General management of patients in ICU Part 1

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

INTENSIVE CARE UNIT SET UP

ICU is highly specified and sophisticated area of a hospital which is specifically
designed, staffed, located, furnished and equipped, dedicated to management of critically
sick patient, injuries or complications.
It is a department with dedicated medical, nursing and allied staff.
It operates with defined policies; protocols and procedures should have its own quality
control, education, training and research programmes.

CORE COMPONENTS TO SET UP AN ICU

A. Initial Planning

Team Formation and Leader/Coordinator

Data Collection and analysis

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

Beds should be specially designated for Renal Replacement Therapy (HD/CRRT)

Modulation according to various types of space availability

10% of beds ( 1 or 2 ) rooms may be used exclusively as isolation cases like for burns,
serious contagious infected patients

C. Central Nursing Station designing and planning

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

Flooring, walls, pillars and ceilings

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

Waste disposal and pollution control

o It is important that all govt. regulations should strictly be complied with.

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.

Hand Hygiene and Prevention of Infection

Protocol about allowing visitors, shoes etc inside ICU

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.

F. Meeting the needs of families and visitors

Signages--Clearly marked and multi linguistic including English

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.

G. POLICIES & PROTOCOLS

Admission, Discharge & Withdrawal of Support.
Legal & Ethical Guidelines & MLC Policies
Standing Orders.
Organ Donation.
Infection Control
o Surveillance
o Sterilization & Disinfection
o Quality Control & Auditing
o Isolation protocols
Bereavement & after care services
o Counselling
o Last office ,
o Support systems for patient relatives & staff

H. Equipment

Will depend on number of beds, target level of the ICU

Most important decisions will be No. of Ventilated beds and Invasive monitoring

ICU Vs HDU

Collecting information about various equipment available with specifications

EQUIPMENT NEEDED IN ICU

Sr.

Name of Equipment

Quantity

Specification

No.
Bedside Monitors [for
1.

ICU]
2.

Monitors for HDU

One per bed

Same

Modular 2 Invasive BP, SpO2, NIBP,

ECG, RR, Temp probes with trays
Same as above. But without invasive BP,
yet upgradable
With pediatric and adult provisions,
graphics and Non Invasive modes [two
ventilators

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

With provision for CPAP and IPAP

2 per bed in ICU

Volumetric with all recent upgraded drug

1 per bed in HDU

calculations

2 per bed in ICU

With recent upgradation

With 2 O2 outlets, two vacuum, one
compressed air and 12 electric outlets,

7.

Head-end panel

1 Per bed

provision for music, alarm, trays for two

monitors, two drip stands, one procedure
light

Sr.

Name of Equipment

Quantity

Specification

2 with TCP facility

Adult

[1standby]

transcutaneous pacing facility

No.
8.

Defibrillator

and

paediatric

Electronically
ICU
9.

beds

[shock

proof, fibre]

pads

maneuvered

with

with

all

positions possible with mattress. There

As per plan

are beds available that allow lateral

positioning of patients
ALL SS with 6 to 8 cupboards in each to

10.

Overbed table

One for each bed

store drugs, side trays for investigation

reports, BHT on wheels

11.

ABG machine
Crash

12.

[second one as standby]

Cart/ 2 for ICU + 1 for To hold all resuscitation medicines and

Resuscitation trolley
Pulse Oximeter [small

13.

units]
14.

Facility for ABG and electrolytes

One + one

HDU

equipment

As standby units

1+1 for use of staff

Freezer

and doctors
2 for ICU, 1 for

15.

Computers

HDU,
Charge

for

In

With deep freeze facility

With laning, internet facility and printer to

be connected with all departments

16.

HD machine

User friendly so that a nurse can operate

17.

CRRT

High flow/ speed model

As described

To prevent DVT

CO,
18.

SVR,

ScvO2

monitor
Sequential

19.

compression device

20.

Air beds

To prevent bedsores

21.

Intubating videoscope

To assist in difficult intubations

Sr.

Name of Equipment

Quantity

Specification

No.
22.

ICU
23.

2 for ICU, 1 for

Glucometer

HDU
dedicated

With recent advances to look instantly

ultrasound and Echo 1

even at odd hours. Vascular filling, central

machine

lines, etc.

24.

Bedside X-ray

25.

ETO sterilization

To sterilize ICU disposables regularly

26.

Spinal Board

For spine trauma patients

For stabilizing cervical spine

Rigid cervical spine

27.

collars
AMBU with masks of

28.

different sizes
Pollution

29.

control

buckets

30.

Trays for procedures

31.

IABP
Fibreoptic

32.

bronchoscope

Silicon, ETO sterilizable

Important Concepts in ICU

Informed Consent
Informed consent is a process for getting permission before conducting a healthcare intervention
on a person. A health care provider may ask a patient to consent to receive therapy before
providing it, or a clinical researcher may ask a research participant before enrolling that person
into a clinical trial.
Organ Donation
Organ donation is the donation of biological tissue or an organ of the human body, from a living
or dead person to a living recipient in need of a transplantation. Transplantable organs and
tissues are removed in a surgical procedure following a determination, based on the donor's
medical and social history, of which are suitable for transplantation.
EASY MNEMONIC FOR MANAGEMENT OF ICU PATIENT FAST HUGS BID
F Feeding
A Analgesia
S Sedation
T Thromboembolic prophylaxis
H Head of bed elevation
U Ulcer prevention
G Glucose control
S Spontaneous Breathing Trial [SBT] or other ventilator-separating strategy
B Bowel function evaluation and maintenance of appropriate bowel function
o Diarrhea can lead to electrolyte imbalances, dehydration, hemorrhoidal irritation with
resultant anemia, and delirium
o Constipation can lead to patient discomfort, feeding intolerance, and delirium
I Indwelling catheters remove ASAP [arterial, venous, urinary, etc.]
D De-escalation of antimicrobial medications and other pharmacotherapies

Principles of Critical Care Nursing

Early diagnosis/ Identification of problems
Prompt treatment
Anticipate complications
Considerate use of technology
Holistic approach
Recognize limits of critical care
Patient autonomy
Justice
Beneficence
Non-maleficence
Veracity

COMMON DRUGS & INFUSIONS IN ICU

A number of emergency drugs are routinely used in a place like ICU. Infusions, its dilution
strengths and label colours vary from institution to institution. Generally all inotropic infusions,
Cordarone, are diluted in Dextrose 5%, Sedatives either used neat or diluted in normal saline,
antibiotics are diluted as per the compatibilities.
The commonly used drugs are as follows:

I. CARDIOVASCULAR DRUGS
a) Inotropes

Catecholamines, e.g. Epinephrine, Norepinephrine, Dobutamine, Dopamine

Phospodiesterase inhibitors, e.g. Milrione

Cardiac glycosides, e.g. Digoxin

b) Anti arrhythmic Drugs

1. Class I A Anti arrhythmics: quinidine, procainamide (Procanbid), and disopyramide.
Class I-B Antiarrhythmics: lidocaine (Xylocaine), mexilitine (Mexitil) and tocainide.
Class I-C Anti Arrhythmics: flecainide (Tambocor), propafenone (Rythmol).
2. Class II Antiarrhythmics: acebutolol, atenolol, bisoprolol, esmolol, metoprolol, and
propanolol.
3. Class III Antiarrhythmics: Amiodarone (Cordarone)
4. Class IV Antiarrhythmics: Diltiazem, and Verapamil.
5. Class V Others: Atropine, Digoxin

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.

Keep physician informed of any changes in intake-output ratio.

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.

Advise patient to report bronchial irritation, nervousness, or sleeplessness. Dosage should be

reduced.

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.

Administer ophthalmic drug at bedtime or following prescribed miotic to minimize

mydriasis, with blurred vision and sensitivity to light (possible in some patients being treated
for glaucoma).

Discontinue epinephrine eye drops and consult a physician if signs of hypersensitivity

develop (edema of lids, itching, discharge, crusting eyelids).

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).

 As an adjunct in the treatment of cardiac arrest and profound hypotension.

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.

 Be alert to patients complaints of headache, vomiting, palpitation, arrhythmias, chest pain,

photophobia, and blurred vision as possible symptoms of overdosage. Reflex bradycardia may
occur as a result of rise in BP.
Continue to monitor vital signs and observe patient closely after cessation of therapy for
clinical sign of circulatory inadequacy.

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

parasympathomimetic (cholinergic) drugs (choline esters, pilocarpine), or cholinesterase

inhibitors (eg, physostigmine, isoflurophate, organophosphorus insecticides)
Contraindications: Atropine generally is contraindicated in patients with glaucoma, pyloric
stenosis or prostatic hypertrophy, except in doses ordinarily used for pre-anesthetic medication.
Adverse effects
CNS: Blurred vision, mydriasis, cycloplegia, photophobia, increased IOP, headache, flushing,
nervousness, weakness, dizziness, insomnia, mental confusion or excitement (after even small
doses in the elderly), nasal congestion
CV: Palpitations, bradycardia (low doses), tachycardia (higher doses)
GI: Dry mouth, altered taste perception, nausea, vomiting, dysphagia, heartburn, constipation,
bloated feeling, paralytic ileus, gastroesophageal reflux
GU: Urinary hesitancy and retention; impotence
Other: Decreased sweating and predisposition to heat prostration, suppression of lactation
Local: Transient stinging
Systemic: Systemic adverse effects, depending on amount absorbed

6. VASOPRESSIN (Pitressin, vasoptin)

Classification: Hormones, Antidiuretic hormones, vasopressor
Injection: 20 units / ml

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

Use Cautiously in:

Perioperative polyuria (increased sensitivity to vasopressin)

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).

II. DRUGS FOR RESPIRATORY SYSTEM

INTRODUCTION
Respiratory system is subjected to a lot of injurers and harms because it is nearly the only system
which is in continuous contact with the external environment during the whole life of human
being. As a result respiratory system is subjected to pollution smoke, chemicals dust, &
microorganism which means it is subjected to everything in the environment.
Drugs that are used for treatment of respiratory problems include
1. Drugs & air flow obstruction.
2. Oxygen.
3. Respiratory stimulants.
4. Expectorants & cough suppressant.
Drugs & air flow obstruction
The aim of treatment in air flow obstruction is to increase ventilation by reducing bronchial
smooth muscle tone with specific agonist & antagonist drugs, by blocking the mechanisms of
allergic response.

Drugs used in the treatment of airways obstruction are:

1. B2 - Adrenoceptors agonist or stimulants: The mechanism of action is by increasing cAMP in
the bronchial smooth muscles and mast cell leading to bronchodilation.
2. Theophylline and other xanthine derivatives: they act by blocking the enzyme
phosphodiesterase leading to increase intracellular cAMP.
3. Mast cell membrane stabilizers: as Na cromoglycate [cromolyn], they prevent the release of
broncho constrictor mediators.
4. Corticosteroids: they stabilize mast cell and improve the pulmonary function in extrinsic and
intrinsic asthma by other mechanisms not well understood.
5. Anti-cholinergic drugs: they act by decreasing muscarinic bronchoconstriction.

1) B2 - ADRENOCEPTORS AGONISTS OR STIMULANTS:

A. SALBUTAMOL: Salbutamol has a relativity long duration of action of about 4 hours or even
longer.
Action:

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:

Asthma, Chronic obstructive airways disease (long-term treatment and

prophylactic), or maintenance therapy (aerosol or oral tablets) or in acute attacks by nebulizers.

Contraindication: Hypersensitivity
Side effect:
1. Tremor due to Stimulation of B2 receptors.
2. Other does-dependent effects resulting from weak activation of B- receptor as tachycardia and
hypokalemia, these are rare however with higher degree of selectivity afforded by aerosol route.

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.

3) MAST CELL MEMBRANE STABILIZERS:

They are not bronchodilators but they prevent bronchoconstriction in patient with extrinsic
(allergic) asthma which is caused by pollen & allergic agents.
Mast cell stabilizers are useful in extrinsic (Allergic) asthma particularly in children & young
adults & can prevent exercise induced asthma.
Response in intrinsic asthma is usually disappointing and these agents have nothing to offer to
patients with (COPD).
Indication: Na Cromoglycate is administered locally to the lung by inhalation as powder or from
pressurized aerosols or nebulizers.

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:

Steroid inhalation represent a significant advance in the management of bronchospasm because

of the adverse effect associated with systemic steroid are minimized (steroids are highly toxic
drugs).
Beclomethasone & betamethasone & administered by aerosol inhalant

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:

larynx with candidiasis may occur (disadvantage).

Aerosol inhalation corticosteroid should replace long term oral corticosteroid therapy wherever
possible as the benefit can be attained without adverse effects of long term systemic steroid
treatment

5) Anti-cholinergic drugs: IPRATROPIUM:

Action: The parasympathetic cholinergic bronchoconstrictor effect can be blocked by the use of
atropine like drugs, usually this effect of anticholinergic on airway resistance is less than that of
sympathetic stimulant agents.
Dosage and Administration
Adults: Aerosol/Inhalation 2 inhalations 4 times daily. Do not exceed 12 inhalations in 24 h.
Solution 500 mcg (1 unit dose vial) administered 3 to 4 times a day by oral nebulization, with
doses 6 to 8 h apart. The solution can be mixed in the nebulizer with albuterol if used within 1 hr.

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.

III. SEDATIVES AND ANALGESICS

Classification:

Barbiturates - Pentobarbital (Nembutal), Phenobarbitol (Luminal)

Benzodiazepines Clonazepam, Diazepam (Valium), Lorazepam (Ativan), Midazolam,

Alprazolam (Xanax)

Muscle Relaxants

Neuromuscular blockers

1. DIAZEPAM
Indications

Management of anxiety disorders or for short-term relief of symptoms of anxiety

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

Parenteral: Treatment of tetanus

Antiepileptic: Adjunct in status epilepticus and severe recurrent convulsive seizures

(parenteral); adjunct in convulsive disorders (oral)

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

Unlabeled use: Treatment of panic attacks

Contraindications and cautions

Contraindicated with hypersensitivity to benzodiazepines; psychoses, acute narrow-angle

glaucoma, shock, coma, acute alcoholic intoxication; pregnancy (cleft lip or palate, inguinal

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)

Anxiety disorders, skeletal muscle spasm, seizure disorders: 210 mg bidqid.

Alcohol withdrawal: 10 mg tidqid first 24 hr; reduce to 5 mg tidqid, as needed.

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.

Anxiety: 210 mg IM or IV; repeat in 34 hr if necessary

Muscle spasm: 510 mg IM or IV initially, then 510 mg in 34 hr if necessary.

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.

Cardioversion: 515 mg IV 510 min before procedure.

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

Dermatologic: Urticaria, pruritus, skin rash, dermatitis

GI: Constipation; diarrhea, dry mouth; salivation; nausea; anorexia; vomiting; difficulty in
swallowing; gastric disorders; elevations of blood enzymesLDH, alkaline phosphatase, AST,
ALT; hepatic dysfunction; jaundice
GU: Incontinence, urinary retention, changes in libido, menstrual irregularities
Hematologic: Decreased hematocrit, blood dyscrasias
Other: Phlebitis and thrombosis at IV injection sites, hiccups, fever, diaphoresis, paresthesias,
muscular disturbances, gynecomastia; pain, burning, and redness after IM injection

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

Relief of moderate to severe acute and chronic pain

Preoperative medication to sedate and allay apprehension, facilitate induction of anesthesia,

and reduce anesthetic dosage

Analgesic adjunct during anesthesia

Component of most preparations that are referred to as Brompton's cocktail or mixture, an

oral alcoholic solution that is used for chronic severe pain, especially in terminal cancer
patients

Intraspinal use with microinfusion devices for the relief of intractable pain

Unlabeled use: Dyspnea associated with acute left ventricular failure and pulmonary edema

Contraindications and cautions: Contraindicated with hypersensitivity to opioids; diarrhea

caused by poisoning until toxins are eliminated; during labor or delivery of a premature infant
(may cross immature bloodbrain barrier more readily); after biliary tract surgery or following
surgical anastomosis; pregnancy; labor (respiratory depression in neonate; may prolong labor).
, COPD,
corpulmonale, preexisting respiratory depression, hypoxia, hypercapnia (may decrease
respiratory drive and increase airway resistance); renal or hepatic dysfunction.

Available forms: Injection0.5, 1, 2, 4, 5, 8, 10, 15, 25, 50 mg/mL; tablets15, 30 mg; CR

tablets15, 60, 100, 200 mg; ER tablets30, 60, 100 mg; soluble tablets10, 15, 30 mg; oral
solution10, 20, 100 mg/5 mL; concentrated oral solution20 mg/mL, 100 mg/5 mL;
suppositories5, 10, 20, 30 mg; capsules15, 30 mg; SR capsules20, 30, 50, 60, 100 mg
Dosages
ADULTS
Preparation: No further preparation needed for direct injection; prepare infusion by
adding 0.11 mg/mL to 5% dextrose in water.
Infusion: Inject slowly directly IV or into tubing of running IV, each 15 mg over 45
min; monitor by controlled infusion device to maintain pain control.
Adverse effects
CNS: Light-headedness, dizziness, sedation, euphoria, dysphoria, delirium, insomnia, agitation,
anxiety, fear, hallucinations, disorientation, drowsiness, lethargy, impaired mental and physical
performance, coma, mood changes, weakness, headache, tremor, seizures, miosis, visual
disturbances, suppression of cough reflex
CV: Facial flushing, peripheral circulatory collapse, tachycardia, bradycardia, arrhythmia,
palpitations, chest wall rigidity, hypertension, hypotension, orthostatic hypotension, syncope
Dermatologic: Pruritus, urticaria, laryngospasm, bronchospasm, edema
GI: Nausea, vomiting, dry mouth, anorexia, constipation, biliary tract spasm; increased colonic
motility in patients with chronic ulcerative colitis
GU: Ureteral spasm, spasm of vesical sphincters, urinary retention or hesitancy, oliguria,
antidiuretic effect, reduced libido or potency
Local: Tissue irritation and induration (SC injection)
Major hazards: Respiratory depression, apnea, circulatory depression, respiratory arrest,
shock, cardiac arrest
Other: Sweating, physical tolerance and dependence, psychological dependence
Nursing considerations
Interventions

Caution patient not to chew or crush controlled-release preparations.

Dilute and administer slowly IV to minimize likelihood of adverse effects.

Tell patient to lie down during IV administration.

Keep opioid antagonist and facilities for assisted or controlled respiration readily available
during IV administration.

Use caution when injecting SC or IM into chilled areas or in patients with hypotension or in
shock; impaired perfusion may delay absorption; with repeated doses, an excessive amount
may be absorbed when circulation is restored.

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

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

 Contraindicated with hypersensitivity to opioids, diarrhea caused by poisoning, acute bronchial

asthma, upper airway obstruction, pregnancy.
Use cautiously with bradycardia, history of seizures, lactation, renal dysfunction.
Available forms
Lozenge on a stick (Actiq)200, 400, 600, 800, 1,200, 1,600 mcg; transdermal25, 50, 75, 100
mcg/hr; injection0.05 mg/mL
Dosages: Individualize dosage; monitor vital signs.
Preparation: May be used undiluted or diluted with 250 mL of D5W. Protect vials from light.
Infusion: Administer slowly by direct injection, each mL over at least 1 min, or into running IV
tubing.
Incompatibilities: Do not mix with methohexital, pentobarbital, thiopental.
Adverse effects
CNS: Sedation, clamminess, sweating, headache, vertigo, floating feeling, dizziness, lethargy,
confusion, light-headedness, nervousness, unusual dreams, agitation, euphoria, hallucinations,
delirium, insomnia, anxiety, fear, disorientation, impaired mental and physical performance,
coma, mood changes, weakness, headache, tremor, seizures
CV: Palpitation, increase or decrease in BP, circulatory depression, cardiac arrest, shock,
tachycardia, bradycardia, arrhythmia, palpitations
Dermatologic: Rash, hives, pruritus, flushing, warmth, sensitivity to cold
EENT: Diplopia, blurred vision
GI: Nausea, vomiting, dry mouth, anorexia, constipation, biliary tract spasm
GU: Ureteral spasm, spasm of vesical sphincters, urinary retention or hesitancy, oliguria,
antidiuretic effect, reduced libido or potency
Local: Phlebitis following IV injection, pain at injection site; tissue irritation and induration (SC
injection)
Respiratory: Slow, shallow respiration, apnea, suppression of cough reflex, laryngospasm,
bronchospasm
Other: Physical tolerance and dependence, psychological dependence; local skin irritation with
transdermal system

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

LOW MOLECULAR WEIGHT HEPARINS (LMWH)

These include drugs such as enoxaparin (Brand name Lovenox, Clexane), dalteparin (Brand
name Fragmin), These drugs are derived from heparin and have some benefits over the standard
heparin.

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.

---END OF PART 1---