DEFINITIONS
Critical Care Unit: It is a specially designed and equipped unit of a hospital, staffed by skilled
multidisciplinary professionals to provide holistic care to patients with actual or potential life
threatening health problems, to limit complications, disability and restore health.
-By Critical Care Nurses Society
Critical Care Nursing: Critical Care Nursing is a specialty which uses advanced competencies
to meet complex and challenging demands in caring for critically and acutely ill patients, to
prevent complications, restore health or to prepare for a dignified death, by assessing, diagnosing
and managing human responses to actual or potential health problems for optimal patient
outcomes.
-By Critical Care Nurses Society
Beginning of the Process and decide about Budget allocation, aims and objectives
B. Decision about ICU Level, Number of beds, Design and Future Thoughts
Planning level of ICU like Level I, Level II or Level III or Tertiary Unit
Number of beds and number of ICUs as needed for the institution - Ideally 8 To 12 Beds
Designing each bed lay out and providing optimum space for the same - 125 to 150 sqft
area per bed
10% of beds ( 1 or 2 ) rooms may be used exclusively as isolation cases like for burns,
serious contagious infected patients
Location, space, Facilitieso ICU should be located in close proximity of ER, Operating rooms, trauma ward
o Should be single entry/exit point to ICU, which should be manned
D. Environmental Planning
Effective steps and planning to control nosocomial infections
Lighting
o Access to outside natural light is recommended by regulatory authorities in USA
o High illumination and spot lighting is needed for procedures, like putting Central
lines etc.
Surroundings
Noise: The international Noise Council recommends that the noise level in an ICU be
under 45 dBA in the daytime, 40 dBA in the evening and 20 dBA at night
Heating/ AC/Ventilation -The ICU should be fully air-conditioned which allows control
of temperature,
Humidity and air change- Central air-conditioning systems and re-circulated air must
pass through appropriate filters
o It is mandatory to have four covered pans (Yellow, blue, Red, Black) provided for
each patient or may be one set between two patients. This is needed to dispose off
different grades of wastes.
E. ICU TEAM
Doctors, Nurses, Respiratory Therapist, Computer Programmer, and support staff like Clerks,
X-ray technician, Lab technicians, Sanitary Attendants who are trained to the needs of ICUs.
Waiting and seating space- Many guidelines suggest that ll/2 to 2 seats per patient bed be
provided in the waiting area. Enough number of restrooms should be provided.
H. Equipment
Most important decisions will be No. of Ventilated beds and Invasive monitoring
ICU Vs HDU
Name of Equipment
Quantity
Specification
No.
Bedside Monitors [for
1.
ICU]
2.
Same
3.
Ventilators
should
be
with
inbuilt
compressor
Each should have a Fisher and Paykel
humidifier these can be directly bought
from F&P
Non
4.
5.
6.
Invasive
Ventilators
Infusion Pumps
Syringe Pumps
calculations
7.
Head-end panel
1 Per bed
Sr.
Name of Equipment
Quantity
Specification
Adult
[1standby]
No.
8.
Defibrillator
and
paediatric
Electronically
ICU
9.
beds
[shock
proof, fibre]
pads
maneuvered
with
with
all
As per plan
10.
Overbed table
11.
ABG machine
Crash
12.
Resuscitation trolley
Pulse Oximeter [small
13.
units]
14.
One + one
HDU
equipment
As standby units
Freezer
and doctors
2 for ICU, 1 for
15.
Computers
HDU,
Charge
for
In
16.
HD machine
17.
CRRT
As described
To prevent DVT
CO,
18.
SVR,
ScvO2
monitor
Sequential
19.
compression device
20.
Air beds
To prevent bedsores
21.
Intubating videoscope
Sr.
Name of Equipment
Quantity
Specification
No.
22.
ICU
23.
Glucometer
HDU
dedicated
machine
lines, etc.
24.
Bedside X-ray
25.
ETO sterilization
26.
Spinal Board
collars
AMBU with masks of
28.
different sizes
Pollution
29.
control
buckets
30.
31.
IABP
Fibreoptic
32.
bronchoscope
I. CARDIOVASCULAR DRUGS
a) Inotropes
c) Vasodilators
i. Angiotensin converting enzyme (ACE) inhibitors: captopril, enalapril, ramipril.
ii. Angiotensin receptor blockers (ARBs): Telmisartan, Valsartan, losartan, olmesartan
iii. Calcium-channel blockers (CCBs): Amlodipine, nicardipine, nifedipine, Verapamil,
Diltiazem
iv. Beta Blockers: Acebutolol, Atenolol, Bisoprolol, Metoprolol, Nebivolol, Propranolol
v. Nitrates: Nitroglycerin
vi. Alpha Blockers: Doxazosin, Prazosin, Terazosin
COMMON DRUGS
1. ADRENALINE (EPINEPHRINE)
Classification: Sympathomimetic, Alpha-adrenergic agonist, Beta1- and beta2-adrenergic
agonist, Cardiac stimulant, Vasopressor, Bronchodilator
Dose and Route: 0.51 mg (510 ml of 1:10,000 solution) IV during resuscitation, 0.5 mg q5
min.
Action: The effects 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.
Indication
Intravenous: In ventricular standstill after other measures have failed to restore circulation;
Treatment and prophylaxis of cardiac arrest and attacks of transitory AV heart block with
syncopal seizures (Stokes-Adams syndrome);syncope due to carotid sinus syndrome; acute
hypersensitivity in acute asthmatic attacks to relieve bronchospasm not controlled by inhalation
or SC injection.
Contraindication: Angle-closure glaucoma, shock, hypovolemia, tachyarrhythmias, ischemic
heart disease, hypertension, diabetes mellitus.
Side effects
CNS: Fear, anxiety, restlessness, headache, light-headedness, dizziness, drowsiness
CV: Arrhythmias, hypertension resulting in intracranial hemorrhage, CV collapse with
hypotension, palpitations, tachycardia
GI: Nausea, vomiting, anorexia
GU: Constriction of renal bloood vessels and decreased urine formation and dysuria
Local: Necrosis at the site of repeat injections.
Nurses Responsibility
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. Observe patient closely for adverse reaction
Report chest pain, dizziness, insomnia, weakness, tremor or irregular heart beats
If more than one inhalation is prescribed, advice patient to wait atleast 2 minutes before
repeating procedure.
Monitor BP, pulse, respirations, and urinary output and observe patient closely following IV
administration. Epinephrine may widen pulse pressure. If disturbances in cardiac rhythm
occur, withhold epinephrine and notify physician immediately.
Check BP repeatedly when epinephrine is administered IV during first 5 min, then q35min
until stabilized.
Advise patient to report to physician if symptoms are not relieved in 20 min or if they
become worse following inhalation.
Monitor blood glucose & HbA1c for loss of glycemic control if diabetic.
Be aware intranasal application may sting slightly. Transitory stinging may follow initial
ophthalmic administration and that headache and brow ache occur frequently at first but
usually subside with continued use. Notify physician if symptoms persist.
2. NORADRENALINE (NOREPINEPHRINE)
Classification: Sympathomimetic, Alpha-adrenergic agonist, Beta1- and beta2-adrenergic
agonist, Cardiac stimulant, Vasopressor, Bronchodilator.
Available dose: Injection: 1mg/ml
Action: Stimulates alpha 1 and beta 1 receptors in the sympathetic nervous system causing
vasoconstriction and cardiac stimulation.
Indication: Restoration of blood pressure in certain hypotensive states (e.g. sympathectomy,
spinal anaesthesia, MI, septicaemia, blood transfusion, drug reactions).
Contraindications
Hypovolemia
Ventricular fibrillation
Tachydysrrhythmia
Pheochromocytoma
Hypotension
Contraindicated in patients during cyclopropane and halothane anesthesia.
Adverse effects:
CNS: Headache , anxiety, insomnia
CV: thrombophlebitis, pulmonary embolism, thrombotic disorders, ectopic beats, tachycardia,
severe hypertension
Respiratory: dyspnea
Skin: rash with or without pruritus, necrosis, tissue sloughing, gangrene
GI: Nausea, vomiting
Other: Anaphylaxis
Nurses responsibility:
Monitor constantly while patient is receiving norepinephrine. Take baseline BP and pulse
before start of therapy, then every 2min from initiation of drug until stabilization occurs at
desired level, then every 5 min if infusion is continued.
Administer IV infusions into a large vein, preferably the antecubital fossa, to prevent
extravasation.
Adjust flow rate to maintain BP at normal (usually 80100 mm Hg systolic) in normotensive
patients. In previously hypertensive patients, systolic is generally maintained no higher than 40
mm Hg below pre existing systolic level.
Observe carefully and record mental status (index of cerebral circulation), skin temperature of
extremities, and colour (especially of earlobes, lips, nail beds) in addition to vital signs.
Monitor I&O. Urinary retention and kidney shutdown are possibilities, especially in
hypovolemic patients. Urinary output is a sensitive indicator of the degree of renal perfusion.
Report decrease in urinary output or change in I&O ratio.
3. DOPAMINE
Generic Name: Dopamine hydrochloride
Drug class: Sympathomimetic, Alpha adrenergic agonist, Beta 1 selective adrenergic agonist,
Dopaminergic agent.
Action: Drug acts directly and by the release of norepinephrine from sympathetic nerve
terminals; dopaminergic receptors mediate dilation of renal and splanchnic beds, which
maintains renal perfusion and function; alpha receptors, which are activated by higher doses of
dopamine, mediate vasoconstriction, which can override the effects of vasodilation; beta 1
receptors mediate the positive inotropic effect on the heart.
Indications: Correction of hemodynamic imbalance in shock due to MI, trauma, endotoxic
septicaemia, open heart surgery, renal failure and chronic cardiac decompensation in CHF
Contraindication: Pheochromocytoma, tachyarrhythmias, hypovolemia.
Side Effects
CVS: ectopic beats, tachycardia, angina pain, palpitations, hypotension, vasoconstriction,
dyspnoea, bradycardia, hypertension, widened QRS complex.
GI: nausea, vomiting.
Others: Headache, pilo-erection, azotemia, gangrene with prolonged use.
Nursing Management
1) Use extreme caution in calculating the drug dosages.
2) Drug should always be diluted.
3) Administer into large veins of the antecubital fossa rather than small veins on the hand.
4) Keep phentolamine ready in case extravasation occurs.
5) Monitor urine flow, cardiac output, and BP closely during infusion.
4. DOBUTAMINE
Classification: Inotropic agent, autonomic nervous system agent; beta-adrenergic agonist;
catecholamine
Action
Dobutamine is an inotropic agent whose primary activity is the stimulation of beta receptors of
the heart while producing comparatively hypertensive, arrhythmogenic and vasodialative
effects.
Causes an increase in cardiac output (C.O) usually not associated with a marked increase in
heart rate, while the stroke volume is usually increased.
Systemic vascular resistance is usually decreased due to stimulation of beta 2 receptors which
contributes to the increased C.O.
Onset of action 1 - 2 minutes however as much as 10 minutes may be required to obtain the
peak effect at a particular infusion rate. Half life is 2 minutes.
Indications: Severe cardiac failure secondary to AMI or cardiomyopathy, Cardiogenic shock,
Septic shock, Congestive cardiac failure, Acute pulmonary oedema.
Available dose: I.V injection: 12.5 mg/ml in 20 ml vial (250 mg)
Contraindications: Idiopathic hypertrophic sub aortic stenosis
Adverse /side effects
CNS: headache, tremors, paresthesias, mild leg cramps, nervousness, fatigue (with overdosage).
CV: increased heart rate and BP, premature ventricular beats, palpitation, anginal pain. GI:
nausea, vomiting.
Other: nonspecific chest pain, shortness of breath.
5. ATROPINE
Classification Anticholinergic, Antimuscarinic, Class V anti arrhythmic
Action: Competitively blocks the effects of acetylcholine at muscarinic cholinergic receptors
that mediate the effects of parasympathetic postganglionic impulses, depressing salivary and
bronchial secretions, dilating the bronchi, inhibiting vagal influences on the heart, relaxing the
GI and GU tracts, inhibiting gastric acid secretion (high doses), relaxing the pupil of the eye
(mydriatic effect), and preventing accommodation for near vision (cycloplegic effect); also
blocks the effects of acetylcholine in the CNS.
Indication
Treatment of parkinsonism; relieves tremor and rigidity
Restoration of cardiac rate and arterial pressure during anesthesia when vagal stimulation
produced by intra-abdominal traction causes a decrease in pulse rate, lessening the degree of
AV block when increased vagal tone is a factor (eg, some cases due to digitalis)
Relief of bradycardia and syncope due to hyperactive carotid sinus reflex
Relaxation of the spasm of biliary and ureteral colic and bronchospasm
Relaxation of the tone of the detrusor muscle of the urinary bladder in the treatment of urinary
tract disorders
Treatment of closed head injuries that cause acetylcholine release into CSF, EEG
abnormalities, stupor, neurologic signs
Antidote
(with
external
cardiac
massage)
for
CV
collapse
from
overdose
of
Action:
Alters the permeability of the renal collecting ducts, allowing reabsorption of water.
Directly stimulates musculature of GI tract.
In high doses acts as a non-adrenergic peripheral vasoconstrictor.
Decreased urine output and increased urine osmolality in diabetes insipidus.
Indications
Central diabetes insipidus due to deficient antidiuretic hormone.
Management of pulseless VT/ VF unresponsive to initial shocks, asystole, or pulseless
electrical activity (PEA)
Vasodilatory shock.
Gastrointestinal hemorrhage.
Contraindications
Comatose patients
Seizures
Migraine headaches
Asthma
Heart failure
Side Effects
CNS: dizziness, "pounding" sensation in head.
CV: MI, angina, chest pain.
GI: abdominal cramps, belching, diarrhea, flatulence, heartburn, nausea, vomiting.
Dermatology: paleness, peri-oral blanching, sweating.
Miscellaneous: allergic reactions, fever, water intoxication (higher doses).
Agents as salbutamol, terbutaline and fenoterol are selective stimulants of B2 receptors; they
act on these receptors in bronchi and small airways and on mast cells.
They cause fewer side effects on heart than adrenadine or isoprenaline which are non-selective
(obsolete).
Action:
1. Relaxation of bronchial smooth muscles.
2. Stabilization of mast cells.
Route of administration:
Salbutamol is best given by inhalation because:
1. It permits direct delivery of the drug to the site of action.
2. It reduces the possibility of general systemic side effect.
3. The total dose administered is very small and this further limits the adverse effects.
4. It provides large surface area for absorption.
5. Rapid onset of action.
Dosage: (each inhalation =100mcg)
Adult acute attack: 1-2 inhalation 4th hourly. Chronic treatment: 2 inhalation 3-4 times daily.
Oral: 2-4mg,3-4 times daily by mouth.
Children one inhalation (100 microgram) 3-4 times daily.
Indication:
NOTE B2 agonist given as aerosol inhalation result in symptomatic relief with minimum cardiac
adverse effects especially in patient with reversible airways obstruction.
Response depends on the patient using the aerosol correctly, even with optimal use only 10% of
the drug is inhaled while the remaining 90% is swallowed or metabolized.
2) AMINOPHYLLINE:
It consists of theophylline and ethylene diamine in ratio of 2:1 it is used in:
1. Severe acute attacks of asthma & status asthmatics.
2. Exacerbation of COPD.
3. Acute left ventricular failure with pulmonary edema.
Oral theophylline preparations are useful in long-term treatment of asthma & reversible (COPD).
A useful bronchodilation response can be often achieved with in the therapeutic range & the S/E
can be minimized with the aid of plasma level measurements.
4) CORTICOSTEROIDS:
The actions on the bronchi is not fully understood, their effect are the result of the following
action:
a. Anti-inflammatory (for any reason).
b. Reduction of mucosal oedema increase airflow.
c. Modification of immune response & stabilization of mast cells.
d. Increase B2 - receptor responsiveness to agonist
In the management of airway obstruction they are given by inhalation orally and IV according to
the condition:
a. Inhalation:
b. Intra venous:
When there is sever unresponsive asthma, especially when there is respiratory failure.
Hydrocortisone (cortisol) is given I.V.
There is a delay in the onset of any steroid induced bronchodilation & this occurs because the
receptors of steroid are found inside cytoplasm and thus they need more time to exert their effect
for this reason Hydrocortisone is not used in case of emergency in addition to that other
measures should be pursued at the same time.
c. oral:
Patients with severe exacerbation of asthma require high doses of prednisolone by mouth after
I.V hydrocortisone.
Adverse effects:
Spray 0.03 formulation: 2 sprays (42 mcg) per nostril 2 or 3 times daily (optimum dose varies).
0.06 formulation: 2 sprays (84 mcg) per nostril 3 or 4 times daily (optimum dose varies).
Indications and Usage
Maintenance treatment of bronchospasm associated with COPD, including chronic bronchitis
and emphysema, used alone or in combination with other bronchodilators (inhalation);
symptomatic relief of rhinorrhea associated with allergic and non-allergic rhinitis and
symptomatic relief of rhinorrhea associated with the common cold (intranasal).
Contraindications
Hypersensitivity to atropine or any anticholinergic derivatives or to soya lecithin or related food
products.
Nurses Responsibility (Resp. Drugs)
1. Assses lung sounds, pulse, and blood pressure before administration and during peak of
medication. Note amount, color, and character of sputum produced.
2. Monitor pulmonary function tests before initiation therapy and periodically throughout course
to determine effectiveness of medication.
3. Observe for paradoxical bronchospasm (wheezing). If condition occurs, withhold medication
and notify physician or other health care professional immediately.
4. Instruct patient to take medication exactly as directed. If on a scheduled dosing regimen, take
missed dose as soon as remembered, spacing remaining dose at regular intervals . Do not double
doses or increase the dose or frequency of doses. Caution patient not to exceed recommended
dose; may cause adverse effects, paradoxical bronchospasm. Advised patient that not all agents
should be should be used for acute attacks.
5. Instruct patient to conduct health care professional immediately if shortness o breath is not
relieved by medication or is accompanied by diaphoresis, dizziness, palpitations, or chest pain.
Actuators should not be changed among products. To
6. Instruct patient to prime unit with 4 sprays before using and to discard cannister after 200
sprays. Actuators should not be changed among products.
7. Advise patient to consult health care professional before taking any OTC medications or
alcohol concurrently with this therapy. Caution patient that albuterol may cause an unusual or
bad taste.
8. Instruct patient in the proper use of the metered- dose inhaler , Rotahaler, or nebulizer.
9. Advise patients to use albuterol first if using other inhalation medications and allow 5 min to
elapse before administering other inhalant medications unless otherwise directed.
10. Advise patient to rinse mouth with water after each inhalation dose to minimize dry mouth.
Muscle Relaxants
Neuromuscular blockers
1. DIAZEPAM
Indications
Acute alcohol withdrawal; may be useful in symptomatic relief of acute agitation, tremor,
delirium tremens, hallucinosis
Muscle relaxant: Adjunct for relief of reflex skeletal muscle spasm due to local pathology
(inflammation of muscles or joints) or secondary to trauma; spasticity caused by upper motor
neuron disorders (cerebral palsy and paraplegia); athetosis, stiff-man syndrome
Preoperative (parenteral): Relief of anxiety and tension and to lessen recall in patients prior
to surgical procedures, cardioversion, and endoscopic procedures
Rectal: Management of selected, refractory patients with epilepsy who require intermittent
use to control bouts of increased seizure activity
hernia, cardiac defects, microcephaly, pyloric stenosis when used in first trimester; neonatal
withdrawal syndrome reported in newborns); lactation.
Use cautiously with elderly or debilitated patients; impaired liver or kidney function.
Available forms
Tablets2, 5, 10 mg; SR capsule15 mg; oral solution1 mg/mL, 5 mg/5 mL; rectal pediatric
gel2.5, 5, 10 mg; rectal adult gel10, 15, 20 mg; injection5 mg/mL
Dosages: Individualize dosage; increase dosage cautiously to avoid adverse effects.
Adults (Oral)
Parenteral
Usual dose is 220 mg IM or IV. Larger doses may be required for some indications
(tetanus). Injection may be repeated in 1 hr.
Status epilepticus: 510 mg, preferably by slow IV. May repeat q 510 min up to total dose
of 30 mg. If necessary, repeat therapy in 24 hr; other drugs are preferable for long-term
control.
Preoperative: 10 mg IM.
Adverse effects
CNS: Transient, mild drowsiness initially; sedation, depression, lethargy, apathy, fatigue, lightheadedness, disorientation, restlessness, confusion, crying, delirium, headache, slurred speech,
dysarthria, stupor, rigidity, tremor, dystonia, vertigo, euphoria, nervousness, difficulty in
concentration, vivid dreams, psychomotor retardation, extrapyramidal symptoms; mild
paradoxical excitatory reactions, during first 2 wk of treatment, visual and auditory disturbances,
diplopia, nystagmus, depressed hearing, nasal congestion
CV: Bradycardia, tachycardia, CV collapse, hypertension and hypotension, palpitations, edema
Dependence: Drug dependence with withdrawal syndrome when drug is discontinued (common
with abrupt discontinuation of higher dosage used for longer than 4 mo); IV diazepam: 1.7%
incidence of fatalities; oral benzodiazepines ingested alone; no well-documented fatal overdoses
2. MORPHINE SULFATE
Action: Principal opium alkaloid; acts as agonist at specific opioid receptors in the CNS to
produce analgesia, euphoria, sedation; the receptors mediating these effects are thought to be the
same as those mediating the effects of endogenous opioids.
Indications
Intraspinal use with microinfusion devices for the relief of intractable pain
Unlabeled use: Dyspnea associated with acute left ventricular failure and pulmonary edema
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.
Teaching points
Take this drug exactly as prescribed. Avoid alcohol, antihistamines, sedatives, tranquilizers,
over-the-counter drugs.
Swallow controlled-release preparation (MS Contin, Oramorph SR) whole; do not cut, crush,
or chew them.
Do not take leftover medication for other disorders, and do not let anyone else take your
prescription.
These side effects may occur: Nausea, loss of appetite (take with food, lie quietly);
constipation (use laxative); dizziness, sedation, drowsiness, impaired visual acuity (avoid
driving or performing tasks that require alertness and visual acuity).
Report severe nausea, vomiting, constipation, shortness of breath or difficulty breathing, rash.
3. FENTANYL
Action: Acts at specific opioid receptors, causing analgesia, respiratory depression, physical
depression, euphoria.
Indications
Analgesic action of short duration during anesthesia and immediate postoperative period
Analgesic supplement in general or regional anesthesia
Administration with a neuroleptic as an anesthetic premedication, for induction of anesthesia,
and as an adjunct in maintenance of general and regional anesthesia
Transdermal system: Management of chronic pain in patients requiring opioid analgesia
Treatment of breakthrough pain in cancer patients being treated with and tolerant to opioids
Contraindications and cautions
Nursing considerations
Administer to women who are nursing a baby 46 hr before the next scheduled feeding to
minimize the amount in milk.
Keep opioid antagonist and facilities for assisted or controlled respiration readily available
during parenteral administration.
Prepare site for transdermal form by clipping (not shaving) hair at site; do not use soap, oils,
lotions, alcohol; allow skin to dry completely before application. Apply immediately after
removal from the sealed package; firmly press the transdermal system in place with the palm of
the hand for 1020 sec, making sure the contact is complete. Must be worn continually for 72
hr.
Teaching points
Do not drink grapefruit juice while using this drug.
These side effects may occur: Dizziness, sedation, drowsiness, impaired visual acuity (ask for
assistance if you need to move); nausea, loss of appetite (lie quietly, eat frequent small meals);
constipation (a laxative may help).
Report severe nausea, vomiting, palpitations, shortness of breath, or difficulty breathing.
4. LORAZEPAM
Action: They are a group of anxiolytics, antiepileptics, muscle relaxants and sedative hypnotics.
Benzodiazepines potentiate the effect of gamma amino butyrate an inhibitory neurotransmitter.
Indication:
Management of anxiety disorders, short term relief symptoms of anxiety.
Short term treatment of insomnia.
Akinetic or myoclonic seizures.
Treatment of panic attacks, periodic leg movements during sleep, hypokinetic dysarthria, acute
manic episodes, neuralgia.
Contraindications:
Hypersensitivity, psychoses, acute narrow angle glaucoma, shock, coma, pregnancy, lactation.
Available forms
Injection2, 4 mg/mL; oral solution2 mg/mL; tablets0.5, 1, 2 mg
Side effects
CNS: Transient mild drowsiness initially, sedation, depression, lethargy, apathy, fatigue, light
headedness, disorientation, anger, hostility, episodes of mania, restlessness, confusion, crying,
headache, stupor, rigidity, tremor, slurred speech.
CV: Bradycardia, tachycardia, CV collapse, hypertension and hypotension, palpitations and
trauma. DERM: Urticaria, pruritis, skin rash, dermatitis.
EENT: visual and auditory disturbances, diplopia, nystagmus, nasal congestion.
GI: Constipation, diarrhoea, dry mouth, salivation, nausea, anorexia, vomiting.
GU: Incontinence, urinary retension, changes in libido, menstrual irregularities.
HAEM: elevation in LDH, AST, ALT, agranulocytosis, leukopenia.
Others: Hiccups, fever, diaphoresis, muscular disturbances, drug dependence with withdrawal
syndrome when drug is discontinued.
Nurses Responsibility
Take drug exactly as prescribed; do not stop taking drug (long-term therapy) without
consulting health care provider.
These side effects may occur: Drowsiness, dizziness (may be transient; avoid driving or
engaging in dangerous activities); GI upset (take drug with food); nocturnal sleep disturbances
for several nights after discontinuing the drug if used as a sedative and hypnotic; depression,
dreams, emotional upset, crying.
Report severe dizziness, weakness, drowsiness that persists, rash or skin lesions, palpitations,
edema of the extremities; visual changes; difficulty voiding.
Keep this and all medications out of the reach of children.
Tell any health care provider who is taking care of you that you are using this drug.
IV. ANTICOAGULANTS
Compounds that do not allow blood to clot are called anticoagulants. These include drugs such as
heparin and coumarin and low molecular weight heparin.
HEPARIN
Heparin is used to prevent blood clots from forming in people who have certain medical
conditions or who are undergoing certain medical procedures that increase the chance that clots
will form. Heparin is also used to stop the growth of clots that have already formed in the blood
vessels, but it cannot be used to decrease the size of clots that have already formed. Heparin is
also used in small amounts to prevent blood clots from forming in catheters (small plastic tubes
through which medication can be administered or blood drawn) that are left in veins over a
period of time. Heparin is in a class of medications called anticoagulants ('blood thinners'). It
works by decreasing the clotting ability of the blood.
Action: - Potentiates the inhibitory effect of anti thrombin on factor Xa and thrombin. In low
doses, prevents the conversation of prothrombin to thrombin by its effects on factor Xa. Higher
doses neutralize thrombin, preventing the conversation of fibrinogen to fibrin .
Therapeutic effects: Prevention of thrombus formation . prevention of extension of existing
thrombi ( full dose)
Indication: - Prophylaxis and treatment of various thromboembolic disorders including: Venous thromboembolism , pulmonary emboli, atrial fibrillation with embolization , acute and
chronic consumptive coagulopathies , peripheral arterial thromboembolism .
Contraindication: - Hypersensitivity, uncontrolled bleeding, severe thrombocytopenia.
Adverse Reaction and Side Effects
GI: drug induced hepatitis.
DERM: alopecia (long term use), rashes, urticaria.
HEMAT: bleeding, anemia, thrombocytopenia.
LOCAL: pain at injection site.
MS: Osteoporosis (long term use)
MISC: fever, hypersensitivity.
Route And Dosage
IV ( Adults) : Intermittent bolus -10,000 units by 5000-10,000 units q 4-6 hr. continuous
infusion -5000 units ( 35-70units/kg ) , followed by 20,000-40,000 units infused over 24 hr (
approx. 1000 units/ hr or 15-18 units/kg/hr ).
SC (Adults): 5000 units IV followed by initial SC dose of 10,000 -20,000 units, then 800010,000 units q 8hr or 15,000-20,000 units q 12hr.
Antidote: Protamine sulfate
WARFARIN
Action: Interferes with hepatic synthesis of Vit K dependent clotting factors (II, VII, IX, & X).
Therapeutic effect: Prevention of thromboembolic events.
Indication : Prophylaxis and treatment of venous thrombosis , pulmonary embolism , Atrial
fibrillation with embolization , management of myocardial infarction , decreases risk of death
,decreases risk of subsequent myocardial infarction , decreases risk of future thromboembolic
events ,prevention of thrombus formation and embolization after prosthetic valve placement.
Contraindication : Uncontrolled bleeding , open wound , active ulcer disease ,recent brain ,eye,
or spinal cord injury or surgery , severe liver disease ,uncontrolled hypertension ,pregnancy.
Adverse Reaction and Side Effects
Loss of appetite, nausea, diarrhea or blurred vision may occur at first as your body adjusts to
the medication,
Unusual bleeding or bruising, blood in the urine or stools, severe headache.
May cause urine to turn orange-red in color.
Symptoms of an allergic reaction include: rash, itching, swelling, dizziness, trouble breathing.
Drug Interaction
Many drugs, both prescription and nonprescription (OTC), can affect the anticoagulant action of
Coumadin. Some medications can enhance the action of Coumadin and cause excessive blood
thinning and life-threatening bleeding. A few examples of such medications include Aspirin,
acetaminophen (Tylenol and others), alcohol, ibuprofen (Motrin), cimetidine (Tagamet),
oxandrolone (Oxandrin), certain vitamins, and antibiotics.
Route and Dosage
PO, IV (Adults) 2.5- 10 mg/ day for 2-4 days; then adjust daily dose by results of prothrombin
time or International Normalized Ratio (INR).
Tablets :1mg, 2mg, 2.5mg, 3mg, 4mg, 5mg, 6mg, 7.5mg, 10mg
Antidote: Vitamin K
Action
They inhibit only clotting factor Xa and reduce platelet levels less frequently. Thus they could
cause less bleeding.
They are better absorbed from a subcutaneous injection.
Their effect lasts for a longer time, hence they may be administered once or twice a day. Their
effect is more predictable, hence repeated monitoring of aPTT is not required.
Route: Subcutaneous.
Dose: 60mg, 80mg, 100mg, 120mg and 150mg graduated syringes.
Side Effects:
1) Bleeding (nosebleeds, gumbleeds, excessive bruising)
2) Irritation at the injection site can occur in some patients.
3) Fatal, allergic reactions, injection site reactions, and increases in liver enzyme tests,
4) Decrease in platelet count, a complication known as Heparin Induced Thrombocytopenia.
Antidote: Protamine sulfate
Role of Nurse in Administration of Anticoagulant Drugs
Obtain a complete health history including recent surgeries or trauma, allergies, drug history,
and possible drug interactions.
Obtain vital signs and assess in context of clients baseline values.
Monitor for adverse clotting reaction(s). (Heparin can cause thrombus formation with
thrombocytopenia, or white clot syndrome. Warfarin may cause microemboli that result in
gangrene, localized vasculitis, or purple toes syndrome.)
Observe for skin necrosis, changes in blue or purple mottling of the feet that blanches with
pressure or fades when the legs are elevated. (Clients on anticoagulant therapy remain at risk
for developing emboli resulting in CVA or PE.)
Use with caution in clients with GI, renal and/or liver disease, alcoholism, diabetes,
hypertension, hyperlipidemia, and in the elderly and premenopausal women. (Clients with
CAD, diabetes, hypertension, and hyperlipidemia are at increased risk for developing
cholesterol microemboli.)
Monitor for signs of bleeding: flulike symptoms, excessive bruising, pallor, epistaxis,
hemoptysis, hematemesis, menorrhagia, hematuria, melena, frank rectal bleeding, or excessive
bleeding from wounds or in the mouth. (Bleeding is a sign of anticoagulant overdose.
Monitor vital signs. (Increase in heart rate accompanied by low blood pressure or subnormal
temperature may signal bleeding.)
Monitor laboratory values: APTT and PTT for therapeutic values. (Heparin may cause
significant elevations of aspartate aminotransferase (AST) and alanine transaminase (ALT),
because the drug is metabolized by the liver)
Monitor CBC, especially in premenopausal women. (Changes in CBC may indicate excessive
bleeding.
Client Education
Immediately report sudden dyspnea, chest pain, temperature or colour change. In the hands,
arms, legs, or feet. Check pulses in the ankle daily.
Protect feet from injury by wearing loose-fitting socks; avoid going barefoot.
Instruct elderly clients, menstruating women, and those with peptic ulcer disease, alcoholism,
or kidney or liver disease that they have an increased risk of bleeding.
Immediately report flulike symptoms (dizziness, chills, weakness, pale skin); blood coming
from a cough, the nose, mouth, or rectum; menstrual flooding; coffee grounds vomit; tarry
stools; excessive bruising; bleeding from wounds that cannot be stopped within 10 minutes; all
physical injuries.
Avoid all contact sports and amusement park rides that cause intense or violent bumping or
jostling.
Use a soft toothbrush and an electric shaver.
Instruct client to immediately report palpitations, fatigue, or feeling faint, which may signal
low blood pressure related to bleeding.
Always inform laboratory personnel of heparin therapy when providing samples.
Carry a wallet card or wear medical ID jewelry indicating heparin therapy.
Instruct client to keep a pad count during menstrual periods to estimate blood losses.