ALUMINUM Hydroxide
MAGNESIUM Hydroxide
Classifications:
Therapeutic: antiulcer agents, hypophosphatemics
Pharmacologic: antacids, phosphate binders
Indications
Lowering of phosphate levels in patients with chronic renal failure.
Adjunctive therapy in the treatment of peptic, duodenal, and gastric ulcers.
Hyperacidity, indigestion, reflux esophagitis.
Action
Binds phosphate in the GI tract. Neutralizes gastric acid and inactivates
pepsin. Therapeutic Effects
Lowering of serum phosphate levels. Healing of ulcers and decreased pain
associated with ulcers or gastric hyperacidity. Constipation limits use alone
in the treatment of ulcer disease. Frequently found in combination with
magnesium-containing compounds.
Contraindications/ Precaution
Contraindicated in: Severe abdominal pain of unknown cause.
Use cautiously in: Hypercalcemia; Hypophosphatemia; OB; Generally
considered safe; chronic high dose therapy should be avoided.
Adverse Reactions/ Side Effects
GI: constipation. F and E: hypophosphatemia.
NURSING IMPLICATION
Assessment
Assess location, duration, character, and precipitating factors of
gastric pain
Lab Test Consideration: Monitor serum phosphate and calcium levels
periodically during chronic use of aluminum hydroxide.
May cause increased serum gastric and decreased serum phosphate
concentration.
In treatment of severe ulcer disease, guaiac stools, and emesis,
monitor pH of gastric secretions.
Patient/ Family Teaching
Instruct patient to take aluminum hydroxide exactly as directed. If on
a regular dosing schedule and a dose is missed, take as soon as
remembered if not almost tim for next dose; do not double doses.
Advise patient not to take aluminum hydroxide within 1-2 hr of other
medications without consulting health care professionals.
Advise pts not to check label for sodium content. Patients with CHF
or hypertension, or those on sodium restriction, should use low-
sodium preparations.
Inform pts of potential for constipation from aluminum hydroxide.
Hyphosphatemia: Pts taking aluminum hydroxide for
hyphosphatemia should be taught the importance of a low-phosphate
diet.
Antacid: Caution pt to consult health care professional before taking
antacids for more than 2 wks if problem is recurring, if taking other
medications, if relief is not obtained, or if symptoms of gastric
bleeding (black tarry stools, coffee-ground emesis) occur.
Amlodipine (am-loe-di-peen)
Classification:
Therapeutic: antihypertensive
Pharmacologic: calcium channel blockers
Indications
Alone or with other agents in the management of hypertension, angina
pectoris, and vasospatic ( Prinzmetals) angina.
Action
Inhibits the transport of calcium into myocardial and vascular smooth
muscle cells, resulting in inhibition of excitation-contraction coupling and
subsequent contraction. Therapeutic effect: vasodilation resulting in
decreased blood pressure. Coronary vasodilation resulting in decreased
frequency and severity of attacks angina.
Contraindications/ Precautions
Contraindicated in: Hypersensitivity: Blood pressure <90 mmHg.
Use cautiously in: Severe hepatic impairment (dosage reduction
recommended); Aortic stenosis; History of CHF; OB, Lactation, Pedi:
Safely not established; Geri: Dose reduction recommended; increased risk
of hypotention.
Adverse Reaction/Side Effects
CNS: headache, dizziness,fatigue. CV: peripheral edema, angina,
bradycardia, hypotension, palpitations. GI: gingival hyperplasia,nausea.
Derm: flushing.
NURSING IMPLICATION
Assessment
Monitor blood pressure and pulse before therapy, during dose
titration, and periodically during therapy. Monitor ECG periodically
during prolonged therapy.
Monitor intake and output ratios and daily weight. Asses for signs of
CHF (peripheral edema, rales/crackles, dyspnea, weight gain, jugular
venous distention)
Angina: Assess location, duration, intensity and precipitating factors
of pts angina pain.
Lab test Considerations: Total serum calcium concentrations are not
affected by calcium channel blockers.
Patient/ Family Teaching
Advise pt to take medication as directed even if feeling well. Take
missed doses as soon as possible unless almost time for next dose; do
not double doses. May need to be discontinued gradually.
Advise pt to avoid large amounts (6-8) glasses of grapefruit
juice/day) during therapy.
Instruct pt on correct technique for monitoring pulse. Instruct pt to
contact health care professional if heart rate is <50 bpm.
May cause drowsiness or dizziness. Advise pt to avoid driving or
other activities requiring alertness until response to the medication is
known.
Hypertension: Encourage pt to comply with other interventions for
hypertension (weight reduction, low-sodium diet, smoking cessation,
moderation of alcohol consumption, regular exercise, and stress
management). Medication control but does not cure hypertension.
Instruct pt and family in proper technique for monitoring blood
pressure. Advise patient to take blood pressure weekly and to report
significant changes to health care professional.
acetylcysteine (a-SEET-il-SIS-teen)
Classification:
Therapeutic: antidotes (for acetaminophen toxicity), mucolytic
Indications
PO: Antidote for the management of potentially hepatotoxic overdose of
acetaminophen (administered within 8-10 hrs [IV] or 24 hrs [PO] of
ingestion. Inhaln: Mucolytic in the management of conditions associated
with thick viscid mucous secretions.
Action
PO: Increases the buildup of a hepatotoxic metabolite in acetaminophen
over dosage. IV: Decreases the buildup of metabolite in acetaminophen
over dosage. Inhaln: Degrades mucus, allowing easier mobilization and
expectoration. Therapeutic Effects: PO: prevention or lessening of liver
damage following acetaminophen overdose. Inhaln: Lowers the viscosity of
mucus.
Contraindications/ Precautions
Contraindicated in: hypersensitivity
Use Cautiously in: Severe respiratory insufficiency, asthma, or history of
bronchospasm; History of GI bleeding (oral only); OB,Lactation: Safety not
established.
Adverse Reaction
CNS: drowsiness. CV: vasodilation, tachycardia, hypotension. EENT:
rhinorrhea. Resp: bronchospasm, bronchial/ tracheal irritation, chest
tightness, secretions. GI: nausea, vomiting, stomatitis. Derm: rash,
clamminess, pruritus, urticaria. Misc: allergic reactions (primarily with
IV), including ANAPHYLAXIS, ANGIOEDEMA, chills and fever.
NURSING IMPLICATIONS
Assessment
Antidote in Acetaminophen Overdose: Assess type, amount, and
time of acetaminophen ingestion. Assess plasma acetaminophen
levels. Initial levels are drawn at least 4 hr after ingestion of
acetaminophen. Plasma level determinations may be difficult to
interpret following ingestion of extended- release preparations. Do
not wait for result to administer dose.
IV: Asses for anaphylaxis. Erythema and flushing are common,
usually occurring 30-60 min after initiating infusion, and may resolve
with continued administration. If rash, hypotension, wheezing, or
dyspnea occur, initiate treatment of anaphylaxis (antihistamine and
epinephrine). Interrupt acetylcysteine infusion until symptoms
resolve and restart carefuly. If anaphylaxis recurs, discontinue
acetylcysteine and use alternative form of treatment.
Assess pt for nausea, vomiting, and uticaria. Notify health care
professionals if these occur.
Mucolytic: Assess respiratory function (lung sounds, dyspnea) and
color, amount, and consistency of secretions before and immediately
following treatment to determine effectiveness of therapy.
Lab Test Considerations: Monitor AST, ALT, and bilirubin levels
among with prothrombin time every 24 hr for 96 hr in pts with
plasma acetaminophen lvels indicating potential hepatoxicity.
Monitor cardiac and renal function (creatinine, BUN), serum
glucose, and electrolytes. Maintain fluid and electrolyte balance,
correct hypoglycemia, and administer vit K or fresh frozen plasma or
clotting factor concentrate if prothrombin time ratio exceeds 1.5 or 3,
respectively.
PATIENT/ FAMILY TEACHING
Acetaminophen Overdose: Explain purpose of medication to pt.
Inhaln: Instruct pt to clear airway by coughing deeply before taking
aerosol treatment.
Inform pt that unpleasant odor of this drug becomes less noticeable as
treatment progresses and medicine dissipates.
Azithromycin (aye- zith-row-my-sin)
Classification:
Therapeutic: agents for atypical mycobacterium, anti-infective
Pharmacologic: macrolides
Indication
Treatment of the following infections due to susceptible organisms: URTI,
including streptococcal pharyngitis, acute bacterial exacerbations of
chronic bronchitis and tonsillitis, Lower respiratory tract infections,
including bronchitis and pneumonia, Acute otitis media, Skin and skin
structure infections, Nongonococcal urethritis, cervicitis, gonorrhea, and
chancroid. Prevention disseminated Mycobacterium avium complex (MAC)
infection in pts with advanced HIV infection. Expended-release suspension
(ZMax). Acute bacterial sinusitis and community-acquired pneumonia in
adults. Unlabeled uses: Prevention of bacterial endocarditis. Treatment of
cystic fibrosis lung disease.
Action
Inhibits protein synthesis at the level of the 50S bacterial ribosome.
Therapeutic Effects: Bacteriostatic action against susceptible bacteria.
Contraindications/ Precaution
Contraindicated in: Hypertensive to azithromycin, erythromycin, or the
macrolide anti-infective.
Use Cautiously in: Severe liver impairment (dosage adjustment may
require); Severe renal impairment (CCr <10 ml/min); OB, Lactation:
Safety not established; Pedi: Safety not established in children <5 yr.
Adverse Reaction/ Side Effects
CNS: dizziness, seizure, drowsiness, fatigue, headache. CV: chest pain,
hypotension, palpitations, QT prolongation (rare). GI:
PSEUDOMEMBRANOUS COLITIS, abdominal pain, diarrhea, nausea,
cholestatic jaundice, elevated liver enzymes, dyspepsia, flatulence, melena
or oral candidiasis. GU: nephritis, vaginitis. Hemat: anemia, leukopenia,
thrombocytopenia. Derm: photosensitivity, Stevens-Johnson syndrome,
rashes. EENT: ototoxicity. F and E: hyprkalemia. Misc: ANGIOEDEMA
NURSING IMPLICATION
Assessment
Assess patient for infection (vital signs; appearance of wound,
sputum, urine, and stool;WBC) at beginning of a throughout.
Obtain specimens for culture and sensitivity before initiating
therapy. First dos may be given
before receiving result.
Observe for signs and symptoms of anaphylaxis (rash, pruritus,
laryngeal edema, wheezing). Notify when physician or other health
care professional immediately if these occur.
Lab Test Consideration: May cause serum bilirubin, AST, ALT,
LDH, and alkaline phosphatase concentration.
May cause creatine phosphokinase, potassium, prothrombin time,
BUN, serum creatinine, and blood glucose concentrations.
May occasionally WBC and platelet count.
Patient/ Family Teaching
Instruct pts to take medications as directed to finish the drug
completely, even if they are feeling better. Tell pt to take missed dose
as soon as possible unless almost time for next dose; do not double
doses. Advise pt that sharing of this medication may be dangerous.
Instruct pt not to take azithromycin with food or antacids.
May cause drowsiness and dizziness. Caution pt to avoid driving or
the activities requiring alertness until response to medication is
known.
Advise pt to use sunscreen and protective clothing to prevent
photosensitivity reactions.
Instruct pt to notify health care professional if fever and diarrhea
develop, especially if stool contains blood, pus, or mucus. Advise pt
not to treat diarrhea without advice of health care professional.
Cimetidine (sye-me-ti-dine)
Classification
Therapeutic: antiulcer agents
Pharmacologic: histamine H2 antagonists
Indications
Short-term treatment of active duodenal ulcers and benign gastric ulcers.
Maintenance therapy for duodenal and gastric ulcers after healing of active
ulcers. Management of GERD. Treatment of heartburn, acid ingestion, and
sour stomach (OTC use). Cimetidine: Management of gastric
hypersecretory states ( Zollinger- Ellison syndrome). Prevention and
treatment of stress- induced upper GI bleeding in critically ill pts.
Action
Inhibits the action of histamine at the H2- receptor site located primarily in
gastric parietal cells, resulting in inhibition of gastric acid secretion.
Therapeutic Effects: Healing and prevention of ulcers. Decreased
symptoms of gastroesophageal reflux. Decreased secretion of gastric acid.
Contraindications/ Precautions
Contraindicated in: Hypersensitivity; Some products contain alcohol and
should be avoided in pts with known intolerance; Some products contain
aspartame and should be avoided in pts with phenylketonuria.
Use Cautiously in: Renal impairment (more susceptible to adverse CNS
reactions; increased dosage interval recommended for cimetidine if CCr
50ml/min; Geri: Geriatric pts (more susceptible to adverse CNS reactions;
dosage reduction recommended);OB, Lactation: Pregnancy or lactation.
Adverse Reaction/ Side Effects
CNS: confusion, dizziness, drowsiness, hallucinations, headache. CV:
ARRHYTMIAS. GI: constipation, diarrhea, drug-induced hepatitis,
nausea. GU: decreased sperm count, erectile dysfunction. Endo:
gynecomastia. Hemat: AGRANULOCYTOSIS, APLASTIC ANEMIA,
anemia, neutropenia, thrombocytopenia. Local: pain in IV site. Misc:
hypersensitivity reaction, vasculitis.
NURSING IMPLICATION
Assessment
Asses for epigastric or abdominal pain and frank or occult blood in
stool, emesis, or gastric aspirate.
Geri: Assess geriatric and debilitated pts routinely for confusion.
Report promptly.
Lab Test Consideration: Monitor CBC with differential periodically
during therapy.
Antagonize effects of pentagastrin and histamine during gastric acid
secretion testing. Avoid administration for 24 hr before the test.
May cause false-negative results in skin tests using allergenic
extracts. Histamine H2 antagonists should be discontinued 24 hr
before the test.
May cause in serum transaminase and serum creatinine.
Serum prolactin concentration may be after IV bolus of cimetidine.
May also use cause parathyroid concentrations.
Patient/ Family Teaching
Instruct pt to take medication as directed for the full course of
therapy, even if feeling better. Take missed doses as soon as
remembered but not if almost time for next dose. Do not double
doses.
Advise pts taking OTC preparations not to take the maximum dose
continuously for more than 2 wk without consulting health care
professional. Notify health care professional if difficult swallowing
occurs or abdominal pain persists.
Inform pt that smoking interferes with the action of histamine
antagonists, encourage pt to quit smoking at least not in smoke after
last dose of the day.
May cause drowsiness or dizziness. Caution pt to avoid driving or
activities requiring alertness until response to the drug is known.
Advise pt to avoid alcohol, products containing aspirin or NSAIDs,
and foods that may cause an increase in GI irritation.
Inform pt that increased fluid and fiber intake and exercise may
minimize constipation.
Advise pt to report onset of black; tarry stools; fever; sore throat;
diarrhea; dizziness; rash; confusion; or hallucinations to health care
professional promptly
Celecoxib (sel-e-kox-ib)
Classification
Thrapeutic: antirheumatics, nonsteroidal anti-inflammatory agents.
Pharmacologic: COX-2 inhibitors
Indication
Relief of signs and symptoms of osteoarthritis, rheumatoid arthritis,
ankylosing spondylitis, and juvenile rheumatoid arthritis. Reduction of the
number of adenomatous colorectal polyps in familial adenomatous
polyposis (FAP), as an adjunct to usual care (endoscopic surveillance,
surgery). Management of acute pain including primary dysmenorrhea.
Action
Inhibits the enzyme COX-2. This enzyme is required for the synthesis of
prostaglandins. Have analgesic, anti-inflammatory, antipyretic properties.
Therapeutic Effects: Decreased pain and inflammation caused by arthritis
or spondylitis. Decreased number of colorectal polyps. Decreased pain.
Contraindications/ Precaution
Contraindicated in: Hypersensitivity; Cross-sensitivity may exist with
other NSAIDs, including aspirin; Hx of allergic-type reactions to
sulfonamides; Hx of asthma, urticaria, or allergic-type reactions to aspirin
or other NSAIDs, including the aspirin triad (asthma, nasal polyps, and
severe hypersensitivity reaction to aspirin); Advanced renal disease; Peri-
operative pain from coronary artery bypass graft (CABG) surgery; OB:
Should not be used in late pregnancy (may cause premature closure of the
ductus arteriosus). Lactation: Potential for serious neonatal adverse effects.
Discontinue drug or bottle feed.
Use Cautiously in: Cardiovascular diseases or risk factor for
cardiovascular disease ( may risk of serious cardiovascular thrombotic
events, myocardial infarction, and stroke, especially with prolonged use);
Pre-existing renal disease , heart failure, liver dysfunction, concurrent
diuretic or ACE inhibitor therapy ( increased risk of renal impairment);
Hypertension or fluid retention; Renal insufficiency (may precipitate acute
renal failure); Serious dehydration ( correct deficits before administering);
Pre-existing asthma; Pedi: Safety not established in children <2 yrs or for
longer than 6 mos. Geri: Concurrent therapy with corticosteroids or
anticoagulants, long duration of NSAID therapy, hx of smoking,
alcoholism, geriatric pts, or poor general health status (increased risk of GI
bleding).: Exercise Extreme Caution in: Hx of ulcer disease or GI
bleeding.
Adverse Reaction/ Side Effects
CNS: dizziness, headache, insomnia. CV: edema. GI: GI BLEEDING,
abdominal pain, diarrhea, dyspepsia, flatulence, nausea. Derm:
EXFOLIATIVE DERMATITIS, STEVENS-JOHNSON SYNDROME,
TOXIC EPIDERMAL NECROLYSIS, rash.
NURSING IMPLICATIONS
Assessment
Assess range of motion, degree of swelling, and pain in affected joints
before and periodically throughout therapy.
Assess pt for allergy to sulfonamides, aspirin, or NSAIDs. Pts with
these allergies should not receive celecoxib.
Lab Test Consideration: May cause AST and ALT levels.
May cause hypophosphatemia and BUN.
Patient/ Family Teachings
Instruct pt to take celocoxib exactly as directed. Do not take more
than prescribed dose. Increasing doses does not appear to increase
effectiveness. Use lowest effective dose for shortest period of time.
Advise pt to notify health care professional promptly if signs or
symptoms of GI toxicity (abdominal pain, black stools), skin rash,
unexplained weight gain, or edema occurs.
Advise pt to notify health care professional if pregnancy is planned
or suspected.
Advise pts with FAP to continue routine surveillance procedures.
Ciprofloxacin (sip-roe-fox-a-sin)
Classification
Therapeutics: anti-infective
Pharmacologic: fluoroquinolones
Indications
PO,IV: Treatment of the following bacterial infections: Urinary tract
infections including cystitis and prostatitis, Gonorrhea (may not be
considered first-line agents due to increasing resistance), Gynecologic
infections, Respiratory tract infections including acute sinusitis, acute
exacerbations of chronic bronchitis, and pneumonia, Skin and skin
structure infections, Bone and joint infections, Intra-abdominal infections,
Febrile neutropenia, Post-exposure treatment of inhalational anthrax.
Action
Inhibit bacterial DNA synthesis by inhibiting DNA gyrase. Therapeutic
Effects: Death of susceptible bacteria. Spectrum: Broad activity includes
many gram-positive pathogens: Staphylococci including methicillin-
resistant Staphylococcus aureus, Staphylococcus epidermidis, S. saprophyticus,
Streptococcus pneumonia, S. pyogenes, and Bacilllus anthracis. Gram-negative
spectrum notable for activity against: Escherichia coli,Klebsiella,
Enterobacter,Salmonella, Shigella , Proteus, Providencia, Morganella morganii,
Pseudomonas aeruginosa, Serratia, Haemophilus, Acinetobacter, Neisseria
gonorrhhoeae, Moraxella catarrhalis, Campylobacter. Additional spectrum
includes: Chlamydia pneumonia, Legionella pneumonia, and Mycoplasma
pneumonia.

Contraindications/ Precautions
Contraindicated in: Hypersensitivity.
Use Cautiously in: Known or suspected CNS disorder; Renal impairment
(dosage reduction if CCr 50 ml/min for ciprofloxacin; Geri: Geriatric pts
( risk of adverse reaction); Lactation: safely not established except for
treatment of anthrax.
Adverse Reaction/ Side Effects
CNS: SEIZURES, dizziness, headache, insomnia, acute psychoses,
agitation, confusion, drowsiness. GI: PSEUDOMEMBRANOUS
COLITIS, diarrhea, nausea, abdominal pain, increased liver function tests,
vomiting. GU: vaginitis. Derm: photosensitivity, ash. Endo:
hyperglycemia, hypoglycemia. Local: phlebitis at IV site. Misc:
hypersensitivity reactions including ANAPHYLAXIS, STEVENS-
JOHNSON SYNDROME.
NURSING IMPLICATIONS
Assessment
Assess for infection (VS; appearance of wound, sputum, urine, and
stool;WBC; urinalysis; frequency and urgency of urination; cloudy or
foul-smelling urine) prior to and during therapy.
Obtain specimens for culture and sensitivity before initiating
therapy. First dose may be given before receiving results.
Observe for s/s of anaphylaxis (rash,prupritus, laryngeal edema,
wheezing). Discontinue drug and notify physician or other health
care professional immediately if these problems occur. Keep
epinephrine, an antihistamine, and resuscitation equipment close by
in case of an anaphylactic reaction.
Lab Test Consideration: May cause serum, AST, Alt, LDH, bilirubin,
and alkaline phosphatase.
May also cause or serum glucose.
Monitor prothrombin time closely in pts receiving fluoroquinolones
and warfarin; may enhance the anticoagulant effects of warfarin.
Patient/Family Teaching
Instruct pts to take medications as directed to finish the drug
completely, even if they are feeling better. Tell pt to take missed dose
as soon as possible unless almost time for next dose; do not double
doses. Advise pt that sharing of this medication may be dangerous.
Advise pt to notify health care professional immediately if they are
taking theophylline.
Encourage pt to maintain a fluid intake of at least 1500-2000 ml/day to
prevent crystalluria.
Advise pt that antacids or medications containing iron or zinc will
decrease absorption. Ciprofloxacin should be taken at least 2 hrs before
or 2 hr after these products.
May cause dizziness and drowsiness. Caution pt to avoid driving or
other activities requiring alertness until response to medication is
known.
Advise pt to notify health care professional of any personal or family
history of QTc prolongation of proarrhytmic conditions such as
recent hypokalemia, significant bradycardia, or recent myocardial
ischemia. Pts with this hx should not receive fluoroquinolones.
Instruct pts being treated for gonorrhea that partners also must be
treated.
Advise pts to report any signs of superinfection (furry overgrowth in
the tongue, vaginal itching or discharge, loose or foul-smelling stools.
Clopidogrel (kloh-pid-oh-grel)
Classification
Therapeutic: antiplatelet agents
Pharmacologic: platelet aggregation inhibitors
Pregnancy Category B
Indication
Reduction of atherosclerotic events (MI, stroke, vascular death) in pts at
risk for such events including recent MI, acute coronary syndrome
(unstable angina/non-Q-wave MI), stroke, or peripheral vascular disease.
Action
Inhibits platelets aggregation by irreversibly inhibiting the binding of ATP
too platelet receptors. Therapeutic Effects: Decreased occurrence of
atherosclerotic events in pts at risk.
Contraindication/ Precaution
Contraindicated in: Hypersensitivity, Pathologic bleeding (peptic ulcer,
intracranial hemorrhage); Lactation.
Use Cautiously in: Pts at risks of bleeding (trauma, surgery, or other
pathologic condition); Hx of GI bleeding/ ulcer disease; Severe hepatic
impairment; OB, Lactation, Pedi: Safety not established; use in pregnancy
only if clearly indicated.
Adverse Reaction/ Side Effects
Incidence of adverse reactions similar to that of aspirin.
CNS: depression, dizziness, fatigue, headache. EENT: epistaxis. Resp:
cough,dyspnea. CV: chest pain, edema, hypertension. GI: GI BLEEDING,
abdominal pain, diarrhea, dyspepsia, gastritis. Derm: pruritus, purpura,
rash. Hemat: BLEEDING, NEUTHROPENIA, THROMBOTIC
THROMBOCYTOPENIC, PURPURA. Metab: hypercholesterolemia.
MS: arthralgia, back pain. Misc: fever, hypersensitivity reactions.
NURSINGIMPLICATIONS
Assessment
Assess patient for symptoms of stroke, peripheral vascular disease, or
MI periodically during therapy.
Monitor patient for signs of thrombotic thrombocytic purpura
(thrombocytopenia, microangiopathic hemolytic anemia, neurologic
findings, renal dysfunction, fever). May rarely occur, even after short
exposure (2 wk). Requires prompt treatment.
Lab Test Considerations: Monitor bleeding time during therapy.
Prolonged bleeding time, which is time- and dose-dependent, is
expected.
Monitor CBC with differential and platelet count periodically during
therapy. Neutropenia and thrombocytopenia may rarely occur.
May causeqserum bilirubin, hepatic enzymes, total cholesterol,
nonprotein nitrogen (NPN), and uric acid concentrations.
Discontinuation of therapy may increase risk of cardiovascular
events.
Patient/Family Teaching
Instruct patient to take medication exactly as directed. Take missed
doses as soon as possible unless almost time for next dose; do not
double doses. Do not discontinue clopidogrel without consulting
health care professional; may increase risk of cardiovascular events.
Advise patient to read the Medication Guide before starting clopidogrel
and with each Rx refill in case of changes.
Advise patient to notify health care professional promptly if fever,
chills, sore throat, rash, or unusual bleeding or bruising occurs.
Instruct patient to notify health care professional of all Rx or OTC
medications, vitamins, or herbal products being taken and to consult
health care professional before taking any other Rx, OTC, or herbal
products, especially those containing aspirin or NSAIDs or proton
pump inhibitors.
Advise female patient to notify health care professional if pregnancy
is planned or suspected, or if breast feeding.
ceftriaxone (sef-try-ax-one)
Classification
Therapeutic: anti-infectives
Pharmacologic: third-generation cephalosporins
Pregnancy Category B
Indications
Treatment of: Skin and skin structure infections, Bone and joint infections,
Complicated and uncomplicated urinary tract infections, Uncomplicated
gynecological infections including gonorrhea, Lower respiratory tract
infections, Intra-abdominal infections, Septicemia, Meningitis, Otitis
media. Perioperative prophylaxis.
Action
Binds to the bacterial cell wall membrane, causing cell death. Therapeutic
Effects: Bactericidal action against susceptible bacteria. Spectrum: Similar
to that of second-generation cephalosporins, but activity against
staphylococci is less, while activity against gram-negative pathogens is
greater, even for organisms resistant to first- and second-generation agents.
Notable is increased action against: Acinetobacter, Enterobacter, Haemophilus
influenzae (including -lactamase-producing strains), Haemophilus
parainfluenzae, Escherichia coli, Klebsiella pneumoniae, Morganella morganii,
Neisseria, Proteus, Providencia, Serratia, Moraxella catarrhalis. Has some
activity against anaerobes, including Bacteroides fragilis. Not active against
methicillin-resistant staphylococci or enterococci.
Contraindications/Precautions
Contraindicated in: Hypersensitivity to cephalosporins; Serious
hypersensitivity to penicillins; Pedi: Neonates _28 days (use in
hyperbilirubinemic neonates may lead to kernicterus); Pedi: Neonates_28
days requiring calcium-containing IV solutions (risk of precipitation
formation).
Use Cautiously in: Combined severe hepatic and renal impairment (dose
reduction/ dosing interval recommended); History of GI disease,
especially colitis; OB, Lactation: Pregnancy and lactation.
Adverse Reactions/Side Effects
CNS: SEIZURES (high doses). GI: PSEUDOMEMBRANOUS
COLITIS, diarrhea, cholelithiasis, gallbladder sludging. Derm: rashes,
urticaria. Hemat: bleeding, eosinophilia, hemolytic anemia, leukopenia,
thrombocytosis. Local: pain at IM site, phlebitis at IV site. Misc: allergic
reactions including ANAPHYLAXIS, superinfection.
NURSING IMPLICATIONS
Assessment
Assess for infection (vital signs; appearance of wound, sputum, urine,
and stool; WBC) at beginning of and throughout therapy.
Before initiating therapy, obtain a history to determine previous use of
and reactions to penicillins or cephalosporins. Persons with a negative
history of penicillin sensitivity may still have an allergic response.
Obtain specimens for culture and sensitivity before initiating therapy.
First dose may be given before receiving results.
Pedi: Assess newborns for jaundice and hyperbilirubinemia; can increase
bilirubinemia and should not be administered to jaundiced neonates,
especially premature neonates.
Observe patient for signs and symptoms of anaphylaxis (rash, pruritus,
laryngeal edema, wheezing). Discontinue the drug and notify health
care professional immediately if these symptoms occur. Keep epinephrine,
an antihistamine, and resuscitation equipment close by in the event of an
anaphylactic reaction.
Monitor bowel function. Diarrhea, abdominal cramping, fever, and
bloody stools should be reported to health care professional promptly
as a sign of pseudomembranous colitis. May begin up to several weeks
following cessation of therapy.
Lab Test Considerations: May cause positive results for Coombs test.
May cause increased serum AST, ALT, alkaline phosphatase, bilirubin,
LDH, BUN,and creatinine.
May rarely cause leukopenia, neutropenia, agranulocytosis,
thrombocytopenia, eosinophilia, lymphocytosis, and thrombocytosis.
Patient/Family Teaching
Advise patient to report signs of superinfection (furry overgrowth on the
tongue, vaginal itching or discharge, loose or foul-smelling stools) and
allergy.
Instruct patient to notify health care professional if fever and diarrhea
develop, especially if diarrhea contains blood, mucus, or pus. Advise
patient not to treat diarrhea without consulting health care professional.
cefotaxime (sef-oh-taks-eem)
Classification
Therapeutic: anti-infectives
Pharmacologic: third-generation cephalosporins
Pregnancy Category B
Indications
Treatment of the following infections caused by susceptible organisms:
Skin and skin structure infections, Bone and joint infections, Urinary tract
infections, Gynecological infections including gonorrhea, Lower
respiratory tract infections, Intra-abdominal infections, Septicemia,
Meningitis, Lyme disease. Perioperative prophylaxis.
Action
Binds to the bacterial cell wall membrane, causing cell death. Therapeutic
Effects: Bactericidal action against susceptible bacteria. Spectrum: Similar
to that of second-generation cephalosporins, but activity against
staphylococci is less, whereas activity against gram-negative pathogens is
greater, even for organisms resistant to first- and second-generation agents.
Notable is increased action against: Acinetobacter, Citrobacter, Enterobacter,
Haemophilus influenzae(including -lactamase producing strains),
Haemophilus parainfluenzae, Escherichia coli, Klebsiella pneumoniae, Morganella
morganii, Neisseria gonorrhoeae and meningitidis,Proteus, Providencia, Serratia,
Moraxella catarrhalis, Borrelia burgdorferi. Has some activity against
anaerobes, includingBacteroides fragilis. Not active against methicillin-
resistant staphylococci.
Contraindications/Precautions
Contraindicated in: Hypersensitivity to cephalosporins; Serious
hypersensitivity to penicillins.
Use Cautiously in: Renal impairment (pdose recommended if CCr _20
mL/ min); History of GI disease, especially colitis; Geri: Dosage
adjustment may be necessary due to age-related in renal function.
Adverse Reactions/Side Effects
CNS: SEIZURES (high doses). GI: PSEUDOMEMBRANOUS
COLITIS, diarrhea, nausea, vomiting. Derm: rashes, pruritis, urticaria.
Hemat: agranulocytosis, bleeding, eosinophilia, hemolytic anemia,
neutropenia, thrombocytopenia. Local: pain at IM site, phlebitis at IV site.
Misc: allergic reactions including ANAPHYLAXIS, superinfection.
NURSINGIMPLICATIONS
Assessment
Assess patient for infection (vital signs; appearance of wound, sputum,
urine, and stool; WBC) at beginning of and throughout therapy.
Before initiating therapy, obtain a history to determine previous use of
and reactions to penicillins or cephalosporins. Persons with a negative
history of penicillin sensitivity may still have an allergic response.
Observe patient for signs and symptoms of anaphylaxis (rash, pruritus,
laryngeal edema, wheezing). Discontinue the drug and notify health
care professional immediately if these symptoms occur. Keep epinephrine,
an antihistamine, and resuscitation equipment close by in the event of an
anaphylactic reaction.
Monitor bowel function. Diarrhea, abdominal cramping, fever, and
bloody stools should be reported to health care professional promptly
as a sign of pseudomembranous colitis. May begin up to several weeks
following cessation of therapy.
Lab Test Considerations: May cause positive results for Coombs test.
May cause serum AST, ALT, alkaline phosphatase, bilirubin, LDH,
BUN, and creatinine.
May rarely cause leukopenia, neutropenia, agranulocytosis,
thrombocytopenia, and eosinophilia.
Patient/Family Teaching
Advise patient to report signs of superinfection (furry overgrowth on the
tongue, vaginal itching or discharge, loose or foul-smelling stools) and
allergy.
Instruct patient to notify health care professional if fever and diarrhea
develop, especially if stool contains blood, pus, or mucus. Advise patient
not to treat diarrhea without consulting health care professional.

glimepiride (glye-me-pye-ride)
Classification
Therapeutic: antidiabetics
Pharmacologic: sulfonylureas
Pregnancy Category C
Indications
PO: Control of blood sugar in type 2 diabetes mellitus when diet therapy
fails. Requires some pancreatic function.
Action
Lowers blood sugar by stimulating the release of insulin from the pancreas
and increasing the sensitivity to insulin at receptor sites. May also decrease
hepatic glucose production. May be used concurrently with metformin
when the combination of diet, exercise, and either drug alone fails to
produce glycemic control. Therapeutic Effects: Lowering of blood sugar in
diabetic patients.
Contraindications/Precautions
Contraindicated in: Hypersensitivity; Hypersensitivity to sulfonamides
(cross sensitivity may occur); Type 1 diabetes; Diabetic coma or
ketoacidosis; Severe renal, hepatic, thyroid, or other endocrine disease ;
Uncontrolled infection, serious burns, or trauma. Use Cautiously in:
Severe cardiovascular or hepatic disease; Glucose 6-phosphate
dehydrogenase deficiency (qrisk of hemolytic anemia); Geri:sensitivity;
dose reduction may be required; Severe renal disease (risk of
hypoglycemia) ; Infection,stress, or changes in diet may alter requirements
for control of blood sugar; Impaired thyroid, pituitary, or adrenal function;
Malnutrition, high fever, prolonged nausea, or vomiting; OB, Lactation:
Safety not established; insulin recommended
during pregnancy.
Adverse Reactions/Side Effects
CNS: dizziness, drowsiness, headache, weakness. GI: constipation, cramps,
diarrhea, drug-induced hepatitis, dyspepsia,qappetite, nausea, vomiting.
Derm: photosensitivity, rashes. Endo: hypoglycemia. F and E:
hyponatremia. Hemat: hemolytic anemia, thrombocytopenia.
NURSING IMPLICATIONS
Assessment
Observe patient for signs and symptoms of hypoglycemic reactions
(sweating, hunger, weakness, dizziness, tremor, tachycardia, anxiety).
Patients on concurrent beta-blocker therapy may have very subtle signs of
hypoglycemia.
Assess patient for allergy to sulfonamides.
Lab Test Considerations: Monitor serum glucose and glycosylated
hemoglobin periodically during therapy to evaluate effectiveness.
Monitor CBC periodically during therapy. Reportpblood counts
promptly.
May cause anqin AST, ALT, LDH, BUN, and serum creatinine.
Toxicity and Overdose: Overdose is manifested by symptoms of
hypoglycemia. Mild hypoglycemia may be treated with administration of
oral glucose. Severe hypoglycemia should be treated with IV D50W
followed by continuous IV infusion of 10% glucose solution at a rate
sufficient to keep serum glucose at approximately 100 mg/dL.
Patient/Family Teaching
Instruct patient to take medication at same time each day. Take missed
doses as soon as remembered unless almost time for next dose. Do not take
if unable to eat.
Explain to patient that this medication controls hyperglycemia but does
not cure diabetes. Therapy is long term.
Review signs of hypoglycemia and hyperglycemia with patient. If
hypoglycemia occurs,advise patient to drink a glass of orange juice or
ingest 23 tsp of sugar, honey, or corn syrup dissolved in water or an
appropriate number of glucose tablets and notify health care professional.
Encourage patient to follow prescribed diet, medication, and exercise
regimen to prevent hypoglycemic or hyperglycemic episodes.
. Concurrent use of alcohol may cause a disulfiram-like reaction
(abdominal cramps, nausea, flushing, headaches, and hypoglycemia).
May occasionally cause dizziness or drowsiness. Caution patient to avoid
driving or other activities requiring alertness until response to medication
is known.
Caution patient to avoid other medications, especially aspirin and
alcohol, while on this therapy without consulting health care professional.
. Advise patient to notify health care professional promptly if unusual
weight gain, swelling of ankles, drowsiness, shortness of breath, muscle
cramps, weakness, sore throat, rash, or unusual bleeding or bruising occurs.
Insulin is the recommended method of controlling blood sugar during
pregnancy. Counsel female patients to use a form of contraception other
than oral contraceptives and to notify health care professional promptly if
pregnancy is planned or suspected.
Advise patient to carry a form of sugar (sugar packets, candy) and
identification describing disease process and medication regimen at all
times.
Emphasize the importance of routine follow-up exams.
ketorolac (kee-toe-role-ak)
Classification
Therapeutic: nonsteroidal anti-inflammatory agents, nonopioid analgesics
Pharmacologic: pyrroziline carboxylic acid
Pregnancy Category C (oral, nasal spray [<30 wk gestation]),
D (nasal spray [30 wk gestation)
Indications
Short-term management of pain (not to exceed 5 days total for all routes
combined.
Action
Inhibits prostaglandin synthesis, producing peripherally mediated
analgesia. Also has antipyretic and anti-inflammatory properties.
Therapeutic Effects: Decreased pain.
Contraindications/Precautions
Contraindicated in: Hypersensitivity; Cross-sensitivity with other
NSAIDs may exist; Preoperative use; Active or history of peptic ulcer
disease or GI bleeding; Known alcohol intolerance (injection only);
Perioperative pain from coronary artery bypass graft (CABG) surgery;
Cerebrovascular bleeding; Advanced renal impairment or at risk for renal
failure due to volume depletion; Concurrent use of pentoxifylline or
probenecid; OB: Chronic use in 3rd trimester may cause constriction of
ductus arteriosus. May inhibit labor and maternal bleeding at delivery.
Use Cautiously in: Cardiovascular disease or risk factors for cardiovascular
disease (may risk of serious cardiovascular thrombotic events, myocardial
infarction, and stroke, especially with prolonged use); Heart failure;
Coagulation disorders; Mild-to-moderate renal impairment (dosage
reduction may be required); Hepatic impairment; Pedi: Safety not
established in neonates; Geri: Appears on Beers list; risk of GI bleeding;
Lactation: Lactation.
Adverse Reactions/Side Effects
CNS: STROKE, drowsiness, abnormal thinking, dizziness, euphoria,
headache. EENT:lacrimation (spray), nasal discomfort (spray), throat
irritation (spray). Resp: asthma, dyspnea. CV: MYOCARDIAL
INFARCTION, edema, pallor, vasodilation. GI: GI BLEEDING,
abnormal taste, diarrhea, dry mouth, dyspepsia, GI pain,qliver
enzymes,nausea. GU: oliguria, renal toxicity, urinary frequency. Derm:
EXFOLIATIVE DERMATITIS, STEVENS-JOHNSON SYNDROME,
TOXIC EPIDERMAL NECROLYSIS, pruritus, purpura, sweating,
urticaria. Hemat: prolonged bleeding time. Local: injection site pain.
Neuro: paresthesia. Misc: allergic reactions including, anaphylaxis.
NURSINGIMPLICATIONS
Assessment
Patients who have asthma, aspirin-induced allergy, and nasal polyps are
at increased risk for developing hypersensitivity reactions. Assess for
rhinitis, asthma, and urticaria.
Assess for rash periodically during therapy. May cause Stevens-Johnson
syndrome or toxic epidermal necrolysis. Discontinue therapy if severe or if
accompanied with fever, general malaise, fatigue, muscle or joint aches,
blisters, oral lesions, conjunctivitis, hepatitis and/or eosinophilia.
Pain: Assess pain (note type, location, and intensity) prior to and 12 hr
following administration.
Lab Test Considerations: Evaluate liver function tests, especially AST and
ALT, periodically in patients receiving prolonged therapy. May cause
levels.
May cause prolonged bleeding time that may persist for 2448 hr
following discontinuation of therapy.
May causes BUN, serum creatinine, or potassium concentrations.
Patient/Family Teaching
Instruct patient on how and when to ask for and take pain medication.
Instruct patient to take medication exactly as directed. Take missed
doses as soon as remembered if not almost time for next dose. Do not
double doses. Do not take more than prescribed or for longer than 5 days.
May cause drowsiness or dizziness. Advise patient to avoid driving or
other activities requiring alertness until response to the medication is
known.
Caution patient to avoid the concurrent use of alcohol, aspirin, NSAIDs,
acetaminophen, or other OTC medications without consulting health care
professional.
Advise patient to inform health care professional of medication regimen
prior to treatment or surgery.
Advise patient to consult health care professional if rash, itching, visual
disturbances, tinnitus, weight gain, edema, black stools, persistent
headache, or influenza-like syndrome (chills, fever, muscle aches, pain)
occurs.
Intranasal: Instruct patient on correct technique for administration, need
to open a new bottle every 24 hr, and the 5 day limit for use.
losartan (loe-sar-tan)
Classification
Therapeutic: antihypertensives
Pharmacologic: angiotensin II receptor antagonists
Pregnancy Category D
Indications
Alone or with other agents in the management of hypertension. Treatment
of diabetic nephropathy in patients with type 2 diabetes. Prevention of
stroke in patients with hypertension and left ventricular hypertrophy.
Action
Blocks the vasoconstrictor and aldosterone-secreting effects of angiotensin
II at various receptor sites, including vascular smooth muscle and the
adrenal glands. Therapeutic Effects: Lowering of BP in hypertensive
patients. Decreased progression of diabetic nephropathy. Decreased
incidence of stroke in patients with hypertension and left ventricular
hypertrophy (effect may be less in black patients).
Contraindications/Precautions
Contraindicated in: Hypersensitivity; Bilateral renal artery stenosis; OB:
Can cause injury or death of fetus if pregnancy occurs, discontinue
immediately; Lactation :Discontinue drug or use formula.
Use Cautiously in: Volume- or salt-depleted patients or patients receiving
high doses of diuretics (correct deficits before initiating therapy or initiate
at lower doses); Black patients (reduction in stroke risk may not apply to
this patient population);Impaired renal function due to primary renal
disease or heart failure (may worsen renal function); Hepatic impairment
(lower initial doses recommended); Women of childbearing potential; Pedi:
Children <6 yr (safety not established).
Adverse Reactions/Side Effects
CNS: dizziness, fatigue, headache, insomnia, weakness. CV: chest pain,
edema, hypotension.EENT: nasal congestion. Endo: hypoglycemia, weight
gain. GI: diarrhea, abdominal pain, dyspepsia, nausea. GU: impaired renal
function. F and E: hyperkalemia. MS: back pain, myalgia. Misc:
ANGIOEDEMA, fever.
NURSINGIMPLICATIONS
Assessment
Assess BP (lying, sitting, standing) and pulse frequently during initial
dose adjustment and periodically during therapy. Notify health care
professional of significant changes.
Monitor frequency of prescription refills to determine compliance.
Assess patient for signs of angioedema (dyspnea, facial swelling). May
rarely cause angioedema.
Lab Test Considerations: Monitor renal function. May cause BUN and
serum creatinine.
May cause AST, ALT, and serum bilirubin.
May cause hyperkalemia.
May cause slight hemoglobin and hematocrit.
Patient/Family Teaching
Emphasize the importance of continuing to take as directed, even if
feeling well. Take missed doses as soon as remembered if not almost time
for next dose; do not double doses. Medication controls but does not cure
hypertension. Instruct patient to take medication at the same time each
day. Warn patient not to discontinue therapy unless directed by health care
professional.
Caution patient to avoid salt substitutes containing potassium or foods
containing high levels of potassium or sodium unless directed by health
care professional.
Caution patient to avoid sudden changes in position to decrease
orthostatic hypotension. Use of alcohol, standing for long periods,
exercising, and hot weather may increase orthostatic hypotension.
May cause dizziness. Caution patient to avoid driving or other activities
requiring alertness until response to medication is known.
Instruct patient to notify health care professional if swelling of face,
eyes, lips, or tongue or if difficulty swallowing or breathing occur.
. Hypertension: Encourage patient to comply with additional
interventions for hypertension(weight reduction, low-sodium diet,
discontinuation of smoking, moderation of alcohol consumption, regular
exercise, stress management). Medication controls but does not cure
hypertension.
Instruct patient and family on proper technique for monitoring BP.
Advise them to check BP at least weekly and to report significant changes.
budesonide (byoo-des-oh-nide)
Classification
Therapeutic: anti-inflammatories (steroidal)
Pharmacologic: corticosteroids
Pregnancy Category B
Indications
NebulizationMaintenance treatment and prophylactic therapy of asthma.
Oral inhalationChronic control of persistent bronchial asthma. May
decrease requirement for or eliminate use of systemic corticosteroids over
time in patients with asthma.
Action
Potent, locally acting anti-inflammatory and immune modifier.
Therapeutic Effects: Decreases frequency/severity of asthma attacks.
Improves asthma symptoms.
Contraindications/Precautions
Contraindicated in: Hypersensitivity to budesonide; Acute attack of
asthma/ status asthmaticus.
Use Cautiously in: Active untreated infections; Diabetes or glaucoma;
Underlying immunosuppression (from disease or concurrent therapy);
Systemic corticosteroid therapy (should not be abruptly discontinued when
inhaled therapy is started; additional corticosteroids needed during stress or
trauma); OB: Has been used safely; use only if clearly needed; Lactation:
Effects on infant are not known; Pedi: Higher than recommended doses can
lead to suppression of hypothalamic-pituitary-adrenal (HPA) function and
suppression of linear growth.

Adverse Reactions/Side Effects
CNS: headache. Derm: rash. EENT: otitis media, dysphonia, epistaxis,
oropharyngeal fungal infections, pharyngitis, rhinitis, sinusitis. Resp:
bronchospasm, cough.GI: abdominal pain, diarrhea, dyspepsia,
gastroenteritis, nausea, vomiting. Endo:adrenal suppression (high dose,
long-term therapy only), growth (children),weight gain. MS: back pain.
Misc: ANAPHYLAXIS, flu-like syndrome.
NURSING IMPLICATIONS
Assessment
Monitor respiratory status and lung sounds. Assess pulmonary function
tests periodically during and for several months following a transfer from
systemic to inhalation corticosteroids.
Assess patients changing from systemic corticosteroids to inhalation
corticosteroids for signs of adrenal insufficiency (anorexia, nausea,
weakness, fatigue, hypotension, hypoglycemia) during initial therapy and
periods of stress. If these signs appear, notify health care professional
immediately; condition may be life threatening.
Monitor for withdrawal symptoms (fatigue, weakness, nausea, vomiting,
hypotension, joint or muscular pain, lassitude, depression) during
withdrawal from oral corticosteroids.
Monitor growth rates in children receiving chronic therapy; lowest
possible dose should be used.
Lab Test Considerations: Periodic adrenal function tests may be ordered to
assess degree of hypothalamic-pituitary-adrenal (HPA) axis suppression in
chronic therapy. Children and patients using higher than recommended
doses are at highest risk for HPA suppression.
May cause serum and urine glucose concentrations if significant
absorption occurs.
Patient/Family Teaching
Advise patient to take medication as directed. Take missed doses as soon
as remembered unless almost time for next dose. Advise patient not to
discontinue medication without consulting health care professional;
gradual decrease is required. Instruct patient to read the Patient Information
and Instructions for Use before using and with each Rx refill, in case of new
information.
Advise patients using inhalation corticosteroids and bronchodilator to
use bronchodilator first and to allow 5 min to elapse before administering
the corticosteroid, unless otherwise directed by health care professional.
Advise patient that inhalation corticosteroids should not be used to treat
an acute asthma attack but should be continued even if other inhalation
agents are used.
Patients using inhalation corticosteroids to control asthma may require
systemic corticosteroids for acute attacks. Advise patient to use regular
peak flow monitoring to determine respiratory status.
Advise patient to rinse mouth with water after treatment to decrease risk
of developing local candidiasis.
Caution patient to avoid smoking, known allergens, and other
respiratory irritants.
Advise patient to notify health care professional if sore throat or mouth
or symptoms of anaphylaxis (rash, severe itching, swelling of the face,
mouth, and tongue, trouble breathing or swallowing, chest pain, anxiety or
feeling of doom) occur.
Instruct patient whose systemic corticosteroids have been recently
reduced or
withdrawn to carry a warning card indicating the need for supplemental
systemic corticosteroids in the event of stress or severe asthma attack
unresponsive to bronchodilators.
Advise female patients to notify health care professional if pregnancy is
planned or suspected or if breast feeding.
gliclazide (glik-la-zide)
Classification
Therapeutic: antidiabetics
Pharmacologic: sulfonylureas
Indications
Control of blood sugar in type 2 diabetes mellitus when control of diet and
exercise fails or when insulin is not an option. Requires some pancreatic
function.
Action
Lowers blood glucose by stimulating the release of insulin from the
pancreas and increasing sensitivity to insulin at receptor sites. Therapeutic
Effects: Lowering of blood glucose in diabetic patients.
Contraindications/Precautions
Contraindicated in: Hypersensitivity; cross sensitivity with other
sulfonylureas may occur; Unstable diabetes, type 1 diabetes mellitus,
diabetic ketoacidosis, diabetic coma or pre-coma; Severe hepatic or renal
disease; Concurrent use of oral/oromucosal miconazole, alcohol or alcohol-
containing medications, or systemic phenylbutazone; OB: Should not be
used during pregnancy, insulin is preferred; Lactation: Should not be used
during lactation, insulin is perferred.
Use Cautiously in: Glucose 6-phosphate dehydrogenase deficiency (risk
of hemolytic anemia); Infection, stress, or changes in diet may alter
requirements for control of blood sugar or require use of insulin; Impaired
thyroid, pituitary, or adrenal function; Malnutrition, high fever, prolonged
nausea, or vomiting; Pedi: Safe and effective use in children_18 yr has not
been established.
Adverse Reactions/Side Effects
Endo: hypoglycemia. GI: abdominal pain, diarrhea, dyspepsia, liver
enzymes,nausea, vomiting.Derm: photosensitivity, rashes.
NURSINGIMPLICATIONS
Assessment
Observe for signs and symptoms of hypoglycemia (hunger, weakness,
sweating, dizziness, tachycardia, anxiety).
Assess patient for allergy to sulfonyureas.
Lab Test Considerations: Monitor serum glucose and glycosylated
hemoglobin periodically during therapy to evaluate effectiveness of
treatment.
Monitor liver function periodically in patients with mild to moderate
liver dysfunction. May cause AST, ALT, alkaline phosphatase and LDH.
Monitor renal function periodically in patients with mild to moderate
renal dysfunction. May cause creatinine and hyponatremia.
Toxicity and Overdose: Overdose is manifested by symptoms of
hypoglycemia. Mild hypoglycemia may be treated with administration of
oral glucose. Treat severe hypoglycemia with IV D50W followed by
continuous IV infusion of more dilute dextrose solution at a rate sufficient
to keep serum glucose at approximately 100 mg/dL.
Patient/Family Teaching
Instruct patient to take gliclazideas directed at the same time every day.
Explain to patient that this medication does not cure diabetes and must
be used in conjunction with a prescribed diet, exercise regimen, to prevent
hypoglycemic and hyperglycemic events.
Instruct patient on proper technique for home glucose monitoring.
Monitor closely during periods of stress or illness and health care
professional notified if significant changes occur.
Review signs of hypoglycemia and hyperglycemia with patient. If
hypoglycemia occurs, advise patient to drink a glass of orange juice or
ingest 23 tsp of sugar, honey, or corn syrup dissolved in water or an
appropriate number of glucose tablets
and notify health care professional.
Encourage patient to follow prescribed diet, medication, and exercise
regimen to prevent hypoglycemic or hyperglycemic episodes.
Concurrent use of alcohol may cause a disulfiram-like reaction
(abdominal cramps, nausea, flushing, headaches, and hypoglycemia).
Caution patient to avoid other medications, especially aspirin and
alcohol, while on this therapy without consulting health care professional.
Advise patient to notify health care professional promptly if unusual
weight gain, swelling of ankles, drowsiness, shortness of breath, muscle
cramps, weakness, sore throat, rash, or unusual bleeding or bruising occurs.
Advise patient to inform health care professional of medication regimen
prior to treatment or surgery.
Advise patient to carry sugar packets or candy, and identification
describing diabetes diagnosis and medication regimen.
 Insulin is the recommended method of controlling blood sugar during
pregnancy. Counsel female patients to use a form of contraception other
than oral contraceptives and to notify health care professional promptly if
pregnancy is planned or suspected.
prednisone (pred-ni-sone)
Classification
Therapeutic: anti-inflammatories (steroidal)
(intermediate acting), immune modifiers
Pregnancy Category C
Indications
Used systemically and locally in a wide variety of chronic diseases
including: Inflammatory, Allergic, Hematologic, Neoplastic, Autoimmune
disorders. Suitable for alternate- day dosing in the management of chronic
illness. Unlabeled Use: Adjunctive therapy of hypercalcemia. Adjunctive
management of nausea and vomiting from chemotherapy.
Action
In pharmacologic doses, suppresses inflammation and the normal immune
response. Has numerous intense metabolic effects (see Adverse Reactions
and Side Effects). Suppresses adrenal function at chronic doses of 5
mg/day. Replaces endogenous cortisol in deficiency states. Has minimal
mineralocorticoid activity. Therapeutic Effects: Suppression of
inflammation and modification of the normal immune response.
Contraindications/Precautions
Contraindicated in: Active untreated infections (may be used in patients
being treated for tuberculous meningitis); Some products contain alcohol
and should be avoided in patients with known intolerance; Lactation: Avoid
chronic use.
Use Cautiously in: Chronic treatment (leads to adrenal suppression; use
lowest possible dose for shortest period of time); Pedi: Chronic use will
result in growth; use lowest possible dose for shortest period of time;
Stress (surgery, infections); supplemental doses may be needed; Potential
infections may mask signs (fever, inflammation); OB: Safety not
established.
Adverse Reactions/Side Effects
Adverse reactions/side effects are much more common with high-
dose/long-term therapy CNS: depression, euphoria, headache,
intracranial pressure (children only), personality changes, psychoses,
restlessness. EENT: cataracts, intraocular pressure. CV: hypertension.
GI: PEPTIC ULCERATION, anorexia, nausea, vomiting. Derm: acne,
wound healing, ecchymoses, fragility, hirsutism, petechiae. Endo: adrenal
suppression, hyperglycemia. F and E: fluid retention (long-term high
doses), hypokalemia, hypokalemic alkalosis. Hemat:
THROMBOEMBOLISM, thrombophlebitis. Metab: weight gain, weight
loss. MS: muscle wasting, osteoporosis, avascular necrosis of joints, muscle
pain. Misc: cushingoid appearance (moon face, buffalo hump),
susceptibility to infection.
NURSINGIMPLICATIONS
Assessment
Indicated for many conditions. Assess involved systems before and
periodically during therapy.
Assess patient for signs of adrenal insufficiency (hypotension, weight
loss, weakness, nausea, vomiting, anorexia, lethargy, confusion,
restlessness) before and periodically during therapy.
Monitor intake and output ratios and daily weights. Observe patient for
peripheral edema, steady weight gain, rales/crackles, or dyspnea. Notify
health care professional if these occur.
Pedi: Children should have periodic evaluations of growth.
Lab Test Considerations: Monitor serum electrolytes and glucose. May
cause hyperglycemia, especially in persons with diabetes. May cause
hypokalemia. Patients on prolonged courses of therapy should routinely
have hematologic values, serum electrolytes, and serum and urine glucose
evaluated. May decrease WBC counts. May serum potassium and
calcium and serum sodium concentrations.
Guaiac-test stools. Promptly report presence of guaiac-positive stools.
May serum cholesterol and lipid values. May uptake of thyroid 123I or
131I.
Suppress reactions to allergy skin tests.
Periodic adrenal function tests may be ordered to assess degree of
hypothalamic-pituitary- adrenal axis suppression in systemic and chronic
topical therapy.
Patient/Family Teaching
Instruct patient on correct technique of medication administration.
Advise patient to take medication as directed. Take missed doses as soon as
remembered unless almost time for next dose. Do not double doses.
Stopping the medication suddenly may result in adrenal insufficiency
(anorexia, nausea, weakness, fatigue, dyspnea, hypotension,
hypoglycemia). If these signs appear, notify health care professional
immediately. This can be life-threatening.
Glucocorticoids cause immunosuppression and may mask symptoms of
infection. Instruct patient to avoid people with known contagious illnesses
and to report possible infections immediately.
Caution patient to avoid vaccinations without first consulting health care
professional.
Review side effects with patient. Instruct patient to inform health care
professional promptly if severe abdominal pain or tarry stools occur.
Patient should also report unusual swelling, weight gain, tiredness, bone
pain, bruising, nonhealing sores, visual disturbances, or behavior changes.
Advise patient to notify health care professional of medication regimen
before treatment or surgery.
Discuss possible effects on body image. Explore coping mechanisms.
Instruct patient to inform health care professional if symptoms of
underlying disease return or worsen.
Advise patient to carry identification describing disease process and
medication regimen in the event of emergency in which patient cannot
relate medical history.
Explain need for continued medical follow-up to assess effectiveness and
possible side effects of medication. Periodic lab tests and eye exams may be
needed.
Long-term Therapy: Encourage patient to eat a diet high in protein,
calcium,
and potassium, and low in sodium and carbohydrates. Alcohol should be
avoided
during therapy.
telmisartan (tel-mi-sar-tan)
Classification
Therapeutic: antihypertensives
Pharmacologic: angiotensin II receptor antagonists
Pregnancy Category D
Indications
Alone or with other agents in the management of hypertension. Reduction
of risk of myocardial infarction, stroke, or cardiovascular death in patients
55 yr who are at high risk for cardiovascular events and are unable to take
ACE inhibitors.
Action
Blocks the vasoconstrictor and aldosterone-secreting effects of angiotensin
II at various receptor sites, including vascular smooth muscle and the
adrenal glands. Therapeutic Effects: Lowering of BP in hypertensive
patients.
Contraindications/Precautions
Contraindicated in: Hypersensitivity; Bilateral renal artery stenosis;
Concurrent use with aliskiren in patients with diabetes or moderate-to-
severe renal impairment (CCr _60 mL/min); OB: Can cause injury or
death of fetus if pregnancy occurs, discontinue immediately; Lactation:
Discontinue drug or use formula.
Use Cautiously in: Volume- or salt-depleted patients or patients receiving
large doses of diuretics (correct deficits before initiating therapy); Black
patients (may not be as effective); Impaired renal function caused by
primary renal disease or heart failure (may worsen renal function);
Obstructive biliary disorders or hepatic impairment; Women of
childbearing potential; Pedi: Safety not established for children <18 yr.

Adverse Reactions/Side Effects
CNS: dizziness, fatigue, headache. CV: hypotension. EENT: sinusitis. F
and E: hyperkalemia. GI: abdominal pain, diarrhea, dyspepsia. GU:
impaired renal function. MS: back pain, myalgia. Misc: ANGIOEDEMA.
NURSING IMPLICATIONS
Assessment
Assess BP (lying, sitting, standing) and pulse frequently during initial
dose adjustment and periodically during therapy. Notify health care
professional of significant changes
Monitor frequency of prescription refills to determine compliance.
Assess patients for signs of angioedema (dyspnea, facial swelling).
Lab Test Considerations: Monitor renal function. May cause BUN and
serum creatinine.
May cause hyperkalemia
Patient/Family Teaching
Emphasize the importance of continuing to take as directed, even if
feeling well. Take missed doses as soon as remembered if not almost time
for next dose; do not double doses. Instruct patient to take medication at
the same time each day. Warn patient not to discontinue therapy unless
directed by health care professional. Advise patient to read Patient
Information prior to starting therapy and with each refill in case of changes.
Caution patient to avoid salt substitutes containing potassium or foods
containing high levels of potassium or sodium unless directed by health
care professional.
Encourage patient to comply with additional interventions for
hypertension (weight reduction, low-sodium diet, discontinuation of
smoking, moderation of alcohol consumption, regular exercise, stress
management). Medication controls but does not cure hypertension.
Instruct patient and family on proper technique for monitoring BP.
Advise them to check BP at least weekly and to report significant changes.
Caution patient to avoid sudden changes in position to decrease
orthostatic hypotension. Use of alcohol, standing for long periods,
exercising, and hot weather may increase orthostatic hypotension
May cause dizziness. Caution patient to avoid driving or other activities
requiring alertness until response to medication is known.
Instruct patient to notify health care professional of all Rx or OTC
medications, vitamins, or herbal products being taken and consult health
care professional before taking any new medications, especially cough,
cold, or allergy remedies
Instruct patient to notify health care professional of medication regimen
before treatment or surgery.
Instruct patient to notify health care professional if swelling of face,
eyes, lips, or tongue or if difficulty swallowing or breathing occur.
Emphasize the importance of follow-up exams to evaluate effectiveness
of medication.
Advise women of childbearing age to use contraception and notify health
care professional if pregnancy is planned or suspected or if breast feeding.
tranexamic acid (tran-ex-am-ikas -id)
Classification
Therapeutic: hemostatic agents
Pharmacologic: antifibrinolytics, plasminogen inactivators
Pregnancy Category B
Indications
IV: Prevention or reduction of hemorrhage during and following dental
surgery in hemophiliacs. PO: Treatment of cyclic heavy menstrual
bleeding.
Action
Inhibits activation of plasminogen, thereby preventing the conversion of
plasminogen to plasmin. Therapeutic Effects: Decreased bleeding
following dental surgery in hemophiliacs. Reduced need for replacement
therapy. Reduced menstrual blood loss.
Contraindications/Precautions
Contraindicated in: Hypersensitivity; Thromboembolic disorders (current,
history of, or at risk for); Acquired defective color vision (IV);
Subarachnoid hemorrhage; Concurrent use of combination hormonal
contraception (PO).
Use Cautiously in: Renal impairment ( dosing interval); Hematuria
originating in the upper urinary tract; Conditions associated with
thrombus formation; Use of hormonal contraceptives (PO);OB, Lactation,
Pedi: Safety not established
Adverse Reactions/Side Effects
CNS, SEIZURES, headache, dizziness. EENT, visual abnormalities.
CV,hypotension, thromboembolism, thrombosis. GI, diarrhea, nausea,
vomiting. MS, pain. Misc, POANAPHYLAXIS.
NURSING IMPLICATIONS
Assessment
Prevention of post-surgical hemorrhage: Observe site of surgery for
excessive bleeding.
Heavy menstrual bleeding: Monitor menstrual flow prior to and during
therapy.
Patients taking tranexamic acid for more than several days should have
ophthalmologic examinations to detect visual abnormalities prior to and at
regular intervals during and after therapy. Discontinue therapy if visual
changes occur.
Implementation
PO: Administer 3 times daily without regard to food. Swallow tablets
whole; do not crush, break, or chew.
IV Administration
Intermittent Infusion: Diluent: May be diluted with most solutions, such
as electrolyte, carbohydrate, amino acid, and dextran solutions. Prepare
mixture on day of infusion. Rate: Infuse at a rate not to exceed 100 mg (1
mL)/min. More rapid administration has resulted in hypotension.
Y-Site Compatibility: heparin.
Y-Site Incompatibility: ampicillin, ampicillin/sulbactam, blood,
penicillin, piperacillin/ tazobactam, ticarcillin/clavulanate.
Patient/Family Teaching
Instruct patient to take medication as directed; do not take more than 6
tablets/ day, for longer than 5 days in any menstrual cycle, or when not
menstruating. Take missed doses as soon as remembered, then take next
dose as least 6 hrs later; do not double doses. Advise patient to read Patient
Information before starting and with each Rx refill in case of changes.
Advise patient to stop medication and inform health care professional of
any changes in vision. Inform patients on prolonged therapy of the
importance of regular ophthalmologic follow-up.
Instruct patient to notify health care professional of all Rx or OTC
medications, vitamins, or herbal products being taken and consult health
care professional before taking any new medications. Caution patient to
avoid taking hormonal contraceptives and products containing aspirin or
NSAIDs without consulting health care professional.
Instruct patient to notify health care professional if signs and symptoms
of thrombosis (severe, sudden headache; pains in chest, groin, or legs,
especially calves; sudden loss of coordination; sudden and unexplained
shortness of breath; slurred speech; visual changes; weakness or numbness
in arm or leg) or anaphylaxis (shortness of breath, throat tightness, rash)
occur.
Instruct patient to notify health care professional if heavy menstrual
bleeding persists or worsens or if bleeding does not lessen after 2 cycles or
tranexamic acid seems to stop working.
omeprazole (o-mep-ra-zole)
Classification
Therapeutic: antiulcer agents
Pharmacologic: proton-pump inhibitors
Pregnancy Category C
Indications
GERD/maintenance of healing in erosive esophagitis. Duodenal ulcers
(with or without anti-infectives for Helicobacter pylori). Short-term
treatment of active benign gastric ulcer. Pathologic hypersecretory
conditions, including Zollinger-Ellison syndrome. Reduction of risk of GI
bleeding in critically ill patients. OTC: Heartburn occurring twice/wk.
Action
Binds to an enzyme on gastric parietal cells in the presence of acidic gastric
pH, preventing the final transport of hydrogen ions into the gastric lumen.
Therapeutic Effects: Diminished accumulation of acid in the gastric lumen
with lessened gastroesophageal reflux. Healing of duodenal ulcers.
Contraindications/Precautions
Contraindicated in: Hypersensitivity; Lactation: Discontinue omeprazole or
discontinue breast feeding.
Use Cautiously in: Liver disease (dose may be necessary); OB, Lactation,
Pedi: Safety not established in pregnant or breast feeding women, or
children >1 yr; Patients using high-doses for >1 year ( risk of hip, wrist, or
spine fractures).
Adverse Reactions/Side Effects
CNS: dizziness, drowsiness, fatigue, headache, weakness. CV: chest pain.
GI: PSEUDOMEMBRANOUS COLITIS, abdominal pain, acid
regurgitation, constipation, diarrhea, flatulence, nausea, vomiting. F and E:
hypomagnesemia (especially if treatment duration 3mo). Derm: itching,
rash. MS: bone fracture.Misc: allergic reactions.
NURSINGIMPLICATIONS
Assessment
Assess patient routinely for epigastric or abdominal pain and frank or
occult blood in the stool, emesis, or gastric aspirate.
Monitor bowel function. Diarrhea, abdominal cramping, fever, and
bloody stools should be reported to health care professional promptly
as a sign of pseudomembranous colitis. May begin up to several weeks
following cessation of therapy.
Lab Test Considerations: Monitor CBC with differential periodically
during therapy.
May cause AST, ALT, alkaline phosphatase, and bilirubin.
May cause serum gastrin concentrations to during first 12 wk of
therapy. Levels return to normal after discontinuation of omeprazole.
Monitor INR and prothrombin time in patients taking warfarin.
May cause hypomagnesemia. Monitor serum magnesium prior to and
periodically during therapy.
Implementation
Do not confuse Prilosec (omeprazole) with Prozac (fluoxetine) or Pristiq
(desvenlafaxine). Do not confuse omeprazole with fomepizole.
PO: Administer doses before meals, preferably in the morning. Capsules
should be swallowed whole; do not crush or chew. Capsules may be opened
and sprinkled on cool applesauce, entire mixture should be ingested
immediately and followed by a drink of water. Do not store for future use.
Powder for oral suspension: Administer on empty stomach, as least 1 hr
before a meal. For patients with nasogastric or enteral feeding, suspend
feeding for 3 hr before and 1 hr after administration. Empty packet contents
into a small cup containing 12 tablespoons of water. Do not use other
liquids or foods. If administered through a nasogastric tube, suspend in 20
mL of water. Stir well and drink immediately. Refill cup with water and
drink again.
May be administered concurrently with antacids.
Patient/Family Teaching
Instruct patient to take medication as directed for the full course of
therapy, even if feeling better. Take missed doses as soon as remembered
but not if almost time for next dose. Do not double doses.
May cause occasional drowsiness or dizziness. Caution patient to avoid
driving or other activities requiring alertness until response to medication
is known.
Advise patient to avoid alcohol, products containing aspirin or NSAIDs,
and foods that may cause an increase in GI irritation.
Advise patient to report onset of black, tarry stools; diarrhea; abdominal
pain; or persistent headache to health care professional promptly.
Instruct patient to notify health care professional of onset of black, tarry
stools; diarrhea; abdominal pain; or persistent headache or if fever and
diarrhea develop, especially if stool contains blood, pus, or mucus. Advise
patient not to treat diarrhea without consulting health care professional.
Advise female patient to notify health care professional if pregnancy is
planned or suspected or if breast feeding.
rosuvastatin (roe-soo-va-sta-tin)
Classification
Therapeutic: lipid-lowering agents
Pharmacologic: HMG-CoA reductase inhibitors (statins)
Pregnancy Category X
Indications
Adjunctive management of primary hypercholesterolemia and mixed
dyslipidemias. Adjunctive management of hypertriglyceridemia.
Adjunctive management of primary dysbetalipoproteinemia. Homozygous
familial hypercholesterolemia. Slows the progression of atherosclerosis as
adjunct to diet. Adjunctive therapy to diet and exercise for the reduction of
LDL cholesterol in children 1017 yrs with heterozygous familial
hypercholesterolemia if diet therapy fails (LDL cholesterol remains 190
mg/dL or remains 160 mg/dL [with family history of premature
cardiovascular disease or 2 risk factors for cardiovascular disease]); may be
used alone or in combination with statin. Primary prevention of
cardiovascular disease (reduces risk of stroke, myocardial infarction, and
revascularization) in patients without clinically evident coronary heart
disease but with an increased risk of cardiovascular disease because of age
(50 yr for men; 60 yr for women), hsCRP 2 mg/L, and the presence of 1
risk factor for cardiovascular disease (hypertension, low HDL-C, smoking,
or premature family history of coronary heart disease).
Action
Inhibits 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase,
an enzyme which is responsible for catalyzing an early step in the
synthesis of cholesterol.Therapeutic Effects: Lowering of total and LDL
cholesterol and triglycerides. Slightly increases HDL cholesterol. Slows the
progression of coronary atherosclerosis.
Contraindications/Precautions
Contraindicated in: Hypersensitivity; Active liver disease or
unexplained persistent elevations in AST & ALT;OB, Lactation: Pregnancy
or lactation.
Use Cautiously in: History of liver disease; Alcoholism; Renal
impairment; Patients with Asian ancestry (may have blood levels and
risk of rhabdomyolysis); Concurrent use of gemfibrozil, azole antifungals,
protease inhibitors, niacin, cyclosporine, amiodarone, or verapamil (higher
risk of myopathy/rhabdomyolysis); OB: Women of childbearing age; Pedi:
Safety not established.
Adverse Reactions/Side Effects
CNS: amnesia, confusion, memory loss, weakness. GI: abdominal pain,
constipation, drug-induced hepatitis, liver function tests, nausea. Derm:
rash. Endo: hyperglycemia. Hemat: thrombocytopenia. Metab:
RHABDOMYOLYSIS, immune-mediated necrotizing myopathy,
myalgia.
NURSINGIMPLICATIONS
Assessment
Obtain a diet history, especially with regard to fat consumption.
Lab Test Considerations: Evaluate serum cholesterol and triglyceride levels
before initiating, after 24 wk of therapy, and periodically thereafter.
Monitor liver function tests before initiation of therapy and as clinically
indicated. If symptoms of serious liver injury, hyperbilirubinemia, or
jaundice occurs, discontinue rosuvastatin and do not restart. May also
causeqalkaline phosphatase, glutamyl transpeptidase, and bilirubin levels.
If patient develops muscle tenderness during therapy, CK levels should
be monitored. If CK levels are markedlyqor myopathy occurs, discontinue
therapy.
May cause proteinuria and microscopic hematuria; if persistent, may
require dose reduction.
Implementation
PO: Administer once daily without regard to food. Swallow tablets
whole; do not crush, break, or chew.
If magnesium or aluminum-containing antacids are used concurrently,
administer antacid at least 2 hr after rosuvastatin.
Avoid grapefruit and grapefruit juice during therapy; may increase risk
of toxicity.
Patient/Family Teaching
Instruct patient to take medication as directed, not to skip doses or
double up on missed doses. Take missed doses as soon as remembered but
not within 12 hr of next dose. Medication helps control but does not cure
elevated serum cholesterol levels.
Advise patient that this medication should be used in conjunction with
diet restrictions (fat, cholesterol, carbohydrates, alcohol), exercise, and
cessation of smoking.
Instruct patient to notify health care professional if unexplained muscle
pain, tenderness, or weakness occurs, especially if accompanied by fever
or malaise.
Advise patient to take magnesium or aluminum-containing antacids, if
needed, at least 2 hr after rosuvastatin.
Instruct female patients to notify health care professional promptly if
pregnancy is planned or suspected.
Instruct patient to notify health care professional of all Rx or OTC
medications, vitamins, or herbal products being taken and consult health
care professional before taking any new medications.
Advise patient to notify health care professional of medication regimen
before treatment or surgery.
Instruct female patient to inform health care professional if pregnancy is
planned or suspected or if she is breast feeding.
Emphasize the importance of follow-up exams to determine effectiveness
and to monitor for side effects.
ranitidine (ra-ni-ti-deen)
Classification
Therapeutic: antiulcer agents
Pharmacologic: histamine H2 antagonists
Pregnancy Category B
Indications
Short-term treatment of active duodenal ulcers and benign gastric ulcers.
Maintentance therapy for duodenal and gastric ulcers after healing of
active ulcer(s). Management of gastric hypersecretory states (Zollinger-
Ellison syndrome). Treatment of and maintenace therapy for erosive
esophagitis. Treatment of gastroesophageal reflux disease (GERD).
Heartburn, acid indigestion, and sour stomach (OTC use). IV: Prevention
and treatment of stress-induced upper GI bleeding in critically ill patients.
Action
Inhibits the action of histamine at the H2-receptor site located primarily in
gastric parietal cells, resulting in inhibition of gastric acid secretion.
Therapeutic Effects: Healing and prevention of ulcers. Decreased
symptoms of gastroesophageal reflux. Decreased secretion of gastric acid.
Contraindications/Precautions
Contraindicated in: Hypersensitivity; Syrup contains alcohol and should
beavoided in patients with known intolerance.
Use Cautiously in: Phenylketonuric patients (effervescent tablets and
granules contain phenylalanine); Geri: Geriatric patients are more
susceptible to adverse CNS reactions including dizziness and confusion;
dosage recommended; Renal impairment (more susceptible to adverse
CNS reactions; dose interval recommended if CCr<50 mL/min); Hepatic
impairment; Acute porphyria (may precipitate an attack); OB: Pregnancy;
Lactation: Passes into breast milk and can cause stomach acid in
the infant.
Adverse Reactions/Side Effects
CNS: confusion, dizziness, drowsiness, hallucinations, headache. CV:
ARRHYTHMIAS. GI: constipation, diarrhea, nausea. GU:psperm count,
erectile dysfunction. Endo: gynecomastia. Hemat: AGRANULOCYTOSIS,
APLASTIC ANEMIA, anemia, neutropenia, thrombocytopenia. Local: pain at
IM site.Misc: hypersensivity reactions, vasculitis.
NURSINGIMPLICATIONS
Assessment
Assess patient for epigastric or abdominal pain and frank or occult blood
in the stool, emesis, or gastric aspirate.
Assess geriatric and debilitated patients routinely for confusion.
Lab Test Considerations: CBC with differential should be monitored
periodically during therapy.
Antagonizes effects of pentagastrin and histamine during gastric acid
secretion testing. Avoid administration for 24 hr preceding the test.
May cause false-negative results in skin tests using allergenic extracts.
Histamine antagonists should be discontinued 24 hr before the test.
May cause anqin serum transaminases and serum creatinine.
May cause false-positive results for urine protein; test with sulfosalicylic
acid.
Patient/Family Teaching
Instruct patient to take medication as directed for the full course of
therapy, even if feeling better. Take missed doses as soon as remembered
but not if almost time for next dose. Do not double doses.
Advise patients taking OTC preparations not to take the maximum dose
continuously for more than 2 wk without consulting health care
professional. Notify health care professional if difficulty swallowing occurs
or abdominal pain persists.
Inform patient that smoking interferes with the action of histamine
antagonists. Encourage patient to quit smoking or at least not to smoke
after last dose of the day.
May cause drowsiness or dizziness. Caution patient to avoid driving or
other activities requiring alertness until response to the drug is known.
Advise patient to avoid alcohol, products containing aspirin or NSAIDs,
excessive amounts of caffeine, and foods that may cause an increase in GI
irritation.
Inform patient that increased fluid and fiber intake and exercise may
minimize constipation.
Advise patient to report onset of black, tarry stools; fever; sore throat;
diarrhea; dizziness; rash; confusion; or hallucinations to health care
professional promptly.
metoclopramide (met-oh-kloe-pra-mide)
Classification
Therapeutic: antiemetics
Pregnancy Category B
Indications
Prevention of chemotherapy-induced emesis. Treatment of postsurgical
and diabetic gastric stasis. Facilitation of small bowel intubation in
radiographic procedures. Management of gastroesophageal reflux.
Treatment and prevention of postoperative nausea and vomiting when
nasogastric suctioning is undesirable. Unlabeled Use: Treatment of
hiccups. Adjunctmanagement of migraine headaches.
Action
Blocks dopamine receptors in chemoreceptor trigger zone of the CNS.
Stimulates motility of the upper GI tract and accelerates gastric emptying.
Therapeutic Effects: Decreased nausea and vomiting. Decreased symptoms
of gastric stasis. Easier passage of nasogastric tube into small bowel.
Contraindications/Precautions
Contraindicated in: Hypersensitivity; Possible GI obstruction or
hemorrhage; History of seizure disorders; Pheochromocytoma; Parkinsons
disease.
Use Cautiously in: History of depression; Diabetes (may alter response to
insulin); Renal impairment ( dose in CCr <50 mL/min); Chronic use >3mo
( risk for tardive dyskinesia); OB, Lactation: Safety not established; Pedi:
Prolonged clearance in neonates can result in high serum concentrations
and the risk for methemoglobinemia. Side effects are more common in
children, especially extrapyramidal reactions; Geri: More susceptible to
oversedation, extrapyramidal reactions, and tardive dyskinesia.
Adverse Reactions/Side Effects
CNS: drowsiness, extrapyramidal reactions, restlessness, NEUROLEPTIC
MALIGNANTSYNDROME, anxiety, depression, irritability, tardive
dyskinesia. CV: arrhythmias (supraventricular tachycardia, bradycardia),
hypertension, hypotension. GI: constipation, diarrhea, dry mouth, nausea.
Endo: gynecomastia. Hemat: methemoglobinemia, neutropenia,
leukopenia, agranulocytosis.
NURSINGIMPLICATIONS
Assessment
Assess for nausea, vomiting, abdominal distention, and bowel sounds
before and after administration.
Assess for extrapyramidal side effects (parkinsoniandifficulty speaking
or swallowing, loss of balance control, pill rolling, mask-like face, shuffling
gait, rigidity, tremors; and dystonicmuscle spasms, twisting motions,
twitching, inability to move eyes, weakness of arms or legs) periodically
throughout course of therapy. May occur weeks to months after initiation
of therapy and are reversible on discontinuation. Dystonic reactions may
occur within minutes of IV infusion and stop within 24 hr of
discontinuation of metoclopramide. May be treated with 50 mg of IM
diphenhydramine or diphenhydramine 1 mg/kg IV may be administered
prophylactically 15min before metoclopramide IV infusion.
Monitor for tardive dyskinesia (uncontrolled rhythmic movement of
mouth, face, and extremities; lip smacking or puckering; puffing of cheeks;
uncontrolled chewing; rapid or worm-like movements of tongue). Usually
occurs after a year or more of continued therapy; risk of tardive dyskinesia
increases with total cumulative dose. Report immediately and discontinue
metoclopramide; may be irreversible.
Monitor for neuroleptic malignant syndrome (hyperthermia, muscle
rigidity,
altered consciousness, irregular pulse or BP, tachycardia, and diaphoresis).
Assess for signs of depression periodically throughout therapy.
Lab Test Considerations: May alter hepatic function test results.
May cause serum prolactin and aldosterone concentrations.
Patient/Family Teaching
Instruct patient to take metoclopramide as directed. Take missed doses as
soon as remembered if not almost time for next dose. Advise patient to
read the Medication Guide before starting therapy and with each Rx refill in
case of changes.
Pedi: Unintentional overdose has been reported in infants and children
with the use of metoclopramide oral solution. Teach parents how to
accurately read labels and administer medication.
May cause drowsiness. Caution patient to avoid driving or other
activities requiring alertness until response to medication is known.
Advise patient to avoid concurrent use of alcohol and other CNS
depressants while taking this medication.
Inform patient of risk of extrapyramidal symptoms, tardive dyskinesia,
and neuroleptic malignant syndrome. Advise patient to notify health care
professional immediately if involuntary or repetitive movements of eyes,
face, or limbs occur.
metronidazole (me-troe-ni-da-zole)
Classification
Therapeutic: anti-infectives, antiprotozoals, antiulcer agents
Pregnancy Category B
Indications
PO, IV: Treatment of the following anaerobic infections: Intra-abdominal
infections (may be used with a cephalosporin), Gynecologic infections,
Skin and skin structure infections, Lower respiratory tract infections, Bone
and joint infections, CNS infections, Septicemia, Endocarditis. IV
Perioperative prophylactic agent in colorectal surgery. PO: Amebicide in
the management of amebic dysentery, amebic liver abscess, and
trichomoniasis: Treatment of peptic ulcer disease caused by Helicobacter
pylori. Topical Treatment of acne rosacea. Vag: Management of bacterial
vaginosis. Unlabeled Use: Treatment of giardiasis. Treatment of anti-
infective associated pseudomembranous colitis.
Action
Disrupts DNA and protein synthesis in susceptible organisms. Therapeutic
Effects: Bactericidal, trichomonacidal, or amebicidal action. Spectrum:
Most notable for activity against anaerobic bacteria, including: Bacteroides,
Clostridium. In addition, is active against: Trichomonas vaginalis, Entamoeba
histolytica, Giardi lamblia, H. pylori, Clostridium difficile.
Contraindications/Precautions
Contraindicated in: Hypersensitivity; Hypersensitivity to parabens
(topical only); OB: First trimester of pregnancy.
Use Cautiously in: History of blood dyscrasias; History of seizures or
neurologic problems; Severe hepatic impairment (dose suggested); OB:
Although safety not established, has been used to treat trichomoniasis in
2nd- and 3rd-trimester pregnancy but not as single-dose regimen;
Lactation: If needed, use single dose and interrupt nursing for 24 hr
thereafter; Patients receiving corticosteroids or predisposed to edema
(injection contains 28mEq sodium/g metronidazole).
Adverse Reactions/Side Effects
CNS: SEIZURES, dizziness, headache, aseptic meningitis (IV),
encephalopathy (IV). EENT: optic neuropathy, tearing (topical only).
GI: abdominal pain, anorexia, nausea, diarrhea, dry mouth, furry tongue,
glossitis, unpleasant taste, vomiting. Derm: STEVENS-JOHNSON
SYNDROME, rash, urticarial topical only, burning, mild dryness, skin
irritation, transient redness. Hemat: leukopenia. Local: phlebitis at IV
site. Neuro: peripheral neuropathy. Misc: superinfection.
NURSINGIMPLICATIONS
Assessment
Assess for infection (vital signs; appearance of wound, sputum, urine,
and stool; WBC) at beginning of and throughout therapy.
Obtain specimens for culture and sensitivity before initiating therapy.
First dose may be given before receiving results.
Monitor neurologic status during and after IV infusions. Inform health
care professional if numbness, paresthesia, weakness, ataxia, or seizures
occur.
Monitor intake and output and daily weight, especially for patients on
sodium restriction. Each 500 mg of premixed injection for dilution contains
14 mEq of sodium.
Assess for rash periodically during therapy. May cause Stevens-Johnson
syndrome. Discontinue therapy if severe or if accompanied with fever,
general malaise, fatigue, muscle or joint aches, blisters, oral lesions,
conjunctivitis, hepatitis and/or eosinophilia.
Giardiasis: Monitor three stool samples taken several days apart,
beginning 34 wk after treatment.
Lab Test Considerations: May alter results of serum AST, ALT, and LDH
tests.
Patient/Family Teaching
Instruct patient to take medication as directed with evenly spaced times
between doses, even if feeling better. Do not skip doses or double up on
missed doses. Take missed doses as soon as remembered if not almost time
for next dose.
Advise patients treated for trichomoniasis that sexual partners may be
asymptomatic sources of reinfection and should be treated concurrently.
Patient should also refrain from intercourse or use a condom to prevent
reinfection.
Caution patient to avoid intake of alcoholic beverages or preparations
containing alcohol during and for at least 3 days after treatment with
metronidazole, including vaginal gel. May cause a disulfiram-like reaction
(flushing, nausea, vomiting, headache, abdominal cramps).
May cause dizziness or light-headedness. Caution patient to avoid
driving or other activities requiring alertness until response to medication
is known.
Instruct patient to notify health care professional promptly if rash
occurs.
Inform patient that medication may cause an unpleasant metallic taste.
Advise patient to notify health care professional of all Rx or OTC
medications, vitamins, or herbal products being taken and to consult with
health care professional before taking other medications.
Advise patient that frequent mouth rinses, good oral hygiene, and
sugarless gum
or candy may minimize dry mouth. Notify health care professional if dry
mouth persists for more than 2 wk.
Inform patient that medication may cause urine to turn dark.
Advise patient to consult health care professional if no improvement in a
few days or if signs and symptoms of superinfection (black, furry
overgrowth on tongue; vaginal itching or discharge; loose or foul-smelling
stools) develop.
Advise patient to inform health care professional if pregnancy is
suspected before taking this medication or if breast feeding.
Vag: Instruct patient in correct technique for intravaginal instillation.
Advise patient to avoid intercourse during treatment with vaginal gel.
Topical: Instruct patient on correct technique for application of topical
gel. Cosmetics may be used after application of gel.
metformin (met-for-min)
Classification
Therapeutic: antidiabetics
Pharmacologic: biguanides
Pregnancy Category B
Indications
Management of type 2 diabetes mellitus; may be used with diet, insulin, or
sulfonylurea oral hypoglycemics.
Action
Decreases hepatic glucose production. Decreases intestinal glucose
absorption. Increases sensitivity to insulin. Therapeutic Effects:
Maintenance of blood glucose.
Contraindications/Precautions
Contraindicated in: Hypersensitivity; Metabolic acidosis; Dehydration,
sepsis, hypoxemia, hepatic impairment, excessive alcohol use (acute or
chronic); Renal dysfunction (SCr >1.5 mg/dL in men or >1.4 mg/dL in
women); Radiographic studies requiring IV iodinated contrast media
(withhold metformin); HF.
Use Cautiously in: Concurrent renal disease; Geri: Geriatric/debilitated
patients ( doses may be required; avoid in patients >80 yr unless renal
function is normal); Chronic alcohol use/abuse; Serious medical conditions
(MI, stroke); Patients undergoing stress (infection, surgical procedures);
Hypoxia; Pituitary deficiency or hyperthyroidism; OB, Lactation, Pedi:
Pregnancy, lactation, or children <10 yr (safety not established; extended
release for use in patients >17 yr only).
Adverse Reactions/Side Effects
GI: abdominal bloating, diarrhea, nausea, vomiting, unpleasant metallic
taste. Endo: hypoglycemia. F and E: LACTIC ACIDOSIS. Misc:
decreased vitamin B12 levels.
NURSING IMPLICATIONS
Assessment
When combined with oral sulfonylureas, observe for signs and
symptoms of hypoglycemic reactions (abdominal pain, sweating, hunger,
weakness, dizziness, headache, tremor, tachycardia, anxiety).
Patients who have been well controlled on metformin who develop
illness or laboratory abnormalities should be assessed for ketoacidosis
orlactic acidosis. Assess serum electrolytes, ketones, glucose, and, if
indicated, blood pH, lactate, pyruvate, and metformin levels. If either form
of acidosis is present, discontinue metformin immediately and treat
acidosis.
Lab Test Considerations: Monitor serum glucose and glycosylated
hemoglobin periodically during therapy to evaluate effectiveness of
therapy. May cause false-positive results for urine ketones.
Assess renal function before initiating and at least annually during
therapy. Discontinue metformin if renal impairment occurs.
Monitor serum folic acid and vitamin B12 every 12 yr in long-term
therapy. Metformin may interfere with absorption.
Implementation
Do not confuse metformin with metronidazole.
Patients stabilized on a diabetic regimen who are exposed to stress, fever,
trauma, infection, or surgery may require administration of insulin.
Withhold metformin and reinstitute after resolution of acute episode.
Metformin should be temporarily discontinued in patients requiring
surgery involving restricted intake of food and fluids. Resume metformin
when oral intake has resumed and renal function is normal.
Withhold metformin before or at the time of studies requiring IV
administration of iodinated contrast media and for 48 hr after study.
PO: Administer metformin with meals tominimize GI effects.
XR tabletsmust be swallowed whole; do not crush, dissolve, or chew.
Patient/Family Teaching
Instruct patient to take metformin at the same time each day, as directed.
Take missed doses as soon as possible unless almost time for next dose. Do
not double doses. Instruct parent/caregiver to read the Medication Guide
prior to use and with each Rx refill; new information may be available.
Explain to patient that metformin helps control hyperglycemia but does
not cure diabetes. Therapy is usually long term.
Encourage patient to follow prescribed diet, medication, and exercise
regimen to prevent hyperglycemic or hypoglycemic episodes.
Review signs of hypoglycemia and hyperglycemia with patient. If
hypoglycemia occurs, advise patient to take a glass of orange juice or 23
tsp of sugar, honey, or corn syrup dissolved in water, and notify health care
professional.
Explain to patient the risk of lactic acidosis and the potential need for
discontinuation of metformin therapy if a severe infection, dehydration,
or severe or continuing diarrhea occurs or if medical tests or surgery is
required. Symptoms of lactic acidosis (chills, diarrhea, dizziness, low
BP, muscle pain, sleepiness, slow heartbeat or pulse, dyspnea, or
weakness)should be reported to health care professional immediately.
Insulin is the recommended method of controlling blood glucose during
pregnancy. Counsel female patients to use a form of contraception other
than oral contraceptives and to notify health care professional promptly if
pregnancy is planned or suspected or if breast feeding.
Advise patient to carry a form of sugar (sugar packets, candy) and
identification describing disease process and medication regimen at all
times.
Emphasize the importance of routine follow-up exams and regular
testing of blood glucose, glycosylated hemoglobin, renal function, and
hematologic parameters.
guaifenesin (gwye-fen-e-sin)
Classification
Therapeutic: allergy, cold, and cough remedies, expectorant
Pregnancy Category C
Indications
Coughs associated with viral upper respiratory tract infections.
Action
Reduces viscosity of tenacious secretions by increasing respiratory tract
fluid. TherapeuticEffects: Mobilization and subsequent expectoration of
mucus.
Contraindications/Precautions
Contraindicated in: Hypersensitivity; Some products contain alcohol;
avoid in patients with known intolerance; Some products contain
aspartame and should be avoided in patients with phenylketonuria.
Use Cautiously in: Cough lasting _1 wk or accompanied by fever, rash, or
headache; Patients receiving disulfiram (liquid products may contain
alcohol); Diabetic patients (some products may contain sugar); OB:
Although safety has not been established, guaifenesin has been used
without adverse effects; Pedi: OTC cough and cold products containing
this medication should be avoided in children <4 yr .
Adverse Reactions/Side Effects
CNS: dizziness, headache. GI: nausea, diarrhea, stomach pain, vomiting.
Derm: rash, urticaria.
NURSING IMPLICATIONS
Assessment
Assess lung sounds, frequency and type of cough, and character of
bronchial secretions periodically during therapy. Maintain fluid intake of
15002000 mL/day
to decrease viscosity of secretions.
Implementation
Do not confuse guaifenesin with guanfacine. Do not confuse Mucinex
withMucomyst.
PO: Administer each dose of guaifenesin followed by a full glass of water
to decrease viscosity of secretions.
Extended-release tablets should be swallowed whole; do not open, break,
crush, or chew.
Patient/Family Teaching
Instruct patient to cough effectively. Patient should sit upright and take
several deep breaths before attempting to cough.
Caution parents to avoid OTC cough and cold products while breast
feeding or administering to children_4 yrs.
Inform patient that drug may occasionally cause dizziness. Avoid
driving or other activities requiring alertness until response to drug is
known.
Advise patient to limit talking, stop smoking, maintain moisture in
environmental air, and take some sugarless gum or hard candy to help
alleviate the discomfort caused by a chronic nonproductive cough.
Instruct patient to contact health care professional if cough persists
longer than 1 wk or is accompanied by fever, rash, or persistent headache or
sore throat.
ceftazidime (sef-tay-zi-deem)
Classification
Therapeutic: anti-infectives
Pharmacologic: third-generation cephalosporins
Pregnancy Category B
Indications
Treatment of the following infections caused by susceptible organisms:
Skin and skin structure infections, Bone and joint infections, Urinary tract
infections, Gynecological infections, Lower respiratory tract infections,
Intra-abdominal infections, Septicemia, Febrile neutropenia,Meningitis.
Action
Binds to the bacterial cell wall membrane, causing cell death. Therapeutic
Effects: Bactericidal action against susceptible bacteria. Spectrum: Similar
to that of second-generation cephalosporins, but activity against
staphylococci is less, while activity against gram-negative pathogens
(particularly Pseudomonas aeruginosa) is greater, even for organisms
resistant to first- and second-generation agents. Notable is increased action
against: Citrobacter, Enterobacter, Haemophilus influenzae( including -
lactamase-producing strains), Escherichia coli, Klebsiella pneumoniae,
Neisseria meningitidis, Proteus, Providencia, Pseudomonas aeruginosa,
Serratia, Moraxella catarrhalis. Not active against methicillin-resistant
staphylococci or enterococci.
Contraindications/Precautions
Contraindicated in: Hypersensitivity to cephalosporins; Serious
hypersensitivity to penicillins.
Use Cautiously in: Renal impairment (dosing/dosing interval
recommended if CCr 50 mL/min); History of GI disease, especially
colitis; Lactation: Direct drug effects and modification of bowel flora may
occur in the nursing infant; Geri: Dose adjustment may be necessary due to
age-related in renal function.
Adverse Reactions/Side Effects
CNS: SEIZURES (high doses in patients with renal impairment),
encephalopathy. GI: PSEUDOMEMBRANOUS COLITIS, abdominal
pain, diarrhea, nausea, vomiting. Derm: rashes, pruritis, urticaria. Hemat:
bleeding, blood dyscrasias, hemolytic anemia. Local: pain at IM site,
phlebitis at IV site. Misc: allergic reactions including ANAPHYLAXIS,
superinfection, fever.
NURSINGIMPLICATIONS
Assessment
Assess for infection (vital signs; appearance of wound, sputum, urine,
and stool; WBC) at beginning of and throughout therapy.
Before initiating therapy, obtain a history to determine previous use of
and reactions to penicillins or cephalosporins. Persons with a negative
history of penicillin sensitivity may still have an allergic response.
Obtain specimens for culture and sensitivity before initiating therapy.
First dose may be given before receiving results.
Observe patient for signs and symptoms of anaphylaxis (rash, pruritus,
laryngeal edema, wheezing). Discontinue the drug and notify health care
professional immediately if these symptoms occur. Keep epinephrine, an
antihistamine, and resuscitation equipment close by in the event of an
anaphylactic reaction.
Monitor bowel function. Diarrhea, abdominal cramping, fever, and
bloody stools should be reported to health care professional promptly
as a sign of pseudomembranous colitis. May begin up to several weeks
following cessation of therapy.
Lab Test Considerations: May cause positive results for Coombs test.
May cause serum AST, ALT, alkaline phosphatase, bilirubin, LDH,
BUN, and creatinine.
May rarely cause leukopenia, neutropenia, agranulocytosis,
thrombocytopenia, eosinophilia, and lymphocytosis.
Patient/Family Teaching
Advise patient to report signs of superinfection (furry overgrowth on the
tongue, vaginal itching or discharge, loose or foul-smelling stools) and
allergy.
Instruct patient to notify health care professional if fever and diarrhea
develop, especially if stool contains blood, pus, or mucus. Advise patient
not to treat diarrhea without consulting health care professional.

hydrocortisone (hye-droe-kor-ti-sone)
Classification
Therapeutic: anti-inflammatories (steroidal)
Pharmacologic: corticosteroids
Pregnancy Category C
Indications
Management of adrenocortical insufficiency; chronic use in other
situations is limited because of mineralocorticoid activity. Used
systemically and locally in a wide variety of disorders including:
Inflammatory, Allergic, Hematologic, Neoplastic, Autoimmune disorders,
Septic shock.
Action
In pharmacologic doses, suppresses inflammation and the normal immune
response. Has numerous intense metabolic effects (see Adverse Reactions
and Side Effects). Suppresses adrenal function at chronic doses of 20
mg/day. Replaces endogenous cortisol in deficiency states. Also has potent
mineralocorticoid (sodium-retaining) activity. Therapeutic Effects:
Replacement therapy in adrenal insufficiency. Suppression of
inflammation and modification of the normal immune response.
Contraindications/Precautions
Contraindicated in: Active untreated infections (may be used in patients
being treated for tuberculous meningitis or septic shock); Lactation: Avoid
chronic use; Known alcohol, bisulfite, or tartrazine hypersensitivity or
intolerance (someproducts contain these and should be avoided in
susceptible patients).
Use Cautiously in: Chronic treatment (will lead to adrenal suppression;
use lowest possible dose for shortest period of time); Pedi: Chronic use will
result in growth; use lowest possible dose for shortest period of time;
Hypothyroidism; Cirrhosis; Ulcerative colitis; Stress (surgery, infections);
supplemental doses may be needed; Potential infections may mask signs
(fever, inflammation); OB: Safety not established.
Adverse Reactions/Side Effects
Adverse reactions/side effects are much more common with high-
dose/long-term therapy CNS: depression, euphoria, headache,
intracranial pressure (children only), personality changes, psychoses,
restlessness. EENT: cataracts, intraocular pressure. CV: hypertension.
GI: PEPTIC ULCERATION, anorexia, nausea, vomiting. Derm: acne,
wound healing, ecchymoses, fragility, hirsutism, petechiae. Endo: adrenal
suppression, hyperglycemia. F and E: fluid retention (long-term high
doses), hypokalemia, hypokalemic alkalosis. Hemat:
THROMBOEMBOLISM, thrombophlebitis. Metab: weight gain, weight
loss. MS: muscle wasting, osteoporosis, avascular necrosis of joints,
muscle pain. Misc: hypersensitivity reactions including ANAPHYLAXIS,
cushingoid appearance (moon face, buffalo hump), susceptibility to
infection.
NURSING IMPLICATIONS
Assessment
Indicated for many conditions. Assess involved systems prior to and
periodically during therapy.
Assess patient for signs of adrenal insufficiency (hypotension, weight
loss, weakness, nausea, vomiting, anorexia, lethargy, confusion,
restlessness) prior to and periodically during therapy.
Monitor intake and output ratios and daily weights. Observe patient for
peripheral edema, steady weight gain, rales/crackles, or dyspnea. Notify
health care professional should these occur.
Children should have periodic evaluations of growth.
Rect: Assess symptoms of ulcerative colitis (diarrhea, bleeding, weight
loss, anorexia, fever, leukocytosis) periodically during therapy.
Lab Test Considerations: SystemicMonitor serum electrolytes and
glucose. May cause hyperglycemia, especially in persons with diabetes.
May cause hypokalemia. Monitor hematologic values, serum electrolytes,
and serum and urine glucose routinely in patients on prolonged therapy.
May cause WBC counts. May cause serum potassium and calcium and
serum sodium concentrations.
Guaiac test stools. Promptly report presence of guaiac-positive stools.
May cause elevated serum cholesterol and lipid values. May cause
uptake of thyroid 123I or 131I.
Suppresses reactions to allergy skin tests.
Periodic adrenal function tests may be ordered to assess degree of
hypothalamic-pituitary-adrenal axis suppression in systemic and chronic
topical therapy.
Patient/Family Teaching
Instruct patient on correct technique of medication administration.
Advise patient to take medication as directed. Take missed doses as soon as
remembered unless almost time for next dose. Do not double doses.
Stopping the medication suddenly may result in adrenal insufficiency
(anorexia, nausea, weakness, fatigue, dyspnea, hypotension,
hypoglycemia). If these signs appear, notify health care professional
immediately. This can be life-threatening.
Corticosteroids cause immunosuppression and may mask symptoms of
infection. Instruct patient to avoid people with known contagious illnesses
and to report possible infections immediately.
Caution patient to avoid vaccinations without first consulting health care
professional.
Review side effects with patient. Instruct patient to inform health care
professional promptly if severe abdominal pain or tarry stools occur.
Patient should also report unusual swelling, weight gain, tiredness, bone
pain, bruising, nonhealing sores, visual disturbances, or behavior changes.
Advise patient to notify health care professional of medication regimen
prior to treatment or surgery.
Discuss possible effects on body image. Explore coping mechanisms.
Instruct patient to inform health care professional if symptoms of
underlying disease return or worsen.
Advise patient to carry identification describing disease process and
medication regimen in the event of emergency in which patient cannot
relate medical history.
Long-term Therapy: Encourage patient to eat a diet high in protein,
calcium, and potassium, and low in sodium and carbohydrates. Alcohol
should be avoided during therapy.
If rectal dose used >21 days, decrease to every other night for 23 weeks to
decrease gradually.
ampicillin (am-pi-sil-in)
Classification
Therapeutic: anti-infectives
Pharmacologic: aminopenicillins
Pregnancy Category B
Indications
Treatment of the following infections: Skin and skin structure infections,
Soft-tissue infections, Otitis media, Sinusitis, Respiratory infections,
Genitourinary infections, Meningitis, Septicemia. Endocarditis
prophylaxis. Unlabeled Use: Prevention of infection in certain high-risk
patients undergoing cesarean section.
Action
Binds to bacterial cell wall, resulting in cell death. Therapeutic Effects:
Bactericidal action; spectrum is broader than penicillin. Spectrum: Active
against: Streptococci, nonpenicillinase-producing staphylococci, Listeria,
Pneumococci, Enterococci, Haemophilus influenzae, Escherichia coli,
Enterobacter, Klebsiella, Proteus mirabilis, Neisseria meningitidis, N.
gonorrhoeae, Shigella, Salmonella.
Contraindications/Precautions
Contraindicated in: Hypersensitivity to penicillins.
Use Cautiously in: Severe renal insufficiency (dose required if CCr <10
mL/ min); Infectious mononucleosis, acute lymphocytic leukemia or
cytomegalovirus infection ( incidence of rash); Patients allergic to
cephalosporins; OB: Has been used during pregnancy; Lactation:
Distributed into breast milk. Can cause rash, diarrhea, and sensitization in
the infant.
Adverse Reactions/Side Effects
CNS: SEIZURES (high doses). GI: PSEUDOMEMBRANOUS
COLITIS, diarrhea, nausea, vomiting. Derm: rash, urticaria. Hemat: blood
dyscrasias. Misc: allergic reactions including ANAPHYLAXIS and
SERUM SICKNESS, superinfection.
NURSINGIMPLICATIONS
Assessment
Assess patient for infection (vital signs, wound appearance, sputum,
urine, stool, and WBC) at beginning of and throughout therapy.
Obtain a history before initiating therapy to determine previous use and
reactions to penicillins or cephalosporins. Persons with a negative history
of penicillin sensitivity may still have an allergic response.
Obtain specimens for culture and sensitivity before therapy. First dose
may be given before receiving results.
Observe patient for signs and symptoms of anaphylaxis (rash, pruritus,
laryngeal edema, wheezing). Discontinue the drug and notify health care
professional immediately if these occur. Keep epinephrine, an
antihistamine, and resuscitation equipment close by in the event of an
anaphylactic reaction.
Monitor bowel function. Diarrhea, abdominal cramping, fever, and
bloody stools should be reported to health care professional promptly
as a sign of pseudomembranous colitis. May begin up to several weeks
following cessation of therapy.
Assess skin for ampicillin rash, a nonallergic, dull red, maculopapular,
mildly pruritic rash.
Lab Test Considerations: May cause AST and ALT. May cause transient
estradiol, total conjugated estriol, estriol-glucuronide, or conjugated
estrone in pregnant women., May cause a false-positive direct Coombs test
result., May cause a false-positive urinary glucose.
Patient/Family Teaching
Instruct patient to take medication around the clock and to finish the
drug completely as directed, even if feeling better. Advise patients that
sharing of this medication can be dangerous.
Advise patient to report the signs of superinfection (furry overgrowth on
the tongue, vaginal itching or discharge, loose or foul-smelling stools) and
allergy.
Caution patient to notify health care professional if fever and diarrhea
occur, especially if stool contains blood, pus, or mucus. Advise patient not
to treat diarrhea without consulting health care professional. May occur up
to several weeks after discontinuation of medication.
Instruct the patient to notify health care professional if symptoms do not
improve.
Patients with a history of rheumatic heart disease or valve replacement
need to be taught the importance of using antimicrobial prophylaxis before
invasive medical or dental procedures.
Advise patients taking oral contraceptives to use an alternate or
additional nonhormonal method of contraception while taking ampicillin
and until next menstrual period.
Advise female patient to notify health care professional if breast feeding.
cloxacillin (klox-a-sill-in)
Classification
Therapeutic: anti-infectives
Pharmacologic: penicillinase resistant penicillins
Indications
Treatment of the following infections due to penicillinase-producing
staphylococci: respiratory tract infections, sinusitis, septicemia,
endocarditis, osteomyelitis, skin and skin structure infections.
Action
Bind to bacterial cell wall, leading to cell death. Not inactivated by
penicillinase enzymes. Therapeutic Effects: Bactericidal action. Spectrum:
Active against most gram-positive aerobic cocci. Spectrum is notable for
activity against: Penicillinaseproducing strains of Staphylococcus aureus ,
Staphylococcus epidermidis. Not active against methicillin-resistant bacteria
(MRSA).
Contraindications/Precautions
Contraindicated in: Previous hypersensitivity to penicillins (cross-
sensitivity exists with cephalosporins and other beta-lactam antibiotics).
Use Cautiously in: Severe renal or hepatic impairment; OB: Safe use in
pregnancy has not been established; Pedi: Safe use in premature and
newborn infants has not been established.
Adverse Reactions/Side Effects
CNS: SEIZURES. GI: PSEUDOMEMBRANOUS COLITIS, diarrhea,
epigastric distress, nausea, vomiting. GU: interstitial nephritis. Derm: rash,
urticaria. Hemat: eosinophilia, leukopenia. Misc: allergic reactions
including ANAPHYLAXIS and SERUM SICKNESS, superinfection.
NURSING IMPLICATIONS
Assessment
Assess for infection (vital signs; appearance of wound, sputum, urine,
and stool; WBC) at beginning of and throughout therapy.
Obtain a history before initiating therapy to determine previous use of
and reactions to cephalosporins or other beta-lactam antibiotics. Persons
with no history of penicillin sensitivity may still have an allergic response.
Obtain specimens for culture and sensitivity prior to initiating therapy.
First dose may be given before receiving results.
Observe patient for signs and symptoms of anaphylaxis (rash, pruritus,
laryngeal edema, wheezing, abdominal pain). Discontinue drug and health
care professional immediately if these occur. Keep epinephrine, an
antihistamine, and resuscitation equipment close by in event of an
anaphylactic reaction.
Monitor bowel function. Diarrhea, abdominal cramping, fever, and
bloody stools should be reported to health care professional promptly
as a sign of pseudomembranous colitis. May begin up to several weeks
following cessation of therapy.
Lab Test Considerations: May cause leukopenia and neutropenia, especially
with prolonged therapy or hepatic impairment.
May cause positive direct Coombs test result.
May cause AST, ALT, LDH, and serum alkaline phosphatase
concentrations.
Patient/Family Teaching
Instruct patient to take medication around the clock and to finish the
drug completely as directed, even if feeling better. Missed doses should be
taken as soon as remembered. Advise patient that sharing of this
medication may be dangerous.
Advise patient to report signs of superinfection (black, furry overgrowth
on the tongue; vaginal itching or discharge; loose or foul-smelling stools)
and allergy.
Instruct patient to notify health care professional if fever and diarrhea
develop, especially if stool contains blood, pus, or mucus. Advise patient
not to treat diarrhea without consulting health care professional.
Instruct patient to notify health care professional if symptoms do not
improve.
sodium chloride (IV/oral) (soe-dee-um klor-ide)
Classification
Therapeutic: mineral and electrolyte replacements/supplements
Pregnancy Category C
Indications
IV: Hydration and provision of NaCl in deficiency states. Maintenance of
fluid and electrolyte status in situations in which losses may be excessive
(excess diuresis or severe salt restriction). 0.45% (half-normal saline)
solution is most commonly used for hydration and the treatment of
hyperosmolar diabetes (hypotonic). 0.9% (normal saline) solution is used
for: Replacement, Treatment of metabolic alkalosis, A priming fluid for
hemodialysis, To begin and end blood transfusions. Small volumes of 0.9%
NaCl (preservative-free or bacteriostatic) are used to reconstitute or dilute
other medications. Hypertonic solution (3%, 5%) may be required in
situations in which rapid replacement of sodium is necessary:
Hyponatremia, Hypochloremia, Renal failure, Heart failure. PO:
Prevention of or management of volume depletion due to salt restriction or
heat prostration when excessive sweating occurs during exposures to high
temperatures. Irrigating Solutions: 0.9% and 0.45%may be used as
irrigating solutions. Concentrated sodium chloride: Used as an additive to
parenteral fluid therapy in very specific situations.
Action
Sodium is a major cation in extracellular fluid and helps maintain water
distribution, fluid and electrolyte balance, acid-base equilibrium, and
osmotic pressure. Chloride is the major anion in extracellular fluid and is
involved in maintaining acid-base balance. Solutions of NaCl resemble
extracellular fluid. Reduces corneal edema by an osmotic effect.
Therapeutic Effects: IV, PO: Replacement in deficiency states and
maintenance of homeostasis.
Contraindications/Precautions
Contraindicated in: Hypertonic (3%, 5%) solutions should not be used in
patients with elevated, slightly decreased, or normal serum sodium; Fluid
retention or hypernatremia.
Use Cautiously in: Patients prone to metabolic, acid-base, or fluid and
electrolyte abnormalities, including: geriatric patients, those with
nasogastric suctioning, vomiting, diarrhea, diuretic therapy, glucocorticoid
therapy, fistulas, HF, severe renal failure, severe liver diseases (additional
electrolytes may be required); Pedi: NaCl preserved with benzyl alcohol
should not be used in neonates; Inadequate hydration (water and other
electrolytesmust be replaced).
Adverse Reactions/Side Effects
Seen primarily during PO and IV use CV: HF, PULMONARY EDEMA,
edema. F and E: hypernatremia, hypervolemia, hypokalemia. Local: IV
extravasation, irritation at IV site.
NURSING IMPLICATIONS
Assessment
Assess fluid balance (intake and output, daily weight, edema, lung
sounds) throughout therapy.
Assess patient for symptoms of hyponatremia (headache, tachycardia,
lassitude, dry mucous membranes, nausea, vomiting, muscle cramps) or
hypernatremia (edema, weight gain, hypertension, tachycardia, fever,
flushed skin, mental irritability) throughout therapy. Sodium is measured
in relation to its concentration to
fluid in the body, and symptoms may change based on patients hydration
status.
Lab Test Considerations: Monitor serum sodium, potassium, bicarbonate,
and chloride concentrations and acid-base balance periodically for patients
receiving prolonged therapy with sodium chloride.
Monitor serum osmolarity in patients receiving hypertonic saline
solutions.
Patient/Family Teaching
Explain to patient the purpose of the infusion.
Advise patients at risk for dehydration due to exposure to extreme
temperatures when and how to take NaCL tablets. Inform patients that
undigested tablets may be passed in the stool; oral electrolyte solutions are
preferable.
amoxicillin (a-mox-i-sill-in)
Classification
Therapeutic: anti-infectives, antiulcer agents
Pharmacologic: aminopenicillins
Pregnancy Category B
Indications
Treatment of: Skin and skin structure infections, Otitis media, Sinusitis,
Respiratory infections, Genitourinary infections. Endocarditis prophylaxis.
Postexposure inhalational anthrax prophylaxis. Management of ulcer
disease due to Helicobacter pylori. Unlabeled Use: Lyme disease in
children_8 yr.
Action
Binds to bacterial cell wall, causing cell death. Therapeutic Effects:
Bactericidal action; spectrum is broader than penicillins. Spectrum: Active
against: Streptococci, Pneumococci, Enterococci, Haemophilus influenzae,
Escherichia coli, Proteus mirabilis, Neisseria meningitidis, N. gonorrhoeae,
Shigella, Chlamydia trachomatis, Salmonella, Borrelia burgdorferi, H. pylori.
Contraindications/Precautions
Contraindicated in: Hypersensitivity to penicillins (cross-sensitivity exists
to cephalosporins and other beta-lactams);.
Use Cautiously in: Severe renal insufficiency (pdose if CCr _30 mL/min);
Infectious mononucleosis, acute lymphocytic leukemia, or cytomegalovirus
infection (q risk of rash); OB, Lactation: Has been used safely.
Adverse Reactions/Side Effects
CNS: SEIZURES (high doses). GI: PSEUDOMEMBRANOUS
COLITIS, diarrhea, nausea, vomiting, liver enzymes. Derm: rash,
urticaria. Hemat: blood dyscrasias. Misc: allergic reactions including
ANAPHYLAXIS, SERUM SICKNESS, superinfection.
NURSING IMPLICATIONS
Assessment
Assess for infection (vital signs; appearance of wound, sputum, urine,
and stool; WBC) at beginning of and throughout therapy.
Obtain a history before initiating therapy to determine previous use of
and reactions to penicillins or cephalosporins. Persons with a negative
history of penicillin sensitivity may still have an allergic response.
Observe for signs and symptoms of anaphylaxis (rash, pruritus,
laryngeal edema, wheezing). Notify health care professional immediately
if these occur.
Obtain specimens for culture and sensitivity prior to therapy. First dose
may be given before receiving results.
Monitor bowel function. Diarrhea, abdominal cramping, fever, and
bloody stools should be reported to health care professional promptly
as a sign of pseudomembranous colitis. May begin up to several weeks
following cessation of therapy.
Lab Test Considerations: May cause serum alkaline phosphatase, LDH,
AST, and ALT concentrations.
May cause false-positive direct Coombs test result.
Patient/Family Teaching
Instruct patients to take medication around the clock and to finish the
drug completely as directed, even if feeling better. Advise patients that
sharing of this medication may be dangerous.
Pedi: Teach parents or caregivers to calculate and measure doses
accurately. Reinforce importance of using measuring device supplied by
pharmacy or with product, not household items.
Advise patient to report the signs of superinfection (furry overgrowth on
the tongue, vaginal itching or discharge, loose or foul-smelling stools) and
allergy.
Instruct patient to notify health care professional immediately if
diarrhea, abdominal cramping, fever, or bloody stools occur and not to treat
with antidiarrheals without consulting health care professional.
Instruct the patient to notify health care professional if symptoms do not
improve.
Teach patients with a history of rheumatic heart disease or valve
replacement the importance of using antimicrobial prophylaxis before
invasive medical or dental procedures.
Instruct female patients taking oral contraceptives to use an alternate or
additional nonhormonal method of contraception during therapy with
amoxicillin and until next menstrual period.

irbesartan (ir-be-sar-tan)
Classification
Therapeutic: antihypertensives
Pharmacologic: angiotensin II receptor antagonists
Pregnancy Category D
Indications
Alone or with other agents in the management of hypertension. Treatment
of diabetic nephropathy in patients with type 2 diabetes and hypertension.
Action
Blocks the vasoconstrictor and aldosterone-secreting effects of angiotensin
II at various receptor sites, including vascular smooth muscle and the
adrenal glands. Therapeutic Effects: Lowering of BP in patients with
hypertension. Decreased progression of diabetic nephropathy.
Contraindications/Precautions
Contraindicated in: Hypersensitivity; Bilateral renal artery stenosis;
Concurrent use with aliskiren in patients with diabetes or moderate-to-
severe renal impairment (CCr _60 mL/min); OB: Can cause injury or
death of fetus if pregnancy occurs, discontinue immediately; Lactation:
Discontinue drug or use formula. Use Cautiously in: Volume- or salt-
depleted patients or patients receiving high doses of diuretics (correct
deficits before initiating therapy or initiate at lower doses); Black patients
(may not be as effective); Impaired renal function due to primary renal
disease or heart failure (may worsen renal function); Women of
childbearing potentialif pregnancy occurs, discontinue immediately; Pedi:
Safety not established.
Adverse Reactions/Side Effects
CNS: anxiety, dizziness, fatigue, headache. CV: chest pain, edema,
hypotension, tachycardia. Derm: rash. GI: abdominal pain, diarrhea,
dyspepsia, nausea, vomiting. GU: impaired renal function. F and E:
hyperkalemia. MS: pain. Misc: ANGIOEDEMA.
NURSING IMPLICATIONS
Assessment
Assess BP (lying, sitting, standing) and pulse frequently during initial
dose adjustment and periodically during therapy. Notify .health care
professional of significant changes.
Monitor frequency of prescription refills to determine compliance.
Assess patients for signs of angioedema (dyspnea, facial swelling). May
rarely cause angioedema.
Lab Test Considerations: Monitor renal function. May cause BUN and
serum creatinine.
May cause hyperkalemia.
May cause slight hemoglobin.
Patient/Family Teaching
Emphasize the importance of continuing to take as directed, even if
feeling well. Take missed doses as soon as remembered if not almost time
for next dose; do not double doses. Instruct patient to take medication at
the same time each day. Warn patient not to discontinue therapy unless
directed by health care professional.
Caution patient to avoid salt substitutes containing potassium or foods
containing high levels of potassium or sodium unless directed by health
care professional.
Caution patient to avoid sudden changes in position to decrease
orthostatic hypotension. Use of alcohol, standing for long periods,
exercising, and hot weather may increase orthostatic hypotension.
May cause dizziness. Caution patient to avoid driving or other activities
requiring alertness until response to medication is known.
Instruct patient to notify health care professional of all Rx or OTC
medications, vitamins, or herbal products being taken and to avoid
concurrent use of Rx, OTC, and herbal products, especially NSAIDs and
cough, cold, or allergy medications, without consulting health care
professional.
Instruct patient to notify health care professional of medication regimen
before treatment or surgery.
Instruct patient to notify health care professional if swelling of face,
eyes, lips, or tongue or if difficulty swallowing or breathing occur.
Advise women of childbearing age to use contraception and notify health
care professional if pregnancy is planned or suspected, or if breast feeding.
Irbesartan should be discontinued as soon as possible when pregnancy is
detected.
Hypertension: Encourage patient to comply with additional
interventions for hypertension (weight reduction, low-sodium diet,
discontinuation of smoking, moderation of alcohol consumption, regular
exercise, stress management). Medication controls but does not cure
hypertension.
meropenem (mer-oh-pen-nem)
Classification
Therapeutic: anti-infectives
Pharmacologic: carbapenems
Pregnancy Category B
Indications
Treatment of: Intra-abdominal infections, Bacterial meningitis. Skin and
skin structure infections. Unlabeled Use: Febrile neutropenia. Hospital-
acquired pneumonia and sepsis.
Action
Binds to bacterial cell wall, resulting in cell death. Meropenem resists the
actions of many enzymes that degrade most other penicillins and
penicillin-like anti-infectives. Therapeutic Effects: Bactericidal action
against susceptible bacteria. Spectrum: Active against the following gram-
positive organisms: Staphylococcus aureus, Streptococcus pneumoniae, Viridans
group streptococci, Enterococcus faecalis. Also active against the following
gram-negative pathogens: Escherichia coli, Haemophilus influenzae, Klebsiella
pneumoniae, Neisseria meningitidis, Pseudomonas aeruginosa, Proteus mirabilis.
Active against the following anaerobes: Bacteroides fragilis, Bacteroides
fragilis group, Peptostreptococcus species.
Contraindications/Precautions
Contraindicated in: Hypersensitivity to meropenem or imipenem; Serious
hypersensitivity to other beta-lactams (penicillins or cephalosporins; cross-
sensitivity may occur).
Use Cautiously in: Renal impairment ( risk of thrombocytopenia and
seizures; dose reduction recommended if CCr <50 mL/min); History of
seizures, brain lesions, or meningitis; OB, Lactation, Pedi: Pregnancy,
lactation, or children <3 mos. (safety not established).
Adverse Reactions/Side Effects
CNS: SEIZURES, dizziness, headache. Resp: APNEA. GI:
PSEUDOMEMBRANOUS COLITIS, constipation, diarrhea, glossitis (
in children), nausea, thrush ( in children), vomiting. Derm: moniliasis
(children only), pruritus, rash. Local: inflammation at injection site,
phlebitis. Neuro: paresthesias. Misc: allergic reactions including
ANAPHYLAXIS.
NURSING IMPLICATIONS
Assessment
Assess for infection (vital signs; appearance of wound, sputum, urine,
and stool; WBC) at beginning of and throughout therapy.
Obtain a history before initiating therapy to determine previous use of
and reactions to penicillins. Persons with a negative history of penicillin
sensitivity may still have an allergic response.
Obtain specimens for culture and sensitivity prior to initiating therapy.
First dose may be given before receiving results.
Observe for signs and symptoms of anaphylaxis (rash, pruritus,
laryngeal edema, wheezing). Discontinue the drug and notify physician
immediately if these symptoms occur. Have epinephrine, an antihistamine,
and resuscitative equipment close by in the event of an anaphylactic
reaction.
Assess injection site for phlebitis, pain, and swelling periodically during
administration.
Lab Test Considerations: Monitor hematologic, hepatic, and renal
functions periodically during therapy.
BUN, AST, ALT, LDH, serum alkaline phosphatase, bilirubin, and
creatinine may be transiently .
 Hemoglobin and hematocrit concentrations may be .
May cause positive direct or indirect Coombs test.
Patient/Family Teaching
Advise patient to report the signs of superinfection (black, furry
overgrowth on the tongue; vaginal itching or discharge; loose or foul-
smelling stools) and allergy.
May cause dizziness. Caution patient to avoid driving or other activities
requiring alertness until response to drug is known.
Caution patient to notify health care professional if fever and diarrhea
occur, especially if stool contains blood, pus, or mucus. Advise patient not
to treat diarrhea without consulting health care professional. May occur up
to several weeks after discontinuation of medication.
Advise patient to notify health care professional of all Rx or OTC
medications, vitamins, or herbal products being taken and to consult with
health care professional before taking other medications.
pantoprazole (pan-toe-pra-zole)
Classification
Therapeutic: antiulcer agents
Pharmacologic: proton-pump inhibitors
Pregnancy Category B
Indications
Erosive esophagitis associated with GERD. Decrease relapse rates of
daytime and nighttime heartburn symptoms on patients with GERD.
Pathologic gastric hypersecretory conditions. Unlabeled Use: Adjunctive
treatment of duodenal ulcers associated with Helicobacter pylori.
Action
Binds to an enzyme in the presence of acidic gastric pH, preventing the
final transport of hydrogen ions into the gastric lumen. Therapeutic
Effects: Diminished accumulation of acid in the gastric lumen, with
lessened acid reflux. Healing of duodenal ulcers and esophagitis. Decreased
acid secretion in hypersecretory conditions.
Contraindications/Precautions
Contraindicated in: Hypersensitivity; OB: Should be used during
pregnancy only if clearly needed; Lactation: Discontinue breast feeding due
to potential for serious adverse reactions in infants.
Use Cautiously in: Patients using high-doses for >1 year ( risk of hip,
wrist, or spine fractures); Pedi: Safety not established.
Adverse Reactions/Side Effects
CNS: headache. GI: PSEUDOMEMBRANOUS COLITIS, abdominal
pain, diarrhea, eructation, flatulence. Endo: hyperglycemia. F and E:
hypomagnesemia (especially if treatment duration 3 mos.). MS: bone
fracture.
NURSING IMPLICATIONS
Assessment
Assess patient routinely for epigastric or abdominal pain and for frank or
occult blood in stool, emesis, or gastric aspirate.
Lab Test Considerations: May cause abnormal liver function tests,
including AST, ALT, alkaline phosphatase, and bilirubin.
May cause hypomagnesemia. Monitor serum magnesium prior to and
periodically during therapy.
Patient/Family Teaching
Instruct patient to take medication as directed for the full course of
therapy, even if feeling better.
Advise patient to avoid alcohol, products containing aspirin or NSAIDs,
and foods that may cause an increase in GI irritation.
Advise patient to report onset of black, tarry stools; diarrhea; or
abdominal pain to health care professional promptly. Instruct patient to
notify health care professional immediately if rash, diarrhea, abdominal
cramping, fever, or bloody stools occur and not to treat with antidiarrheals
without consulting health care professional.
Instruct patient to notify health care professional of all Rx or OTC
medications, vitamins, or herbal products being taken and consult health
care professional before taking any new medications.
Advise female patients to notify health care professional if pregnancy is
planned or suspected or if breast feeding.
levofloxacin (le-voe-flox-a-sin)
Classification
Therapeutic: anti-infectives
Pharmacologic: fluoroquinolones
Pregnancy Category C
Indications
PO, IV: Treatment of the following bacterial infections: Urinary tract
infections, including cystitis, pyelonephritis, and prostatitis, Respiratory
tract infections, including acute sinusitis, acute exacerbations of chronic
bronchitis, community-acquired pneumonia, and nosocomial pneumonia,
Uncomplicated and complicated skin and skin structure infections. Post-
exposure treatment of inhalational anthrax. Treatment and prophylaxis of
plague.
Action
Inhibits bacterial DNA synthesis by inhibiting DNA gyrase enzyme.
Therapeutic Effects: Death of susceptible bacteria. Spectrum: Active
against gram-positive pathogens, including: Staphylococcus aureus,
Staphylococcus epidermidis, Staphylococcus saprophyticus, Streptococcus pyogenes,
Streptococcus pneumoniae, Enterococcus faecalis, Bacillus anthracis. Gram-
negative spectrum notable for activity against: Escherichia coli, Klebsiella
pneumoniae, Enterobacter cloacae, Proteus mirabilis, Pseudomonas aeruginosa,
Serratia marcescens, Haemophilus influenzae, Moraxella catarrhalis. Additional
spectrum includes: Chlamydophylia pneumoniae, Legionella pneumoniae,
Mycoplasma pneumoniae, and Yersinia pestis.
Contraindications/Precautions
Contraindicated in: Hypersensitivity (cross-sensitivity within class may
exist); QTc interval prolongation; Uncorrected hypokalemia or
hypomagnesemia; Concurrent use of Class IA antiarrhythmics
(disopyramide, quinidine, procainamide) or Class III antiarrhythmics
(amiodarone, sotalol) ( risk of QTc interval prolongation and torsade de
pointes); History of myasthenia gravis (may worsen symptoms including
muscle weakness and breathing problems); OB: Pregnancy; Lactation: Not
recommended.
Use Cautiously in: Known or suspected CNS disorder; Renal impairment
(dose recommended if CCr 50 mL/min); Cirrhosis; Concurrent use of
corticosteroids (q risk of tendonitis/tendon rupture); Kidney, heart, or lung
transplant patients ( risk of tendonitis/tendon rupture); Dialysis patients
( risk of adverse reactions); Geri: risk of adverse reactions; Pedi:
Children <18 yr [except for inhalational anthrax (post-exposure) and
anthrax] ( risk of arthralgia, arthritis, tendinopathy, and gait
disturbances).
Adverse Reactions/Side Effects
CNS: ELEVATED INTRACRANIAL PRESSURE (including
pseudotumor cerebri), SEIZURES, agitation, anxiety, confusion,
depression, dizziness, drowsiness, hallucinations, headache, insomnia,
nightmares, paranoia, tremor. CV: TORSADE DE POINTES, QT
interval prolongation. GI: HEPATOTOXICITY,
PSEUDOMEMBRANOUS COLITIS, nausea, abdominal pain, diarrhea,
vomiting. GU: vaginitis. Derm: STEVENS-JOHNSON SYNDROME,
photosensitivity, rash. Endo: hyperglycemia, hypoglycemia. Local:
phlebitis at IV site. Neuro: peripheral neuropathy. MS: arthralgia,
tendinitis, tendon rupture. Misc: hypersensitivity reactions including
ANAPHYLAXIS.
NURSING IMPLICATIONS
Assessment
Assess for infection (vital signs; appearance of wound, sputum, urine,
and stool; WBC; urinalysis; frequency and urgency of urination; cloudy or
foul-smelling urine) at beginning of and during therapy.
Obtain specimens for culture and sensitivity before initiating therapy.
First dose may be given before receiving results.
Observe patient for signs and symptoms of anaphylaxis (rash, pruritus,
laryngeal edema, wheezing). Discontinue drug and notify physician or
other health care professional immediately if these problems occur. Keep
epinephrine, an antihistamine, and resuscitation equipment close by in case
of an anaphylactic reaction.
Monitor bowel function. Diarrhea, abdominal cramping, fever, and
bloody stools should be reported to health care professional promptly
as a sign of pseudomembranous colitis. May begin up to several weeks
following cessation of therapy.
Assess for rash periodically during therapy. May cause Stevens-Johnson
syndrome. Discontinue therapy if severe or if accompanied with fever,
general malaise, fatigue, muscle or joint aches, blisters, oral lesions,
conjunctivitis, hepatitis and/or eosinophilia.
Assess for signs and symptoms of peripheral neuropathy (pain, burning,
tingling, numbness, and/or weakness or other alterations of sensation
including light touch, pain, temperature, position sense, and vibratory
sensation) periodically during therapy. Symptoms may be irreversible;
discontinue levofloxacin if symptoms occur.
Lab Test Considerations: May cause serum AST, ALT, LDH, bilirubin,
and alkaline phosphatase.
May also cause or serum glucose.
Patient/Family Teaching
Instruct patient to take medication as directed at evenly spaced times and
to finish drug completely, even if feeling better. Take missed doses as soon
as possible, unless almost time for next dose. Do not double doses. Advise
patient that sharing of this medication may be dangerous.
Advise patients to notify health care professional immediately if they are
taking theophylline.
Encourage patient to maintain a fluid intake of at least 15002000 mL/day
to prevent crystalluria.
Advise patient that antacids or medications containing calcium,
magnesium, aluminum, iron, or zinc will decrease absorption and should
not be taken within 4 hr before and 2 hr after taking this medication.
May cause dizziness and drowsiness. Caution patient to avoid driving or
other activities requiring alertness until response to medication is known.
Advise patient to notify health care professional of any personal or
family history of QTc prolongation or proarrhythmic conditions such as
recent hypokalemia, significant bradycardia, or recent myocardial ischemia
or if fainting spells or palpitations occur. Patients with this history should
not receive levofloxacin.
Advise patient to stop taking levofloxacin and notify health care
professional immediately if signs and symptoms of peripheral neuropathy
occur.
Caution patient to use sunscreen and protective clothing to prevent
phototoxicity reactions during and for 5 days after therapy. Notify health
care professional if a sunburn-like reaction or skin eruption occurs.
Advise patient to report signs of superinfection (furry overgrowth on the
tongue, vaginal itching or discharge, loose or foul-smelling stools).
Advise patient to notify health care professional of all Rx or OTC
medications, vitamins, or herbal products being taken and to consult with
health care professional before taking other medications.
Instruct patient to notify health care professional if fever and diarrhea
develop, especially if stool contains blood, pus, or mucus. Advise patient
not to treat diarrhea without consulting health care professional.
Instruct patient to notify health care professional immediately if rash,
jaundice, signs of hypersensitivity, or tendon (shoulder, hand, Achilles,
and other) pain, swelling, or inflammation occur. If tendon symptoms
occur, avoid exercise and use of the affected area. Increased risk in _65
yr old, kidney, heart and lung transplant recipients, and patients taking
corticosteroids concurrently. Therapy should be discontinued.
pregabalin (pre-gab-a-lin)
Classification
Therapeutic: analgesics, anticonvulsants
Pharmacologic: gamma aminobutyric acid
(GABA) analogues, nonopioid analgesics
Pregnancy Category C
Indications
Neuropathic pain associated with diabetic peripheral neuropathy.
Postherpetic neuralgia. Fibromyalgia. Neuropathic pain associated with
spinal cord injury. Adjunctive therapy of partial-onset seizures in adults.
Action
Binds to calcium channels in CNS tissues which regulate neurotransmitter
release. Does not bind to opioid receptors. Therapeutic Effects: Decreased
neuropathic or post-herpetic pain. Decreased partial-onset seizures.
Contraindications/Precautions
Contraindicated in: Myopathy (known/suspected); Lactation: Lactation.
Use cautiously in: All patients (may risk of suicidal thoughts/behaviors);
Renal impairment (dose alteration recommended for CCr <60 mL/min);
HF; History of drug dependence/drug-seeking behavior; OB: Use only if
maternal benefit outweighs fetal risk; may risk of male-mediated
teratogenicity; Pedi: Safety not established; Geri: Consider age-related in
renal function when determining dose.
Adverse Reactions/Side Effects
CNS: SUICIDAL THOUGHTS, dizziness, drowsiness, impaired
attention/concentration/ thinking. CV: edema. EENT: blurred vision. GI:
dry mouth, abdominal pain, constipation, appetite, vomiting. Hemat:
thrombocytopenia. Metab: weight gain. Misc: allergic reactions, fever.
NURSINGIMPLICATIONS
Assessment
Monitor closely for notable changes in behavior that could indicate the
emergence or worsening of suicidal thoughts or behavior or depression.
Diabetic Peripheral Neuropathy, Postherpetic Neuralgia, Fibromyalgia,
and Spinal Cord Injury Pain: Assess location, characteristics, and intensity
of pain periodically during therapy.
Seizures: Assess location, duration, and characteristics of seizure
activity.
Lab Test Considerations: May cause creatine kinase levels.
May cause platelet count.
Patient/Family Teaching
Instruct patient to take medication as directed. If a dose is missed take as
soon as remembered unless almost time for next dose; do not double doses.
Do not discontinue abruptly; may cause insomnia, nausea, headache, or
diarrhea or increase in frequency of seizures. Advise patient to read the
Patient Information Leaflet prior to taking pregabalin.
May cause dizziness, drowsiness, and blurred vision. Caution patient to
avoid driving or activities requiring alertness until response to medication
is known. Advise patient to notify health care professional if changes in
vision occur. Patients with seizures should not resume driving until health
care professional gives clearance based on control of seizure disorder.
Instruct patient to promptly report unexplained muscle pain, tenderness,
or weakness, especially if accompanied by malaise or fever. Discontinue
therapy if myopathy is diagnosed or suspected or if markedly elevated
creatine kinase levels occur.
Advise patient and family to notify health care professional if thoughts
about suicide or dying, attempts to commit suicide; new or worse
depression; new or worse anxiety; feeling very agitated or restless; panic
attacks; trouble sleeping; new or worse irritability; acting aggressive; being
angry or violent; acting on dangerous impulses; an extreme increase in
activity and talking, other unusual changes in behavior or mood occur.
Inform patient that pregabalin may cause edema and weight gain.
Caution patient to avoid alcohol or other CNS depressants with
pregabalin.

acyclovir (ay-sye-kloe-veer)
Classification
Therapeutic: antivirals
Pharmacologic: purine analogues
Pregnancy Category B (PO, buccal, IV), C (topical)
Indications
PO: Recurrent genital herpes infections. Localized cutaneous herpes zoster
infections (shingles) and chickenpox (varicella). Buccal: Recurrent herpes
labialis (cold sores) in nonimmunosuppressed patients. IV: Severe initial
episodes of genital herpes in nonimmunosuppressed patients. Mucosal or
cutaneous herpes simplex infections or herpes zoster infections (shingles)
in immunosuppressed patients. Herpes simplex encephalitis. Topical:
CreamRecurrent herpes labialis (cold sores). OintmentTreatment of
limited nonlife-threatening herpes simplex infections in
immunocompromised patients (systemic treatment is preferred)
Action
Interferes with viral DNA synthesis. Therapeutic Effects: Inhibition of
viral replication, decreased viral shedding, and reduced time for healing of
lesions.
Contraindications/Precautions
Contraindicated in: Hypersensitivity to acyclovir or
valacyclovir.;Hypersensitivity to milk protein concentrate (buccal only)
Use Cautiously in: Pre-existing serious neurologic, hepatic, pulmonary, or
fluid and electrolyte abnormalities; Renal impairment (dose alteration
recommended if CCr<50 mL/min); Geri: Due to age relatedpin renal
function; Obese patients (dose should be based on ideal body weight);
Patients with hypoxia; OB, Lactation: Safety not established.
Adverse Reactions/Side Effects
CNS: SEIZURES, dizziness, headache, hallucinations, trembling. GI:
diarrhea, nausea, vomiting, liver enzymes, hyperbilirubinemia,
abdominal pain, anorexia. GU: RENAL FAILURE, crystalluria, hematuria,
renal pain. Derm: STEVENS-JOHNSON SYNDROME, acne, hives,
rash, unusual sweating. Endo: changes in menstrual cycle. Hemat:
THROMBOTIC THROMBOCYTOPENIC
PURPURA/HEMOLYTIC UREMIC SYNDROME (high doses in
immunosuppressed patients). Local: pain, phlebitis, local irritation. MS:
joint pain. Misc: polydipsia.
NURSING IMPLICATIONS
Assessment
Assess lesions before and daily during therapy.
Assess frequency of recurrences.
Monitor neurologic status in patients with herpes encephalitis.
Lab Test Considerations: Monitor BUN, serum creatinine, and CCr before
and during therapy. BUN and serum creatinine levels or CCr may
indicate renal failure.
Patient/Family Teaching
Instruct patient to take medication as directed for the full course of
therapy. Take missed doses as soon as possible but not just before next dose
is due; do not double doses. Acyclovir should not be used more frequently
or longer than prescribed.
Advise patients that the additional use of OTC creams, lotions, and
ointments may delay healing and may cause spreading of lesions.
Inform patient that acyclovir is not a cure. The virus lies dormant in the
ganglia, and acyclovir will not prevent the spread of infection to others.
Advise patient that condoms should be used during sexual contact and
that no sexual contact should be made while lesions are present.
Patient should consult health care professional if symptoms are not
relieved after 7 days of topical therapy or if oral acyclovir does not decrease
the frequency and severity of recurrences. Immunocompromised patients
may require a longer time, usually 2 weeks, for crusting over of lesions.
Instruct women with genital herpes to have yearly Papanicolaou smears
because they may be more likely to develop cervical cancer.
Topical: Instruct patient to apply ointment in sufficient quantity to
cover all lesions every 3 hr, 6 times/day for 7 days. 0.5-in. ribbon of
ointment covers approximately 4 square in. Use a finger cot or glove when
applying to prevent inoculation of other areas or spread to other people.
Keep affected areas clean and dry. Loose fitting clothing should be worn to
prevent irritation.
Avoid drug contact in or around eyes. Report any unexplained eye
symptoms to health care professional immediately; ocular herpetic
infection can lead to blindness.
Buccal: Instruct patient on correct application and use of buccal tablet. If
buccal tablet does not adhere or falls off within first 6 hours, reposition
immediately with same tablet. If tablet cannot be repositioned, apply new
tablet. If swallowed within first 6 hours, advise patient to drink a glass of
water and apply a new tablet. Do not reapply if tablet falls out after 6 hrs.
Chloramphenicol (klor-am-FEN-i-kole
Classification
Therapeutic: Antibiotic
Indications
Treatment of serious infections due to organisms resistant to other less
toxic antibiotics or when its penetrability into the site of infection is
clinically superior to other antibiotics to which the organism is sensitive;
useful in infections caused by Bacteroides, H. influenzae, Neisseria
meningitidis, Salmonella, and Rickettsia; active against many vancomycin-
resistant enterococci.
Action
Inhibiting of protein synthesis, irreversibly binds to a receptor site on the
50S subunit of the bacterial ribosomes, inhibiting peptidyl transferase. This
inhibition consequently results to the prevention of amino acid transfer to
growing peptide chains, ultimately leading to inhibition of protein
formation.
Adverse Reaction/ Side Effects
CNS: Confusion, delirium, depression, fever, headache Derm:
Angioedema, rash, urticaria GI: Diarrhea, enterocolitis, glossitis, nausea,
stomatitis, vomiting Hema: Aplastic anemia, bone marrow suppression,
granulocytopenia, hypoplastic anemia, pancytopenia, thrombocytopenia
Ocular: Optic neuritis Misc: Anaphylaxis, hypersensitivity reactions,
Gray syndrome.
NURSING IMPLICATIONS
Assessment
Lab tests: Perform bacterial culture and susceptibility tests prior to
first dose and periodically thereafter. Baseline CBC,platelets,serum
iron,and reticulocyte cell counts before initiation of therapy,at 48 h
intervals during therapy,and periodically.
Monitor chloramphenicol blood levels weekly or more frequently
with hepatic dysfunction and in patients receiving therapy for longer
than 2 wk. Desired concentrations: peak 1020 mcg/mL; through 510
mcg/mL. Monitor blood studies.
Chloramphenicol should be discontinued upon appearance of
leukopenia, reticulocytopenia,thrombocytopenia,or anemia. Non-
dose-related irreversible bone marrow depression may appear weeks
or months after drug therapy is terminated. The potential for this side
effect is greatest in patients with impaired hepatic or renal
function,infants,children,and premenopausal women.
Observe the patient closely,because blood studies are not always
reliable predictors of irreversible bone marrow depression.
Check temperature at least q4h. Usually chloramphenicol is
discontinued if temperature remains normal for 48 h. Monitor I&O
ratio or pattern: Report any appreciable change.
More frequent determinations of serum glucose are recommended in
patients receiving oral antidiabetic agents.
Monitor for S&S of Gray syndrome,which has occurred 29 d after
initiation of high dose chloramphenicol therapy in premature infants
and neonates and in children 2 y. Report early signs: abdominal
distention,failure to feed,pallor,changes in vital signs. Early detection
and prompt termination of therapy can interrupt a potentially fatal
course.
Patient & Family Education
A bitter taste may occur 1520 s after IV injection; it usually lasts only
23 min.
Report immediately sore throat, fever, fatigue, petechiae, nose bleeds,
bleeding gums, or other unusual bleeding or bruising, or any other
suspicious sign of symptom.
Drug therapy should be discontinued if abnormal bleeding occurs.
Watch for S&S of superinfection .
Follow dosage and duration of therapy as prescribed by physician.
Avoid prolonged or frequent intermittent use of topical preparations
because systemic absorption and toxicity can occur.
Withhold medication and check with physician immediately if signs
of hypersensitivity reaction irritation, superinfection, or other
adverse reactions appear.
Do not breast feed while taking this drug
famotidine (fa-moe-ti-deen)
Acid Control, Pepcid, Pepcid AC, Peptic Guard, Ulcidine
Classification
Therapeutic: antiulcer agents
Pharmacologic: histamine H2 antagonists
Pregnancy Category B
Indications
Short-term treatment of active duodenal ulcers and benign gastric ulcers.
Maintenance therapy for duodenal ulcers after healing of active ulcer(s).
Management of gastroesophageal reflux disease (GERD). Treatment of
heartburn, acid indigestion, and sour stomach (OTC use). Management of
gastric hypersecretory states (Zollinger- Ellison syndrome). Prevention
and treatment of stress-induced upper GI bleeding in critically ill patients.
Unlabeled Use: Management of GI symptoms associated with the use of
NSAIDs. Prevention of stress ulceration or aspiration pneumonitis.
Prevention of acid inactivation of supplemental pancreatic enzymes in
patients with pancreatic insufficiency. Management of urticaria.
Action
Inhibits the action of histamine at the H2-receptor site located primarily in
gastric parietal cells, resulting in inhibition of gastric acid secretion.
Therapeutic Effects: Healing and prevention of ulcers. Decreased
symptoms of gastroesophageal reflux. Decreased secretion of gastric acid.
Contraindications/Precautions
Contraindicated in: Hypersensitivity; Phenylketonuria (chewable tablets
only); OB: Crosses placenta; no adequate human studies; Lactation:
Discontinue breast feeding to avoid exposure of infant to serious side
effects.
Use Cautiously in: Renal impairment (more susceptible to adverse CNS
reactions; dosage interval recommended if CCr <10 mL/min); Pedi:
Injection contains benzyl alcohol which has been associated with gasping
syndrome in neonates; Geri: More susceptible to adverse CNS reactions;
dose recommended.
Adverse Reactions/Side Effects
CNS: confusion, dizziness, drowsiness, hallucinations, headache. CV:
ARRHYTHMIAS. GI: constipation, diarrhea, nausea. GU:psperm count,
erectile dysfunction. Endo: gynecomastia. Hemat:
AGRANULOCYTOSIS, APLASTIC ANEMIA, anemia, neutropenia,
thrombocytopenia. Local: pain at IM site. Misc: hypersensivity reactions.
NURSINGIMPLICATIONS
Assessment
Assess for epigastric or abdominal pain and frank or occult blood in the
stool, emesis, or gastric aspirate.
Geri: Assess elderly and debilitated patients routinely for confusion.
Report promptly.
Lab Test Considerations: Monitor CBC with differential periodically
during therapy.
Antagonize effects of pentagastrin and histamine during gastric acid
secretion testing. Avoid administration for 24 hr preceding the test.
May cause false-negative results in skin tests using allergenic extracts.
Histamine antagonists should be discontinued 24 hr prior to the test.
May cause an in serum transaminases and serum creatinine.
May cause false-positive results for urine protein; test with sulfosalicylic
acid.
Patient/Family Teaching
Instruct patient to take medication as directed for the full course of
therapy, even if feeling better. Take missed doses as soon as remembered
but not if almost time for next dose. Do not double doses.
Advise patients taking OTC preparations not to take the maximum dose
continuously for more than 2 wk without consulting health care
professional. Notify health care professional if difficulty swallowing occurs
or abdominal pain persists.
Inform patient that smoking interferes with the action of histamine
antagonists. Encourage patient to quit smoking or at least not to smoke
after last dose of the day.
May cause drowsiness or dizziness. Caution patient to avoid driving or
other activities requiring alertness until response to the drug is known.
Advise patient to avoid alcohol, products containing aspirin or NSAIDs,
and foods that may cause an increase in GI irritation.
Inform patient that increased fluid and fiber intake and exercise may
minimize constipation.
Advise patient to report onset of black, tarry stools; fever; sore throat;
diarrhea; dizziness; rash; confusion; or hallucinations to health care
professional promptly.
ferrous sulfate (30% elemental iron) (fer-us sul-fate)
Classification
Therapeutic: antianemics
Pharmacologic: iron supplements
Indications
PO: Treatment & prevention iron deficiency anemia.
Action
An essential mineral found in hemoglobin, myoglobin, and many enzymes.
Enters the bloodstream and is transported to the organs of the
reticuloendothelial system(liver, spleen, bone marrow) where it becomes
part of iron stores. Therapeutic Effects: Resolution or prevention of iron
deficiency anemia.
Contraindications/Precautions
Contraindicated in: Anemia not due to iron deficiency; Hemochromatosis;
Hemosiderosis; Hypersensitivity to iron products.
Use Cautiously in: Peptic ulcer disease; Ulcerative colitis or regional
enteritis (condition may be aggravated); Alcoholism; Severe hepatic
impairment; Severe renal impairment.
Adverse Reactions/Side Effects
CNS: dizziness, headache, syncope. GI: nausea, constipation, dark stools,
epigastric pain, GI bleeding, vomiting. Misc: temporary staining of teeth
(liquid preparations).
NURSING IMPLICATIONS
Assessment
Assess nutritional status and dietary history to determine possible cause
of anemia and need for patient teaching.
Assess bowel function for constipation or diarrhea. Notify physician or
other health care professional and use appropriate nursing measures should
these occur.
Lab Test Considerations: Monitor hemoglobin, hematocrit, and
reticulocyte values prior to and every 3 wk during the first 2 mo of therapy
and periodically thereafter. Serum ferritin and iron levels may also be
monitored to assess effectiveness of therapy.
Occult blood in stools may be obscured by black coloration of iron in
stool. Guaiac test results may occasionally be false-positive. Benzidine test
results are not affected by iron preparations.
 Toxicity and Overdose: Early symptoms of overdose include stomach pain,
fever, nausea, vomiting (may contain blood), and diarrhea. Late symptoms
include bluish lips, fingernails, and palms; drowsiness; weakness;
tachycardia; seizures; metabolic acidosis; hepatic injury; and cardiovascular
collapse. Patient may appear to recover prior to the onset of late symptoms.
Therefore, hospitalization continues for 24 hr after patient becomes
asymptomatic to monitor for delayed onset of shock or GI bleeding. Late
complications of overdose include intestinal obstruction, pyloric stenosis,
and gastric scarring.
If patient is comatose or seizing, gastric lavage with sodium bicarbonate
is performed. Deferoxamine is the antidote. Additional supportive
treatments to maintain fluid and electrolyte balance and correction of
metabolic acidosis are also indicated.
Patient/Family Teaching
Explain purpose of iron therapy to patient.
Encourage patient to comply with medication regimen. Take missed
doses as soon as remembered within 12 hr; otherwise, return to regular
dosing schedule. Do not double doses.
Advise patient that stools may become dark green or black.
Instruct patient to follow a diet high in iron.
terbutaline (ter-byoo-ta-leen)
Classification
Therapeutic: bronchodilators
Pharmacologic: adrenergics
Pregnancy Category B
Indications
Management of reversible airway disease due to asthma or COPD;
inhalation and subcut used for short-term control and oral agent as long-
term control. Unlabeled Use: Management of preterm labor (tocolytic)
(the FDA has recommended that injectable terbutaline should not be used
in pregnancy for the prevention or prolonged treatment [>4872 hr] of
preterm labor in either the inpatient or outpatient settings because of the
potential for serious maternal heart problems and death; oral terbutaline
should not be used for the prevention or any treatment of preterm labor
because of a lack of efficacy and the potential for serious material heart
problems and death).
Action
Results in the accumulation of cyclic adenosine monophosphate (cAMP) at
beta-adrenergic receptors. Produces bronchodilation. Inhibits the release of
mediators of immediate hypersensitivity reactions from mast cells.
Relatively selective for beta2(pulmonary)-adrenergic receptor sites, with
less effect on beta1(cardiac)-adrenergic receptors. Therapeutic Effects:
Bronchodilation.
Contraindications/Precautions
Contraindicated in: Hypersensitivity to adrenergic amines.
Use Cautiously in: Cardiac disease; Hypertension; Hyperthyroidism;
Diabetes; Glaucoma; Geri: More susceptible to adverse reactions; may
require dose ; Excessive use may lead to tolerance and paradoxical
bronchospasm (inhaler); OB, Lactation: Pregnancy (near term) and
lactation.
Adverse Reactions/Side Effects
CNS: nervousness, restlessness, tremor, headache, insomnia. Resp:
pulmonary edema. CV: angina, arrhythmias, hypertension, myocardial
ischemia, tachycardia. GI: nausea, vomiting. Endo: hyperglycemia. F and
E: hypokalemia.
NURSING IMPLICATIONS
Assessment
Bronchodilator: Assess lung sounds, respiratory pattern, pulse, and BP
before administration and during peak of medication. Note amount, color,
and character of sputum produced, and notify health care professional of
abnormal findings.
Monitor pulmonary function tests before initiating therapy and
periodically throughout therapy to determine effectiveness of medication.
Preterm Labor: Monitor maternal pulse and BP, frequency and duration
of contractions, and fetal heart rate. Notify health care professional if
contractions persist or increase in frequency or duration or if symptoms of
maternal or fetal distress occur. Maternal side effects include tachycardia,
palpitations, tremor, anxiety, and headache.
Assess maternal respiratory status for symptoms of pulmonary edema
(increased rate, dyspnea, rales/crackles, frothy sputum).
Monitor mother and neonate for symptoms of hypoglycemia (anxiety;
chills; cold sweats; confusion; cool, pale skin; difficulty in concentration;
drowsiness; excessive hunger; headache; irritability; nausea; nervousness;
rapid pulse; shakiness; unusual tiredness; or weakness) and mother for
hypokalemia (weakness, fatigue, U wave on ECG, arrhythmias).
Lab Test Considerations: May cause transientpin serum potassium
concentrations with higher than recommended doses.
Monitor maternal serum glucose and electrolytes. May cause
hypokalemia and hypoglycemia. Monitor neonates serum glucose, because
hypoglycemia may also occur in neonates.
Toxicity and Overdose: Symptoms of overdose include persistent agitation,
chest pain or discomfort, decreased BP, dizziness, hyperglycemia,
hypokalemia, seizures, tachyarrhythmias, persistent trembling, and
vomiting.
Treatment includes discontinuing beta-adrenergic agonists and
symptomatic, supportive therapy. Cardioselective beta blockers are used
cautiously, because they may induce bronchospasm.
Patient/Family Teaching
Instruct patient to take medication as directed. If on a scheduled dosing
regimen, take a missed dose as soon as possible; space remaining doses at
regular intervals. Do not double doses. Caution patient not to exceed
recommended dose; may cause adverse effects, paradoxical bronchospasm,
or loss of effectiveness of medication.
Instruct patient to contact health care professional immediately if
shortness of breath is not relieved by medication or is accompanied by
diaphoresis, dizziness, palpitations, or chest pain.
Advise patient to consult health care professional before taking any OTC
medications or alcoholic beverages concurrently with this therapy. Caution
patient also to avoid smoking and other respiratory irritants.
Preterm Labor: Notify health care professional immediately if labor
resumes or if significant side effects occur.
carvedilol (kar-ve-di-lole)
Classification
Therapeutic: antihypertensives
Pharmacologic: beta blockers
Pregnancy Category C
Indications
Hypertension. HF (ischemic or cardiomyopathic) with digoxin, diuretics,
and ACE inhibitors. Left ventricular dysfunction aftermyocardial
infarction.
Action
Blocks stimulation of beta1(myocardial) and beta2 (pulmonary, vascular,
and uterine)- adrenergic receptor sites. Also has alpha1 blocking activity,
which may result in orthostatic hypotension. Therapeutic Effects:
Decreased heart rate and BP. Improved cardiac output, slowing of the
progression of HF and decreased risk of death.
Contraindications/Precautions
Contraindicated in: History of serious hypersensitivity reaction (Stevens-
Johnson syndrome, angioedema, anaphylaxis); Pulmonary edema;
Cardiogenic shock; Bradycardia, heart block or sick sinus syndrome (unless
a pacemaker is in place); Uncompensated HF requiring IV inotropic agents
(wean before starting carvedilol); Severe hepatic impairment; Asthma or
other bronchospastic disorders. Use Cautiously in: HF (condition may
deteriorate during initial therapy); Renal impairment; Hepatic impairment;
Diabetes mellitus (may mask signs of hypoglycemia); Thyrotoxicosis
(may mask symptoms); Peripheral vascular disease; History of severe
allergic reactions (intensity of reactions may be increased); OB: Crosses
placenta and may cause fetal/neonatal bradycardia, hypotension,
hypoglycemia, or respiratory depression); Lactation, Pedi: Safety not
established; Geri: sensitivity to beta blockers; initial dose reduction
recommended.
Adverse Reactions/Side Effects
CNS: dizziness, fatigue, weakness, anxiety, depression, drowsiness,
insomnia, memory loss, mental status changes, nervousness, nightmares.
EENT: blurred vision, dry eyes, intraoperative floppy iris syndrome, nasal
stuffiness. Resp: bronchospasm, wheezing. CV: BRADYCARDIA, HF,
PULMONARY EDEMA. GI: diarrhea, constipation, nausea. GU: erectile
dysfunction, libido. Derm: STEVENS-JOHNSON SYNDROME,
TOXIC EPIDERMAL NECROLYSIS, itching, rashes, urticaria. Endo:
hyperglycemia, hypoglycemia. MS: arthralgia, back pain, muscle cramps.
Neuro: paresthesia. Misc: ANAPHYLAXIS, ANGIOEDEMA, drug-
induced lupus syndrome.
NURSINGIMPLICATIONS
Assessment
Monitor BP and pulse frequently during dose adjustment period and
periodically during therapy. Assess for orthostatic hypotension when
assisting patient up from supine position.
Monitor intake and output ratios and daily weight. Assess patient
routinely for evidence of fluid overload (peripheral edema, dyspnea, rales/
crackles, fatigue, weight gain, jugular venous distention). Patients may
experience worsening of symptoms during initiation of therapy for HF.
Hypertension: Check frequency of refills to determine adherence.
Lab Test Considerations: May cause BUN, serum lipoprotein, potassium,
triglyceride, and uric acid levels.
May cause ANA titers.
May cause in blood glucose levels.
Toxicity and Overdose: Monitor patients receiving beta blockers for signs
of overdose (bradycardia, severe dizziness or fainting, severe drowsiness,
dyspnea, bluish fingernails or palms, seizures). Notify health care
professional immediately if these signs occur.
Patient/Family Teaching
Instruct patient to take medication as directed, at the same time each
day, even if feeling well. Do not skip or double up on missed doses. Take
missed doses as soon as possible up to 4 hr before next dose. Abrupt
withdrawal may precipitate life-threatening arrhythmias, hypertension, or
myocardial ischemia.
Advise patient to make sure enough medication is available for
weekends, holidays, and vacations. A written prescription may be kept in
wallet in case of emergency.
Teach patient and family how to check pulse and BP. Instruct them to
check pulse daily and BP biweekly. Advise patient to hold dose and contact
health care professional if pulse is_50 bpm or BP changes significantly.
May cause drowsiness or dizziness. Caution patients to avoid driving or
other activities that require alertness until response to the drug is known.
Advise patient to change positions slowly to minimize orthostatic
hypotension, especially during initiation of therapy or when dose is
increased.
Caution patient that this medication may increase sensitivity to cold.
Instruct patient to notify health care professional of all Rx or OTC
medications, vitamins, or herbal products being taken and to consult health
care professional before taking other Rx, OTC, or herbal products,
especially cold preparations, concurrently with this medication.
Patients with diabetes should closely monitor blood glucose, especially if
weakness, malaise, irritability, or fatigue occurs. Medication may mask
some signs of hypoglycemia, but dizziness and sweating may still occur.
Advise patient to notify health care professional if slow pulse, difficulty
breathing, wheezing, cold hands and feet, dizziness, confusion, depression,
rash, fever, sore throat, unusual bleeding, or bruising occurs.
Instruct patient to inform health care professional of medication regimen
before treatment or surgery.
Advise patient to carry identification describing disease process and
medication regimen at all times.
Hypertension: Reinforce the need to continue additional therapies for
hypertension (weight loss, sodium restriction, stress reduction, regular
exercise, moderation of alcohol consumption, and smoking cessation).
Medication controls but does not cure hypertension.
cefuroxime (se-fyoor-ox-eem)
Classification
Therapeutic: anti-infectives
Pharmacologic: second-generation cephalosporins
Pregnancy Category B
Indications
Treatment of: Respiratory tract infections, Skin and skin structure
infections, Bone and joint infections (IV), Urinary tract infections ,
Gynecological infections, Septicemia (IV), Otitis media (PO), Meningitis
(IV), Lyme disease (PO). Perioperative prophylaxis (IV).
Action
Binds to bacterial cell wall membrane, causing cell death. Therapeutic
Effects: Bactericidal action against susceptible bacteria. Spectrum: Similar
to that of first generation cephalosporins but has increased activity against
several other gram-negative pathogens including: Haemophilus influenzae
(including -lactamase-producing strains), Haemophilus parainfluenzae,
Escherichia coli, Klebsiella pneumoniae, Neisseria , Proteus, Moraxella
catarrhalis, Borrelia burgdorferi. Not active against methicillin-resistant
staphylococci or enterococci.
Contraindications/Precautions
Contraindicated in: Hypersensitivity to cephalosporins; Serious
hypersensitivity to penicillins.
Use Cautiously in: Renal impairment (dose reduction/increased dosing
interval recommended if CCr 20 mL/min); History of GI disease,
especially colitis; Geriatric patients (dose adjustment may be required due
to age-relatedpin renal function); Pregnancy and lactation (has been used
safely).
Adverse Reactions/Side Effects
CNS: SEIZURES (high doses). GI: PSEUDOMEMBRANOUS
COLITIS, diarrhea, nausea, vomiting, cramps. Derm: rashes, urticaria,
diaper dermatitis. Hemat: bleeding, eosinophilia, hemolytic anemia,
leukopenia. Local: pain at IM site, phlebitis at IV site. Misc: allergic
reactions including ANAPHYLAXIS, superinfection.
NURSING IMPLICATIONS
Assessment
Assess for infection (vital signs; appearance of wound, sputum, urine,
and stool; WBC) at beginning of and throughout therapy.
Before initiating therapy, obtain a history to determine previous use of
and reactions to penicillins or cephalosporins. Persons with a negative
history of penicillin sensitivity may still have an allergic response.
Obtain specimens for culture and sensitivity before initiating therapy.
First dose may be given before receiving results.
Observe patient for signs and symptoms of anaphylaxis (rash, pruritus,
laryngeal edema, wheezing). Discontinue the drug and notify health care
professional immediately if these symptoms occur. Keep epinephrine, an
antihistamine, and resuscitation equipment close by in the event of an
anaphylactic reaction.
Monitor bowel function. Diarrhea, abdominal cramping, fever, and
bloody stools should be reported to health care professional promptly
as a sign of pseudomembranous colitis. May begin up to several weeks
following cessation of therapy.
Lab Test Considerations: May cause positive results for Coombs test.
 May cause serum AST, ALT, alkaline phosphatase, bilirubin, LDH,
BUN, and creatinine.
May rarely cause leukopenia, neutropenia, and eosinophilia.
Patient/Family Teaching
Instruct patient to take medication around the clock at evenly spaced
times and to finish the medication completely, even if feeling better.
Missed doses should be taken as soon as possible unless almost time for
next dose; do not double doses. Advise patient that sharing of this
medication may be dangerous. Pedi: Tell parents or caregivers to use
calibrated measuring device with liquid preparations.
Advise patient to report signs of superinfection (furry overgrowth on the
tongue, vaginal itching or discharge, loose or foul-smelling stools) and
allergy.
Instruct patient to notify health care professional if fever and diarrhea
develop, especially if stool contains blood, pus, or mucus. Advise patient
not to treat diarrhea without consulting health care professional.
metronidazole (me-troe-ni-da-zole)
Classification
Therapeutic: anti-infectives, antiprotozoals, antiulcer agents
Pregnancy Category B
Indications
PO, IV: Treatment of the following anaerobic infections: Intra-abdominal
infections (may be used with a cephalosporin), Gynecologic infections,
Skin and skin structure infections, Lower respiratory tract infections, Bone
and joint infections, CNS infections, Septicemia, Endocarditis. IV
Perioperative prophylactic agent in colorectal surgery. PO: Amebicide in
the management of amebic dysentery, amebic liver abscess, and
trichomoniasis: Treatment of peptic ulcer disease caused by Helicobacter
pylori. Topical Treatment of acne rosacea. Vag: Management of bacterial
vaginosis. Unlabeled Use: Treatment of giardiasis. Treatment of anti-
infective associated pseudomembranous colitis.
Action
Disrupts DNA and protein synthesis in susceptible organisms. Therapeutic
Effects: Bactericidal, trichomonacidal, or amebicidal action. Spectrum:
Most notable for activity against anaerobic bacteria, including: Bacteroides,
Clostridium. In addition, is active against: Trichomonas vaginalis, Entamoeba
histolytica, Giardia lamblia, H. pylori, Clostridium difficile.
Contraindications/Precautions
Contraindicated in: Hypersensitivity; Hypersensitivity to parabens
(topical only); OB: First trimester of pregnancy.
Use Cautiously in: History of blood dyscrasias; History of seizures or
neurologic problems; Severe hepatic impairment (dosepsuggested); OB:
Although safety not established, has been used to treat trichomoniasis in
2nd- and 3rd-trimester pregnancy but not as single-dose regimen;
Lactation: If needed, use single dose and interrupt nursing for 24 hr
thereafter; Patients receiving corticosteroids or predisposed to edema
(injection contains 28mEq sodium/g metronidazole).
Adverse Reactions/Side Effects
CNS: SEIZURES, dizziness, headache, aseptic meningitis (IV),
encephalopathy (IV). EENT: optic neuropathy, tearing (topical only). GI:
abdominal pain, anorexia, nausea, diarrhea, dry mouth, furry tongue,
glossitis, unpleasant taste, vomiting. Derm: STEVENS-JOHNSON
SYNDROME, rash, urticariatopical only, burning, mild dryness, skin
irritation, transient redness. Hemat: leukopenia. Local: phlebitis at IV site.
Neuro: peripheral neuropathy. Misc: superinfection.
NURSING IMPLICATIONS
Assessment
Assess for infection (vital signs; appearance of wound, sputum, urine,
and stool; WBC) at beginning of and throughout therapy.
Obtain specimens for culture and sensitivity before initiating therapy.
First dose may be given before receiving results.
Monitor neurologic status during and after IV infusions. Inform health
care professional if numbness, paresthesia, weakness, ataxia, or seizures
occur.
Assess for rash periodically during therapy. May cause Stevens-Johnson
syndrome. Discontinue therapy if severe or if accompanied with fever,
general malaise, fatigue, muscle or joint aches, blisters, oral lesions,
conjunctivitis, hepatitis and/or eosinophilia.
Giardiasis: Monitor three stool samples taken several days apart,
beginning 34 wk after treatment.
Lab Test Considerations: May alter results of serum AST, ALT, and LDH
tests.
Patient/Family Teaching
Advise patients treated for trichomoniasis that sexual partners may be
asymptomatic sources of reinfection and should be treated concurrently.
Patient should also refrain fromintercourse or use a condom to prevent
reinfection.
Caution patient to avoid intake of alcoholic beverages or preparations
containing alcohol during and for at least 3 days after treatment with
metronidazole, including vaginal gel. May cause a disulfiram-like reaction
(flushing, nausea, vomiting, headache, abdominal cramps).
May cause dizziness or light-headedness. Caution patient to avoid
driving or other activities requiring alertness until response to medication
is known.
Instruct patient to notify health care professional promptly if rash
occurs.
Inform patient that medication may cause an unpleasant metallic taste.
Advise patient to notify health care professional of all Rx or OTC
medications, vitamins, or herbal products being taken and to consult with
health care professional before taking other medications.
Advise patient that frequent mouth rinses, good oral hygiene, and
sugarless gum or candy may minimize dry mouth. Notify health care
professional if dry mouth persists for more than 2 wk.
Inform patient that medication may cause urine to turn dark.
Advise patient to consult health care professional if no improvement in a
few days or if signs and symptoms of superinfection (black, furry
overgrowth on tongue; vaginal itching or discharge; loose or foul-smelling
stools) develop.
Advise patient to inform health care professional if pregnancy is
suspected before taking this medication or if breast feeding.
Vag: Instruct patient in correct technique for intravaginal instillation.
Advise patient to avoid intercourse during treatment with vaginal gel.
Topical: Instruct patient on correct technique for application of topical
gel. Cosmetics may be used after application of gel.
azithromycin (aye-zith-roe-mye-sin)
Classification
Therapeutic: agents for atypicalmycobacterium, anti-infectives
Pharmacologic: macrolides
Pregnancy Category B
Indications
Treatment of the following infections due to susceptible organisms: Upper
respiratory tract infections, including streptococcal pharyngitis, acute
bacterial exacerbations of chronic bronchitis and tonsillitis, Lower
respiratory tract infections, including bronchitis and pneumonia, Acute
otitis media, Skin and skin structure infections, Nongonococcal urethritis,
cervicitis, gonorrhea, and chancroid. Prevention of disseminated
Mycobacterium avium complex (MAC) infection in patients with advanced
HIV infection. Extended-release suspension (ZMax) Acute bacterial sinusitis
and community-acquired pneumonia in adults. Unlabeled Use: Prevention
of bacterial endocarditis. Treatment of cystic fibrosis lung disease.
Treatment and post exposure
prophylaxis of pertussis in infants.
Action
Inhibits protein synthesis at the level of the 50S bacterial ribosome.
Therapeutic Effects: Bacteriostatic action against susceptible bacteria.
Spectrum: Active against the following gram-positive aerobic bacteria:
Staphylococcus aureus, Streptococcus pneumoniae, S. pyogenes (group A strep).
Active against these gram-negative aerobic bacteria: Haemophilus influenzae,
Moraxella catarrhalis, Neisseria gonorrhoeae. Also active against: Bordetella
pertussis, Mycoplasma, Legionella, Chlamydia pneumoniae, Ureaplasma
urealyticum, Borrelia burgdorferi, M. avium. Not active against methicillin-
resistant S. aureus.
Contraindications/Precautions
Contraindicated in: Hypersensitivity to azithromycin, erythromycin, or
other macrolide anti-infectives; History of cholestatic jaundice or hepatic
dysfunction with prior use of azithromycin.; QT interval prolongation,
hypokalemia, hypomagnesemia, or bradycardia.; Concurrent use of
quinidine, procainamide, dofetilide, amiodarone, or sotalol.
Use Cautiously in: Severe liver impairment (dose adjustment may be
required); Severe renal impairment (CCr <10 mL/min); Myasthenia gravis
(may worsen symptoms); Geri: May have risk of QT interval
prolongation; OB, Lactation: Safety not established.
Adverse Reactions/Side Effects
CNS: dizziness, seizures, drowsiness, fatigue, headache. CV: TORSADES
DE POINTES, chest pain, hypotension, palpitations, QT interval
prolongation. GI: HEPATOTOXICITY, PSEUDOMEMBRANOUS
COLITIS, abdominal pain, diarrhea, nausea, cholestatic jaundice, liver
enzymes, dyspepsia, flatulence, melena, oral candidiasis, pyloric stenosis.
GU: nephritis, vaginitis. Hemat: anemia, leukopenia, thrombocytopenia.
Derm: STEVENS-JOHNSON SYNDROME, TOXIC EPIDERMAL
NECROLYSIS, photosensitivity, rash. EENT: ototoxicity. F and E:
hyperkalemia. Misc: ANGIOEDEMA.
NURSING IMPLICATIONS
Assessment
Assess patient for infection (vital signs; appearance of wound, sputum,
urine, and stool; WBC) at beginning of and throughout therapy.
Obtain specimens for culture and sensitivity before initiating therapy.
First dose may be given before receiving results.
Observe for signs and symptoms of anaphylaxis (rash, pruritus,
laryngeal edema, wheezing). Notify health care professional immediately
if these occur.
Assess patient for skin rash frequently during therapy. Discontinue
azithromycin at first sign of rash; may be life-threatening. Stevens-
Johnson syndrome or toxic epidermal necrolysis may develop. Treat
symptomatically; may recur once treatment is stopped.
Lab Test Considerations: May cause serum bilirubin, AST, ALT, LDH,
and alkaline phosphatase concentrations.
May cause creatine phosphokinase, potassium, prothrombin time,
BUN, serum creatinine, and blood glucose concentrations.
Patient/Family Teaching
Instruct patients to take medication as directed and to finish the drug
completely, even if they are feeling better. Take missed doses as soon as
possible unless almost time for next dose; do not double doses. Advise
patients that sharing of this medication may be dangerous.
Instruct patient not to take azithromycin with food or antacids.
May cause drowsiness and dizziness. Caution patient to avoid driving or
other activities requiring alertness until response to medication is known.
Advise patient to use sunscreen and protective clothing to prevent
photosensitivity reactions.
Advise patient to report symptoms of chest pain, palpitations, yellowing
of skin or eyes, or signs of superinfection (black, furry overgrowth on the
tongue; vaginal itching or discharge; loose or foul-smelling stools) or rash.
Instruct patient to notify health care professional if fever and diarrhea
develop, especially if stool contains blood, pus, or mucus. Advise patient
not to treat diarrhea without advice of health care professional.
Advise patients being treated for nongonococcal urethritis or cervicitis
that sexual partners should also be treated.
Instruct parents, caregivers, or patient to notify health care professional
if symptoms do not improve.
Pedi: Tell parents or caregivers that medication is generally well tolerated
in children. Most common side effects in children are mild diarrhea and
rash. Tell parents to notify health care practitioner if these occur.
Doxofylline
Classification
Therapeutic: antiasthma
INDICATIONS
For the treatment of COPD, bronchial asthma and pulmonary disease with
spastic bronchial component.
DOSAGE
Elderly Patients: 200 mg tablet two or three times daily.
Adults: 400 mg tablet two or three times daily or as prescribed by a
physician.
CONTRAINDICATIONS
This product is contraindicated in individuals who have shown
hypersensitivity to its components. It is also contraindicated in patients
with acute myocardial infarction, hypotension and in lactating women.
ADVERSE EFFECTS
After xanthine administration, nausea, vomiting, epigastric pain,
cephalalgia, irritability, insomnia, tachycardia, extrasystole, tachypnea, and
occasionally hyperglycemia and albuminuria, may occur. If a potential oral
overdose is established, the patient may present with severe arrhythmias
and seizure; these symptoms could be the first sign of intoxication.
Adverse reactions may cause the withdrawal from treatment; a lower dose
rechallenge may start only after the advice of physician.
SPECIAL PRECAUTIONS
The half-life of xanthine derivatives is influenced by a number of known
variables. It may be prolonged in patients with liver disease, in patients
with congestive heart failure, in those affected with chronic obstructive
lung disease or concomitant infections, and in those patients taking certain
other drugs (erythromycin, troleandomycin, lincomycin, and other
antibiotics of the same group, allopurinol, cimetidine, propranolol, and
anti-flu vaccine). In these cases, a lower dose of Doxofylline may be
needed. Phenytoins, other anti-convulsants and smoking may cause an
increase in clearance with a shorter mean half-life: in these cases higher
doses of Doxofylline may be needed. Use with caution in patients with
hypoxemia, hyperthyroidism, liver disease, renal disease, in those with
history of peptic ulcer and in elderly.
Frequently, patients with congestive heart failure have markedly prolonged
drug serum levels following discontinuation of the drug.
Use in Pregnancy and Lactation
Animal reproduction studies indicate that Doxofylline does not cause fetal
harm when administered to pregnant animals nor can affect reproduction
capacity. However, since there is limited experience in humans during
pregnancy, xanthines should be given to a pregnant woman only if clearly
needed. Doxofylline is contraindicated in nursing mothers.
DRUG INTERACTIONS AND OTHERS
Doxofylline should not be administered together with other xanthine
derivatives, including beverages and foods containing caffeine. Toxic
synergism with ephedrine has been documented for xanthines.
Concomitant therapy with erythromycin, troleandomycin, lincomycin,
clindamycin, allopurinol, cimetidine, propranolol and anti-flu vaccine may
decrease the hepatic clearance of xanthines causing an increase in blood
levels.

Paracetamol (also known as acetaminophen)
Classification
Therapeutic: analgesic and antipyretic
Indications
PO, Rect: Treatment of: Mild pain, Fever. IV Treatment of: Mild to
moderate pain, Moderate to severe pain with opioid analgesics, Fever.
Action
Inhibits the synthesis of prostaglandins that may serve as mediators of
pain and fever, primarily in the CNS. Has no significant anti-
inflammatory properties or GI toxicity.
TherapeuticEffects: Analgesia. Antipyresis
Contraindications/Precautions
Contraindicated in: Previous hypersensitivity; Products containing alcohol,
aspartame, saccharin, sugar, or tartrazine (FDC yellow dye #5) should be
avoided in patients who have hypersensitivity or intolerance to these
compounds; Severe hepatic impairment/active liver disease.
Use Cautiously in: Hepatic disease/renal disease (lower chronic doses
recommended); Alcoholism, chronic malnutrition, severe hypovolemia or
severe renal impairment (CCr <30 mL/min, dosing interval and daily
dose may be necessary); Chronic alcohol use/abuse; Malnutrition; OB: Use
in pregnancy only if clearly needed (for IV); Lactation: Use cautiously (for
IV); Pedi: Neonates (safety and effectiveness not established) (for IV).
Adverse Reactions/Side Effects
CNS: agitation ( in children) (IV), anxiety (IV), headache (IV), fatigue
(IV), insomnia (IV). Resp: atelectasis (qin children) (IV), dyspnea (IV).
CV: hypertension (IV), hypotension (IV). GI: HEPATOTOXICITY (
DOSES), constipation ( in children) (IV), liver enzymes, nausea (IV),
vomiting (IV). F and E: hypokalemia (IV). GU: renal failure (high
doses/chronic use). Hemat: neutropenia, pancytopenia. MS: muscle
spasms (IV), trismus (IV). Derm: ACUTE GENERALIZED
EXANTHEMATOUS PUSTULOSIS, STEVENS-JOHNSON
SYNDROME, TOXIC EPIDERMAL NECROLYSIS, rash, urticaria.
NURSING IMPLICATIONS
Assessment
Assess overall health status and alcohol usage before administering
acetaminophen. Patients who are malnourished or chronically abuse
alcohol are at higher risk of developing hepatotoxicity with chronic use of
usual doses of this drug.
Assess amount, frequency, and type of drugs taken in patients self-
medicating, especially with OTC drugs. Prolonged use of acetaminophen
increases the risk of adverse renal effects. For short-term use, combined
doses of acetaminophen and salicylates should not exceed the
recommended dose of either drug given alone. Do not exceed maximum
daily dose of acetaminophen when considering all routes of administration
and all combination products containing acetaminophen.
Pain: Assess type, location, and intensity prior to and 3060 min
following administration.
Fever: Assess fever; note presence of associated signs (diaphoresis,
tachycardia, and malaise).
Lab Test Considerations: Evaluate hepatic, hematologic, and renal function
periodically during prolonged, high-dose therapy.
May alter results of blood glucose monitoring. May cause falselypvalues
when measured with glucose oxidase/peroxidase method, but probably not
with hexokinase/ G6PD method. May also cause falselyqvalues with
certain instruments; see manufacturers instruction manual.
Increased serum bilirubin, LDH, AST, ALT, and prothrombin time may
indicate hepatotoxicity.
Toxicity and Overdose: If overdose occurs, acetylcysteine (Acetadote) is
the antidote.
Patient/Family Teaching
Advise patient to take medication exactly as directed and not to take
more than the recommended amount. Chronic excessive use of _4 g/day (2
g in chronic alcoholics) may lead to hepatotoxicity, renal or cardiac
damage. Adults should not take acetaminophen longer than 10 days and
children not longer than 5 days unless directed by health care professional.
Short-term doses of acetaminophen with salicylates or NSAIDs should not
exceed the recommended daily dose of either drug alone.
Advise patient to avoid alcohol (3 or more glasses per day increase the
risk of liver damage) if taking more than an occasional 12 doses and to
avoid taking concurrently with salicylates or NSAIDs for more than a few
days, unless directed by health care professional.
Advise patient to discontinue acetaminophen and notify health care
professional if rash occurs.
Inform patients with diabetes that acetaminophen may alter results of
blood glucose monitoring. Advise patient to notify health care professional
if changes are noted.
Caution patient to check labels on all OTC products. Advise patients to
avoid taking more than one product containing acetaminophen at a time to
prevent toxicity.
Advise patient to consult health care professional if discomfort or fever
is not relieved by routine doses of this drug or if fever is greater than
39.5_C (103F) or lasts longer than 3 days.
Pedi: Advise parents or caregivers to check concentrations of liquid
preparations. All OTC single ingredient acetaminophen liquid products
now come in a single concentration of 160 mg/5 mL. Errors have resulted
in serious liver damage. Have parents or caregivers determine the correct
formulation and dose for their child (based on the childs age/
weight), and demonstrate how to measure it using an appropriate
measuring device.
D5.09 NaCL
Indications and Usage
For Dextrose and Sodium Chloride Injection Intravenous solutions
containing dextrose and sodium chloride are indicated for parenteral
replenishment of fluid,minimal carbohydrate calories,and sodium chloride
as required by the clinical condition of the patient.
Warnings:
Solutions containing sodium ions should be used with great care,if at all,in
patients with congestive heart failure,severe renal insufficiency and in
clinical states in which there exists edema with sodium retention.
Excessive administration of potassium-free solutions may result in
significant hypokalemia. In patients with diminished renal function,
administration of solutions containing sodium ions may result in sodium
retention. The intravenous administration of these solutions can cause
fluid and/or solute overloading resulting in dilution of serum electrolyte
concentrations,overhydration, congested states or pulmonary edema. The
risk of dilutional states is inversely proportional to the electrolyte
concentrations of administered parenteral solutions. The risk of solute
overload causing congested states with peripheral and pulmonary edema is
directly proportional to the electrolyte concentrations of such solution.
Precautions
Clinical evaluation and periodic laboratory determinations are
necessary to monitor changes in fluid balance,electrolyte
concentrations and acid-base balance during prolonged parenteral
therapy or whenever the condition of the patient warrants such
evaluation.
Solutions containing dextrose should be used with caution in patients
with known subclinical or overt diabetes mellitus.
Caution must be exercised in the administration of parenteral
fluids,especially those containing sodium ions to patients receiving
corticosteroids or corticotropin.
Do not administer unless solution is clear and container is
undamaged. Discard unused portion.
Pregnancy Category C. Animal reproduction studies have not been
conducted with dextrose or sodium chloride. It is also not known
whether dextrose or sodium chloride can cause fetal harm when
administered to a pregnant woman or can affect reproduction
capacity. Dextrose or sodium chloride should be given to a pregnant
woman only if clearly needed.
Pediatric Use. The safety and effectiveness in the pediatric
population are based on the similarity of the clinical conditions of the
pediatric and adult populations. In neonates or very small infants,the
volume of fluid may affect fluid and electrolyte balance.
Frequent monitoring of serum glucose concentrations is required
when dextrose is prescribed to pediatric patients, particularly
neonates and low birth weight infants.
Geriatric Use. An evaluation of current literature revealed no clinical
experience identifying differences in response between elderly and
younger patients. In general,dose selection for an elderly patient
should be cautious,usually starting at the low end of the dosing
range,reflecting the greater frequency of decreased hepatic,renal,or
cardiac function,and of concomitant disease or other drug therapy.
Sodium ions are known to be substantially excreted by the
kidney,and the risk of toxic reactions may be greater in patients with
impaired renal function. Because elderly patients are more likely to
have decreased renal function,care should be taken in dose
selection,and it may be useful to monitor renal function.

Adverse Reactions
Reactions which may occur because of the solution or the technique of
administration include febrile response,infection at the site of
injection,venous thrombosis or phlebitis extending from the site of
injection,extravasation and hypervolemia. If an adverse reaction does
occur,discontinue the infusion, evaluate the patient,institute appropriate
therapeutic countermeasures and save the remainder of the fluid for
examination if deemed necessary.