0.5 to 2.0 ng/ml

Phenergan Promethazine Nonselective phenothiazine Antihistamine, antiemetic, sediative-

hypnotic Black box warning: don’t use

suppositories in patients under the age of 2 due to potential for fatal respiratory depression

Phenergan, cont. Action- blocks effects but not release of

histamine and exerts strong alpha-adrenergic effects. Inhibits chemoreceptor triggers in the medulla and alters the dopamine effects by indirectly reducing stimulation in CNS

Availability: Injection: 25 mg/ml, 50 mg/mlSuppositories: 12.5 mg, 25 mg, 50 mgSyrup: 6.25/5mlTablets: 12.5 mg, 25 mg, 50 mg

Phenergan, cont. Indications: Type 1 hypersensitivity

reaction, nausea, motion sickness, sedation Dosages: Adults- 25-50 mg PO, PR, IM or IV

q4-6 hours prn At City, IV doses are limited to 12.5 mg

IV push diluted in 10 ml NS administered through the port farthest from the patient over several minutes. Phenergan should not be administered through a saline lock. IV fluids must be infusing.

Phenergan, cont. Contraindications: hypersensitivity,

previous idiosyncratic reaction to phenothiazines, asthma, COPD, obstructive sleep apnea, coma

Precautions: cardiovascular or hepatic disease, seizures, bone marrow depression, narrow angle glaucoma, prostatic hypertrophy, stenosing peptic ulcer, pyloroduodenal or bladder neck obstruction, CNS depression, pregnant or breastfeeding patients, children under age 2

Phenergan, cont. Administration: Administer no faster than 25

mg/min or in concentrations greater than 25 mg/ml, inject deep IM into large muscle, don’t give subcutaneously

Adverse reactions: confusion, disorientation, fatigue, drowsiness, sedation, dizziness, extrapyramidal reactions, insomnia, nervousness, neuroleptic malignant syndrome, hypertension, hypotension, brady & tachycardia, blurred vision, tinnitus, constipation, dry mouth, blood dyscrasias, respiratory depression, rash

Phenergan, cont. Interactions:

Drug-drug: additive anticholinergic effects with anticholinergics; CNS depressants: additive CNS depression; Epinephrine: reversal of epi’s vasopressor effects; MAO inhibitors: increased extrapyramidal effectsDrug-diagnostic tests: increased glucose levels, false positive or negative pregnancy tests, false negative skin allergan testsDrug-herbs:evening primrose- increased risk seizures, kava- increased risk adverse drug reactionsDrug-behavior: additive CNS depression with alcohol, increased risk photosensitivity with sun exposure

Robinul (glycopyrrolate) Class: anticholinergic, antispasmodic,

antimuscarinic, parasympatholytic Action: inhibits action of acetylcholine on

muscarinic receptors that mediate effects of parasympathetic postganglionic impulses. This inhibition relaxes cardiac smooth muscle, inhibits vagal reflexes, and decreases tracheal and bronchial secretions

Robinul, cont.

Availability:IV: 0.2 mg/mlTablets: 1 mg, 2 mg

Robinul, cont.

Indications and dosage: adjunct in peptic ulcer disorders, to diminish secretions and block cardiac vagal reflexes before or during surgery, to diminish or block cholinergic effects caused by anticholinesterase

1 mg PO tid to max 8 mg/day OR 0.1-0.2 mg IM or IV tid to qid

Robinul, cont. Off label uses: sweating

Contraindications: hypersensitivity to drug, arrhythmias, COPD, GI disease, infection, atony, or ileus, myasthenia gravis, glaucoma, obstructive uropathy, severe prostatic hypertrophy

Precautions: cardiovascular disease, heart failure, hypertension, renal or hepatic disease, Down syndrome, hyperthyroidism, hiatal hernia, ulcerative colitis, mild to moderate BPH, autonomic heuropathy, spasticity, suspected brain damage, pregnant or breastfeeding patients

Robinul, cont.

Administration: give oral dose 30-60 minutes before meals

IV administration: either undiluted or diluted with D5W or saline, give each 0.2 mg over 1-2 min.

Keep resuscitation equipment on hand to treat curare-like effects of overdose

Robinul, cont. Adverse reactions: weakness, nervousness,

insomnia, drowsiness, dizziness, headache, confusion, excitement, palpitations, tachycardia, blurred vision, photophobia, mydriasis, increased intraocular pressure, cycloplegia, nausea, vomiting, constipation, abdominal distention, epigastric distress, heartburn, gastroesophageal reflux, dry mouth, paralytic ileus, urinary hesitancy or retention, lactation suppression, erectile dysfunction, urticaria, decreased sweating or anhidrosis, loss of taste, fever, allergic reaction, irritation at IM injection site, anaphylaxis, malignant hyperthermia

Robinul, cont.

Interactions: increased anticholinergic effects with amantidine, antihistamines, antiparkinsonians, disopyramide, glutethimide, meperidine, phenothiazines, procainamide, quinidine, tircyclic antidepressants

Solumedrol (methylprednisolone sodium succinate)

Class: glucocorticoid, antiasthmatic, anti-inflammatory (steroidal), immunosuppressant

Action: reduces inflammation and prevents edema by stabilizing membranes and reducing permeability of leukocytic cells. Suppresses immune system by interfering with antigen-antibody interactions of macrophages and T cells

Solumedrol, cont.

Availability:Solution for IV/IM: 40 mg, 125 mg, 500 mg, 1 g, 2 gSuspension for injection: 20 mg/ml, 40 mg/ml, 80 mg/mlTablets: 2 mg, 4 mg, 8 mg, 16 mg, 24 mg, 32 mg

Solumedrol, cont. Indications:

diseases and disorders of endocrine system, collagen, skin, eye, GI, respiratory, or hematologic system, neoplastic diseases, allergies, multiple sclerosis, tuberculous meningitis, trichinosis, rheumatic disorders, osteoarthritis, bursitis, localized inflammatory lesions

Solumedrol, cont.

Dosages:4-160 mg PO daily in four divided doses depending on disease or disorderHigh dose therapy: 30 mg/kg IV over at least 30 min., may be repeated in 4-6 ours for 48 hours.

Solumedrol, cont.

Off label uses: lupus nephritis, pneumocystis jiroveci pneumonia in AIDS patients

Contraindications: hypersensitivity to drug or its component, systemic fungal infections

Solumedrol, cont. Precautions: cardiovascular, hepatic,

renal, or GI disease. Active untreated infections, thromboembolic tendency, idiopathic thrombocytopenia purpura, osteoporosis, myasthenia gravis, hypothyroidism, glaucoma, ocular herpes simplex, vaccinia or varicella, seizure disorders, metastatic cancer, pregnant or breastfeeding patients, children

Solumedrol, cont. Give prophylactic antacids in patients

receiving high doses to prevent peptic ulcers

Methylprednisilone acetate is not for IV use- IM, intra-articular, intralesional or soft tissue injection

Methylprednisilone sodium succinate is for IV or IM use

For IV use, inject 500 mg dose over 2 to 3 min or more

Solumedrol, cont. Adverse reactions: headache, restlessness, nervousness,

depression, euphoria, personality changes, psychoses, vertigo, paresthesias, insomnia, adhesive arachnoiditis, conus medullarus syndrome, increased intracranial pressure, seizures, meningitis, hypotension, hypertension, arrhythmias, heart failure, shock, fat embolism, thrombophlebitis, thromboembolism, cataracts, glaucoma, increased intraoccular pressure, nasal irritation, nasal septum perforation, sneezing, epistaxis, nasopharyngeal or oropharyngeal fungal infection, dysphonia, hoarseness, throat irritation, nausea, vomiting, abdominal distention, rectal bleeding, dry mouth, anorexia, esophageal candidiasis, esophageal ulcer, peptic ulcer, pancreatitis, amenorrhea, irregular menses, cough, wheezing, bronchospasm, decreased growth, hyperglycemia, fluid retention, cushingoid state, hypothalamic-pituitary-adrenal suppresion, adrenal suppression, acute adrenal insufficiency, muscle wasting, tendon rupture, weakness, rash, pruritis, decreased wound healing, fragile skin, skin atrophy, bad taste, weight gain, etc.

Solumedrol, cont.

Interactions:Drug to drug: amphotericin B, mezlocillin, piperacillin, thiazide and loop diuretics, ticarcillin- additive hypokalemai, fluoroquinolones- increased risk of tendon rupture, isoniazid, phenobarbital, phenytoin, rifampin- decreased

Valium Diazepam Action: produces anxiolytic effect and CNS

depression by stimulating gamma-amniobutyric acid receptors, relaxes skeletal muscles of the spine by inhibiting afferent pathways, controls seizures by enhancing presynaptic inhibition

Availability: Injection: 5 mg/mlOral solution: 1 mg/ml, 5 mg/5 mlRectal gel: 2.5 mg, 10 mg, 15 mg, 20 mgTablets: 2 mg, 5 mg, 10 mg

Valium, cont. Indications: anxiety disorders, before

interventional procedures, status epilepticus and severe recurrent seizures, muscle spasm, acute alcohol withdrawal

Off label uses: panic attacks, adjunct to general anesthesia

Contraindications: hypersensitivity, other benzodiazepines, alcohol, or tartrazine, coma or CNS depression, narrow angle glaucoma

Valium, cont. Dosages: Adults 2-10 mg PO two to four times a day,

2-10 mg IV q3-4 hours, 5-15 mg IV pre-cardioversion or endoscopy

Precautions: hepatic dysfunction, severe renal impairment, elderly patients, pregnant or breastfeeding patients, children

For IV administration: administer slowly into large vein, rate of 1 minute per 5 mg in adults or at least 3 minutes for each 0.25 mg/kg in children

IV route preferred over IM route Don’t mix wit other meds or solutions in syringe Enforce bed rest for 3 hours post-administration Give deep IM and slowly into large muscle mass

Valium, cont. Adverse reactions: dizziness, drowsiness, lethargy,

depression, light-headedness, disorientation, anger, manic or hypomanic episodes, restlessness, paresthesia, headache, slurred speech, dysarthria, stupor, tremor, dystonia, vivid dreams, extrapyrimidal reactions, mild paradoxical excitation, brady or tachycardia, hyper or hypotension, palpitations, cardiovascular collapse, blurred vision, diplopia, nystagmus, nasal congestion, nausea, vomiting, diarrhea, constipation, gastric disorders, difficulty swallowing, increased salivation, urinary retention or incontinence, menstrual irregularities, gynecomastia, libido changes, blood dyscrasias, hepatic dysfunction, muscle rigidity, dermatitis, rash, pruritus, diaphoresis, weight gain or loss, decreased appetite, edema, hiccups, fever, dependence

Valium, cont. Interactions:

Drug-drug: additive effects with antidepressants, antihistamines, barbiturates, opioids; decreased levels with numerous drugs- check ddrug references, increased dig levels, decreased levodopa levelsDrug-diagnostic tests: increased levels of liver enzymes, decreased platelet countsDrug-behavior: increased CNS depression with alcohol

Valium, cont.

Patient monitoring: vital signs and neuro status, supervise ambulation especially in elderly, monitor cbc, renal, and liver enzymes

Avoid sudden drug withdrawal, taper gradually to termination of therapy

Questions How fast are each of the following

meds pushed?1. solumedrol2. decadron3. robinal4. digoxin5. valium6. phenergan

Answer

SLOW IV PUSH

Questions

Which medication may only be push for maintenance purposes only? Meaning if this is the initial administration of this drug to establish a therapeutic value, the LPN may not push it.

Answer

Digoxin

Questions

Which drug must be diluted in 10 ml normal saline, pushed through the port farthest from the patient over several minutes?

Answer

Phenergan

Questions

Which drug has an off label use for panic attacks but is commonly used pre-procedurally for endoscopy and cardioversion?

Answer

Valium

Questions

Which two things must be verified before bar coding the patient in preparation for drug administration every time?

Answer

Patient’s correct name and date of birth, no nicknames

Questions

What are the five rights to drug administration that the prudent nurse checks EVERY time a medication is administered?

Answer

Right patient Right drug Right dose Right route Right time

Medication Checklist

Please obtain a copy of the Medication #2 Checklist from your Nurse Manager.

You must complete IV administration of three different medications. One of those three medications must be phenergan and you must be directly observed administering phenergan on 3 separate occasions.