NR 327 Medications List

Terbutaline Sulfate (Brethine) "terb" -beta-adrenergic for tocolysis -bronchodilator (also tx asthma)

**Tocolytic Drug ACTION: inhibits contractions, increasing placental blood flow & reducing intermittent pressure of the fetus against the pelvis and cord DOSAGE/ROUTE: -IV infusion: Start with 0.01 to 0.05 mg/min. Increase rate by 0.01 mg/min at 10- to 30-min intervals until contractions or the maximum dose of 0.08 mg/min is reached. Maintain this dose for 1 hr, then reduce the rate at 20-min intervals to reach the minimum maintenance dose when contractions stop. Continue maintenance dose for 12 hr or as ordered. -Subcutaneous (most common parenteral route): Intermittent injections, 0.25 mg, every 4 hr. By subcutaneous infusion pump: low-dose continuous (baseline) drug infusion plus intermittent bolus doses. The subcutaneous pump is typically placed and its programming for continuous and bolus doses is verified before removing the IV infusion line for terbutaline or magnesium sulfate. -Oral: Should not be used to either treat preterm labor or prevent recurrent preterm labor ONSET: 6-15 minutes CONTRAINDICATION: -should not be used >48-72 hrs for preterm labor. SIDE EFFECTS: -Cardiovascular: Maternal and fetal tachycardia, palpitations, cardiac dysrhythmias, chest pain, wide pulse pressure -Respiratory: Dyspnea, chest discomfort -Central nervous system: Tremors, restlessness, weakness, dizziness, headache -Metabolic: Hypokalemia, hyperglycemia -Gastrointestinal: Nausea, vomiting, reduced bowel motility -Skin: Flushing, diaphoresis NURSE CONSIDERATION: -assess Pt's apical HR & lung sounds before admin each dose. **DONT give if: HR >120 or lungs sound "wet". or tachycardia w/ SOB. -Terbutaline is not approved by the U.S. Food and Drug Administration (FDA) for inhibiting uterine activity and now carries a boxed warning and contraindications ("black box") against use as a tocolytic rather than its intended use as a bronchodilator. -Infusion rate is not increased or may be decreased if maternal pulse rate exceeds 120 beats per minute (bpm) or systolic blood pressure (BP) falls below 80 to 90 mm Hg. -Propranolol (Inderal)--> blocks beta-adrenergic drugs, should be available to reverse severe adverse effects.

Generic Name: metoclopramide Trade Name: Reglan antiemetics Preg Cat B

✓ INDICATION: prevent n/v -chemo, post surgery & when NG suctioning. ✓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. ✓DOSAGE/ROUTEPrevention of Chemotherapy-Induced Vomiting PO, IV (Adults and Children): 1-2 mg/kg 30 min before chemotherapy. Additional doses of 1-2 mg/kg may be given q 2-4 hr, pretreatment with diphenhydramine will ↓ the risk of extrapyramidal reactions to this dose. Facilitation of Small Bowel Intubation IV (Adultsand Children > 14 yr): 10 mg over 1-2 min. IV (Children 6-14 yr): 2.5-5 mg (dose should not exceed 0.5 mg/kg) over 1-2 min. IV (Children <6 yr): 0.1 mg/kg over 1-2 min. Diabetic Gastroparesis PO, IV (Adults): 10 mg 30 min before meals and at bedtime for 2-8 weeks. Gastroesophageal Reflux IM, IV (Adults): 10-15 mg 30 min before meals and at bedtime (not to exceed 0.5 mg/kg/day). A single dose of 20 mg may be given preventively. Some patients may respond to doses as small as 5 mg. IM, IV (Neonates, Infants, and Children): 0.4-0.8 mg/kg/day in 4 divided doses. Postoperative Nausea/Vomiting IM, IV (Adults and Children > 14 yr): 10 mg at the end of surgical procedure, repeat in 6-8 hr if needed. IM, IV (Children<14 yr): 0.1-0.2 mg/kg/dose, repeat in 6-8 hr if needed. Treatment of Hiccups PO, IM (Adults): 10-20 mg 4 times daily PO; may be preceded by a single 10-mg dose IM (unlabeled). ✓CONTRAINIDICATION: Hypersensitivity; Possible GI obstruction or hemorrhage; History of seizure disorders; Pheochromocytoma; Parkinson's disease. ✓SIDE EFFECTS: CNS: drowsiness, extrapyramidal reactions, restlessness NEUROLEPTIC MALIGNANT SYNDROME, 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. ✓ NURSING CONSIDERATIONS: • Assess NV abdominal distention, and bowel sounds before and after administration. • Assess for extrapyramidal side effects (parkinsonian—difficulty speaking or swallowing, loss of balance control, pill rolling, mask-like face, shuffling gait, rigidity, tremors; and dystonic—muscle spasms, twisting motions, twitching, inability to move eyes, weakness of arms or legs) periodically throughout course of therapy. • 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). • 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. PO: Administer doses 30 min before meals and at bedtime. • IM: For prevention of postoperative nausea and vomiting, inject IM near the end of surgery. ✓ PT TEACHING: • PEDS, used measurements for doses. risk for OD. • May cause drowsiness. safety • avoid ETOH and CNS depress.

Tocolytic Drugs: Drug that inhibits uterine contractions.

Classifications of drugs to inhibit preterm contractions include magnesium sulfate, calcium channel blockers such as nifedipine, prostaglandin synthesis inhibitors such as indomethacin, and beta-adrenergics such as terbutaline.

Generic Name: Fentanyl Trade Name: Sublimaze Classification: opioid agonists Sched II Preg Cat C

✓ACTION: Supplement in anesthesia. Used to decrease pain. Binds to opiate receptors in the CNS altering the response and perception of pain. ✓DOSAGE/ROUTE: IV/IM: 50-100mcg/dose q1-2h as needed (adjunct to general anesthesia: 2-50mcg/kg), Buccal (general): 100mcg, Buccal Soluble Film: 200mcg-1200mcg (no more than 4 doses per day, separate by at least 2 hours), Transdermal: 25mcg/hr initially, may increase after 3 days, Transmucosal: 200-400mcg for breakthrough pain, Epidural: Bolus of 100mcg followed by continuous infusion of 10mcg/ml concentration at 4- 12ml/hr ✓CONTRAINIDICATION: Hypersensitivity to fentanyl or adhesives; Patients who are not opioid tolerant Acute, mild, intermittent, or postoperative pain; Significant respiratory depression; Acute or severe bronchial asthma; Paralytic ileus; Severe hepatic or renal impairment Alcohol intolerance (small amounts of alcohol released into skin); OB: Not recommended during labor and delivery; Lactation: May cause adverse affects in infant. ✓SIDE EFFECTS: CNS: confusion, sedation, weakness, dizziness, restlessness. Resp: APNEA, bronchoconstriction, laryngospasm, respiratory depression. CV: bradycardia. GI: anorexia, constipation, dry mouth, nausea, vomiting. Derm: sweating, erythema. Local: application site reactions. MS: skeletal and thoracic muscle rigidity. Misc: physical dependence, psychological dependence. (Vallerand 549) Vallerand, April H., Cynthia Sanoski. Davis's Drug Guide for Nurses, 14th Edition. F.A. Davis Company, 06/2014. VitalBook file. ✓ NURSING CONSIDERATIONS: Establish baseline B/P and respirations. Assess type, location, intensity, and duration of pain. Resuscitative equipment and opiate antagonist (naloxone 0.5 mcg/kg) must be available. Assist with ambulation, monitor respiratory rate, B/P,heart rate, O2 Sats. Assess for pain relief. Increase fluids and administer stool softener to prevent constipation. ✓ PT TEACHING: Instruct patient in how and when to ask for and take pain medication. • Instruct patient in correct method for application and disposal of transdermal system. - May be worn while bathing, showering, or swimming. • avoid grapefruit juice during therapy. • May cause drowsiness or dizziness. • change positions slowly to minimize dizziness. • avoid CNS depress and ETOH • Advise patient that fever, electric blankets, heating pads, saunas, hot tubs, and heated water beds increase the release of fentanyl from the patch. • Advise patient that good oral hygiene, frequent mouth rinses, and sugarless gum or candy may decrease dry mouth.

Generic Name: Nalbuphine Hydrochloride Trade Name: Nubain Preg Cat C

✓ACTION: Binds to opiate receptors in the CNS. Alters the perception of and response to painful stimuli while producing generalized CNS depression. In addition, has partial antagonist properties, which may result in opioid withdrawal in physically dependent patients. ✓DOSAGE/ROUTE: Analgesia IM: Subcut: IV (Adults): Usual dose is 10 mg q 3-6 hr (maximum: 20 mg/dose or 160 mg/day). IM: Subcut: IV Children): 0.1-0.15 mg/kg q 3-6 hr (maximum: 20 mg/dose or 160 mg/day). Supplement to Balanced Anesthesia IV (Adults): Initial—0.3-3 mg/kg over 10-15 min. Maintenance—0.25-0.5 mg/kg as needed. Opioid-induced pruritus IV (Adults): 2.5-5 mg; may repeat dose. ✓CONTRAINIDICATION: Hypersensitivity to nalbuphine or bisulfites; Patients physically dependent on opioids and who have not been detoxified (may precipitate withdrawal). ✓SIDE EFFECTS: CNS: dizziness, headache, sedation, confusion, dysphoria, euphoria, floating feeling, hallucinations, unusual dreams. EENT: blurred vision, diplopia, miosis (high doses). Resp: respiratory depression. CV: hypertension, orthostatic hypotension, palpitations. GI: dry mouth, NV, constipation, ileus. GU: urinary urgency. Derm: clammy feeling, sweating. Misc: physical dependence, psychological dependence, tolerance. Interactions caution w/ MOAIs, CNS depress Drug-Natural Products: Concomitant use of kava-kava, valerian, skullcap, chamomile, or hops can ↑ CNS depression. ✓ NURSING CONSIDERATIONS: • Assess type, location, and intensity of pain before and 1 hr after IM or 30 min (peak) after IV administration. • Assess BP, pulse, and respirations before and periodically during administration. If respiratory rate is <10/min, assess level of sedation. • Lab Test Considerations: May cause ↑ serum amylase and lipase concentrations. Implementation •IM: Administer deep into well-developed muscle. Rotate sites of injections. • IV Administer slowly, each 10 mg over 3-5 min. ✓ PT TEACHING: • Instruct patient on how and when to ask for pain medication. • May cause drowsiness or dizziness. safety • Caution patient to change positions slowly to minimize orthostatic hypotension. • Advise patient that frequent mouth rinses, good oral hygiene, and sugarless gum or candy may decrease dry mouth. • Encourage patient to turn, cough, and breathe deeply every 2 hr to prevent atelectasis. • Advise patient to avoid concurrent use of alcohol or other CNS depressants with this medication.

Generic Name: oxycodone/APAP Trade Name: (Percocet) Sched II Preg Cat B

✓ACTION: Binds to opiate receptors in the CNS. Alters the perception of and response to painful stimuli, while producing generalized CNS depression. Therapeutic Effects: Decreased pain. ✓DOSAGE/ROUTE: Larger doses may be required during chronic therapy PO (Adults ≥50 kg): 5-10 mg q 3-4 hr initially, as needed. Controlled-release tablets (Oxycontin) may be given q 12 hr. PO (Adults <50 kg): 0.2 mg/kg q 3-4 hr initially, as needed. PO (Children): 0.05-0.15 mg/kg q 4-6 hr as needed, as immediate-release product Rect (Adults): 10-40 mg 3-4 times daily initially, as needed. ✓CONTRAINIDICATION: Hypersensitivity; Some products contain alcohol or bisulfites and should be avoided in patients with known intolerance or hypersensitivity; Significant respiratory depression; Paralytic ileus; Acute or severe bronchial asthma. Acute, mild, intermittent, or postoperative pain (extended-release); ✓SIDE EFFECTS: CNS: confusion, sedation, dizziness, dysphoria, euphoria, floating feeling, hallucinations, headache, unusual dreams. EENT: blurred vision, diplopia, miosis. Resp: RESPIRATORY DEPRESSION. CV: orthostatic hypotension. GI: constipation, dry mouth, choking, GI obstruction, nausea, vomiting. GU: urinary retention. Derm: flushing, sweating. Misc: physical dependence, psychological dependence, tolerance. ✓ NURSING CONSIDERATIONS: • assess pain • Assess BP, pulse, and respirations before and periodically during administration. If respiratory rate is <10/min, assess level of sedation. Physical stimulation may be sufficient to prevent significant hypoventilation. Dose may need to be decreased by 25-50%. Initial drowsiness will diminish with continued use. • assess bowl function • Lab Test Considerations: May ↑ plasma amylase and lipase levels. ✓ PT TEACHING: • Instruct patient on how and when to ask for and take pain medication. • Medication may cause drowsiness or dizziness. Advise patient to call for assistance when ambulating or smoking. Caution patient to avoid driving and other activities requiring alertness until response to medication is known. • Advise patients taking Oxycontin tablets that empty matrix tablets may appear in stool. • Advise patient to make position changes slowly to minimize orthostatic hypotension. • Advise patient to avoid concurrent use of alcohol or other CNS depressants with this medication. • Encourage patient to turn, cough, and breathe deeply every 2 hr to prevent atelectasis. • Advise patient to notify health care professional if pregnancy is planned or suspected, or if breast feeding.

Generic Name: Ondansetron Trade Name: Zofran Therapeutic: antiemetics Pharmacologic: 5-HT3 antagonists Pregnancy Category B

✓ACTION: Blocks the effects of serotonin at 5-HT3-receptor sites (selective antagonist) located in vagal nerve terminals and the chemoreceptor trigger zone in the CNS. Therapeutic Effects: Decreased incidence and severity of nausea and vomiting following chemotherapy or surgery. ✓DOSAGE/ROUTE: PO (Adults): Prevention of nausea/vomiting associated with highly-emetogenic chemotherapy—24 mg 30 min prior to chemotherapy. PO (Adults and Children >11 yr): Prevention of nausea/vomiting associated with moderately emetogenic chemotherapy—8 mg 30 min prior to chemotherapy and repeated 8 hr later; 8 mg q 12 hr may be given for 1-2 days following chemotherapy. Prevention of radiation-induced nausea/vomiting—8 mg 1-2 hr prior to radiation; may be repeated q 8 hr, depending on type, location, and extent of radiation. Prevention of postoperative nausea/vomiting—16 mg 1 hr before induction of anesthesia. PO (Children 4-11 yr): Prevention of nausea/vomiting associated with moderately emetogenic chemotherapy—4 mg 30 min prior to chemotherapy and repeated 4 and 8 hr later; 4 mg q 8 hr may be given for 1-2 days following chemotherapy. IV (Adults): Prevention of chemotherapy-induced nausea/vomiting—0.15 mg/kg (max dose = 16 mg) 30 min prior to chemotherapy, repeated 4 and 8 hr later. IM, IV (Adults): Prevention of postoperative nausea/vomiting—4 mg before induction of anesthesia or postoperatively. IV (Children 6 mo-18 yr): Prevention of chemotherapy-induced nausea/vomiting—0.15 mg/kg (max dose = 16 mg) 30 min prior to chemotherapy, repeated 4 and 8 hr later. IV (Children 1 mo-12 yr and >40 k g): Prevention of postoperative nausea/vomiting—4 mg. IV (Children 1 mo-12 yr and ≤40 kg): Prevention of postoperative nausea/vomiting—0.1 mg/kg. Hepatic Impairment IM, IV (Adults): Severe hepatic impairment—Not to exceed 8 mg/day. ✓CONTRAINIDICATION: Hypersensitivity; Orally disintegrating tablets contain aspartame and should not be used in patients with phenylketonuria; Congenital long QT syndrome; Concurrent use of apomorphine. OB: Lactation, Pedi: Pregnancy, lactation, or children ≤3 yr (PO) or <1 mo (parenteral) (safety not established). ✓SIDE EFFECTS: CNS: headache, dizziness, drowsiness, fatigue, weakness. CV: TORSADE DE POINTES, QT interval prolongation. GI: constipation, diarrhea, abdominal pain, dry mouth, ↑ liver enzymes. Neuro: extrapyramidal reactions. Interactions Drug-Drug: Use with apomorphine ↑ risk of severe hypotension and loss of consciousness; concurrent use contraindicated. Carbamazepine, phenytoin, and rifampin may ↓ levels. ✓ NURSING CONSIDERATIONS: • assess n/v abd pain and distention before admin • Assess patient for EPS • Monitor ECG in patients with hypokalemia, hypomagnesemia, HF, bradyarrhythmias, or patients taking concomitant medications that prolong the QT interval. • Lab Test Considerations: May cause transient ↑ in serum bilirubin, AST, and ALT levels. ✓ PT TEACHING: • Instruct patient to take ondansetron as directed. • Advise patient to notify health care professional immediately if symptoms of irregular heart beat or involuntary movement of eyes, face, or limbs occur.

Generic Name: Naloxone Trade Name: Narcan

✓ACTION: Competitively blocks the effects of opioids, including CNS and respiratory depression, without producing any agonist (opioid-like) effects. Therapeutic Effects: Reversal of signs of opioid excess. ✓DOSAGE/ROUTE: IV (Adults): 0.02-0.2 mg q 2-3 min until response obtained; repeat q 1-2 hr if needed. IV (Children): 0.01 mg/kg; may repeat q 2-3 min until response obtained. Additional doses may be given q 1-2 hr if needed. IM, IV, Subcut (Neonates): 0.01 mg/kg; may repeat q 2-3 min until response obtained. Additional doses may be given q 1-2 hr if needed. Opioid-Induced Respiratory Depression During Chronic (>1 wk) Opioid Use IV, IM, Subcut, (Adults >40 kg): 20-40 mcg (0.02-0.04 mg) given as small, frequent (q min) boluses or as an infusion titrated to improve respiratory function without reversing analgesia. IV, IM, Subcut, (Adults and Children <40 kg): 0.005-0.02 mg/dose given as small, frequent (q min) boluses or as an infusion titrated to improve respiratory function without reversing analgesia. Overdose of Opioids IV, IM, Subcut, (Adults): Patients not suspected of being opioid dependent—0.4 mg (10 mcg/kg); may repeat q 2-3 min (IV route is preferred). Some patients may require up to 2 mg. Patients suspected to be opioid dependent—Initial dose should be ↓ to 0.1-0.2 mg q 2-3 min. May also be given by IV infusion at rate adjusted to patient's response. IV, IM, Subcut, (Children > 5 yr or > 20 kg): 2 mg/dose, may repeat q 2-3 min. IV, IM, Subcut, (Infants up to 5 yr or 20 kg): 0.1 mg/kg, may repeat q 2-3 min. Opioid-Induced Pruritus IV (Children): 2 mcg/kg/hr continuous infusion, may ↑ by 0.5 mcg/kg/hr every few hours if pruritus continues. ✓CONTRAINIDICATION: Hypersensitivity. Use Cautiously in: Cardiovascular disease; Patients physically dependent on opioids (may precipitate severe withdrawal); OB: May cause acute withdrawal syndrome in mother and fetus if mother is opioid dependent; Lactation: Safety not established; Pedi: May cause acute withdrawal syndrome in neonates of opioid-dependent mothers. ✓SIDE EFFECTS: VENTRICULAR ARRHYTHMIAS, hypertension, hypotension. GI: nausea, vomiting. ✓ NURSING CONSIDERATIONS: Monitor respiratory rate, rhythm, and depth; pulse, ECG, BP; and level of consciousness frequently for 3-4 hr after the expected peak of blood concentrations. After a moderate overdose of a short half-life opioid, physical stimulation may be enough to prevent significant hypoventilation. The effects of some opioids may last longer than the effects of naloxone, and repeat doses may be necessary. • Patients who have been receiving opioids for >1 wk are extremely sensitive to the effects of naloxone. Dilute and administer carefully. • Assess patient for level of pain after administration when used to treat postoperative respiratory depression. Naloxone decreases respiratory depression but also reverses analgesia. • Assess patient for signs and symptoms of opioid withdrawal (vomiting, restlessness, abdominal cramps, increased BP, and temperature). Symptoms may occur within a few minutes to 2 hr. Severity depends on dose of naloxone, the opioid involved, and degree of physical dependence. • Lack of significant improvement indicates that symptoms are caused by a disease process or other non-opioid CNS depressants not affected by naloxone. • Toxicity and Overdose: Naloxone is a pure antagonist with no agonist properties and minimal toxicity. ✓ PT TEACHING: As medication becomes effective, explain purpose and effects of naloxone to patient.

Generic Name: Zolpidem Trade Name: Ambien Nonbenzodiazepines Therapeutic: sedative/hypnotics Schedule IV Preg Cat: C Sedative & hypnotic effects. *Breast feeding: -Risk category L3: Moderately safe. Minimal excretion into breast milk.

✓ACTION: Induces deep sleep. Produces CNS depression by binding to GABA receptors. Has no analgesic properties ✓DOSAGE/ROUTE: PO, SL (Adults): Tablets, spray, or SL tablets (Edluar)—5 mg (for women) and 5-10 mg (for men) at bedtime; may ↑ to 10 mg at bedtime if 5-mg dose not effective; SL tablets (Intermezzo)—1.75 mg (for women) or 3.5 mg (for men) once upon awakening in the middle-of-the-night; Extended-release tablets—6.25 mg (for women) and 6.25-12.5 mg (for men) at bedtime; may ↑ to 12.5 mg at bedtime if 6.25-mg dose not effective. ✓CONTRAINIDICATION: Use Cautiously in: Hx of psych illness, suicide attempt, substance abuse; Hepatic impairment (initial dose ↓ recommended); Pulmonary disease; Sleep apnea Myasthenia gravis Geri: Initial dose ↓ recommended. ✓SIDE EFFECTS: Amnesia. -CNS: daytime drowsiness, dizziness, abnormal thinking, agitation, amnesia, behavior changes, "drugged" feeling, hallucinations, sleep-driving. -GI: NVD -ANAPHYLAXIS, hypersensitivity reactions, physical dependence, psychological dependence, tolerance. Interactions -CNS depression may ↑ with sedatives/hypnotics, alcohol, phenothiazines, tricyclic antidepressants, opioid analgesics, or antihistamines. - kava-kava, valerian, or chamomile: can ↑ CNS depression. - Food ↓ & delays absorption. ✓ NURSING CONSIDERATIONS/PT TEACHING: • Assess mental status, sleep patterns, & potential for abuse prior to admin. •Prolonged use of >7-10 days may lead to dependence. • Assess alertness at time of peak effect. Notify provider if desired sedation does not occur. • Assess patient for pain. Medicate as prn. Untreated pain decreases sedative effects. • Before admin, reduce external stimuli & provide comfort measures to increase effectiveness of medication. • Safety. Raise bed side rails. Assist with ambulation. Remove patient's cigarettes. • Use lowest effective dose. ** PO: Tablets should be swallowed whole with full glass of water. For faster onset of sleep, do not administer with or immediately after a meal. • SL: Place the tablet under the tongue, allow to disintegrate; do not swallow or take with water. • Intermezzo: Only take if at least 4 hr left prior to time to awakening. • Oral Spray: Do not take with or immediately after a meal. Spray is a clear, colorless, and cherry-flavor solution. PT TEACHING: -take w/ full glass of H2O or juice. -Allow for at least 8 hours of sleep when taking. -Avoid ETOH & other CNS depress. -Don't D/C abruptly after prolonged use. -Don't take w/ food to help work. -Go to bed right after taking b/c rapid onset. -not for long term use. longer than 7-10 days. If used for 2 wk or longer, abrupt withdrawal may result in fatigue, n/v, flushing, light-headedness, uncontrolled crying, GI upset, panic attack, or nervousness. -avoid driving or other activities requiring alertness until response to this medication is known. -may cause sleep driving. ** Oral Spray: To prime, patients should be told to point the black spray opening away from their face and other people and spray 5 times. For administration, hold container upright with the black spray opening pointed directly into the mouth. Press down fully on pump to make sure a full dose (5 mg) is sprayed directly into mouth over tongue. For 10-mg dose, a second spray should be administered. If not used for 14 days, re-prime with 1 spray.

Generic Name: Ketorolac Trade Name: Toradol 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])

✓ACTION: Inhibits prostaglandin synthesis, producing peripherally mediated analgesia. Also has antipyretic and anti-inflammatory properties. Therapeutic Effects: Decreased pain. ✓DOSAGE/ROUTE: Oral therapy is indicated only as a continuation of parenteral therapy. Total duration of therapy by all routes should not exceed 5 days PO (Adults <65 yr): 20 mg initially, followed by 10 mg q 4-6 hr (not to exceed 40 mg/day). PO (Adults ≥65 yr, <50 kg, or with renal impairment): 10 mg q 4-6 hr (not to exceed 40 mg/day). PO (Children 2-16 yr, <50 kg): 1 mg/kg as a single dose. No data available for multiple doses. IM: (Adults <65 yr): Single dose—60 mg. Multiple dosing—30 mg q 6 hr (not to exceed 120 mg/day). IM: (Adults ≥65 yr, <50 kg, or with renal impairment): Single dose—30 mg. Multiple dosing—15 mg q 6 hr (not to exceed 60 mg/day). IM: (Children 2-16 yr, <50 kg): Single dose—0.4-1 mg/kg (maximum: 30 mg/dose). Multiple dosing—0.5 mg/kg q 6 hr. IV (Adults <65 yr): Single dose—30 mg. Multiple dosing—30 mg q 6 hr (not to exceed 120 mg/day). IV (Adults ≥65 yr, <50 kg, or with renal impairment): Single dose—15 mg. Multiple dosing—15 mg q 6 hr (not to exceed 60 mg/day). IV (Children 2-16 yr, <50 kg): Single dose—0.4-1 mg/kg (maximum: 15 mg/dose). Multiple dosing—0.5 mg/kg q 6 hr. Intranasal (Adults<65 yr): 1 spray in each nostril q 6-8 hr (not to exceed 4 sprays in each nostril/day). Intranasal (Adults≥65 yr, <50 kg, or with renal impairment): 1 spray in only one nostril q 6-8 hr (not to exceed 4 sprays in one nostril/day). ✓CONTRAINIDICATION: 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. ✓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, ↑ liver 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 includinganaphylaxis. ✓ NURSING CONSIDERATIONS: • 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. Stevens-Johnson syndrome or toxic epidermal necrolysis. D/C • assess pain • 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 24-48 hr following discontinuation of therapy. • May cause ↑ BUN, serum creatinine, or potassium concentrations. • Administration in higher-than-recommended doses does not provide increased effectiveness but may cause increased side effects. Duration of ketorolac therapy, by all routes combined, should not exceed 5 days. Use lowest effective dose for shortest period of time. • Coadministration with opioid analgesics may have additive analgesic effects and may permit lower opioid doses. • PO: Ketorolac therapy should always be given initially by the IM or IV route. Use oral therapy only as a continuation of parenteral therapy. IV Administration • Direct IV: Administer undiluted. Concentration: 15-30 mg/mL. Rate: Administer over at least 15 sec. ✓ PT TEACHING: • Instruct patient on how and when to ask for and take pain medication. • Do not double doses. Do not take more than prescribed or for longer than 5 days. • May cause drowsiness or dizziness. safety • Caution patient to avoid the concurrent use of alcohol, aspirin, NSAIDs, acetaminophen, or other OTC medications without consulting health care professional. • can effect immune system, higher risk for infection. • notify 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.

Dermoplast spray ✓Trade Name: Dermoplast spray ✓Classification: anesthetics

✓Action: Inhibits initiation and conduction of sensory nerve impulses. Used to relieve perineal pain and discomfort postpartum especially if the patient underwent an episiotomy. ✓Dosage/Route/Frequency: spray to affected area not more than 3 to 4 times daily ✓Side Effects: N/A ✓Nursing Implications:(Considerations) : Instruct patient to keep the perineal area clean. Contact doctor if condition worsens. Assess integrity of skin before and during therapy. Assess type, location, and intsensity of pain before and a few minutes after administration.

Generic Name: Erythromycin (eye ointment) Trade Name: Ilotycin

✓Classification: Anti-infective ✓Dosage/Route/Frequency for population being served: PO (Neonates): Ethylsuccinate— 20-50 mg/kg/day divided q 6-12 hr. ✓Action: Inhibits folic acid synthesis by preventing PABA use, which is necessary for bacterial growth ✓Side Effects: •CNS-headache •CV-hypertension, tachycardia, dysrythmias •EENT-burning, stinging •GI-bitter taste ✓Nursing Implications: •Monitor opthalmic exams and intraocular pressure readings •Monitor blood counts; renal/heptic function tests and serum electrolytes during long-term treatment •Assess for infection (vital signs; appearance of wound, sputum, urine, and stool; WBC) at beginning of and during therapy

Generic Name: Magnesium Sulfate Trade Name: Epsom Salt

✓Classification: Electrolyte; anticonvulsant, laxative, saline; antacid ✓Dose/Route/Frequency for population being served: (breastfeeding) 335-350 mg/day; (pregnancy) 320 mg/day; PO 200-400 mg in divided doses tid-qid; IM 1 g q6hrs x 4 doses; IV 5g (severe) ✓Action: Increases osmotic pressure, draws fluid into the colon and neutralizes HCl ✓Side Effects: •CNS-flaccid paralysis, hypothermia •CV-circulatory collapse •GI-nausea, vomiting, anorexia, cramps •RESP-respiratory depression/paralysis ✓Nursing Implications: •Assess I&O ratio to check for decrease in urinary output •Assess cause of constipation; lack of fluids, bulk or exercise •Assess cramping, rectal bleeding, nausea, vomiting; product should be d/c'd •Assess Mg toxicity: thirst, confusion, decrease in reflexes •Assess visual changes: blurring, halos, corneal and retinal damage •Assess edema in feet, ankles, and legs •Assess prior product history; there are many product interactions

Generic Name: Carboprost Tromethamine Trade Name: Hemabate

✓Classification: oxytocics ✓Dosage/Route/Frequency: IM 250 mcg every 1.5-3 hours, may be increased to 500 mcg if several doses of 250 mcg is inadequate Not to exceed 2 days of continuos therapy or total dose of 12 mg) ✓Action: produces strong, prompt, contractions of uterine smooth muscle, possibly mediated by calcium and cAMP. used to terminate pregnancy between 13-20 weeks gestation. Also used for postpartum hemorrhage from uterine atony ✓Side Effects: uterine rupture, wheezing ✓Nursing Implications:(Considerations) : Notify physician if contractions are absent or last more than 1 minute. Monitor temp, BP and pulse periodically. Large doses can cause hypertension. Monitor amount and type of discharge. Report signs of hemorrhage. pretreating patient with antiemetics and antidiarrheals decrease risk of GI effects

Hepatitis B Vaccine (Recombivax HB)

✓Generic/Trade Name: Hepatitis B Vaccine ✓Classification: Vaccination ✓Dosage/Route/Frequency for population being served: •0.5 mL IM at 0, 1-2, and 6-18 mo. Dose is same for patients age 0-19 yr. •Infants born to HBsAg-positive mothers: Administer 0.5 mL of hepatitis B immune globulin IM and 1st dose of hepatitis B vaccine; give 2nd and 3rd doses of hepatitis B vaccine at 1 mo and 6 mo, respectively. ✓Action: Prevention of development of Hepatitis B ✓Side Effects: Local soreness

Generic Name: Bupivacaine Trade Name:: (Marcaine, Sensorcaine) Preg Cat: C Generic Name: Ropivacaine Trade Name: (Marcaine, Sensorcaine) Preg Cat: B

✓INDICATION Local or regional anesthesia or analgesia for surgical, obstetric, or diagnostic procedures. ✓ACTION: Local anesthetics inhibit initiation and conduction of sensory nerve impulses by altering the influx of sodium and efflux of potassium in neurons, slowing or stopping pain transmission. Epidural administration allows action to take place at the level of the spinal nerve roots immediately adjacent to the site of administration. The catheter is placed as close as possible to the dermatomes (skin surface areas innervated by a single spinal nerve or group of spinal nerves) that, when blocked, will produce the most effective spread of analgesia for the site of injury. Therapeutic Effects: Decreased pain or induction of anesthesia; low doses have minimal effect on sensory or motor function; higher doses may produce complete motor blockade. ✓DOSAGE/ROUTE: Solutions containing preservatives should not be used for caudal or epidural blocks. **Bupivacaine Epidural (Adults and Children) > 12 yr): 10-20 mL of 0.25% (partial to moderate block), 0.5% (moderate to complete block), or 0.75% (complete block) solution. Administer in increments of 3-5 mL allowing sufficient time to detect toxic signs/symptoms of inadvertent IV or IT administration. A test dose of 2-3 mL of 0.5% with epinephrine solution is recommended prior to epidural blocks. **Ropivacaine Surgical Anesthesia Epidural (Adults): Lumbar epidural—15-30 mL of 0.5% solution or 15-25 mL of 0.75% solution or 15-20 mL of 1% solution; Lumbar epidural for cesarean section—20-30 mL of 0.5% solution or 15-20 mL of 0.75% solution; Thoracic epidural—5-15 mL of 0.5-0.75% solution. Labor Pain Epidural (Adults): Lumbar epidural—10-20 mL of 0.2% solution initially, then continuous infusion of 6-14 mL/hr of 0.2% solution with incremental injection of 10-15 mL/hr of 0.2% solution. Postoperative Pain Epidural (Adults): Lumbar or thoracic epidural—Continuous infusion of 6-14 mL/hr of 0.2% solution. ✓CONTRAINIDICATION: Hypersensitivity; cross-sensitivity with other amide local anesthetics may occur (lidocaine, mepivacaine, prilocaine); Bupivacaine contains bisulfites and should be avoided in patients with known intolerance OB: Bupivacaine only—Do not use 0.75% concentration. Only 0.5% and 0.25% concentrations should be used for obstetrical anesthesia due to reports of cardiac arrest and difficult resuscitation with the 0.75% concentration; Lactation: Discontinue nursing. OB: Bupivacaine and ropivacaine—both agents rapidly cross the placenta with obstetrical paracervical block anesthesia and can result in maternal, fetal, or neonatal toxicity with cardiac, central nervous system, or vascular tone abnormalities. May cause maternal hypotension; ✓SIDE EFFECTS: CNS: SEIZURES, anxiety, dizziness, headache, irritability. EENT: blurred vision, tinnitus. CV: CARDIOVASCULAR COLLAPSE, arrhythmias, bradycardia, hypotension, tachycardia. GI: nausea, vomiting. GU: urinary retention. Derm: pruritus. F and E: metabolic acidosis. Neuro: circumoral tingling/numbness, tremor. MS: chondrolysis. Misc: allergic reactions, fever. ✓ Interactions Drug-Drug: Additive toxicity with concurrent use of other amide local anesthetics (including lidocaine, mepivacaine, and prilocaine). Use of bupivacaine solution containing epinephrine with MAO inhibitors may cause hypertension. Fluvoxamine, amiodarone, ciprofloxacin, and propofol may ↑ effects of ropivacaine. ✓ NURSING CONSIDERATIONS: Assessment -neuro checks • Systemic Toxicity: Assess for systemic toxicity (circumoral tingling and numbness, ringing in ears, metallic taste, dizziness, blurred vision, tremors, slow speech, irritability, twitching, seizures, cardiac dysrhythmias) each shift. Report to health care professional. • Orthostatic Hypotension monitoring • Unwanted Motor and Sensory Deficit • Assess for sensory deficit every shift. Ask patient to point to numb and tingling skin areas (numbness and tingling at the incision site is common and usually normal). ✓ PT TEACHING: • Instruct patient to notify nurse if signs or symptoms of systemic toxicity occur. • Advise patient to request assistance during ambulation until orthostatic hypotension and motor deficits are ruled out.

Rubella Classification: Attenuated live virus vaccine. Pregnancy Risk Category: X Lactation: L2

✓INDICATION: Prevention of MMR infection -Indications for Childbearing Women: Administered at least 28 days before pregnancy or after childbirth or abortion to women whose antibody screen shows they are not immune to rubella. This vaccine prevents rubella infection and possible severe congenital defects in the fetus during a subsequent pregnancy. ✓ACTION: Produces a modified rubella (German measles) infection that is not communicable, causing the formation of antibodies against rubella virus. ✓DOSAGE/ROUTE: 0.5 mL subcutaneously ✓CONTRAINIDICATION: The vaccine is contraindicated in women who are immunosuppressed, pregnant, or sensitive to vaccine components, or have a moderate or severe illness. The attenuated virus may appear in breast milk and some infants may develop a rash, but this is not a contraindication to vaccination of lactating women. Although it can be given near the time of Rho(D) immune globulin administration, women receiving the vaccine should be tested for immune status at 6 to 8 weeks to be sure that they are immune. ✓SIDE EFFECTS: Transient stinging at site, fever, lymphadenopathy, arthralgia, and transient arthritis are most common. ✓ NURSING CONSIDERATIONS: Vials should be refrigerated. Reconstitute only with diluent supplied with the vial. Use immediately after reconstitution and discard if not used within 8 hours. Protect from light. Check with health care provider before giving near time of administration of Rho(D) immune globulin. Birth of infants with congenital rubella syndrome has not been documented when the vaccine has been given inadvertently during pregnancy, but women are advised to avoid pregnancy for at least 4 weeks after vaccination. ✓ PT TEACHING:

Generic Name: lidocaine Trade Name: Xylocaine High Alert Med Preg Cat B Risk category L2. Considered safe for breastfeeding. Anesthetic Antiarrhythmic

✓INDICATION: -IV: Ventricular arrhythmia -IM: Self-injected or when IV unavailable (during transport to hospital facilities). -Local: Infiltration/mucosal/topical anesthetic. -Patch: Pain due to post-herpetic neuralgia. (Lidoderm) ✓ACTION: IM: Suppresses automaticity and spontaneous depolarization of the ventricles during diastole by altering the flux of sodium ions across cell membranes with little or no effect on heart rate. Local: Produces local anesthesia by inhibiting transport of ions across neuronal membranes, thereby preventing initiation and conduction of normal nerve impulses. Therapeutic Effects: Control of ventricular arrhythmias. Local anesthesia. ✓DOSAGE/ROUTE: Ventricular Tachycardia (with a Pulse) or Pulseless Ventricular Tachycardia/Ventricular Fibrillation IV (Adults): 1-1.5 mg/kg bolus; may repeat doses of 0.5-0.75 mg/kg q 5-10 min up to a total dose of 3 mg/kg; may then start continuous infusion of 1-4 mg/min. Endotracheal: (Adults): Give 2-2.5 times the IV loading dose down the endotracheal tube, followed by a 10 mL saline flush. IV (Children): 1 mg/kg bolus (not to exceed 100 mg), followed by 20-50 mcg/kg/min continuous infusion (range 20-50 mcg/kg/min); may administer second bolus of 0.5-1 mg/kg if delay between bolus and continuous infusion. Endotracheal (Children): Give 2-3 mg/kg down the endotracheal tube followed by a 5 mL saline flush. IM (Adults and Children ≥50 kg): 300 mg (4.5 mg/kg); may be repeated in 60-90 min. Local Infiltration: (Adults and Children): Infiltrate affected area as needed (increased amount and frequency of use increases likelihood of systemic absorption and adverse reactions). Topical (Adults): Apply to affected area 2-3 times daily. Mucosal (Adults): For anesthetizing oral surfaces—20 mg as 2 sprays/quadrant (not to exceed 30 mg/quadrant) may be used. 15 mL of the viscous solution may be used q 3 hr for oral or pharyngeal pain. For anesthetizing the female urethra—3-5 mL of the jelly or 20 mg as 2% solution may be used. For anesthetizing the male urethra—5-10 mL of the jelly or 5-15 mL of 2% solution may be used before catheterization or 30 mL of jelly before cystoscopy or similar procedures. Topical solutions may be used to anesthetize mucous membranes of the larynx, trachea, or esophagus. Patch (Adults): Up to 3 patches may be applied once for up to 12 hr in any 24-hr period; consider smaller areas of application in geriatric or debilitated patients. ✓CONTRAINIDICATION: Contraindicated in: Hypersensitivity; cross-sensitivity may occur; Third-degree heart block. Use Cautiously in: Liver disease, HF, patients weighing <50 kg, and geriatric patients; Respiratory depression; Shock; Heart block; OB, Lactation: Safety not established; Pedi: Safety not established for transdermal patch. ✓SIDE EFFECTS: CNS: SEIZURES, confusion, drowsiness, blurred vision, dizziness, nervousness, slurred speech, tremor. EENT: mucosal use: ↓ or absent gag reflex. CV: CARDIAC ARREST, arrhythmias, bradycardia, heart block, hypotension. GI: nausea, vomiting. Resp: bronchospasm. Hemat: methemoglobinemia. Local: stinging, burning, contact dermatitis, erythema. MS: chondrolysis. Misc: allergic reactions, including ANAPHYLAXIS. Interactions. Drug-Drug: ↑ cardiac depression and toxicity with phenytoin, amiodarone, quinidine, procainamide, or propranolol. Cimetidine, azole antifungals, clarithromycin, erythromycin, fluoxetine, nefazodone, paroxetine, protease inhibitors, ritonavir, verapamil, and beta blockers may ↓ metabolism and ↑ risk of toxicity. Lidocaine may ↑ levels of calcium channel blockers, certain benzodiazepines, cyclosporine, fluoxetine, lovastatin, simvastatin, mirtazapine, paroxetine, ritonavir, tacrolimus, theophylline, tricyclic antidepressants, and venlafaxine. Effects of lidocaine may be ↓ by carbamazepine, phenobarbital, phenytoin, and rifampin. ✓ NURSING CONSIDERATIONS: Assessment • Antiarrhythmic: Monitor ECG continuously and BP and respiratory status frequently during administration. • Anesthetic: Assess degree of numbness of affected part. • Transdermal: Monitor for pain intensity in affected area periodically during therapy. • Lab Test Considerations: Serum electrolyte levels should be monitored periodically during prolonged therapy. • IM administration may cause ↑ CPK levels. • Signs and symptoms of toxicity include confusion, excitation, blurred or double vision, nausea, vomiting, ringing in ears, tremors, twitching, seizures, difficulty breathing, severe dizziness or fainting, and unusually slow heart rate. • If symptoms of overdose occur, stop infusion and monitor patient closely. • High Alert: Lidocaine is readily absorbed through mucous membranes. Inadvertent overdosage of lidocaine jelly and spray has resulted in patient harm or death from neurologic and/or cardiac toxicity. Do not exceed recommended doses. • Throat Spray: Ensure that gag reflex is intact before allowing patient to drink or eat. • IM: IM injections are recommended only when ECG monitoring is not available and benefits outweigh risks. Administer IM injections only into deltoid muscle while frequently aspirating to prevent IV injection. ✓ PT TEACHING: • May cause drowsiness and dizziness. Advise patient to call for assistance during ambulation and transfer. • Topical: Apply Lidoderm Patch to intact skin to cover the most painful area. Patch may be cut to smaller sizes with scissors before removing release liner. Clothing may be worn over patch. If irritation or burning sensation occurs during application, remove patch until irritation subsides. Wash hands after application; avoid contact with eyes. Dispose of used patch to avoid access by children or pets. • Caution women to consult health care professional before using a topical anesthetic for a mammogram or other procedures. If recommended, use lowest drug concentration, and apply it sparingly. Do not apply to broken or irritated skin, do not wrap skin, and do not apply heat to area (heating pad/electric blanket), to decrease chance that drug may be absorbed into the body. May result in seizures, cardiac arrhythmias, respiratory failure, coma, and death.

Generic Name: Indomethasone Trade Name: Indocin Prostaglandin Synthesis Inhibitors.

✓INDICATION: -most often used for tocolytic ✓ACTION: Inhibits prostaglandin synthesis. In the treatment of PDA, decreased prostaglandin production allows the ductus to close. Therapeutic Effects: PO: Suppression of pain and inflammation. IV: Closure of PDA. ✓DOSAGE/ROUTE: Anti-inflammatory PO (Adults): Antiarthritic—25-50 mg 2-4 times daily or 75-mg extended-release capsule once or twice daily (not to exceed 200 mg or 150 mg of SR/day). A single bedtime dose of 100 mg may be used. Antigout—100 mg initially, followed by 50 mg 3 times daily for relief of pain, then ↓ further. PO (Children >2 yr): 1-2 mg/kg/day in 2-4 divided doses (not to exceed 4 mg/kg/day or 150-200 mg/day). PDA Closure IV (Neonates): Treatment—0.2 mg/kg initially, then 2 subsequent doses at 12-24 hr intervals of 0.1 mg/kg if age <48 hr at time of initial dose; 0.2 mg/kg if 2-7 days at initial dose; 0.25 mg/kg if age >7 days at initial dose Prophylaxis—0.1-0.2 mg/kg initially, then 0.1 mg/kg q 12-24 hr for 2 doses. ✓CONTRAINIDICATION: Hypersensitivity; Known alcohol intolerance (suspension); Cross-sensitivity may exist with other NSAIDs, including aspirin; Active GI bleeding; Ulcer disease; Proctitis or recent history of rectal bleeding; Intraventricular hemorrhage; Thrombocytopenia; Pedi: ↑ risk of necrotizing enterocolitis and bowel perforation in premature infants with PDA. Use Cautiously in: Severe cardiovascular, renal, or hepatic disease; History of ulcer disease; Epilepsy; Hypertension; OB: Not recommended during 2nd half of pregnancy (potential for causing premature closure of ductus arteriosus); Lactation: Usually compatible with breast feeding (AAP); Geri: ↑ risk of adverse reactions. ✓SIDE EFFECTS: -Maternal side effects are minimal because of the brief duration of therapy. Gastrointestinal side effects are usually limited to nausea, vomiting, and heartburn. -Fetal adverse effects are more serious and may include constriction of the ductus arteriosus, pulmonary hypertension, and oligohydramnios. The ductus arteriosus should remain open before birth and close after birth. Fetal adverse effects are unlikely if treatment is no longer than 48 to 72 hours and the gestation is less than 32 weeks. The drug's effect in reducing the amount of amniotic fluid makes indomethacin useful for normalizing the volume if hydramnios is present. The amniotic fluid volume usually returns to its previous level when indomethacin treatment is discontinued. Regular ultrasound examinations and fetal echocardiography help determine if indomethacin is having adverse effects on the infant. After birth, assessment of the infant may be performed for other complications such as pulmonary hypertension or intracranial hemorrhage, depending on the duration of maternal indomethacin intake, the infant's gestation, and the probability that delivery occurs less than 24 hours after the drug is discontinued. CNS: dizziness, drowsiness, headache, psychic disturbances. EENT: blurred vision, tinnitus. CV: hypertension, edema. GI: PO: DRUG-INDUCED HEPATITIS, GI BLEEDING, constipation, dyspepsia, nausea, vomiting, discomfort, necrotizing enterocolitis. GU: cystitis, hematuria, renal failure. Derm: rashes. F and E: hyperkalemia; IV, dilutional hyponatremia; IV, hypoglycemia. Hemat: thrombocytopenia, blood dyscrasias, prolonged bleeding time. Local: phlebitis at IV site. Misc: allergic reactions including ANAPHYLAXIS. Interactions Drug-Drug: Concurrent use with aspirin may ↓ effectiveness. Additive adverse GI effects with aspirin, other NSAIDs, corticosteroids, or alcohol. Drug-Natural Products: ↑ bleeding risk with anise, arnica, chamomile, clove, dong quai, feverfew, garlic, ginger, ginkgo, Panax ginseng. ✓ NURSING CONSIDERATIONS: -The nurse should observe the woman for gastrointestinal side effects. Because indomethacin can prolong bleeding time, the nurse observes for abnormal bleeding such as prolonged bleeding after injections and bruising with no apparent cause. The antiinflammatory effect of indomethacin can mask infection because fever may not be present. Checking the height of the fundus at the beginning of therapy and daily thereafter helps identify reduced amniotic fluid. Decreased fetal movements and absent FHR accelerations with fetal movement may occur if the fetal condition deteriorates. • Arthritis: Assess limitation of movement and pain—note type, location, and intensity before and 1-2 hr after administration. • PDA: Monitor respiratory status, heart rate, BP, echocardiogram, and heart sounds routinely throughout therapy. • Monitor intake and output. Fluid restriction is usually instituted throughout therapy. • Lab Test Considerations: Evaluate BUN, serum creatinine, CBC, serum potassium levels, and liver function tests periodically in patients receiving prolonged therapy. • Serum potassium, BUN, serum creatinine, AST, and ALT tests may show ↑ levels. Blood glucose concentrations may be altered. Hemoglobin and hematocrit concentrations, leukocyte and platelet counts, and CCr may be ↓. • Urine glucose and urine protein concentrations may be ↑. • Leukocyte and platelet count may be ↓. Bleeding time may be prolonged for several days after discontinuation. • PO: Administer after meals, with food, or with antacids to decrease GI irritation. Do not break, crush, or chew sustained-release capsules. Shake suspension before administration. Do not mix with antacid or any other liquid. ✓ PT TEACHING: • Advise patient to take this medication with a full glass of water and to remain in an upright position for 15-30 min after administration. • May cause drowsiness or dizziness. safety. • avoid alcohol, aspirin, other NSAIDs, acetaminophen, or other OTC medications without consulting health care professional. • sunscreen-- photosensitivity reactions. • Advise patient to inform health care professional of medication regimen before treatment or surgery. • notify if rash, itching, chills, fever, muscle aches, visual disturbances, weight gain, edema, abdominal pain, black stools, or persistent headache occurs.

Generic Name: Hydrocodone Trade Name: Lortab/Norco Classification: Therapeutic: allergy, cold, & cough remedies (antitussive), opioid analgesics Pharmacologic: opioid agonists/nonopioid analgesic combinations Schedule II Pregnancy Category C -neonatal respiratory depression L2/L3 breastfeed: -infant sedation

✓INDICATION: -pain control: mod to severe ✓ACTION: -Bind to opiate receptors in the CNS. Alter the perception of and response to painful stimuli while producing generalized CNS depression: Suppress the cough reflex via a direct central action. Therapeutic Effects: Decrease in severity of moderate pain. Suppression of the cough reflex. ✓DOSAGE/ROUTE: PO (Adults): Analgesic—2.5-10 mg q 3-6 hr as needed; if using combination products, acetaminophen dosage should not exceed 4 g/day and should not exceed 5 tablets/day of ibuprofen-containing products; Antitussive—5 mg q 4-6 hr as needed; Extended release—10 mg q 12 hr; may ↑ as needed in increments of 10 mg q 12 hr q 3-7 days. PO (Children): Analgesic (1-13 yr)—0.1-0.2 mg/kg q 3-4 hr. Antitussive—0.6 mg/kg/day divided q 6-8 hr; (maximum doses <2 yr: 1.25 mg/dose; 2-12 yr: 5 mg/dose; >12 yr: 10 mg/dose). ✓CONTRAINIDICATION: -Hypersensitivity to hydrocodone (cross-sensitivity may exist to other opioids); Significant respiratory depression Paralytic ileus Acute or severe bronchial asthma or hypercarbia Hypersensitivity to acetaminophen/ibuprofen (for combination products); Ibuprofen-containing products should be avoided in patients with bleeding disorders or thrombocytopenia; Acetaminophen-containing products should be avoided in patients with severe hepatic or renal disease; Ibuprofen-containing products should be avoided in patients undergoing coronary artery bypass graft surgery; OB, Lactation: Avoid chronic use; 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. ✓SIDE EFFECTS: CNS: confusion, dizziness, sedation, euphoria, hallucinations, headache, unusual dreams. EENT: blurred vision, diplopia, miosis. Resp: respiratory depression. CV: hypotension, bradycardia. GI: constipation, dyspepsia, N/V. GU: urinary retention. Derm: sweating. Misc: physical dependence, psychological dependence, tolerance. ✓Interactions Drug-Drug: Use with extreme caution in patients receiving MAO inhibitors (may produce severe, unpredictable reactions—do not use within 14 days of each other). CYP3A4 inhibitors may ↑ levels and effects CYP3A4 inducers may ↓ levels and effects Additive CNS depression with alcohol, antihistamines, and sedative/hypnotics. Administration of partial antagonist opioids (buprenorphine, butorphanol, nalbuphine, or pentazocine) may ↓ analgesia or precipitate opioid withdrawal in physically dependent patients. Drug-Natural Products: Concomitant use of kava-kava, valerian, skullcap, chamomile, or hops can ↑ CNS depression. ✓ NURSING CONSIDERATIONS: -Assess vitals: BP, HR, RR before & during. -Check LOC if RR < 10/min -assess bowel function. Laxatives if constipation >2-3 days. -assess pain: type, location, intensity -- prior & 1 hr after. -assess cough & lung sounds (antitussive) -may admin w/ food/milk to reduce GI upset. ✓ LABS: May cause ↑ plasma amylase and lipase concentrations. **OD: Naloxone (Narcan) ✓ PT TEACHING: -take as directed, caution when taking additional TYL. -Safety: ay cause drowsiness. call for assistance & change positions slowly. -Avoid ETOH & other CNS depress. -Turn, cough, deep breathe q 2 hrs. -maintain good oral hygiene, frequent mouth rinse. Sugarless gum/candy may decrease dry mouth.

Generic Name: Citrates sodium citrate & citric acid Trade Name: Bicitra) **

✓INDICATION: -reduce gastric acidity before surgery. -Management of chronic metabolic acidosis associated with chronic renal insufficiency or renal tubular acidosis. -Alkalinization of urine. -Prevention of cystine and urate urinary calculi. -Prevention of aspiration pneumonitis during surgical procedures. -Used as a neutralizing buffer. ✓ACTION: - raise the gastric pH and make secretions less acidic. Converted to bicarbonate in the body, resulting in increased blood pH. As bicarbonate is renally excreted, urine is also alkalinized, increasing the solubility of cystine and uric acid. Neutralizes gastric acid. Therapeutic Effects: Provision of bicarbonate in metabolic acidosis. Alkalinization of the urine. Prevention of cystine and urate urinary calculi. Prevention of aspiration pneumonitis. ✓DOSAGE/ROUTE: Adjust dosage according to urine pH. Contains 1 mEq sodium and 1 mEq bicarbonate/mL solution. Alkalinizer PO (Adults): 10-30 mL solution diluted in water 4 times daily. PO (Children): 5-15 mL solution diluted in water 4 times daily. Antiurolithic PO (Adults): 10-30 mL solution diluted in water 4 times daily. Neutralizing Buffer PO (Adults): 15-30 mL solution diluted in 15-30 mL of water. ✓CONTRAINIDICATION: Severe renal insufficiency; Severe sodium restriction; HF, untreated hypertension, edema, or toxemia of pregnancy. Use Cautiously in: OB: Lactation: Safety not established. ✓SIDE EFFECTS: GI: diarrhea. F and E: fluid overload, hypernatremia (severe renal impairment), hypocalcemia, metabolic alkalosis (large doses only). MS: tetany. ✓Interactions Drug-Drug: May partially antagonize the effects of antihypertensives. Urinary alkalinization may result in ↓ salicylate or barbiturate levels or ↑ levels of quinidine, flecainide, or amphetamines. ✓ NURSING CONSIDERATIONS: Assessment - Assess for signs of alkalosis (confusion, irritability, paresthesia, tetany, altered breathing pattern) or hypernatremia (edema, weight gain, hypertension, tachycardia, fever, flushed skin, mental irritability) throughout therapy. - Monitor patients with renal dysfunction for fluid overload (discrepancy in intake and output, weight gain, edema, rales/crackles, and hypertension). • Lab Test Considerations: Prior to and every 4 mo throughout chronic therapy, monitor hematocrit, hemoglobin, electrolytes, pH, creatinine, urinalysis, and 24-hr urine for citrate. • Monitor urine pH if used to alkalinize urine. Implementation • PO: Solution is more palatable if chilled. Administer with 30-90 mL of chilled water. Administer 30 min after meals or as bedtime snack to minimize saline laxative effect. • When used as preanesthetic, administer 15-30 mL of sodium citrate with 15-30 mL of chilled water. ✓ PT TEACHING: • Take as directed. Missed doses should be taken within 2 hr. Do not double doses. • Instruct patients receiving chronic sodium citrate on correct method of monitoring urine pH, maintenance of alkaline urine, and the need to increase fluid intake to 3000 mL/day. When treatment is discontinued, pH begins to fall toward pretreatment levels. -avoid salty food. Evaluation/Desired Outcomes • Correction of metabolic acidosis. • Maintenance of alkaline urine with resulting decreased stone formation. • Buffering the pH of gastric secretions, thereby preventing aspiration pneumonitis associated with intubation and anesthesia.

Labetalol Class: Alpha- and Beta- Adrenergic Blocking Agent

✓INDICATION: 1. Alone or in combination with other drugs to control Hypertension 2. Hypertensive Emergencies ✓ACTION: 1. Alpha Blockade leads to: vasodilation, decreased peripheral resistance, and orthostatic hypotension. 2. Beta Blockade leads to: effects on SA, AV nodes, and ventricular muscle that leads to bradycardia, delay in AV conduction and depression of cardiac contractility. ✓DOSAGE/ROUTE: Routes: IVPB, IV, IO (can also be seen in PO form for home medication) Dosages: Adults: 20 mg slow IV push with 40-80 mg every 10 minutes, to a max dose of 300 mg total OR 2 mg/min continuous IVPB, to a total max dose of 300 mg Pediatric: Safety in children has not been established - not recommended. ✓CONTRAINIDICATION: 1. Cardiogenic shock 2. cardiac failure 3. bradycardia 4. bronchial asthma 5. 2nd or 3rd degree heart block ✓SIDE EFFECTS: Cardiovascular: postural hypotension, angina, palpitations, bradycardia, syncope, CHF CNS: Dizziness, vertigo, numbness, somnolence, Tingling of the scalp or skin Respiratory: Dyspnea, bronchospasm Miscellaneous: flushing, sweating,

Generic Name: Rho(D) Immune Globulin Trade Name: RhOGAM, Hyprho-D, Gamulin Rh Classification: Concentrated immunoglobulins directed toward the red blood cell (RBC) antigen Rho(D).

✓INDICATION: Administered to Rh-negative women who have been exposed to Rh-positive blood by doing the following: 1. Delivering an Rh-positive infant 2. Aborting an Rh-positive fetus 3. Undergoing chorionic villus sampling, amniocentesis, or intraabdominal trauma while carrying an Rh-positive fetus 4. Receiving inadvertent transfusion of Rh-positive blood -All unsensitized Rh-negative women should receive RhoGAM after abortion, ectopic pregnancy, chorionic villus sampling, amniocentesis, or birth of an Rh-positive infant. RhoGAM prevents the development of Rh antibodies that would result in destruction of fetal erythrocytes in subsequent pregnancies. ✓ACTION: ✓DOSAGE/ROUTE: One standard dose (300 mcg) administered intramuscularly: 1. At 28 weeks of pregnancy and within 72 hours of delivery of a Rh-positive infant 2. Within 72 hours after termination of a pregnancy of 13 weeks or more of gestation One microdose (50 mcg) within 72 hours after the termination of a pregnancy of less than 13 weeks of gestation. Dose is calculated based on the volume of fetal-maternal hemorrhage or Rh-positive blood administered in transfusion accidents. A standard dose will protect against 30 mL of Rh-positive whole blood or 15 mL of packed RBCs. - A microdose (50 mcg) is given to the woman whose fetus is less than 13 weeks of gestational age at the time of the abortion. ✓CONTRAINIDICATION: Women who are Rh-positive or women previously sensitized to Rho(D) should not receive Rho(D) immune globulin. It is used cautiously for women with previous hypersensitivity reactions to immune globulins. ✓SIDE EFFECTS: Local pain at intramuscular site, fever, or both. ✓ NURSING CONSIDERATIONS: Type and antibody screening of the mother's blood and cord blood type of the newborn must be performed to determine the need for the medication. The mother must be Rh-negative and negative for Rh antibodies. The newborn must be Rh-positive. If the fetal blood type after termination of pregnancy is uncertain, the medication should be administered. The newborn may have a weakly positive antibody test if the woman received Rho(D) immune globulin during pregnancy. The drug is administered to the mother, not the infant. The deltoid muscle is recommended for intramuscular administration. ✓ PT TEACHING: About Rh Incompatibility What does it mean to be Rh-negative? • Those who are Rh-negative lack a substance that is present in the red blood cells of those who are Rh-positive. How can the expectant mother be Rh-negative and the fetus be Rh-positive? • The fetus can inherit the Rh-positive factor from the father. What does sensitization mean? • Sensitization means that the Rh-negative person has been exposed to Rh-positive blood and has developed antibodies against the Rh factor. Do the antibodies harm the woman? • No, because she does not have the Rh factor. Do Rh-positive men always father Rh-positive children? • No. Rh-positive men who have an Rh-positive gene and an Rh-negative gene can father Rh-negative children. Two Rh-positive parents can conceive an Rh-negative fetus who inherits the Rh-negative gene from each parent. Why is Rho(D) immune globulin (RhoGAM) necessary during pregnancy and after childbirth? • RhoGAM prevents the development of Rh antibodies in the mother, which might be harmful to subsequent fetuses who are Rh-positive. Administering Rho(D) immune globulin during pregnancy to the mother who delivers an Rh-positive or Rh-negative infant is not harmful to the baby. Why will the next fetus be jeopardized if RhoGAM is not administered? • If RhoGAM is not administered when the newborn is Rh-positive, the woman may develop antibodies that cross the placental barrier and affect the next Rh-positive fetus.

AMINOGLYCOSIDES Generic Name: amikacin Trade Name: Gentamycin Classification Therapeutic: anti-infectives Pharmacologic: aminoglycosides Pregnancy Category C (gentamicin, topical use of others), D (amikacin, neomycin, streptomycin, tobramycin)

✓INDICATION: Amikacin, gentamicin, and tobramycin: Treatment of serious gram-negative bacterial infections and infections caused by staphylococci when penicillins or other less toxic drugs are contraindicated. Streptomycin: In combination with other agents in the management of active tuberculosis. Neomycin: Used orally to prepare the GI tract for surgery, to decrease the number of ammonia-producing bacteria in the gut as part of the management of hepatic encephalopathy, and to treat diarrhea caused by Escherichia coli. Tobramycin by inhalation: Management of Pseudomonas aeruginosa in cystic fibrosis patients. Gentamicin, streptomycin: In combination with other agents in the management of serious enterococcal infections. Gentamicin IV: Prevention of infective endocarditis. Gentamicin (topical): Treatment of localized infections caused by susceptible organisms. Unlabeled Use: Amikacin: In combination with other agents in the management of Mycobacterium avium complex infections. ✓ACTION: Inhibits protein synthesis in bacteria at level of 30S ribosome. Therapeutic Effects: Bactericidal action. Spectrum: Most aminoglycosides notable for activity against: P. aeruginosa, Klebsiella pneumoniae, E.coli, Proteus, Serratia, Acinetobacter, Staphylococcus aureus. In treatment of enterococcal infections, synergy with a penicillin is required. Streptomycin and amikacin also active against Mycobacterium. ✓DOSAGE/ROUTE: IM, IV (Adults): 1-2 mg/kg q 8 hr (up to 6 mg/kg/day in 3 divided doses); Once-daily dosing (unlabeled)—4-7 mg/kg q 24 hr. IM, IV (Children >5 yr): 2-2.5 mg/kg/dose q 8 hr; Once daily—5-7.5 mg/kg/dose q 24 hr; Cystic fibrosis—2.5-3.3 mg/kg/dose q 6-8 hr; Hemodialysis—1.25-1.75 mg/kg/dose postdialysis. IM, IV (Children 1 mo-5 yr): 2.5 mg/kg/dose q 8 hr; Once daily—5-7.5 mg/kg/dose q 24 hr; Cystic fibrosis—2.5-3.3 mg/kg/dose q 6-8 hr; Hemodialysis—1.25-1.75 mg/kg/dose postdialysis. IM, IV (Neonates full term and/or >1 wk): Weight <1200 g—2.5 mg/kg/dose q 18-24 hr; Weight 1200-2000 g—2.5 mg/kg/dose q 8-12 hr; Weight >2000 g—2.5 mg/kg/dose q 8 hr; ECMO—2.5 mg/kg/dose q 18 hr, subsequent doses based on serum concentrations; Once daily—3.5-5 mg/kg/dose q 24 hr. IM, IV (Neonates premature and/or ≤1 wk): Weight <1000 g—3.5 mg/kg/dose q 24 hr; Weight 1000-1200 g—2.5 mg/kg/dose q 18-24 hr; Weight >1200 g—2.5 mg/kg/dose q 12 hr; Once daily—3.5-4 mg/kg/dose q 24 hr. IT (Adults): 4-8 mg/day. IT (Infants >3 mo and Children): 1-2 mg/day. IT (Neonates): 1 mg/day. Topical (Adults and Children >1 mo): Apply cream or ointment 3-4 times daily. Renal Impairment IM, IV (Adults): Initial dose of 2 mg/kg. Subsequent doses/intervals based on blood level monitoring and renal function assessment. ✓CONTRAINIDICATION: Hypersensitivity to aminoglycosides; Most parenteral products contain bisulfites and should be avoided in patients with known intolerance; Pedi: Products containing benzyl alcohol should be avoided in neonates; Intestinal obstruction (neomycin only). OB: Tobramycin and streptomycin may cause congenital deafness; Lactation: Safety not established; Pedi: Neonates have ↑ risk of neuromuscular blockade; difficulty in assessing auditory and vestibular function and immature renal function; Geri: Difficulty in assessing auditory and vestibular function and age-related renal impairment. ✓SIDE EFFECTS: CNS: ataxia, vertigo. EENT: ototoxicity (vestibular and cochlear). GU: nephrotoxicity. GI: Neomycin—diarrhea, nausea, vomiting. F and E: hypomagnesemia. MS: muscle paralysis (high parenteral doses). Neuro: ↑ neuromuscular blockade. Resp: apnea; Tobramycin, Inhaln only—bronchospasm, wheezing. Misc: hypersensitivity reactions. Interactions Drug-Drug: Inactivated by penicillins and cephalosporins when coadministered to patients with renal insufficiency. Possible respiratory paralysis after inhalation anesthetics or neuromuscular blocking agents. ↑ incidence of ototoxicity with loop diuretics. ↑ incidence of nephrotoxicity with other nephrotoxic drugs. Neomycin may ↑ anticoagulant effects of warfarin. Neomycin may ↓ absorption of digoxin and methotrexate. ✓ NURSING CONSIDERATIONS: • Assess for infection (vital signs, wound appearance, sputum, urine, stool, WBC) at beginning of and throughout therapy. • Obtain C&S • Eval eighth cranial nerve function by audiometry before and throughout therapy. Hearing loss is usually in the high-frequency range. Prompt recognition and intervention are essential in preventing permanent damage. Also monitor for vestibular dysfunction (vertigo, ataxia, nausea, vomiting). Eighth cranial nerve dysfunction is associated with persistently elevated peak aminoglycoside levels. Discontinue aminoglycosides if tinnitus or subjective hearing loss occurs. • monitor I&O and daily wts. • Assess for signs of superinfection (fever, upper respiratory infection, vaginal itching or discharge, increasing malaise, diarrhea). • Hepatic Encephalopathy: Monitor neurologic status. Before administering oral medication, assess patient's ability to swallow. • Lab Test Considerations: Monitor renal function by urinalysis, specific gravity, BUN, creatinine, and CCr before and during therapy. • May cause ↑ BUN, AST, ALT, serum alkaline phosphatase, bilirubin, creatinine, and LDH concentrations. • May cause ↓ serum calcium, magnesium, potassium, and sodium concentrations (streptomycin and tobramycin). Keep patient well hydrated (1500-2000 mL/day) during therapy. • Preoperative Bowel Prep: Neomycin is usually used in conjunction with erythromycin, a low-residue diet, and a cathartic or enema. • PO: Neomycin may be administered without regard to meals. • IV: If aminoglycosides and penicillins or cephalosporins must be administered concurrently, administer in separate sites, at least 1 hr apart. ✓ PT TEACHING: • Instruct patient to report signs of hypersensitivity, tinnitus, vertigo, hearing loss, rash, dizziness, or difficulty urinating. • drinking plenty of liquids. • Teach patients with a history of rheumatic heart disease or valve replacement the importance of using antimicrobial prophylaxis before invasive medical or dental procedures. • Caution patient that neomycin may cause nausea, vomiting, or diarrhea. • Inhaln: Instruct patient to take inhalation twice daily as close to 12 hr apart as possible; not <6 hr apart. Solution is colorless to pale yellow and may darken with age without effecting quality. Administer over 15 min period using a hand-held PARI LC PLUS reusable nebulizer . Instruct patient to sit or stand upright during inhalation and breathe normally through mouthpiece of nebulizer. Nose clips may help patient breath through mouth. Store at room temperature for up to 28 days. Advise patient to disinfect the nebulizer parts (except tubing) by boiling them in water for a full 10 minutes every other treatment day. • Instruct patient in correct technique for use of TOBI Podhaler. Wipe mouthpiece with clean, dry cloth after use; do not wash with water. • Advise female patient to notify health care professional if pregnancy is planned or suspected or if breast feeding.

Generic Name: Nifedipine Trade Name: (Procardia) Classification Therapeutic: antianginals: antihypertensives; Pharmacologic: calcium channel blockers Pregnancy Category C

✓INDICATION: Management of: Hypertension (extended-release only), Angina pectoris, Vasospastic (Prinzmetal's) angina. Unlabeled Use: Prevention of migraine headache. Management of HF or cardiomyopathy. ✓ACTION: Inhibits calcium transport into myocardial and vascular smooth muscle cells, resulting in inhibition of excitation-contraction coupling and subsequent contraction. Therapeutic Effects: Systemic vasodilation, resulting in decreased BP. Coronary vasodilation, resulting in decreased frequency and severity of attacks of angina.] ✓DOSAGE/ROUTE: PO (Adults): 10-30 mg 3 times daily (not to exceed 180 mg/day), or 10-20 mg twice daily as immediate-release form, or 30-90 mg once daily as sustained-release (CC, XL) form (not to exceed 90-120 mg/day). ✓CONTRAINIDICATION: Hypersensitivity; Sick sinus syndrome; 2nd- or 3rd-degree AV block (unless an artificial pacemaker is in place); Systolic BP <90 mm Hg; Coadministration with grapefruit juice, rifampin, rifabutin, phenobarbital, phenytoin, carbamazepine, or St. John's wort. Use Cautiously in: Severe hepatic impairment (↓ dose recommended); History of porphyria; Severe renal impairment (↓ dose may be necessary); History of serious ventricular arrhythmias or HF; OB, Lactation: Use only if potential benefit justifies potential risks Pedi: Safety not established; Geri: Short-acting forms appear on Beers list due to ↑ risk of hypotension and constipation (↓ dose recommended); also associated with ↑ incidence of falls. ✓SIDE EFFECTS: CNS: headache, abnormal dreams, anxiety, confusion, dizziness, drowsiness, jitteriness, nervousness, psychiatric disturbances, weakness. EENT: blurred vision, disturbed equilibrium, epistaxis, tinnitus. Resp: cough, dyspnea, shortness of breath. CV: ARRHYTHMIAS, HF, peripheral edema, bradycardia, chest pain, hypotension, palpitations, syncope, tachycardia. GI: ↑ liver enzymes, anorexia, constipation, diarrhea, dry mouth, dysgeusia, dyspepsia, GI obstruction, nausea, ulcer, vomiting. GU: dysuria, nocturia, polyuria, sexual dysfunction, urinary frequency. Derm: flushing, dermatitis, erythema multiforme, ↑ sweating, photosensitivity, pruritus/urticaria, rash. Endo: gynecomastia, hyperglycemia. Hemat: anemia, leukopenia, thrombocytopenia. Metab: weight gain. MS: joint stiffness, muscle cramps. Neuro: paresthesia, tremor. Misc: STEVENS-JOHNSON SYNDROME, gingival hyperplasia. Interactions Drug-Natural Products: St. John's wort may significantly ↓ levels and effects; concurrent use is contraindicated. Drug-Food: Grapefruit and grapefruit juice ↑ serum levels and effect; avoid concurrent use. ✓ NURSING CONSIDERATIONS: • Monitor BP 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. Assess for signs of HF (peripheral edema, rales/crackles, dyspnea, weight gain, jugular venous distention). • Patients receiving digoxin concurrently with nifedipine should have routine tests of serum digoxin levels and be monitored for signs and symptoms of digoxin toxicity. • 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. • Angina: Assess location, duration, intensity, and precipitating factors of patient's anginal pain. • Lab Test Considerations: Total serum calcium concentrations are not affected by calcium channel blockers. Monitor serum potassium periodically. Hypokalemia increases risk of arrhythmias; should be corrected. • Monitor renal and hepatic functions periodically during long-term therapy. Several days of therapy may cause ↑ hepatic enzymes, which return to normal upon discontinuation of therapy. • Nifedipine may cause positive ANA and direct Coombs' test results. • Avoid administration with grapefruit juice. • Sublingual use is not recommended due to serious adverse drug reactions. ✓ PT TEACHING: Advise patient 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. • Instruct patient on technique for monitoring pulse. Instruct patient to contact health care professional if heart rate is <50 bpm. •no grapefruit • change positions slowly to minimize orthostatic hypotension. • May cause drowsiness or dizziness. safety • Geri: Teach patients and family about risk for falls and how to reduce risk in the home. • instructions for dry mouth • Advise patient to notify health care professional if rash, irregular heartbeat, dyspnea, swelling of hands and feet, pronounced dizziness, nausea, constipation, or hypotension occurs or if headache is severe or persistent. • photosensitivity reactions. • Angina: Instruct patient on concurrent nitrate or beta-blocker therapy to continue taking both medications as directed and use SL nitroglycerin as needed for anginal attacks. • Inform patient that anginal attacks may occur 30 min after administration because of reflex tachycardia. This is usually temporary and is not an indication for discontinuation. • Advise patient to contact health care professional if chest pain does not improve, worsens after therapy, or occurs with diaphoresis; if shortness of breath occurs; or if persistent headache occurs. • Caution patient to discuss exercise restrictions with health care professional before exertion. • Hypertension: Encourage patient to comply with other interventions for hypertension Medication controls but does not cure hypertension. Instruct patient and family in proper technique for monitoring BP. Advise patient to take BP weekly and to report significant changes to health care professional.

Generic Name: Cefazolin Trade Name: Ancef cephalosporin antibx 1st generation Preg Cat B. Beta-lactam antibx Broad spectrum similar to PCNs Effective against rapid growing organisms.

✓INDICATION: Perioperative prophylaxis, biliary tract infections, UTIs, pelvic infections, genital infections, bacterial endocarditis prophylaxis for dental & upper respiratory tract procedures ✓ACTION: Bind to bacterial cell wall membrane, causing cell death. Spectrum: Active against many gram-positive cocci including: Streptococcus pneumoniae, Group A beta-hemolytic streptococci, Penicillinase-producing staphylococci. Not active against: Methicillin-resistant staphylococci, Bacteroides fragilis, Enterococcus. Active against some gram-negative rods including: Klebsiella pneumoniae, Proteus mirabilis, Escherichia coli. ✓DOSAGE/ROUTE: IM, IV (Adults): Moderate to severe infections—500 mg-2 g q 6-8 hr (maximum 12 g/day). Mild infections with gram-positive cocci—250-500 mg q 8 hr. Uncomplicated urinary tract infections—1 g q 12 hr. Pneumococcal pneumonia—500 mg q 12 hr. Infective endocarditis or septicemia—1-1.5 g q 6 hr. Perioperative prophylaxis—1 g given 30-60 min prior to incision. Additional 500 mg-1 g should be given for surgeries ≥2 hr. 500 mg-1 g should then be given for all surgeries q 6-8 hr for 24 hr postoperatively. IM, IV (Children and Infants >1 mo): 16.7-33.3 mg/kg q 8 hr (maximum 6 g/day); Bacterial endocarditis prophylaxis in penicillin-allergic patients: 25 mg/kg 30 min prior to procedure (maximum dose = 1 g). IM, IV (Neonates ≤7 days): 40 mg/kg/day divided q 12 hr. IM, IV (Neonates >7 days and ≤2 kg): 40 mg/kg/day divided q 12 hr. IM, IV (Neonates >7 days and >2 k g): 60 mg/kg/day divided q 8 hr. Renal Impairment IM: IV (Adults): CCr 10-30 mL/min—Administer q 12 hr; CCr ≤10 mL/min—Administer q 24 hr. ✓CONTRAINIDICATION: Hypersensitivity to cephalosporins; Serious hypersensitivity to penicillins. ✓SIDE EFFECTS: CNS: seizures (high doses). GI: pseudomembranous colitis, NVD, ABD cramps. Derm: stevens-johnson syndrome, rashes, pruritis, urticaria. Hemat: agranulocytosis, eosinophilia, hemolytic anemia, neutropenia, thrombocytopenia. Local: pain at IM site, phlebitis at IV site. Misc: allergic reactions including anaphylaxis and serum sickness, superinfection. "GIANT" GI: NVD Increase in glucose. Anaphylaxis, ETOH may cause vomiting. Nephrotoxicity Thrombocytopenia ✓ INTERACTIONS: Drug-Drug: Probenecid ↓ excretion and ↑ blood levels of renally excreted cephalosporins. Concurrent use of loop diuretics or aminoglycosides may ↑ risk of renal toxicity. ✓ NURSING CONSIDERATIONS: -Most are considered safe for breastfeeding. **Disulfiram Reaction: vomiting from ETOH. - PO: Administer around the clock. May be administered on full or empty stomach. - Shake oral suspension well before administering. Use calibrated measuring device with liquid preparations. Refrigerate oral suspensions. - IM NS flush & (Ventrogluteal) -IV Administration (slow admin) - IV: Monitor site frequently for thrombophlebitis (pain, redness, swelling). **Change sites q 48-72 hr to prevent phlebitis. ** Do not use solutions that are cloudy or contain a precipitate. - Solution is stable for 24 hr at room temperature & 10 days if refrigerated. - assess prior allergic reactions. - Obtain specimens for culture & sensitivity BEFORE starting med. (1st dose may be given before receiving results.) -Observe patient for signs and symptoms of anaphylaxis (rash, pruritus, laryngeal edema, wheezing). D/c drug & notify provider. -Keep epinephrine & resuscitation equipment close by in case of an anaphylactic reaction. - Monitor bowel function. Diarrhea, abdominal cramping, fever, & bloody stools should be reported promptly as a sign of pseudomembranous colitis. May begin up to several weeks following d/c of therapy. • Assess for rash frequently during therapy. D/C cephalosporins 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 positive results for Coombs' test in patients receiving high doses or in neonates whose mothers were given cephalosporins before delivery. • May cause ↑ serum AST, ALT, alkaline phosphatase, bilirubin, LDH, BUN, creatinine. • May rarely cause leukopenia, neutropenia, agranulocytosis, thrombocytopenia, or eosinophilia. - Monitor, & PT. BUN & creatinine. VS, I & O, bleeding & SE. Assess for infection (vital signs; appearance of wound, sputum, urine, and stool; WBC) at beginning and during therapy. -if DM, glucose levels ✓ PT TEACHING: - take medication around the clock at evenly spaced times & to finish the medication completely. -Take missed doses as ASAP unless almost time for next dose; do not double doses. - Report signs of superinfection (furry overgrowth on the tongue, vaginal itching or discharge, loose or foul-smelling stools) and allergy. - notify MD if rash, or fever and diarrhea develop, especially if diarrhea contains blood, mucus, or pus. Advise patient not to treat diarrhea without consulting health care professional.

Generic Name: Methylergonovine Maleate Trade Name: (Methergine) Therapeutic: oxytocic Pharmacologic: ergot alkaloids Pregnancy Category C

✓INDICATION: Prevention and treatment of postpartum or postabortion hemorrhage caused by uterine atony or subinvolution. ✓ACTION: Directly stimulates uterine and vascular smooth muscle. Therapeutic Effects: Uterine contraction. ✓DOSAGE/ROUTE: PO (Adults): 200-400 mcg (0.4-0.6 mg) q 6-12 hr for 2-7 days. IM, IV (Adults): 200 mcg (0.2 mg) q 2-4 hr for up to 5 doses. ✓CONTRAINIDICATION: Hypersensitivity; OB: Should not be used to induce labor; Lactation: Do not breast feed during treatment and for 12 hours after the last dose Concurrent use of potent CYP3A4 inhibitors. Use Cautiously in: Hypertensive or eclamptic patients (more susceptible to hypertensive and arrhythmogenic side effects); History of or risk factors for coronary artery disease; Severe hepatic or renal disease; Sepsis. Concurrent use of moderate CYP3A4 inhibitors Exercise Extreme Caution in: OB: Third stage of labor. ✓SIDE EFFECTS: CNS: STROKE, dizziness, headache. EENT: tinnitus. Resp: dyspnea. CV: HYPERTENSION, arrhythmias, AV block, chest pain, palpitations. GI: nausea, vomiting. GU: cramps. Derm: diaphoresis. Neuro: paresthesia. Misc: allergic reactions. ✓ NURSING CONSIDERATIONS: • Monitor BP, heart rate, and uterine response frequently during medication administration. Notify health care professional promptly if uterine relaxation becomes prolonged or if character of vaginal bleeding changes. • Assess for signs of ergotism (cold, numb fingers and toes, chest pain, nausea, vomiting, headache, muscle pain, weakness). • Lab Test Considerations: If no response to methylergonovine, calcium levels may need to be assessed. Effectiveness of medication is ↓ with hypocalcemia. • May cause ↓ serum prolactin levels. -IV admin only emergency ✓ PT TEACHING: Instruct patient to take medication as directed; do not skip or double up on missed doses. If a dose is missed, omit it and return to regular dose schedule. • Advise patient that medication may cause menstrual-like cramps. • Caution patient to avoid smoking, because nicotine constricts blood vessels. • Instruct patient to notify health care professional if infection develops, as this may cause increased sensitivity to the medication. • notify of all other meds taking

Generic Name: Simethicone Trade Name: Gas-X, Degas, Flatulex Classification Therapeutic: antiflatulent Pregnancy Category UK

✓INDICATION: Relief of painful symptoms of excess gas in the GI tract that may occur postoperatively or as a consequence of: Air swallowing, Dyspepsia, Peptic ulcer, Diverticulitis. ✓ACTION: Causes the coalescence of gas bubbles. Does not prevent the formation of gas. Therapeutic Effects: Passage of gas through the GI tract by belching or passing flatus. ✓DOSAGE/ROUTE: PO (Adults): 40-125 mg qid, after meals and at bedtime (up to 500 mg/day). PO (Children 2-12 yr): 40 mg 4 times daily. PO (Children <2 yr): 20 mg 4 times daily (up to 240 mg/day). ✓CONTRAINIDICATION: not recommended for infant colic. Use Cautiously in: Abdominal pain of unknown cause, especially when accompanied by fever; OB: Lactation: Has been used safely. ✓SIDE EFFECTS: n/a ✓ NURSING CONSIDERATIONS: • Assess patient for abdominal pain, distention, and bowel sounds prior to and periodically throughout course of therapy. Frequency of belching and passage of flatus should also be assessed. PO: Administer after meals and at bedtime for best results. Shake liquid preparations well prior to administration. Chewable tablets should be chewed thoroughly before swallowing for faster and more complete results. • Drops can be mixed with 30 mL of cool water, infant formula, or other liquid as directed. Shake well before using. ✓ PT TEACHING: • Explain to patient the importance of diet and exercise in the prevention of gas. Also explain that this medication does not prevent the formation of gas. • Advise patient to notify health care professional if symptoms are persistent.

Gernic Name: Mefoxin Trade Name: Cefprozil Classification Therapeutic: anti-infectives Pharmacologic: second-generation cephalosporins Pregnancy Category B

✓INDICATION: Treatment of the following infections caused by susceptible organisms: Respiratory tract infections, Skin and skin structure infections, Bone and joint infections (not cefaclor or cefprozil), Urinary tract infections (not cefprozil). Cefotetan and cefoxitin: Intra-abdominal and gynecologic infections. Cefuroxime: Meningitis, gynecologic infections, and Lyme disease. Cefaclor, cefprozil, cefuroxime: Otitis media. Cefoxitin and cefuroxime: Septicemia. Cefotetan, cefoxitin, cefuroxime: Perioperative prophylaxis. ✓ACTION: Bind to bacterial cell wall membrane, causing cell death. Therapeutic Effects: Bactericidal action against susceptible bacteria. Spectrum: Similar to that of first-generation cephalosporins but have ↑ activity against several other gram-negative pathogens including: Haemophilus influenzae, Escherichia coli, Klebsiella pneumoniae, Morganella morganii, Neisseria gonorrhoeae (including penicillinase-producing strains), Proteus, Providencia, Serratia marcescens, Moraxella catarrhalis. Not active against methicillin-resistant staphylococci or enterococci. Cefuroxime: Active against Borrelia burgdorferi. Cefotetan and cefoxitin: Active against Bacteroides fragilis. ✓DOSAGE/ROUTE: PO (Adults): Most infections—250-500 mg q 12 hr or 500 mg q 24 hr. PO (Children 6 mo-12 yr): Otitis media—15 mg/kg q 12 hr. Acute sinusitis—7.5-15 mg/kg q 12 hr (higher dose should be used for moderate-to-severe infections). PO (Children 2-12 yr): Pharyngitis/tonsillitis—7.5 mg/kg q 12 hr. Skin/skin structure infections—20 mg/kg q 24 hr. Renal Impairment PO (Adults and Children ≥6 mo): CCr <30 mL/min—½ of usual dose at normal dosing interval. ✓CONTRAINIDICATION: Hypersensitivity to cephalosporins; Serious hypersensitivity to penicillins. Use Cautiously in: Renal impairment (↓ dose/↑ dosing interval recommended for: cefotetan if CCr ≤30 mL/min, cefoxitin if CCr ≤50 mL/min, cefprozil if CCr <30 mL/min, cefuroxime if CCr ≤20 mL/min); Patients with hepatic dysfunction, poor nutritional state, or cancer may be at ↑ risk for bleeding; History of GI disease, especially colitis; Cefprozil (oral suspension) contains aspartame and should be avoided in patients with phenylketonuria; Geri: Dose adjustment due to age-related ↓ in renal function may be necessary; may also be at ↑ risk for bleeding with cefotetan or cefoxitin; OB: Lactation: Have been used safely. ✓SIDE EFFECTS: CNS: SEIZURES (high doses). GI: PSEUDOMEMBRANOUS COLITIS, diarrhea, cramps, nausea, vomiting. Derm: rashes, urticaria. Hemat: agranulocytosis, bleeding (↑ with cefotetan and cefoxitin), eosinophilia, hemolytic anemia, neutropenia, thrombocytopenia. Local: pain at IM site, phlebitis at IV site. Misc: allergic reactions including ANAPHYLAXIS and SERUM SICKNESS, superinfection. Interactions Drug-Drug: Probenecid ↓ excretion and ↑ blood levels. If alcohol is ingested within 48-72 hr of cefotetan, a disulfiram-like reaction may occur. Cefotetan may ↑ risk of bleeding with anticoagulants, antiplatelet agents, thrombolytics, and NSAIDs. Antacids ↓ absorption of cefaclor. Concurrent use of aminoglycosides or loop diuretics may ↑ risk of nephrotoxicity. ✓ NURSING CONSIDERATIONS: • Assess for infection (vital signs; appearance of wound, sputum, urine, and stool; WBC) at beginning and during therapy. • allergy hx • C&S • s/s of anaphylaxis • 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 in patients receiving high doses or in neonates whose mothers were given cephalosporins before delivery. • Cefotetan—monitor prothrombin time and assess patient for bleeding (guaiac stools; check for hematuria, bleeding gums, ecchymosis) daily in high-risk patients; may cause hypoprothrombinemia. • May cause ↑ serum AST, ALT, alkaline phosphatase, bilirubin, LDH, BUN, and creatinine. • Cefoxitin may cause falsely ↑ test results for serum and urine creatinine; do not obtain serum samples within 2 hr of administration. • May rarely cause leukopenia, neutropenia, agranulocytosis, thrombocytopenia, and eosinophilia. • May be administered on full or empty stomach. Administration with food may minimize GI irritation. Shake oral suspension well before administering. • Do not administer cefaclor within 1 hr of antacids. ✓ PT TEACHING: • Pedi: Instruct 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. • Caution patients that concurrent use of alcohol with cefotetan may cause a disulfiram-like reaction • 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.

Generic Name: Butorphanol Trade Name: Stadol Class: Opioid

✓INDICATION: systemic pain relief during labor. ✓ACTION: Opioid analgesic with some agonist-antagonist effects; exact mechanism of action unknown; produces respiratory depression that does not increase markedly with larger doses. ✓DOSAGE/ROUTE: 1 mg every 3-4 hours; range 0.5-2 mg IV; may be given by PCA ✓CONTRAINIDICATION: -Has some narcotic antagonist effects; should not be given to the opiate-dependent woman (may precipitate withdrawal) or after other narcotics such as meperidine (may reverse their analgesic effects); also a respiratory depressant. ✓SIDE EFFECTS: Respiratory depression or apnea (woman or newborn), anaphylaxis; dizziness, lightheadedness, sedation, lethargy, headache, euphoria, mental clouding, fainting, restlessness, excitement, tremors, delirium, insomnia; nausea, vomiting, constipation, increased biliary pressure, dry mouth, anorexia; flushing, altered heart rate and blood pressure, circulatory collapse; urinary retention; sensitivity to cold. ✓ NURSING CONSIDERATIONS: Assess for allergies and opiate dependence. Observe vital signs and respiratory function in woman (respiratory rate of at least 12 breaths per minute) and newborn (respiratory rate of at least 30 breaths per minute). Have naloxone and resuscitation equipment available for treatment of respiratory depression in woman and neonate. Report nausea or vomiting to the birth attendant for a possible order for an antiemetic. Antiemetics or other central nervous system depressants may enhance the respiratory depressant effects of butorphanol.

Generic Name: famotidine Trade Name: Pepcid histamine H2 antagonist antiulcer Preg Cat B

✓INDICATION: ulcers, GERD, heart burn, indigestion, prevent/Tx stress related upper GI bleed, Mgmt of GI symptoms. ✓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. ✓DOSAGE/ROUTEPO (Adults): Short-term treatment of active duodenal ulcers—40 mg/day at bedtime or 20 mg twice daily for up to 8 wk. Treatment of benign gastric ulcers—40 mg/day at bedtime. Maintenance treatment of duodenal ulcers—20 mg once daily at bedtime. GERD—20 mg twice daily for up to 6 wk; up to 40 mg twice daily for up to 12 wk for esophagitis with erosions, ulcerations, and continuing symptoms. Gastric hypersecretory conditions—20 mg q 6 hr initially, up to 160 mg q 6 hr. OTC use—10 mg for relief of symptoms; for prevention—10 mg 60 min before eating or take 10 mg as chewable tablet 15 minutes before heartburn-inducing foods or beverages (not to exceed 20 mg/24 hr for up to 2 wk). PO, IV (Children 1-16 yr): Peptic ulcer—0.5 mg/kg/day as a single bedtime dose or in 2 divided doses (up to 40 mg daily); GERD—1 mg/kg/day in 2 divided doses (up to 80 mg twice daily). PO (Infants >3 mo-1 yr): GERD—0.5 mg/kg/dose twice daily. PO (Infants and neonates <3 mo): GERD—0.5 mg/kg/dose once daily. IV (Adults): 20 mg q 12 hr. Renal Impairment PO (Adults): CCr <50 mL/min—administer normal dose q 36-48 hr or 50% of normal dose at normal dosing interval. CCr <10 mL/min—dosing interval may need to be ↑ to q 36-48 hr. ✓CONTRAINIDICATION: Hypersensitivity; Some products contain alcohol and should be avoided in patients with known intolerance; Some products contain aspartame and should be avoided in patients with phenylketonuria. ✓SIDE EFFECTS: CNS: confusion, dizziness, drowsiness, hallucinations, headache. CV: ARRHYTHMIAS. GI: constipation, diarrhea, drug-induced hepatitis (nizatidine, cimetidine), nausea. GU: ↓ sperm count, erectile dysfunction (cimetidine). Endo: gynecomastia. Hemat: AGRANULOCYTOSIS, APLASTIC ANEMIA, anemia, neutropenia, thrombocytopenia. Local: pain at IM site. Misc: hypersensivity reactions, vasculitis. ✓ NURSING CONSIDERATIONS: -assess epigastric/ABD pain & frank/occult blood in stool, emesis, or gastric aspirate. -assess Geri for confusion & report. *Labs: Monitor CBC w/ diff 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 transaminases and serum creatinine. • Serum prolactin concentration may be ↑ after IV bolus of cimetidine. May also cause ↓ parathyroid concentrations. • Nizatidine may cause ↑ alkaline phosphatase concentrations. • Ranitidine and famotidine may cause false-positive results for urine protein; test with sulfosalicylic acid. PO: Administer with meals/immediately afterward & @bedtime to prolong effect. • If antacids or sucralfate are used concurrently for relief of pain, avoid administration of antacids within 30 min-1 hr of the H2 antagonist and take sucralfate 2 hr after H2 antagonist; may ↓ absorption of H2 antagonist. • Shake oral suspension before administration. Discard unused suspension after 30 days. • Remove foil from ranitidine effervescent tablets and dissolve in 6-8 oz water before drinking. ✓ PT TEACHING: • take full course. Do not double doses. • Advise patients taking OTC preparations not to take the maximum dose continuously for more than 2 wk. • smoking interferes w/ meds • May cause drowsiness or dizziness. Safety • Advise patient to avoid alcohol, products containing aspirin or NSAIDs, and foods that may cause an increase in GI irritation. • increase fluid & fiber 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.

Generic Name: amoxicillin/clavulanate Trade Name: Augmentin Therapeutic: anti-infectives Pharmacologic: aminopenicillins/beta lactamase inhibitors PCNs: amoxicillin (Amoxil), ampicillin (Omnipen, Polycillin), penicillin G Risk category B. No reported adverse fetal effects. Penicillins combined with beta-lactamase inhibitors (amoxicillin/clavulanate [Augmentin], ticarcillin/clavulanate [Timentin], and ampicillin/sulbactam [Unasyn]) also are risk category B. Breast milk Risk category L1. Low concentrations of penicillins in breast milk, including those combined with beta-lactamase inhibitors. Observe for infant diarrhea or candidiasis.

✓INDICATION: Skin & skin structure infections, Otitis media, Sinusitis, Respiratory tract infections, GU tract infections. ✓ACTION: Binds to bacterial cell wall, causing cell death; spectrum of amoxicillin is broader than penicillin. Clavulanate resists action of beta-lactamase, an enzyme produced by bacteria that is capable of inactivating some penicillins. Therapeutic Effects: Bactericidal action against susceptible bacteria. Spectrum: Active against: Streptococci, Pneumococci, Enterococci, Haemophilus influenzae, Escherichia coli, Proteus mirabilis, Neisseria meningitidis, N. gonorrhoeae, Staphylococcus aureus, Klebsiella pneumoniae, Shigella, Salmonella, Moraxella catarrhalis. ✓DOSAGE/ROUTE: -Most Infections (Dosing based on amoxicillin component) PO (Adults and Children >40 kg): 250 mg q 8 hr or 500 mg q 12 hr. -Serious Infections and Respiratory Tract Infections PO (Adults and Children >40 kg): 875 mg q 12 hr or 500 mg q 8 hr; Acute bacterial sinusitis—2000 mg q 12 hr for 10 days as extended release (XR) product; Community-acquired pneumonia—2000 mg every 12 hr for 7-10 days as extended release (XR) product. 148 149 -Recurrent/persistent acute otitis media due to Multidrug-resistant Streptococcus pneumonia, H. influenzae, or M. catarrhalis PO (Children <40 kg): 80-90 mg/kg/day in divided doses q 12 hr for 10 days (as ES formulation only). -Renal Impairment PO (Adults): CCr 10-30 mL/min—250-500 mg q 12 hr (do not use 875 mg tablet); CCr <10 mL/min—250-500 mg q 24 hr. -Otitis Media, Sinusitis, Lower Respiratory Tract Infections, Serious Infections PO (Children ≥3 mo): 200 mg/5 mL or 400 mg/5 mL suspension—45 mg/kg/day divided q 12 hr; 125 mg/5 mL or 250 mg/5 mL suspension—40 mg/kg/day divided q 8 hr. -Less Serious Infections PO (Children ≥3 mo): 200 mg/5 mL or 400 mg/5 mL suspension—25 mg/kg/day divided q 12 hr or 20 mg/kg/day divided q 8 hr (as 125 mg/5 mL or 250 mg/5 mL suspension). PO (Children <3 mo): 15 mg/kg q 12 hr (125 mg/mL suspension recommended). • Two 250-mg tablets are not bioequivalent to one 500-mg tablet; 250-mg tablets and 250-mg chewable tablets are also not interchangeable. Two 500-mg tablets are not interchangeable with one 1000-mg XR tablet; amounts of clavulanic acid and durations of action are different. Augmentin ES 600 (600 mg/5 mL) does not contain the same amount of clavulanic acid as any of the other Augmentin suspensions. Suspensions are not interchangeable. • Pedi: Do not administer 250-mg chewable tablets to children <40 kg due to clavulanate content. 149 150Children <3 mo should receive the 125-mg/5 mL oral solution. ✓INTERACTIONS Drug-Drug: Probenecid ↓ renal excretion and ↑ blood levels of amoxicillin—therapy may be combined for this purpose. May ↑ the effect of warfarin. Concurrent allopurinol therapy ↑ risk of rash. May ↓ the effectiveness of hormonal contraceptives. Drug-Food: Clavulanate absorption is ↓ by a high fat meal. ✓CONTRAINIDICATION: Hypersensitivity to penicillins or clavulanate; Suspension and chewable tablets contain aspartame and should be avoided in phenylketonurics; History of amoxicillin/clavulanate-associated cholestatic jaundice. Use Cautiously in: Severe renal insufficiency (dose ↓ necessary); Infectious mononucleosis (↑ risk of rash); Hepatic impairment (dose cautiously, monitor liver function). ✓SIDE EFFECTS: CNS: seizures (high doses). GI: pseudomembranous colitis, hepatic dysfunction, NVD. GU: vaginal candidiasis. Derm: rash, urticaria. Hemat: blood dyscrasias. Misc: allergic reactions including anaphylaxis and serum sickness, superinfection. ✓ NURSING CONSIDERATIONS: • Assess for infection (vital signs; appearance of wound, sputum, urine, and stool; WBC) at beginning of and throughout therapy. • check for reaction to prior antibx. • watch for s/s of anaphylaxis (rash, pruritus, laryngeal edema, wheezing). Notify health care professional immediately if these occur. • C&S before start Tx. 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. Elderly men and patients receiving prolonged treatment are at ↑ risk for hepatic dysfunction. • May cause false-positive direct Coombs' test result. • PO: Administer around the clock. Administer at the start of a meal to enhance absorption and to decrease GI side effects. -Don't admin with high fat meals; absorption is decreased. - Capsule contents may be emptied and swallowed with liquids. -Shake oral suspension before administering. **Refrigerated reconstituted suspension should be discarded after 10 days. ✓ PT TEACHING: -finish all of med. -PEDS give exact dose. -report superinfection (furry overgrowth on the tongue, vaginal itching or discharge, loose or foul-smelling stools) and allergy. -notify provider for diarrhea/bloody stool or s/s don't improve. -Use alternative birth control if taking oral BC. during therapy & until next period.

Generic Name: Hydromorphone Trade Name: Dilaudid Classification: Therapeutic: allergy, cold, and cough remedies (antitussives), opioid analgesics Pharmacologic: opioid agonists Schedule II Pregnancy Category C Neonatal respiratory depression is most significant adverse effect when large amounts of opiates are used during labor, making them a category D at this time. Neonatal withdrawal may occur if woman is addicted to an opiate drug. Risk category L2 or L3. Most narcotics given briefly and in therapeutic doses are compatible with breastfeeding, including intrathecal (before epidural catheter removal) morphine given postoperatively. Prolonged infant sedation during early postpartum period may occur with maternal meperidine analgesia.

✓INDICATION: -Mod-severe pain, requiring around-the-clock pain control. -At low dose (antitussive) ✓ACTION: -Binds to opiate receptors in the CNS. Alters the perception of and response to painful stimuli while producing generalized CNS depression. Suppresses the cough reflex via a direct central action. -Therapeutic Effects: Decrease in moderate to severe pain. Suppression of cough. ✓DOSAGE/ROUTE: Doses depend on level of pain and tolerance. Larger doses may be required during chronic therapy. Analgesic PO (Adults ≥50 kg): Immediate-release—4-8 mg q 3-4 hr initially (some patients may respond to doses as small as 2 mg initially); or once 24-hr opioid requirement is determined, convert to extended-release by administering total daily oral dose once daily. PO (Adults and Children <50 kg): 0.06 mg/kg q 3-4 hr initially, younger children may require smaller initial doses of 0.03 mg/kg. Maximum dose 5 mg. IV, IM, Subcut (Adults ≥50 kg): 1.5 mg q 3-4 hr as needed initially; may be ↑. IV, IM, Subcut (Adults and Children <50 kg): 0.015 mg/kg mg q 3-4 hr as needed initially; may be ↑. IV (Adults): Continuous infusion (unlabeled)—0.2-30 mg/hr depending on previous opioid use. An initial bolus of twice the hourly rate in mg may be given with subsequent breakthrough boluses of 50-100% of the hourly rate in mg. *Rect (Adults): 3 mg q 6-8 hr initially as needed. *Antitussive -PO (Adults and Children >12 yr): 1 mg q 3-4 hr. -PO (Children 6-12 yr): 0.5 mg q 3-4 hr. ✓CONTRAINIDICATION: Hypersensitivity; Some products contain bisulfites and should be avoided in patients with known hypersensitivity; Severe respiratory depression (in absence of resuscitative equipment) (extended-release only); Acute or severe bronchial asthma (extended-release only); Paralytic ileus (extended-release only); Acute, mild, intermittent, or postoperative pain (extended-release only); Prior GI surgery or narrowing of GI tract (extended-release only); Opioid non-tolerant patients (extended-release only); OB, Lactation: Avoid chronic use during pregnancy or lactation. ✓SIDE EFFECTS: CNS: confusion, sedation, dizziness, dysphoria, euphoria, floating feeling, hallucinations, headache, unusual dreams. EENT: blurred vision, diplopia, miosis. Resp: respiratory depression. CV: hypotension, bradycardia. GI: constipation, dry mouth, N/V. GU: urinary retention. Derm: flushing, sweating. Misc: physical dependence, psychological dependence, tolerance. ✓INTERACTIONS Drug-Drug: Exercise extreme caution with MAO inhibitors (may produce severe, unpredictable reactions—reduce initial dose of hydromorphone to 25% of usual dose, discontinue MAO inhibitors 2 wk prior to hydromorphone). ↑ risk of CNS depression with alcohol, antidepressants, antihistamines, and sedative/hypnotics including benzodiazepines and phenothiazines. Administration of partial antagonists (buprenorphine, butorphanol, nalbuphine, or pentazocine) may precipitate opioid withdrawal in physically dependent patients. Nalbuphine or pentazocine may ↓ analgesia. Drug-Natural Products: Concomitant use of kava-kava, valerian, chamomile, or hops can ↑ CNS depression. ✓ NURSING CONSIDERATIONS: -Assess Vitals: BP, HR, RR -- before & periodically during admin. -Assess cough & lung sounds. - RR <10/min assess LOC & level of sedation. -GERI & PEDS more sensitive. -Bowel function. Prevent constipation by increase fluid intake & bulk. -Laxatives if constipated >2-3 days. -Assess pain: type, location, intensity prior to & 1 hr after IM/PO. 5 min after IV. -Continuous infusion should have bolus q15-30 min PRN for breakthrough pain. The bolus dose is usually set to the amount of drug infused each hour by continuous infusion. -May admin w/ food/milk. -Dilute IV admin w/ 5mL NS. Slow admin, 2 mg over 3-5 min. **Rapid admin: may cause resp. depression & circulatory collapse. *Labs: May ↑ plasma amylase and lipase concentrations. *OD: Naloxone (Narcan) ✓ PT TEACHING: -Don't d/c abruptly -teach to ask for med PRN. better to control before pain is worse. -Instruct Pt to call for assistance when ambulating -- may cause dizziness/drowsiness. -Caution to avoid driving. -Change position slowly. -Avoid ETOH & other CNS depressants. -Turn, cough, & deep breathe q2 hours to prevent atelectasis. -Ed to prevent constipation.

Generic Name: Morphine Trade Name: Duramorph, Astromorph, Avinza, Embeda Schedule II Opioid analgesic Preg Cat: C

✓INDICATION: mod to severe pain. ✓ACTION: Binds to opiate receptors in the CNS. Alters the perception of and response to painful stimuli while producing generalized CNS depression. Therapeutic Effects: Decrease in severity of pain. Addition of naltrexone in Embeda product is designed to prevent abuse or misuse by altering the formulation. Naltrexone has no effect unless the capsule is crushed or chewed. ✓DOSAGE/ROUTE: (PO, Rect (Adults ≥50 kg): Usual starting dose for moderate to severe pain in opioid-naive patients—30 mg q 3-4 hr initially or once 24-hr opioid requirement is determined, convert to controlled-, extended-, or sustained-release morphine by administering total daily oral morphine dose every 24 hr (as Kadian or Avinza), 50% of the total daily oral morphine dose every 12 hr (as Kadian, MS Contin), or 33% of the total daily oral morphine dose every 8 hr (as MS Contin). See equianalgesic chart, Appendix K. Avinza dose should not exceed 1600 mg/day because of fumaric acid in formulation. (PO, Rect (Adults and Children <50 kg): Usual starting dose for moderate to severe pain in opioid-naive patients—0.3 mg/kg q 3-4 hr initially. PO (Children >1 mo): Prompt-release tablets and solution—0.2-0.5 mg/kg/dose q 4-6 hr as needed. Controlled-release tablet—0.3-0.6 mg/kg/dose q 12 hr. IM, IV, Subcut (Adults ≥ 50 kg): Usual starting dose for moderate to severe pain in opioid-naive patients—4-10 mg q 3-4 hr. MI—8-15 mg, for very severe pain additional smaller doses may be given every 3-4 hr. IM, IV, Subcut (Adults and Children <50 kg): Usual starting dose for moderate to severe pain in opioid-naive patients—0.05-0.2 mg/kg q 3-4 hr, maximum: 15 mg/dose. IM, IV, Subcut (Neonates): 0.05 mg/kg q 4-8 hr, maximum dose: 0.1 mg/kg. Use preservative-free formulation. IV, Subcut (Adults): Continuous infusion—0.8-10 mg/hr; may be preceded by a bolus of 15 mg (infusion rates vary greatly; up to 400 mg/hr have been used). IV, Subcut (Children >1 mo): Continuous infusion, postoperative pain—0.01-0.04 mg/kg/hr. Continuous infusion, sickle cell or cancer pain—0.02-2.6 mg/kg/hr. IV (Neonates): Continuous infusion—0.01-0.03 mg/kg/hr. Epidural (Adults): Intermittent injection—5 mg/day (initially); if relief is not obtained at 60 min, 1-2 mg increments may be made (total dose not to exceed 10 mg/day. Continuous infusion—2-4 mg/24 hr; may ↑ by 1-2 mg/day (up to 30 mg/day). Epidural (Children >1 mo): 0.03-0.05 mg/kg, maximum dose: 0.1 mg/kg or 5 mg/24 hr. Use preservative-free formulation. IT (Adults): 0.2-1 mg. Use preservative-free formulation. ✓CONTRAINIDICATION: Hypersensitivity; Some products contain tartrazine, bisulfites, or alcohol and should be avoided in patients with known hypersensitivity. Acute, mild, intermittent, or postoperative pain (extended/sustained-release); Significant respiratory depression (extended/sustained-release); Acute or severe bronchial asthma (extended/sustained-release); Paralytic ileus (extended/sustained-release); ✓OB, Lactation: Avoid chronic use; has been used during labor but may cause respiratory depression in the newborn; Pedi: Neonates and infants <3 mo (more susceptible to respiratory depression); Pedi: Neonates (oral solution contains sodium benzoate which can cause potentially fatal gasping syndrome). ✓SIDE EFFECTS: CNS: confusion, sedation, dizziness, dysphoria, euphoria, floating feeling, hallucinations, headache, unusual dreams. EENT: blurred vision, diplopia, miosis. Resp: RESPIRATORY DEPRESSION. CV: hypotension, bradycardia. GI: constipation, nausea, vomiting. GU: urinary retention. Derm: flushing, itching, sweating. Misc: physical dependence, psychological dependence, tolerance. ✓Interactions Drug-Drug: Use with extreme caution in patients receiving MAO inhibitors within 14 days prior (may result in unpredictable, severe reactions—↓ initial dose of morphine to 25% of usual dose). ↑ CNS depression with alcohol, sedative/hypnotics, clomipramine, barbiturates, tricyclic antidepressants, and antihistamines. Administration of partial-antagonist opioid analgesics may precipitate opioid withdrawal in physically dependent patients. Buprenorphine, nalbuphine, butorphanol, or pentazocine may ↓ analgesia. May ↑ the anticoagulant effect of warfarin. Cimetidine ↓ metabolism and may ↑ effects. ✓Drug-Natural Products: Concomitant use of kava-kava, valerian, or chamomile can ↑ CNS depression. ✓Maternal Effects: Malnutrition, anemia, increased incidence of STDs, HIV exposure, hepatitis, thrombosis, cardiac disease, spontaneous abortion, preterm labor. ✓Fetal Effects: FGR, LBW, perinatal asphyxia, meconium aspiration syndrome, fetal or neonatal death, SIDS, child abuse and neglect; long-term developmental effects unclear. ✓ NURSING CONSIDERATIONS: -assess pain: type, location, intensity. before & 1 hr after PO, Subcut, IM & 20 min after IV. -vitals -bowel function, constipation - Naloxone (Narcan) -- OD -gradually D/C to avoid withdrawal. -admin w/ milk/food to decrease upset. -Oral Soln may be diluted w/ juice. (oral syringe/measure device) - Multiple doses do IM rather than subcut. ✓LABS: May ↑ plasma amylase and lipase levels. ✓ PT TEACHING: -Safety: ask for assistance ambulation. Change positions slowly. Caution against driving. -no ETOH/CNS depress. -turn, cough, deep breathe q2 hrs

Generic Name: Hydroxizine Trade Name: (Vistaril) Classification Therapeutic: antianxiety agents, antihistamines, sedative/hypnotics Pregnancy Category C

✓INDICATIONS: Treatment of anxiety. Preoperative sedation. Antiemetic. Antipruritic. May be combined with opioid analgesics. ✓ACTION: Acts as a CNS depressant at the subcortical level of the CNS. Has anticholinergic, antihistaminic, and antiemetic properties. Blocks histamine 1 receptors. Therapeutic Effects: Sedation. Relief of anxiety. Decreased nausea and vomiting. Decreased allergic symptoms associated with release of histamine, including pruritus. ✓DOSAGE/ROUTE: -Parenteral hydroxyzine can be given only intramuscularly, by injection into a large muscle with the deep Z-track technique. Hydroxyzine is not given by the IV route. PO (Adults): Antianxiety—25-100 mg 4 times/day, not to exceed 600 mg/day. Preoperative sedation—50-100 mg single dose. Antipruritic—25 mg 3-4 times daily. PO (Children): —2 mg/kg/day divided q 6-8 hr. IM (Adults): Preoperative sedation—25-100 mg single dose. Antiemetic, adjunct to opioid analgesics—25-100 mg q 4-6 hr as needed. IM (Children): —0.5-1 mg/kg/dose q 4-6 hr as needed. ✓CONTRAINIDICATION: Hypersensitivity; OB: Potential for congenital defects (oral clefts and hypoplasia of cerebral hemisphere; Lactation: Safety not established. Use Cautiously in: Severe hepatic dysfunction; OB: Has been used safely during labor; Pedi: Injection contains benzyl alcohol, which can cause potentially fatal gasping syndrome in neonates; Geri: Appears on Beers list. Geriatric patients are more susceptible to adverse reactions due to anticholinergic effects; dosage ↓ recommended. ✓SIDE EFFECTS: CNS: drowsiness, agitation, ataxia, dizziness, headache, weakness. Resp: wheezing. GI: dry mouth, bitter taste, constipation, nausea. GU: urinary retention. Derm: flushing. Local: pain at IM site, abscesses at IM sites. Misc: chest tightness. Interactions Drug-Drug: Additive CNS depression with other CNS depressants, including alcohol, antidepressants, antihistamines, opioid analgesics, and sedative/hypnotics. Additive anticholinergic effects with other drugs possessing anticholinergic properties, including antihistamines, antidepressants, atropine, haloperidol, phenothiazines, quinidine, and disopyramide. Can antagonize the vasopressor effects of epinephrine. ✓ NURSING CONSIDERATIONS: • Assess patient for profound sedation and provide safety precautions as indicated (side rails up, bed in low position, call bell within reach, supervision of ambulation and transfer). Geri: Older adults are more sensitive to CNS and anticholinergic effects (delirium, acute confusion, dizziness, dry mouth, blurred vision, urinary retention, constipation, tachycardia). Monitor for drowsiness, agitation, over sedation, and other systemic side effects. Assess falls risk and implement prevention strategies. • Anxiety: Assess mental status (orientation, mood, and behavior). • Nausea and Vomiting: Assess degree of nausea and frequency and amount of emesis. • Pruritus: Assess degree of itching and character of involved skin. • Do not confuse hydroxyzine with hydralazine or Atarax (hydroxyzine) with Ativan (lorazepam). • PO: Tablets may be crushed and capsules opened and administered with food or fluids for patients having difficulty swallowing. ✓ PT TEACHING: • May cause drowsiness or dizziness. safety. • Advise patient to avoid concurrent use of alcohol or other CNS depressants with this medication. • Inform patient that frequent mouth rinses, good oral hygiene, and sugarless gum or candy may help decrease dry mouth. If dry mouth persists for more than 2 wk, consult dentist about saliva substitute. • If used for anxiety, advise patient that psychotherapy is beneficial in addressing sources of anxiety and improving coping skills. • Teach other methods to decrease anxiety, such as increased exercise, support groups, and relaxation techniques.

Generic Name: Diphenhydramine Trade Name: Benadryl Therapeutic: allergy, cold, and cough remedies, antihistamines, antitussives Preg Cat B L1

✓INDICATIONS: Relief of allergic symptoms caused by histamine release including: Anaphylaxis, Seasonal and perennial allergic rhinitis, Allergic dermatoses. Parkinson's disease and dystonic reactions from medications. Mild nighttime sedation. Prevention of motion sickness. Antitussive (syrup only). -Given to relieve pruritus from epidural narcotics. -may be prescribed for with other meds for vomiting. ✓ACTION: Antagonizes the effects of histamine at H1−receptor sites; does not bind to or inactivate histamine. Significant CNS depressant and anticholinergic properties. Therapeutic Effects: Decreased symptoms of histamine excess (sneezing, rhinorrhea, nasal and ocular pruritus, ocular tearing and redness, urticaria). Relief of acute dystonic reactions. Prevention of motion sickness. Suppression of cough. ✓DOSAGE/ROUTE: PO (Adults and Children>12 yr): Antihistaminic/antiemetic/antivertiginic—25-50 mg q 4-6 hr, not to exceed 300 mg/day. Antitussive—25 mg q 4 hr as needed, not to exceed 150 mg/day. Antidyskinetic—25-50 mg q 4 hr (not to exceed 400 mg/day). Sedative/hypnotic—50 mg 20-30 min before bedtime. PO (Children 6-12 yr): Antihistaminic/antiemetic/antivertiginic—12.5-25 mg q 4-6 hr (not to exceed 150 mg/day). Antidyskinetic—1-1.5 mg/kg q 6-8 hr as needed (not to exceed 300 mg/day). Antitussive—12.5 mg q 4 hr (not to exceed 75 mg/day). Sedative/hypnotic—1 mg/kg/dose 20-30 min before bedtime (not to exceed 50 mg). PO (Children 2-6 yr): Antihistaminic/antiemetic/antivertiginic—6.25-12.5 mg q 4-6 hr (not to exceed 37.5 mg/day). Antidyskinetic—1-1.5 mg/kg q 4-6 hr as needed (not to exceed 300 mg/day). Antitussive—6.25 mg q 4 hr (not to exceed 37.5 mg/24 hr). Sedative/hypnotic—1 mg/kg/dose 20-30 min before bedtime (not to exceed 50 mg). IM, IV (Adults): 25-50 mg q 4 hr as needed (may need up to 100-mg dose, not to exceed 400 mg/day). IM, IV (Children): 1.25 mg/kg (37.5 mg/m2) 4 times daily (not to exceed 300 mg/day). Topical (Adults and Children ≥2 yr): Apply to affected area up to 3-4 times daily. ✓CONTRAINIDICATION: Hypersensitivity; Acute attacks of asthma; Lactation: Lactation; Known alcohol intolerance (some liquid products). Use Cautiously in: Severe liver disease; Angle-closure glaucoma; Seizure disorders; Prostatic hyperplasia; Peptic ulcer; May cause paradoxical excitation in young children; Hyperthyroidism; OB: Safety not established; Geri: Appears on Beers list. Geriatric patients are more susceptible to adverse drug reactions and anticholinergic effects (delirium, acute confusion, dizziness, dry mouth, blurred vision, urinary retention, constipation, tachycardia); dose ↓ or nonanticholinergic antihistamine recommended. ✓SIDE EFFECTS: CNS: drowsiness, dizziness, headache, paradoxical excitation (increased in children). EENT: blurred vision, tinnitus. CV: hypotension, palpitations. GI: anorexia, dry mouth, constipation, nausea. GU: dysuria, frequency, urinary retention. Derm: photosensitivity. Resp: chest tightness, thickened bronchial secretions, wheezing. Local: pain at IM site. ✓INTERACTIONS Drug-Drug: ↑ risk of CNS depression with other antihistamines, alcohol, opioid analgesics, and sedative/hypnotics. ↑ anticholinergic effects with tricyclic antidepressants, quinidine, or disopyramide. MAO inhibitors intensify and prolong the anticholinergic effects of antihistamines. Drug-Natural Products: Concomitant use of kava-kava, valerian, or chamomile can ↑ CNS depression. ✓ NURSING CONSIDERATIONS: Assessment - Geri: Appears in the Beers list. May cause sedation and confusion due to increased sensitivity to anticholinergic effects. assess for confusion, delirium, other anticholinergic side effects and fall risk. Institute measures to prevent falls. -Prevention & Treatment of Anaphylaxis: Assess for urticaria and for patency of airway. -Allergic Rhinitis: Assess degree of nasal stuffiness, rhinorrhea, and sneezing. -Parkinsonism and Extrapyramidal Reactions: Assess movement disorder before and after administration. - Insomnia: Assess sleep patterns. - Motion Sickness: Assess nausea, vomiting, bowel sounds, and abdominal pain. - Cough Suppressant: Assess frequency and nature of cough, lung sounds, and amount and type of sputum produced. Unless contraindicated, maintain fluid intake of 1500-2000 mL daily to decrease viscosity of bronchial secretions. - Pruritus: Assess degree of itching, skin rash, and inflammation. • Lab Test Considerations: May ↓ skin response to allergy tests. Discontinue 4 days before skin testing. Implementation -Insomnia: admin 20 min before QHS. -Motion sickness: admin 30 mins before & 1-2 hr after. -Take with Milk to reduce GI upset. -H20 & food - Orally disintegrating tablets and strips should be left in the package until use. -IM injection in large muscle. ✓ PT TEACHING: -May cause drowsiness. -Safety precautions w/ driving etc. -dry mouth: oral rinse, hygiene, sugarless gum/candy. Notify health care professional if dry mouth persists for more than 2 wk. - SLEEP HYGIENE (dark room, quiet, bedtime ritual, limit daytime napping, avoidance of nicotine and caffeine) to patients taking diphenhydramine to aid sleep. -use sunscreen to prevent photosensitivity reactions. -avoid CNS depress & ETOH **Caution parents to avoid OTC cough and cold products while breast feeding or to children <4 yr.

Generic Name: Vitamin K ----Injection (Phytonadione, AquaMEPHYTON, Konakion, Mephyton) Classification: Fat-soluble vitamin, antihemorrhagic.

✓Indication: Prevention or treatment of vitamin K-deficiency bleeding (hemorrhagic disease of the newborn). ACTION: Promotes the formation of factors II (prothrombin), VII, IX, and X by the liver for clotting; provides vitamin K, which is not synthesized in the intestines until intestinal flora necessary for vitamin K production are established. ✓DOSAGE/ROUTE: 0.5 to 1 mg (0.25 to 0.5 mL of solution containing 1 mg/0.5 mL) given once intramuscularly within 1 hour of birth for prophylaxis. May be delayed for breastfeeding in delivery room. ✓CONTRAINIDICATION: n/a ✓SIDE EFFECTS: Erythema, pain, and edema at injection site; anaphylaxis; hemolysis; or hyperbilirubinemia, especially in a preterm infant or when a large dose is used. ✓ NURSING CONSIDERATIONS: Protect the drug from light until just before administration to prevent decomposition and loss of potency. Observe all infants for signs of vitamin K deficiency (ecchymoses or bleeding from any site). Check that the infant has had vitamin K before a circumcision is performed. Vitamin K is given to neonates because they cannot synthesize it in the intestines without bacterial flora. This places them at risk for hemorrhagic disease of the newborn (vitamin K-deficiency disease). One dose of vitamin K intramuscularly after birth prevents bleeding problems until the infant is able to produce vitamin K in sufficient amounts. Although the injection is usually given within the first hour after birth, it can be delayed until the infant has finished breastfeeding in the delivery room.

Generic Name: Betamethasone Trade Name: Celestone long-acting corticosteroids Pregnancy Category C Betamethasone are used to accelerate maturation of fetal lungs if preterm delivery is likely. Risk category L2. Prednisone and prednisolone compatible with breastfeeding. Delay nursing 4 hr after dose to reduce transfer to infant. Remove from nipples before nursing if applied topically.

✓Indications -Administering the steroid as late as 37 weeks of gestation may be chosen if fetal lung maturity studies demonstrate immature lungs later than 34 weeks. ✓ACTION: all agents suppress inflammation and the normal immune response. All agents have numerous intense metabolic effects ✓DOSAGE/ROUTE: IM, (ADULT): 0.5-9 mg as betamethasone sodium phosphate/acetate suspension. Prevention of respiratory distress syndrome in newborn—12 mg daily for 2-3 days before delivery (unlabeled). IM, (Children): Adrenocortical insufficiency—17.5 mcg/kg/day (500 mcg/m2/day) in 3 divided doses every 3rd day or 5.8-8.75 mcg/kg (166-250 mcg/m2)/day as a single dose. ✓CONTRAINIDICATION: Active untreated infections (may be used in patients being treated for some forms of meningitis); Lactation: Avoid chronic use; Known alcohol, bisulfite, or tartrazine hypersensitivity or intolerance (some products contain these and should be avoided in susceptible patients); Administration of live virus vaccines. Use Cautiously in: Chronic treatment (will lead to adrenal suppression; use lowest possible dose for shortest period of time); Hypothyroidism; Immunosuppression. Cirrhosis; Pedi: Children (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); Traumatic brain injury (high doses may be associated with ↑ mortality); OB: Safety not established; Pedi: Neonates (avoid use of benzyl alcohol containing injectable preparations; use preservative-free formulations). ✓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: HTN. GI: PEPTIC ULCERATION, anorexia, N/V. Derm: acne, ↓ wound healing, ecchymoses, fragility, hirsutism, petechiae. Endo: adrenal suppression, hyperglycemia. fluid retention (long-term high doses), hypokalemia, hypokalemic alkalosis. Hemat: THROMBOEMBOLISM, thrombophlebitis. Metab: weight gain. MS: muscle wasting, osteoporosis, avascular necrosis of joints, muscle pain. Misc: cushingoid appearance (moon face, buffalo hump), ↑ susceptibility to infection. ✓ Interactions Drug-Drug: ↑ risk of hypokalemia with thiazide and loop diuretics, or amphotericin B. Hypokalemia may ↑ risk of digoxin toxicity. May increase requirement for insulin or oral hypoglycemic agents. Phenytoin, phenobarbital, and rifampin ↑ metabolism; may ↓ effectiveness. Hormonal contraceptives may ↓ metabolism. ↑ risk of adverse GI effects with NSAIDs (including aspirin). At chronic doses that suppress adrenal function, may ↓ antibody response to and ↑ risk of adverse reactions from live-virus vaccines. May ↑ serum concentrations of cyclosporine and tacrolimus. May ↑ risk of tendon rupture from fluoroquinolones. Antacids ↓ absorption of prednisone and dexamethasone. Known inhibitors of the CYP3A4 enzyme including ketoconazole, itraconazole, ritonavir, indinavir, saquinavir, and erythromycin may ↑ blood levels and effects of budesonide (↓ dose may be necessary). May ↓ isoniazid levels and effectiveness. May antagonize the effects of anticholinergic agents in myasthenia gravis. Drug-Food: Grapefruit juice ↑ serum levels and effects of budesonide (avoid concurrent use). ✓ NURSING CONSIDERATIONS: Assessment • Assess for signs of adrenal insufficiency (hypotension, weight loss, weakness, nausea, vomiting, anorexia, lethargy, confusion, restlessness) before and periodically during therapy. - Monitor I&Os, daily weight, fluid overload s/s. Observe patient for peripheral edema, steady weight gain, rales/crackles, or dyspnea. Notify health care professional if these occur. • Cerebral Edema: Assess for changes in level of consciousness and headache during therapy. • Lab Test Considerations: Monitor serum electrolytes and glucose. May cause hyperglycemia, especially in persons with diabetes. May cause hypokalemia. Patients on prolonged therapy should routinely have CBC, serum electrolytes, and serum and urine glucose evaluated. May ↓ WBCs. May ↓ serum potassium and calcium and ↑ serum sodium concentrations. • Guaiac-test stools. Promptly report presence of guaiac-positive stools. Implementation • Do not confuse prednisone with prednisolone. Do not confuse Solu-Cortef with Solu-Medrol. • If dose is ordered daily or every other day, administer in the morning to coincide with the body's normal secretion of cortisol. • Periods of stress, such as surgery, may require supplemental systemic corticosteroids. • Patients with mild to moderate Crohn's disease may be switched from oral prednisolone without adrenal insufficiency by gradually decreasing prednisolone doses and adding budesonide. • PO: Administer with meals to minimize GI irritation. • For orally disintegrating tablets (ODT): place tablet on tongue; may be swallowed whole or allowed to dissolve in mouth, with or without water. Tablets are friable; do not cut, split, or break. ** IM, Subcut: Shake suspension well before drawing up. IM doses should not be administered when rapid effect is desirable. Do not dilute with other solution or admix. Do not administer suspensions IV. ✓ PT TEACHING: • 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. • avoid grapefruit • Corticosteroids cause immunosuppression and may mask symptoms of infection. Instruct patient to avoid people with known contagious illnesses and to report possible infections immediately. • Prelone syrup should not be refrigerated, Pediapred solution may be refrigerated, Orapred solution should be refrigerated. • ask MD about vaccines before getting. • report severe abdominal pain or tarry stools occur. unusual swelling, weight gain, tiredness, bone pain, bruising, nonhealing sores, visual disturbances, or behavior changes. • notify if exposed to chicken pox or measles. • Need to f/u & have routine labs. • Long-term Therapy: Encourage patient to eat a diet high in protein, calcium, and potassium, and low in sodium and carbohydrates (see Appendix M). Alcohol should be avoided during therapy; may ↑ risk of GI irritation. • If rectal dose used 21 days, decrease to every other night for 2-3 wk to decrease gradually.

Generic Name: Dinoprostone Trade Name: Cervidil vaginal insert Other brands: Prepidil Endocervical Gel, Prostin E Vaginal Suppository Therapeutic: cervical ripening agent

✓Indications Endocervical Gel, Vaginal Insert: Used to "ripen" the cervix in pregnancy at or near term when induction of labor is indicated. Vaginal Suppository: Induction of midtrimester abortion, Management of missed abortion up to 28 wk, Management of nonmetastatic gestational trophoblastic disease (benign hydatidiform mole). ✓ACTION: Produces contractions similar to those occurring during labor at term by stimulating the myometrium (oxytocic effect). Initiates softening, effacement, and dilation of the cervix ("ripening"). Also stimulates GI smooth muscle. Therapeutic Effects: Initiation of labor. Expulsion of fetus. ✓DOSAGE/ROUTE: Cervical Ripening Vag, (Adults, Cervical): Endocervical gel—0.5 mg; if response is unfavorable, may repeat in 6 hr (not to exceed 1.5 mg/24 hr). Vaginal insert—one 10-mg insert. Abortifacient Vag (Adults): One 20-mg suppository, repeat q 3-5 hr (not to exceed 240 mg total or longer than 48 hr). ✓CONTRAINIDICATION: Hypersensitivity to prostaglandins or additives in the gel or suppository; The gel/insert should be avoided in situations in which prolonged uterine contractions should be avoided, including: Previous cesarean section or uterine surgery; Cephalopelvic disproportion; Traumatic delivery or difficult labor; Multiparity (≥6 term pregnancies); Hyperactive or hypertonic uterus; Fetal distress (if delivery is not imminent); Unexplained vaginal bleeding; Placenta previa; Vasa previa; Active herpes genitalis; Obstetric emergency requiring surgical intervention; Situations in which vaginal delivery is contraindicated; Presence of acute pelvic inflammatory disease or ruptured membranes; Concurrent oxytocic therapy (wait for 30 min after removing insert before using oxytocin). Use Cautiously in: Uterine scarring; Asthma; Hypotension; Cardiac disease; Adrenal disorders; Anemia; Jaundice; Diabetes mellitus; Epilepsy; Glaucoma; Pulmonary, renal, or hepatic disease; Multiparity (up to 5 previous term pregnancies); Women >30 yr, those with complications during pregnancy, and those with a gestational age >40 wk (↑ risk of disseminated intravascular coagulation) ✓SIDE EFFECTS: Endocervical Gel, Vaginal Insert GU: uterine contractile abnormalities, warm feeling in vagina. MS: back pain. Misc: AMNIOTIC FLUID EMBOLISM, fever. CNS: headache, drowsiness, syncope. Resp: coughing, dyspnea, wheezing. CV: hypotension, hypertension. GI: diarrhea, nausea, vomiting. GU: UTERINE RUPTURE, urinary tract infection, uterine hyperstimulation, vaginal/uterine pain. Misc: allergic reactions including ANAPHYLAXIS, chills, fever. ✓ NURSING CONSIDERATIONS: • Abortifacient: Monitor frequency, duration, and force of contractions and uterine resting tone. Opioid analgesics may be administered for uterine pain. • Monitor temperature, pulse, and BP periodically throughout therapy. Dinoprostone-induced fever (elevation >1.1°C or 2°F) usually occurs within 15-45 min after insertion of suppository. This returns to normal 2-6 hr after discontinuation or removal of suppository from vagina. • Auscultate breath sounds. Wheezing and sensation of chest tightness may indicate hypersensitivity reaction. • Assess for NVD in patients receiving suppository. Vomiting and diarrhea occur frequently. Patient should be premedicated with antiemetic and antidiarrheal. • Monitor amount and type of vaginal discharge. Notify health care professional immediately if symptoms of hemorrhage (increased bleeding, hypotension, pallor, tachycardia) occur. • Cervical Ripening: Monitor uterine activity, fetal status, and dilation and effacement of cervix continuously throughout therapy. Assess for hypertonus, sustained uterine contractility, and fetal distress. Insert should be removed at the onset of active labor. Implementation • Abortifacient: Warm the suppository to room temperature just before use. • Patient should remain supine for 10 min after insertion of suppository; then she may be ambulatory. • Vaginal Insert: Place vaginal insert transversely in the posterior vaginal fornix immediately after removing from foil package. Warming of insert and sterile conditions are not required. Use vaginal insert only with a retrieval system. Use minimal amount of water-soluble lubricant during insertion; avoid excess because it may hamper release of dinoprostone from insert. Patient should remain supine for 2 hr after insertion, then may ambulate. • Vaginal insert delivers dinoprostone 0.3 mg/hr over 12 hr. Remove insert at the onset of active labor, before amniotomy, or after 12 hr. • Oxytocin should not be used during or less than 30 min after removal of insert. • Endocervical Gel: Determine degree of effacement before insertion of the endocervical catheter. Do not administer above the level of the internal os. Use a 20-mm endocervical catheter if no effacement is present and a 10-mm catheter if the cervix is 50% effaced. • Use caution to prevent contact of dinoprostone gel with skin. Wash hands thoroughly with soap and water after administration. • Bring gel to room temperature just before administration. Do not force warming with external sources (water bath, microwave). Remove peel-off seal from end of syringe; then remove the protective end cap and insert end cap into plunger stopper assembly in barrel of syringe. Aseptically remove catheter from package. Firmly attach catheter hub to syringe tip; click is evidence of attachment. Fill catheter with sterile gel by pushing plunger to expel air from catheter before administration to patient. Gel is stable for 24 mo if refrigerated. • Patient should be in dorsal position with cervix visualized using a speculum. Introduce gel with catheter into cervical canal using sterile technique. Administer gel by gentle expulsion from syringe and then remove catheter. Do not attempt to administer small amount of gel remaining in syringe. Use syringe for only 1 patient; discard syringe, catheter, and unused package contents after using. • Patient should remain supine for 15-30 min after administration to minimize leakage from cervical canal. • Oxytocin may be administered 6-12 hr after desired response from dinoprostone gel. If no cervical/uterine response to initial dose of dinoprostone is obtained, repeat dose may be administered in 6 hr. ✓ PT TEACHING: • Explain purpose of medication and vaginal exams. • Abortifacient: Instruct patient to notify health care professional immediately if fever and chills, foul-smelling vaginal discharge, lower abdominal pain, or increased bleeding occurs. • Provide emotional support throughout therapy. • Cervical Ripening: Inform patient that she may experience a warm feeling in her vagina during administration. • Advise patient to notify health care professional if contractions become prolonged. Evaluation/Desired Outcomes • Complete abortion. Continuous administration for more than 2 days is not usually recommended. • Cervical ripening and induction of labor.

Generic Name: Meperidine Trade Name: (Demerol) Classification Therapeutic: opioid analgesics Pharmacologic: opioid agonists Schedule II Pregnancy Category C

✓Indications Moderate or severe pain (alone or with nonopioid agents). Anesthesia adjunct. Analgesic during labor. Preoperative sedation. Unlabeled Use: Rigors. ✓ACTION: Binds to opiate receptors in the CNS. Alters the perception of and response to painful stimuli, while producing generalized CNS depression. Therapeutic Effects: Decrease in severity of pain. ✓DOSAGE/ROUTE: PO, IM: Subcut (Adults): Analgesia—50 mg q 3-4 hr; may be ↑ as needed (not to exceed 600 mg/24 hr). Analgesia during labor—50-100 mg IM or subcut when contractions become regular; may repeat q 1-3 hr. Preoperative sedation—50-100 mg IM or subcut 30-90 min before anesthesia. PO, IM: Subcut: (1-15)): Analgesia—1-1.5 mg/kg q 3-4 hr (should not exceed 100 mg/dose). Preoperative sedation—1-2 mg/kg 30-90 min before anesthesia (not to exceed adult dose). IV (Adults): 15-35 mg/hr as a continuous infusion; PCA—10 mg initially; with a range of 1-5 mg/incremental dose, recommended lockout interval is 6-10 min (minimum 5 min). IV (Children): Continuous infusion—0.5-1 mg/kg loading dose followed by 0.3 mg/kg/hr, titrate to effect up to 0.5-0.7 mg/kg/hr. ✓CONTRAINIDICATION: Hypersensitivity; Hypersensitivity to bisulfites (some injectable products); Recent (within 14 days) MAO inhibitor therapy; Severe respiratory insufficiency; OB: Chronic use may pose risk to the fetus including possible addiction; Lactation: Excreted in breast milk and can cause respiratory depression in the infant. ✓SIDE EFFECTS: CNS: SEIZURES, confusion, sedation, dysphoria, euphoria, floating feeling, hallucinations, headache, unusual dreams. EENT: blurred vision, diplopia, miosis. Resp: respiratory depression. CV: hypotension, bradycardia. GI: constipation, nausea, vomiting. GU: urinary retention. Derm: flushing, sweating. Misc: allergic reactions including ANAPHYLAXIS, physical dependence, psychological dependence, tolerance. Interactions Drug-Drug: Do not use in patients receiving MAO inhibitors or procarbazine (may cause fatal reaction—contraindicated within 14 days of MAO inhibitor therapy). ↑ CNS depression with alcohol, antihistamines, and sedative/hypnotics. Administration of agonist/antagonist opioid analgesics may precipitate opioid withdrawal in physically dependent patients. Nalbuphine or pentazocine may ↓ analgesia. Protease inhibitors may ↑ effects and adverse reactions (concurrent use should be avoided). Phenytoin ↑ metabolism and may ↓ effects. Chlorpromazine and thioridazine may ↑ the risk of adverse reactions (concurrent use should be avoided). May aggravate side effects of isoniazid. Acyclovir may ↑ plasma concentrations of meperidine and normeperidine. Drug-Natural Products: Concomitant use of kava-kava, valerian, or chamomile can ↓ CNS depression. St. John's wort may ↑ serious side effects, concurrent use is not recommended. ✓ NURSING CONSIDERATIONS: Assessment • Assess type, location, and intensity of pain prior to and 1 hr following PO, subcut, and IM doses and 5 min (peak) following IV administration. • Assess BP, pulse, and respirations before and periodically during administration. If respiratory rate is <10/min, assess level of sedation. Dose may need to be decreased by 25-50%. Initial drowsiness will diminish with continued use. • Assess bowel function routinely. Prevention of constipation should be instituted with increased intake of fluids and bulk and with laxatives to minimize constipating effects. Stimulant laxatives should be administered routinely if opioid use exceeds 2-3 days, unless contraindicated. • Monitor patients on chronic or high-dose therapy for CNS stimulation (restlessness, irritability, seizures) due to accumulation of normeperidine metabolite. Risk of toxicity increases with doses >600 m g/24 hr, chronic administration (>2 days), and renal impairment. • Geri: Meperidine has been reported to cause delirium in the elderly; older adults are at increased risk for normeperidine toxicity. Monitor frequently. • Pedi: Assess pediatric patient frequently; neonates, infants, and children are more sensitive to the effects of opioid analgesics and may experience respiratory complications, excitability, and restlessness more frequently. • Lab Test Considerations: May ↑ plasma amylase and lipase concentrations. • May be administered via PCA pump. • PO: Doses may be administered with food or milk to minimize GI irritation. Syrup should be diluted in half-full glass of water. • IM: Administration of repeated subcut doses may cause local irritation. ✓ PT TEACHING: • Instruct patient on how and when to ask for and take pain medication. • Instruct patient to take meperidine as directed. If dose is less effective after a few weeks, do not increase dose without consulting health care professional. Pedi: Teach parents or caregivers how to accurately measure liquid medication and to use only the measuring device dispensed with the medication. • May cause drowsiness or dizziness. • change positions slowly •avoid ETOH and CNS depress • Advise ambulatory patients that nausea and vomiting may be decreased by lying down. • turn, cough, and breathe deeply every 2 hr to prevent atelectasis.

Generic Name: Misoprostol Trade Name: (Cytotec) Antiulcer agent Cytoprotective agents Preg Cat: X

✓Indications Prevention of gastric mucosal injury from NSAIDs, including aspirin, in high-risk patients (geriatric patients, debilitated patients, or those with a history of ulcers). With mifepristone for termination of pregnancy.Unlabeled Use: Treatment of duodenal ulcers. Cervical ripening and labor induction. -preferred regimen of misoprostol for second-trimester pregnancy termination is 400 mg intravaginally every 6 hours. The woman usually expels the early pregnancy within 14 days of her first visit. -may help control bleeding. -misoprostol (Cytotec) may be needed to induce uterine contractions that expel the fetus. A D&C may be needed to remove the placenta. ✓ACTION: Acts as a prostaglandin analogue, decreasing gastric acid secretion (antisecretory effect) and increasing the production of protective mucus (cytoprotective effect). Causes uterine contractions. Therapeutic Effects: Prevention of gastric ulceration from NSAIDs. With mifepristone terminates pregnancy of less than 49 days. ✓DOSAGE/ROUTE: PO (Adults): Antiulcer—200 mcg 4 times daily with or after meals and at bedtime, or 400 mcg twice daily, with the last dose at bedtime. If intolerance occurs, dose may be ↓ to 100 mcg 4 times daily. Termination of pregnancy—400 mcg single dose 2 days after mifepristone if abortion has not occurred. Intravaginally: (Adults): 25 mcg (1/4 of 100-mcg tablet); may repeat q 3-6 hr, if needed. ✓CONTRAINIDICATION: Hypersensitivity to prostaglandins; OB: Should not be used to prevent NSAID-induced gastric injury due to potential for fetal harm or death; Lactation: May cause severe diarrhea in the nursing infant. Use Cautiously in: OB: Patients with childbearing potential should be counseled to avoid pregnancy during misoprostol therapy for prevention of NSAID-induced gastric injury. Pregnancy status should be determined before initiating therapy; Pedi: Safety not established. Exercise Extreme Caution in: When used for cervical ripening (unlabeled use) may cause uterine rupture (risk factors are late trimester pregnancy, previous caesarian section or uterine surgery or ≥5 previous pregnancies). ✓SIDE EFFECTS: CNS: headache. GI: abdominal pain, diarrhea, constipation, dyspepsia, flatulence, nausea, vomiting. GU: miscarriage, menstrual disorders. ✓ Interactions Drug-Drug: ↑ risk of diarrhea with magnesium-containing antacids. ✓ NURSING CONSIDERATIONS: Assessment • Assess epigastric or abdominal pain and for frank or occult blood in the stool, emesis, or gastric aspirate. • Assess women of childbearing age for pregnancy. Misoprostol is usually begun on 2nd or 3rd day of menstrual period following a negative pregnancy test result. • Termination of pregnancy: Monitor uterine cramping and bleeding during therapy. • Cervical Ripening: Assess dilation of cervix periodically during therapy. Implementation • Misoprostol therapy should be started at the onset of treatment with NSAIDs. • PO: Administer medication with meals and at bedtime to reduce severity of diarrhea. • Antacids may be administered before or after misoprostol for relief of pain. Avoid those containing magnesium, because of increased diarrhea with misoprostol. ✓ PT TEACHING: • Inform patient that misoprostol will cause spontaneous abortion. • Inform patient that diarrhea may occur. notify if >1 week. • Advise patient to avoid alcohol and foods that may cause an increase in GI irritation. Evaluation/Desired Outcomes • The prevention of gastric ulcers in patients receiving chronic NSAID therapy. • Termination of pregnancy. • Cervical ripening and induction of labor.

Generic Name: Promethazine Trade Name: (Phenergan) Therapeutic: antiemetics, antihistamines, sedative/hypnotics Pharmacologic: phenothiazines Pregnancy Category C

✓Indications Treatment of various allergic conditions and motion sickness. Preoperative sedation. Treatment and prevention of nausea and vomiting. Adjunct to anesthesia and analgesia. ✓ACTION: Blocks the effects of histamine. Has inhibitory effect on the chemoreceptor trigger zone in the medulla, resulting in antiemetic properties. Alters the effects of dopamine in the CNS. Possesses significant anticholinergic activity. Produces CNS depression by indirectly decreased stimulation of the CNS reticular system. Therapeutic Effects: Relief of symptoms of histamine excess usually seen in allergic conditions. Diminished nausea or vomiting. Sedation. ✓DOSAGE/ROUTE: Antihistamine PO (Adults): 6.25-12.5 mg 3 times/day and 25 mg at bedtime. PO (Children ≥2 yr): 0.1 mg/kg/dose (not to exceed 12.5 mg) q 6 hr during the day and 0.5 mg/kg/dose (not to exceed 25 mg) at bedtime. IM, IV, Rect (Adults): 25 mg; may repeat in 2 hr. Rect (Children ≥2 yr): 0.125 mg/kg q 4-6 hr or 0.5 mg/kg at bedtime. Antivertigo (Motion Sickness) PO (Adults): 25 mg 30-60 min before departure; may be repeated in 8-12 hr. PO, Rect (Children ≥2 yr): 0.5 mg/kg (not to exceed 25 mg) 30-60 min before departure; may be given q 12 hr as needed. Sedation PO, Rect, IM, IV (Adults): 25-50 mg; may repeat q 4-6 hr if needed. PO, Rect, IM (Children >2 yr): 0.5-1 mg/kg (not to exceed 50 mg) q 6 hr as needed. Sedation during Labor IM, IV (Adults): 50 mg in early labor; when labor is established, additional doses of 25-75 mg may be given 1-2 times at 4-hr intervals (should not exceed 100 mg/24 hr). Antiemetic PO, Rect, IM, IV (Adults): 12.5-25 mg q 4 hr as needed; initial PO dose should be 25 mg. PO, Rect, IM, IV (Children ≥2 yr): 0.25-1 mg/kg (not to exceed 25 mg) q 4-6 hr. ✓CONTRAINIDICATION: Hypersensitivity; Comatose patients; Prostatic hypertrophy; Bladder neck obstruction; Some products contain alcohol or bisulfites and should be avoided in patients with known intolerance; Angle-closure glaucoma; Pedi: May cause fatal respiratory depression in children <2 yr. OB: Has been used safely during labor; avoid chronic use during pregnancy; Lactation: Safety not established; may cause drowsiness in infant;Geri: Appears on Beers list. Sensitive to anticholinergic effects and have ↑ risk for side effects. ✓SIDE EFFECTS: CNS: NEUROLEPTIC MALIGNANT SYNDROME, confusion, disorientation, sedation, dizziness, extrapyramidal reactions, fatigue, insomnia, nervousness. EENT: blurred vision, diplopia, tinnitus. CV: bradycardia, hypertension, hypotension, tachycardia. GI: constipation, drug-induced hepatitis, dry mouth. Derm: photosensitivity, severe tissue necrosis upon infiltration at IV site, rashes. Hemat: blood dyscrasias. Interactions Drug-Drug: Additive CNS depression. Additive anticholinergic effects. May precipitate seizures when used with drugs that lower seizure threshold. Concurrent use with MAO inhibitors may result in ↑ sedation and anticholinergic side effects. ✓ NURSING CONSIDERATIONS: Assessment • Monitor BP, pulse, and respiratory rate frequently in patients receiving IV doses. • Assess level of sedation after administration. risk for CNS depress • Monitor patient for onset of EPS. Notify health care professional if these symptoms occur. • Monitor for development of neuroleptic malignant syndrome. • Geri: Assess for adverse anticholinergic effects (delirium, acute confusion, dizziness, dry mouth, blurred vision, urinary retention, constipation, tachycardia). • IV: High Alert: If administered IV, assess for burning and pain at IV site; may cause severe tissue injury. Avoid IV administration, if possible. If pain occurs, discontinue administration immediately. • Lab Test Considerations: May cause false-positive or false-negative pregnancy test results. • Evaluate CBC periodically during chronic therapy; blood dyscrasias may occur. • May cause ↑ serum glucose. • May cause false-negative results in skin tests using allergen extracts. Promethazine should be discontinued 72 hr before the test. • When administering promethazine concurrently with opioid analgesics, supervise ambulation closely to prevent injury from increased sedation. • PO: Administer with food, water, or milk to minimize GI irritation. can crush & mix with fluid/food. • IM: deep muscle ✓ PT TEACHING: • May cause drowsiness. safety • Advise patient that frequent mouth rinses, good oral hygiene, and sugarless gum or candy may decrease dry mouth. • Caution patient to use sunscreen --photosensitivity reactions. • change positions slowly. • avoid Etoh and CNS depress • notify if sore throat, fever, jaundice, or uncontrolled movements are noted. • Motion Sickness: When used as prophylaxis for motion sickness, advise patient to take medication at least 30 min and preferably 1-2 hr before exposure to conditions that may cause motion sickness.

Generic Name: Clindamycin Preg Cat: B Antiinfective

✓Indications • IM: IV: Treatment of: Skin and skin structure infections, Respiratory tract infections, Septicemia, Intra-abdominal infections, Gynecologic infections, Osteomyelitis, Endocarditis prophylaxis. Topical: Severe acne. Bacterial vaginosis. Unlabeled Use: IM: IV: Treatment of Pneumocystis carinii pneumonia, CNS toxoplasmosis, and babesiosis. ✓ACTION: Inhibits protein synthesis in susceptible bacteria at the level of the 50S ribosome. Therapeutic Effects: Bactericidal or bacteriostatic, depending on susceptibility and concentration. Spectrum: Active against most gram-positive aerobic cocci, including: Staphylococci, Streptococcus pneumoniae, other streptococci, but not enterococci. Has good activity against those anaerobic bacteria that cause bacterial vaginosis, including Bacteroides fragilis, Gardnerella vaginalis, Mobiluncus spp.,Mycoplasma hominis, and Corynebacterium. Also active against Pneumocystis jirovecii and Toxoplasma gondii. ✓DOSAGE/ROUTE: PO (Adults): Most infections—150-450 mg q 6 hr. P. carinii pneumonia—1200-1800 mg/day in divided doses with 15-30 mg Primaquine/day (unlabeled). CNS toxoplasmosis—1200-2400 mg/day in divided doses with pyrimethamine 50-100 mg/day (unlabeled); Bacterial endocarditis prophylaxis—600 mg 1 hr before procedure. PO (Children>1 mo): 10-30 mg/kg/day divided q 6-8 hr; maximum dose 1.8 g/day. Bacterial endocarditis prophylaxis—20 mg/kg 1 hr before procedure. IM, IV (Adults): Most infections—300-600 mg q 6-8 hr or 900 mg q 8 hr (up to 4.8 g/day IV has been used; single IM doses of >600 mg are not recommended). P. carinii pneumonia—2400-2700 mg/day in divided doses with Primaquine (unlabeled). Toxoplasmosis—1200-4800 mg/day in divided doses with pyrimethamine. Bacterial endocarditis prophylaxis—600 mg 30 min before procedure. IM, IV (Children >1 mo): 25-40 mg/kg/day divided q 6-8 hr; maximum dose: 4.8 g/day. Bacterial endocarditis prophylaxis—20 mg/kg 30 min before procedure; maximum dose: 600 mg. IM, IV (Infants <1 mo and <2 kg): 5 mg/kg q 8-12 hr; ≥2 kg—20-30 mg/kg/day divided q 6-8 hr. Vag (Adults and Adolescents): Cleocin, Clindamax—1 applicatorful (5 g) at bedtime for 3 or 7 days (7 days in pregnant patients); Clindesse—one applicatorful (5 g) single dose; or 1 suppository (100 mg) at bedtime for 3 nights. Topical (Adults and Adolescents): Solution—1% solution/suspension applied twice daily (range 1-4 times daily). Foam, gel—1% foam or gel applied once daily. ✓CONTRAINIDICATION: Contraindicated in: Hypersensitivity; Regional enteritis or ulcerative colitis (topical foam) Previous pseudomembranous colitis; Severe liver impairment; Diarrhea; Known alcohol intolerance (topical solution, suspension). ***Use Cautiously in: OB: Safety not established for systemic and topical; approved for vaginal use in 3rd trimester of pregnancy; Lactation: Has been used safely but appears in breast milk and exposes infant to drug and its side effects. ✓SIDE EFFECTS: CNS: dizziness, headache, vertigo. CV: arrhythmias, hypotension. GI: PSEUDOMEMBRANOUS COLITIS, diarrhea, bitter taste (IV only), nausea, vomiting. Derm: rash. Local: local irritation (topical products), phlebitis at IV site. ✓Interactions Drug-Drug: Kaolin/pectin may ↓ GI absorption. May enhance the neuromuscular blocking action of other neuromuscular blocking agents. Topical: Concurrent use with irritants, abrasives, or desquamating agents may result in additive irritation. ✓ NURSING CONSIDERATIONS: Assessment • Assess for infection (vital signs; appearance of wound, sputum, urine, and stool; WBC) at beginning of and during therapy. • obtain C&S • Monitor bowel elimination. Diarrhea, abdominal cramping, fever, and bloody stools should be reported to health care professional promptly as a sign of pseudomembranous colitis. This may begin up to several weeks following the cessation of therapy. • Assess patient for hypersensitivity (skin rash, urticaria). • Lab Test Considerations: Monitor CBC; may cause transient ↓ in leukocytes, eosinophils, and platelets. • May cause ↑ alkaline phosphatase, bilirubin, CPK, AST, and ALT concentrations. Implementation -full glass of H20 w/ or w/o food. -don't refrigerate soln -ok at Rm temp for 14 days. • IM, Do not administer >600 mg in a single IM injection. • Vag: Applicators are supplied for vaginal administration. When treating bacterial vaginosis, concurrent treatment of male partner is not usually necessary. • Topical: Contact with eyes, mucous membranes, and open cuts should be avoided during topical application. If accidental contact occurs, rinse with copious amounts of cool water. • Wash affected areas with warm water and soap, rinse, and pat dry prior to application. Apply to entire affected area. ✓ PT TEACHING: • take doses even spaced out, take missed ASAP, dont double dose • 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. • Advise patient to report signs of superinfection (furry overgrowth on the tongue, vaginal or anal itching or discharge). • Notify health care professional if no improvement within a few days. • Patients with a history of rheumatic heart disease or valve replacement need to be taught the importance of antimicrobial prophylaxis before invasive medical or dental procedures. • may have bitter taste • Vag: Instruct patient on proper use of vaginal applicator. Insert high into vagina at bedtime. Instruct patient to remain recumbent for at least 30 min following insertion. Advise patient to use sanitary napkin to prevent staining of clothing or bedding. Continue therapy during menstrual period. • avoid sex while on med • condoms weakened by vaginal cream • Topical soln is flammable. • Advise patient to wait 30 min after washing or shaving area before applying. Evaluation/Desired Outcomes • Resolution of the signs and symptoms of infection. Length of time for complete resolution depends on the organism and site of infection. • Endocarditis prophylaxis. • Improvement in acne vulgaris lesions. Improvement should be seen in 6 wk but may take 8-12 wk for maximum benefit. **Penicillin is the first-line agent for antibiotic treatment of the infected woman during birth. Cephazolin is the alternative for the patient with non-life-threatening penicillin allergy. Clindamycin is used for the woman at high risk for anaphylaxis. **Anaerobic organisms may also cause infection for a woman who requires a cesarean birth, and medications such as clindamycin or metronidazole may be prescribed **tx endometriosis BV while peg

Generic Name: Oxytocin Trade Name: (Pitocin)

✓Trade Name: Pitocin ✓Classification: Oxytocics/hormones ✓Dosage/Route/Frequency: IV: (Adults) 0.5-1 milliunits/min; ↑ by 1-2 milliunits/min q 30-60 min until desired contraction pattern established; dose may be ↓ after desired frequency of contractions is reached and labor has progressed to 5-6 cm dilation. (Postpartum Hemorrage): IV: (Adults) 10 units infused at 20-40 milliunits/min. IM: (Adults) 10 units after delivery of placenta. ✓Action: Stimulates uterine smooth muscle, producing uterine contractions similar to those in spontaneous labor; Induction of labor. Control of postpartum bleeding. ✓Side Effects: CNS: (materna)l: COMA, SEIZURESfetal: INTRACRANIAL HEMORRHAGE Resp: (feta)l: ASPHYXIA, hypoxia CV: maternal: hypotensionfetal: arrhythmias F and E: maternal: hypochloremia, hyponatremia, water intoxication Misc: maternal: ↑ uterine motility, painful contractions, abruptio placentae, ↓ uterine blood flow, hypersensitivity ✓Nursing Implications:(Considerations) Fetal maturity, presentation, and pelvic adequacy should be assessed prior to administration of oxytocin for induction of labor. - Assess character, frequency, and duration of uterine contractions; resting uterine tone; and fetal heart rate frequently throughout administration. If contractions occur <2 min apart and are >50-65 mm Hg on monitor, if they last 60-90 sec or longer, or if a significant change in fetal heart rate develops, stop infusion and turn patient on her left side to prevent fetal anoxia. Notify health care professional immediately. Monitor maternal BP and pulse frequently and fetal heart rate continuously.

Tucks

✓Trade Name: Witch Hazel ✓Classification: astringent ✓Dosage/Route/Frequency: Apply externally to the affected area up to 6 times daily or after each bowel movement After application ✓Action: : temporarily relieves the local itching and discomfort associated with hemorrhoids, aids in protecting irritated ano-rectal areas, temporarily relieves irritation and burning ✓Side Effects: N/A ✓Nursing Implications:(Considerations) : Instruct patient not to exceed recommended daily dose. Do not put directly into rectum by using fingers or mechanical device.