NUR 138 ECPI Drug Cards

Trade Name/Generic Name: Packed RBC's*

Classification: Uses/Actions: Packed red blood cells, also known as packed cells, are red blood cells that have been separated for blood transfusion. They are typically used in anemia that is either causing symptoms or when the hemoglobin is less than usually 70-80 g/L (7-8 g/dL). Contraindications: Should not be used to treat anemia that can be corrected with a non-transfusion therapy (iron therapy) unless immediate correction is urgently needed; Not indicated solely to providing blood volume and/or oncotic pressure, a sense of well-being, or to improve wound healing Side Effects: hemolytic transfusion reactions; febrile non-hemolytic reactions; allergic reactions ranging from hives to severe allergic reaction(anaphylaxis); septic reactions; transfusion related acute lung injury (TRALI); circulatory overload; transfusion associated graft versus host disease; post-transfusion skin discoloration Nursing Implications: Identify the client according to facility/agency policy prior to administration of red blood cells/ blood products (e.g., prescription for administration, correct type, correct client, cross matching complete, consent obtained). Check the client for appropriate venous access for red blood cell/blood product administration (e.g., correct gauge needle, integrity of access site). Document necessary information on the administration of red blood cells/blood products. Administer blood products and evaluate client response Usual Dosage and Route: Adult: Insufficient Tissue Oxygen Delivery Due to Active Bleeding / Symptomatic Anemia,1 unit increase hemoglobin 1 g/dl in average sized adults without active bleeding or hemolysis; usually given over 1-2 hours but not longer than 4 hours. Rarely necessary to transfuse to hemoglobin over 10 g/dl. Activity bleeding patients dosing and rate of administration varies depending on rate of bleeding and must be evaluate on a case by case basis Information Patient Needs: Must be willing to have blood transfusion.

Trade Name/Generic Name: Ketalar (ketamine)*

Classification: Anesthetic Uses/Actions: the sole anesthetic agent for cardiac catheterization, skin grafts, orthopedic procedures, diagnostic procedures on the eye, ear, nose, and throat most commonly for short procedures (used in animals as well) Contraindications: hypertension, glaucoma, hepatic or renal impairment Side Effects: low blood pressure, nausea, vomiting, loss of appetite, dream-like feeling, blurred vision, double vision, dizziness, drowsiness, sleep problems (insomnia), or hallucinations. Nursing Implications: Use requires patient monitoring, chronic alcoholic patients or acutely intoxicated, too rapid administration may cause respiratory depression Usual Dosage and Route: 10mg/mL, 50mg/mL, 100mg/mL-- IM or IV Information Patient Needs: May cause dependence and tolerance with prolonged use, do not operate machinery within 24 hr of administration

Trade Name/ Generic Name: Cardarone (aminodarone)*

Classification: Antiarrhythmics (class III). Uses/ Action: Suppression of arrhythmias. Prolongs action potential and refractory period. Inhibits adrenergic stimulation. Slows the sinus rate, increases PR and QT intervals, and decreases peripheral vascular resistance (vasodilation). Side Effects: Confusion states, disorientation, hallucinations, dizziness, fatigue, malaise, headache, insomnia, corneal micro deposits, abnormal sense of smell, dry eyes, optic neuritis, optic neuropathy, photophobia, adult respiratory distress syndrome, pulmonary fibrosis, pulmonary toxicity, worsening of arrhythmias, bradycardia, hypotension, anorexia, constipation, nausea, vomiting, abdominal pain, abnormal sense of taste, liver enzymes, libido, epididymitis, toxic epidermal necrolysis (rare), photosensitivity, blue discoloration, hypothyroidism, hyperthyroidism, ataxia, involuntary movement, paresthesia, peripheral neuropathy, poor coordination, tremor. Nursing Implications: Monitor ECG continuously during IV therapy or initiation of oral therapy. Monitor heart rate and rhythm throughout therapy; PR prolongation, slight QRS widening, T-wave amplitude reduction with T-wave widening and bifurcation, and U waves may occur. QT prolongation may be associated with worsening of arrhythmias and should be monitored closely during IV therapy. Report bradycardia or increase in arrhythmias promptly; patients receiving IV therapy may require slowing rate, discontinuing infusion, or inserting a temporary pacemaker. Assess pacing and defibrillation threshold in patients with pacemakers and implanted defibrillators at beginning and periodically during therapy. Usual Dosage & Route: PO (Adults): 800- 1600 mg/day in 1- 2 doses for 1- 3 week, then 600- 800 mg/day in 1- 2 doses for 1 month, then 400 mg/day maintenance dose. IV (Adults): 150 mg over 10 min, followed by 360 mg over the next 6 hours and then 540 mg over the next 18 hr. Continue infusion at 0.5 mg/min until oral therapy is initiated. If arrhythmia recurs, a small loading infusion of 150 mg over 10 min should be given. Information Patient Needs: Advise patient to avoid drinking grapefruit juice during therapy. Inform patient that side effects may not appear until several days, weeks, or year after initiation of therapy and may persist for several months after withdrawal. Teach patients to monitor pulse daily and report abnormalities. Advise patients that photosensitivity reactions may occur through window glass, thin clothing, and sunscreens. Protective clothing and sunblock are recommended during and for 4 months after therapy. If photosensitivity occurs, dosage reduction may be useful. Inform patients that bluish discoloration of the face, neck, and arms is a possible side effect of this drug after prolonged use. This is usually reversible and will fade over several mo. Notify health care professional if this occurs.

Trade Name/Generic Name: Eskalith (lithium)*

Classification: Mood stabilizer Uses/Actions: treatment, maintenance, prophylaxis for manic episodes of bipolar 1 disorder/ alters cation transport in nerve and muscle, influences reuptake of nerotrans. Contraindications: lactating/pregnant women, thyroid and renal disease Side Effects: fatigue, impaired memory, ECG changes, hypothyroidsim, anorexia, bloating, blurred vision Nursing Implications: assess mental, give med with food, monitor for lithium toxicity Usual Dosage and Route: PO 300-600 mg 3 times daily (adults) Information Patient Needs: instruct patient to take med even if feeling well, advise to report fainting, instruct patient to avoid large amounts of caffeine products, review principles of low-calorie diet

Trade name/ Generic name: Nardil (phenelzine)*

Classification: Non-selective and irreversible monoamine oxidase inhibitor (MAOI) Uses/ Actions: Phenelzine is an antidepressant (monoamine oxidase inhibitor). This medication treats depression by restoring the balance of certain natural substances (neurotransmitters) in the brain. Phenelzine can improve your mood and feelings of well-being. Usually, this medication is used in persons who have not responded to treatment with other drugs. Contraindications: NARDIL should not be used in patients who are hypersensitive to the drug or its ingredients, with pheochromocytoma, congestive heart failure, severe renal impairment or renal disease, a history of liver disease, or abnormal liver function tests. Side Effects: CNS: SEIZURES, dizziness, drowsiness, fatigue, headache, hyperreflexia, insomnia, tremor, twitching, weakness, euphoria, paresthesia, restlessness. EENT: blurred vision, glaucoma, nystagmus. CV: HYPERTENSIVE CRISIS, edema, orthostatic hypotension. GI:constipation, dry mouth, abdominal pain, liver function test elevation, nausea, vomiting. GU: sexual dysfunction, urinary retention. Derm: pruritis, rashes. F and E: hypernatremia. Endo: weight gain. Nursing Implications: Assess mental status, mood changes, and anxiety level frequently. Assess for suicidal tendencies, especially during early therapy. Restrict amount of drug available to patient. Monitor BP and pulse rate before and frequently during therapy. Report significant changes promptly. Monitor intake and output ratios and daily weight. Assess patient for peripheral edema and urinary retention. Lab Test Considerations: Assess hepatic function periodically during prolonged or high-dose therapy. Monitor serum glucose closely in diabetic patients; hypoglycemia may occur. Toxicity and Overdose: Concurrent ingestion of tyramine-rich foods and many medications may result in a life-threatening hypertensive crisis. Signs and symptoms of hypertensive crisis include chest pain, tachycardia or bradycardia, severe headache, nausea, vomiting, photosensitivity, neck stiffness, sweating, and enlarged pupils. Treatment includes IV phentolamine. Usual Dosage & Route: The usual starting dose of NARDIL is one tablet (15 mg) PO three times a day. Information Patient Needs: take medication as directed. Take missed doses if remembered within 2 hours; otherwise, omit and return to regular dosage schedule. Do not discontinue abruptly as withdrawal symptoms (nausea, vomiting, malaise, nightmares, agitation, psychosis, seizures) may occur. Caution patient to avoid alcohol, CNS depressants, OTC drugs, and foods or beverages containing tyramine or excessive caffeine during and for at least 2 weeks after therapy has been discontinued; they may precipitate a hypertensive crisis. Instruct patient to notify health care professional immediately if symptoms of hypertensive crisis (e.g. severe headache, palpitations, chest or throat tightness, sweating, dizziness, neck stiffness, nausea, or vomiting) develop.

Trade Name/ Generic Name: Natrecor (nesirtide)*

Classification: None assigned and vasodilators (human B-type natriuretic peptide). Uses/Action: Dose-dependent reduction in pulmonary capillary wedge pressure (PCWP) and systemic arterial pressure in patients with heart failure with resultant decrease in dyspnea. Low cardiac filling pressure, significant valvular stenosis, restrictive/subtractive cardiomyopathy, constrictive pericarditis/cardiac tamponade, or other conditions in which cardiac output is dependent on venous return. Use Cautiously in heart failure where renal function is dependent on activity of the renin/angiotensin/aldosterone system (may cause azotemia); Cardiogenic shock (should not be used as primary therapy) Side Effects: Anxiety, confusion, dizziness, headache, hypotension (dose related), insomnia, drowsiness, amblyopia, apnea, cough, hemoptysis, hypotension, arrhythmias, bradycardia, abdominal pain, nausea, vomiting, serum creatinine, renal failure, itching, rash, sweating, anemia, injection site reactions, back pain, leg cramps, paresthesia, and tremor. Nursing Implications: Monitor BP, pulse, ECG, respiratory rate, cardiac index, PCWP, and central venous pressure frequently during administration. May cause hypotension, especially in patients with a BP less than 100 mm Hg. Monitor intake and output and weigh daily. Assess for decrease in signs of HF (dyspnea, rales/crackles, peripheral edema, weight gain). Usual Dosage and Route: IV (Adults): 2 mcg/kg bolus followed by 0.01 mcg/kg/min as a continuous infusion. May by 0.005 mcg/kg/min every 3 hour up to a maximum infusion rate of 0.03 mcg/ kg/min (based on response). Important Patient Needs: Explain purpose of nesiritide to patient and family. Advise patient to notify health care professional immediately if signs and symptoms of allergic reaction occurs.

Trade Name/Generic Name: Ambien (zolpidem)*

Classification: Sedative/Hypnotic Uses/Actions: used to treat insomnia, produces CNS depression Contraindications: hypersensitivity, sleep apnea, psychiatric illness, Side Effects: CNS: daytime drowsiness, dizziness, abnormal thinking, agitation, amnesia, behavior changes, "drugged" feeling, hallucinations, sleep-driving. GI: diarrhea, nausea, vomiting. Misc: ANAPHYLAXIS, hypersensitivity reactions, physical dependence, psychological dependence, tolerance. Nursing Implications: assess mental status, assess for pain Usual Dosage and Route: PO, SL for adults, 5-10 mg depending Information Patient Needs: take as directed, do not take unless able to stay in bed for 7-8 hours, bc of rapid onset, go to bed immediately after consumption, avoid driving if feeling drowsy

Trade name/ Generic name: Haldol (haloperidol)*

Classification: The first of the butyrophenone series of major antipsychotics. Uses/ Actions: antipsychotic drug that decreases excitement in the brain. Haldol is used to treat psychotic disorders like schizophrenia, to control motor (movement) and verbal (for example, Tourette's syndrome) tics and is used to treat severe behavior problems in children. Contraindications: HALDOL (haloperidol) is contraindicated in severe toxic central nervous system depression or comatose states from any cause and in individuals who are hypersensitive to this drug or have Parkinson's disease. Side Effects: Increased mortality in elderly patients with dementia-related psychosis, cardiovascular fffects, tardive dyskinesia, neuroleptic malignant syndrome, treatment withdrawal, falls, usage in pregnancy, combined use of haldol and lithium. Precautions are leukopenia, neutropenia, and agranulocytosis Nursing Implications: Assess mental status (orientation, mood, behavior) prior to and periodically during therapy. Assess positive (hallucination, delusions) and negative (social isolation) symptoms of schizophrenia. Monitor BP (sitting, standing, lying) and pulse prior to and frequently during the period of dose adjustment. May cause QT interval changes on ECG. Observe patient carefully when administering medication, to ensure that medication is actually taken and not hoarded. Monitor intake and output ratios and daily weight. Assess patient for signs and symptoms of dehydration (decreased thirst, lethargy, hemoconcentration), especially in geriatric patients. Assess fluid intake and bowel function. Increased bulk and fluids in the diet help minimize constipating effects. Monitor patient for onset of akathisia (restlessness or desire to keep moving), which may appear within 6 hour of 1st dose and may be difficult to distinguish from psychotic agitation. Usual Dosage & Route: available as a sterile parenteral form for intramuscular injection. The injection provides 5 mg haloperidol (as the lactate) and lactic acid for pH adjustment between 3.0-3.6. Information Patient Needs: Advise patient to take medication as directed. Take missed doses as soon as remembered, with remaining doses evenly spaced throughout the day. May require several weeks to obtain desired effects. Do not increase dose or discontinue medication without consulting health care professional. Abrupt withdrawal may cause dizziness; nausea; vomiting; GI upset; trembling; or uncontrolled movements of mouth, tongue, or jaw. Inform patient of possibility of extrapyramidal symptoms, tardive dyskinesia, and neuroleptic malignant syndrome. Caution patient to report symptoms immediately. Advise patient to change positions slowly to minimize orthostatic hypotension. May cause drowsiness. Caution patient to avoid driving or other activities requiring alertness until response to medication is known. Caution patient to avoid taking alcohol or other CNS depressants concurrently with this medication. Advise patient to use sunscreen and protective clothing when exposed to the sun to prevent photosensitivity reactions. Extremes of temperature should also be avoided; drug impairs body temperature regulation. Instruct patient to use frequent mouth rinses, good oral hygiene, and sugarless gum or candy to minimize dry mouth.

Trade Name/ Generic Name: Cardiazem (diltiazem)*

Classification: Therapeutic: Antianginals, antiarrhythmics (class IV), antihypertensives. Pharmacologic: Calcium channel blockers. Uses/Actions: Systemic vasodilation resulting in decreased BP, coronary vasodilation resulting in decreased frequency and severity of attacks of angina, reduction of ventricular rate in atrial fibrillation or flutter. Inhibits transport of calcium into myocardial and vascular smooth muscle cells, resulting in inhibition of excitation-contraction coupling and subsequent contraction. Contraindications: Hypersensitivity, sick sinus syndrome; 2nd- or 3rd-degree AV block (unless an artificial pacemaker is in place); systolic blood pressure 90 mm hg; recent MI or pulmonary congestion; concurrent use of rifampin, use cautiously in severe hepatic impairment, risk of hypotension, consider age-related decrease in body mass, hepatic/renal/cardiac function, concurrent drug therapy and other disease states); severe renal impairment; serious ventricular arrhythmias or heart failure. Side Effects: Abnormal dreams, anxiety, confusion, dizziness, drowsiness, headache, nervousness, psychiatric disturbances, weakness, blurred vision, disturbed equilibrium, epistaxis, tinnitus, cough, dyspnea, arrhythmias, heart failure, peripheral edema, bradycardia, chest pain, hypotension, palpitations, syncope, tachycardia, liver enzymes, anorexia, constipation, diarrhea, dry mouth, dyspepsia, nausea, and vomiting. Nursing Implications: Monitor BP and pulse prior to therapy, during dose titration, and periodically during therapy, monitor ECG periodically during prolonged therapy, may cause prolonged PR interval, Monitor intake and output ratios and daily weight. Assess for signs of heart failure (peripheral edema, rales/crackles, dyspnea, weight gain, jugular venous distention). Usual Dosage & Route: PO and IV. PO (Adults): 30- 120 mg 3- 4 times daily or 60- 120 mg twice daily as SR capsules or 180- 240 mg once daily as CD or XR capsules or LA tablets (up to 360 mg/day). IV (Adults): 0.25 mg/kg; may repeat in 15 min with a dose of 0.35 mg/kg. Information Patient Needs: Advise patient to take medication as directed at the same time each day, even if feeling well. Take missed doses as soon as possible unless almost time for next dose; do not double doses. May need to be discontinued gradually. Advise patient to avoid large amounts (6- 8 glasses of grapefruit juice/day) during therapy. Instruct patient on correct technique for monitoring pulse. Instruct patient to contact health care professional if heart rate is less than 50 bpm.

Trade Name/ Generic Name: Nitrostat (nitroglycerine)*

Classification: Therapeutic: Antianginals. Pharmacologic: Nitrates Uses/ Actions: Relief or prevention of heart attacks, increased cardiac output, reduction of blood pressure, flow to ischemic regions, produces vasodilation (venous greater than arterial), decreases left ventricular end-diastolic pressure and left ventricular end-diastolic volume (preload) and reduces myocardial oxygen consumption. Contraindications: Hypersensitivity, severe anemia; pericardial tamponade; constrictive pericarditis; alcohol intolerance (large IV doses only), use cautiously in head trauma or cerebral hemorrhage, glaucoma, hypertrophic cardiomyopathy, severe liver impairment and malabsorption or hyper motility. Side Effects: Dizziness, headache, apprehension, restlessness, weakness, blurred vision, hypotension, tachycardia, syncope, abdominal pain, nausea, vomiting, contact dermatitis (transdermal), alcohol intoxication (large IV doses only), cross-tolerance, flushing, tolerance. Nursing Implications: Assess location, duration, intensity, and precipitating factors of patient's anginal pain, monitor BP and pulse before and after administration. Patients receiving IV nitroglycerin require continuous ECG and BP monitoring. Additional hemodynamic parameters may be monitored. Usual Dosage & Route: Sublingual (Adults): 0.3- 0.6 mg; may repeat q 5 min for 2 additional doses for acute attack. Translingual Spray (Adults): 1- 2 sprays; may be repeated q 5 min for 2 additional doses for acute attack. PO (Adults): 2.5- 9 mg q 8- 12 hr. IV (Adults): 5 mcg/min;qby 5 mcg/min q 3- 5 min to 20 mcg/min; if no response, qby 10- 20 mcg/min q 3- 5 min (dosing determined by hemodynamic parameters; max: 200 mcg/min). Transdermal (Adults): Ointment—1- 2 in. q 6- 8 hr. Transdermal patch— 0.2- 0.4 mg/hr initially; may titrate up to 0.4- 0.8 mg/hr. Patch should be worn 12- 14 hr/day and then taken off for 10- 12 hr/day. Information Patient Needs: Instruct patient to take medication as directed, even if feeling better. Take missed doses as soon as remembered unless next dose is scheduled within 2 hours (6 hours with extended-release preparations). Do not double doses. Do not discontinue abruptly; gradual dose reduction may be necessary to prevent rebound angina, caution patient to change positions slowly to minimize orthostatic hypotension. First dose should be taken while in a sitting or reclining position, especially in geriatric patients. Advise patient to avoid concurrent use of alcohol with this medication. Patient should also consult health care professional before taking OTC medications while taking nitroglycerin.

Trade Name/ Generic Name: Primacor (milrinone)*

Classification: Therapeutic: Inotropics Uses/ Actions: Increases myocardial contractility, decreases preload and afterload by a direct dilating effect on vascular smooth muscle, and increased cardiac output (inotropic effect). Contraindications: Hypersensitivity; severe aortic or pulmonic valvular heart disease; hypertrophic subaortic stenosis, use cautiously in history of arrhythmias, electrolyte abnormalities, abnormal digoxin levels, or insertion of vascular catheters (risk of ventricular arrhythmias) and renal impairment. Side Effects: Headache, tremor, ventricular arrhythmias, angina pectoris, chest pain, hypotension, supraventricular arrhythmias, skin rash, liver enzymes, hypokalemia and thrombocytopenia. Nursing Implications: Monitor heart rate and blood pressure continuously during administration. Slow or discontinue if blood pressure drops excessively. Monitor intake and output and daily weight. Assess patient for resolution of signs and symptoms of heart failure (peripheral edema, dyspnea, rales/crackles, weight gain) and improvement in hemodynamic parameters (increase in cardiac output and cardiac index, decrease in pulmonary capillary wedge pressure). Correct effects of previous aggressive diuretic therapy to allow for optimal filling pressure. Usual Dosage & Route: IV (Adults): Loading dose—50 mcg/kg followed by continuous infusion at 0.5 mcg/kg/min (range 0.375- 0.75 mcg/kg/min). IV (Infants and Children): Loading dose—50 mcg/kg over 10 min followed by continuous infusion at 0.5 mcg/kg/min (range 0.25- 0.75 mcg/kg/min). Information Patient Needs: Inform patient and family of reasons for administration, milrinone is not a cure but is a temporary measure to control the symptoms of heart failure.

Trade Name/ Generic Name: Inderal (propranolol)*

Classification: Therapeutic: antianginals, antiarrhythmics (Class II), antihypertensives, vascular headache suppressants. Pharmacologic: beta blockers. Uses/Actions: Management of hypertension, angina, arrhythmias, hypertrophic cardiomyopathy, thyrotoxicosis, essential tremors, pheochromocytoma. Also used in the prevention and management of MI, and the prevention of vascular headaches. Unlabeled Use: Also used to manage alcohol withdrawal, aggressive behavior, antipsychotic-associated akathisia, situational anxiety, and esophageal varices. Action Blocks stimulation of beta1(myocardial) and beta2 (pulmonary, vascular, and uterine)-adrenergic receptor sites. Therapeutic Effects: Decreased heart rate and BP, suppression of arrhythmias, and prevention of MI. Contraindications: Uncompensated HF; Pulmonary edema; Cardiogenic shock; Bradycardia, sick sinus syndrome, or heart block (unless pacemaker present). Use Cautiously in: Renal or hepatic impairment; Pulmonary disease (including asthma); Diabetes mellitus (may mask signs of hypoglycemia); Thyrotoxicosis (may mask symptoms); history of severe allergic reactions. Side Effects: fatigue, weakness, anxiety, dizziness, drowsiness, insomnia, memory loss, mental depression, mental status changes, nervousness, nightmares, blurred vision, dry eyes, nasal stuffiness, bronchospasm, wheezing, arrhythmias, bradycardia, hear failure, pulmonary edema, orthostatic hypotension, peripheral vasoconstriction, constipation, diarrhea, nausea, and erectile dysfunction. Nursing Implications: Monitor BP and pulse frequently during dose adjustment period and periodically during therapy. Abrupt withdrawal of propranolol may precipitate life-threatening arrhythmias, hypertension, or myocardial ischemia. Drug should be tapered over a 2-week period before discontinuation. Assess patient carefully during tapering and after medication is discontinued. Consider that patients taking propranolol for non-cardiac indications may have undiagnosed cardiac disease. Abrupt discontinuation or withdrawal over too-short a period of time (less than 9 days) should be avoided. Usual Dosage & Route: For oral dosage form (solution): Adults—180 to 240 milligrams (mg) per day, given in divided doses. Children—Dose is based on body weight and must be determined by your doctor. For oral dosage form (tablets): Adults—At first, 40 milligrams (mg) three times a day. Your doctor may increase your dose if needed. Children—Use and dose must be determined by your doctor. Information Patient Needs: Instruct patient to take medication as directed, at the same time each day, even if feeling well; do not skip or double up on missed doses. Take missed doses as soon as possible up to 4 hours before next dose (8 hours with extended-release propranolol). Inform patient that abrupt withdrawal can cause life-threatening arrhythmias, hypertension, or myocardial ischemia. Advise patient to make sure enough medication is available for weekends, holidays, and vacations. A written prescription may be kept in wallet in case of emergency.

Trade Name/ Generic Name: Linoxin (digoxin)*

Classification: Therapeutic: antiarrhythmics and inotropics. Pharmacologic: digitalis glycosides. Uses/ Actions: Increases the force of myocardial contraction, prolongs refractory period of the AV node. Decreases conduction through the SA and AV nodes. Therapeutic Effects: Increased cardiac output (positive inotropic effect) and slowing of the heart rate (negative chronotropic effect). Contraindications: Hypersensitivity, uncontrolled ventricular arrhythmias, Av block (in absence of pacemaker); idiopathic hypertrophic subaortic stenosis; constrictive pericarditis; known alcohol intolerance (elixir only). Use cautiously in, hypokalemia (risk of digoxin toxicity); hypercalcemia (risk of toxicity, especially with mild hypokalemia); hypomagnesemia (risk of digoxin toxicity); and diuretic use (may cause electrolyte abnormalities including hypokalemia and hypomagnesemia). Side Effects: Fatigue, headache, weakness, blurred vision, yellow or green vision, arrhythmias, bradycardia, ECG changes, AV block, SA block, anorexia, nausea, vomiting, diarrhea, thrombocytopenia, and electrolyte imbalances with acute digoxin toxicity. Nursing Implications: Monitor apical pulse for 1 full minute before administering. Withhold dose and notify health care professional if pulse rate is less than 60 bpm in an adult, less than 70 bpm in a child, or less than 90 bpm in an infant. Also notify health care professional promptly of any significant changes in rate, rhythm, or quality of pulse. Usual Dosage & Route: IV and PO. IV (Adults): Digitalizing dose—0.5- 1 mg given as 50% of the dose initially and one quarter of the initial dose in each of 2 subsequent doses at 6-12 hour intervals. IV (Children 10 year): Digitalizing dose—8- 12 mcg/kg given as 50% of the dose initially and one quarter of the initial dose in each of 2 subsequent doses at 6-12 hour intervals. PO (Adults): Digitalizing dose—0.75- 1.5 mg given as 50% of the dose initially and one quarter of the initial dose in each of 2 subsequent doses at 6- 12 hour intervals. Maintenance dose—0.125- 0.5 mg/day depending on patient's lean body weight, renal function, and serum level. Information Patient Needs: Instruct patient to take medication as directed, at the same time each day. Teach parents or caregivers of infants and children how to accurately measure medication. Take missed doses within 12 hour of scheduled dose or omit, do not double doses, consult health care professional if doses for 2 or more days are missed. Do not discontinue medication without consulting health care professional.

Trade Name/ Generic Name: Atro-pen (atropine)*

Classification: Therapeutic: antiarrhythmics. Pharmacologic: anticholinergics and antimuscarinics. Uses/ Actions: Inhibits the action of acetylcholine at postganglionic sites located in smooth muscle, secretory glands, CNS (antimuscarinic activity). Low doses decreases sweating, salivation, respiratory secretions. Intermediate doses result in mydriasis (pupillary dilation), cycloplegia (loss of visual accommodation), and increased heart rate. GI and GU tract motility are decreased at larger doses. Contraindications: Hypersensitivity; angle-closure glaucoma; acute hemorrhage; tachycardia secondary to cardiac insufficiency or thyrotoxicosis; obstructive disease of the GI tract. Use cautiously in: intra-abdominal infections; prostatic hyperplasia; chronic renal, hepatic, pulmonary, or cardiac disease; IV administration may produce fetal tachycardia; infants with down syndrome have increased sensitivity to cardiac effects and mydriasis. Children may have increased susceptibility to adverse reactions. Side Effects: Drowsiness, confusion, hyperpyrexia, blurred vision, photophobia, dry eyes, mydriasis, tachycardia, palpitations, arrhythmias, dry mouth, constipation, impaired GI motility, urinary hesitancy, retention, impotency, and pulmonary edema. Nursing Implications: Assess vital signs and ECG tracings frequently during IV drug therapy. Report any significant changes in heart rate or blood pressure, or increased ventricular ectopy or angina to health care professional promptly. Monitor intake and output ratios in elderly or surgical patients because atropine may cause urinary retention. Usual Dosage & Route: IM, IV, Subcut (adults): 0.4- 0.6 mg 30- 60 min pre-op. IM, IV, Subcut (children more than 5 kg): 0.01- 0.02 mg/kg/dose 30- 60 min preop to a maximum of 0.4 mg/dose; minimum: 0.1 mg/dose. Information Patient Needs: May cause drowsiness. Caution patients to avoid driving or other activities requiring alertness until response to medication is known. Instruct patient that oral rinses, sugarless gum or candy, and frequent oral hygiene may help relieve dry mouth. Caution patients that atropine impairs heat regulation. strenuous activity in a hot environment may cause heat stroke. Advise patient to notify health care professional of all RX or over the counter medications, vitamins, or herbal products being taken and to consult with health care professional before taking other medications.

Trade Name/Generic Name: Luminal (phenobarbital)*

Classification: Therapeutic: anticonvulsants, sedative/hypnotics. Pharmacologic: barbiturates Uses/Actions: Produces all levels of CNS depression. Depresses the sensory cortex, decreases motor activity, and alters cerebellar function. Inhibits transmission in the nervous system and raises the seizure threshold. Capable of inducing (speeding up) enzymes in the liver that metabolize drugs, bilirubin, and other compounds. Contraindications: Contraindicated in: GI obstruction; Gastric retention; Toxic colitis; Megacolon; Bowel perforation. Use Cautiously in: Abdominal pain of uncertain cause, particularly if accompanied by fever;OB, Pedi:Safety not established. Hypersensitivity; comatose patients or those with pre-existing CNS depression; severe respiratory disease, sedatives, opioids Side Effects: depressions, drowsiness, lethargy, photosensitivity, constipation, diarrhea, vomiting, nausesea Nursing Implications: monitor for resp. distress, monitor vitals, guard against falls and trauma Usual Dosage and Route: IV & PO 1-3 mg/kg/day, IM 30-120 mg/day Information Patient Needs: advise patient to avoid alcohol and other CNS depressants

Trade Name/ Generic Name: Prinivil (lisinopril)*

Classification: Therapeutic: antihypertensives. Pharmacologic: ACE inhibitors. Uses/ Actions: Lowering of BP in hypertensive patients. Increased survival and decreased symptoms in patients with heart failure. Increased survival after myocardial infarction. Angiotensin-converting enzyme (ACE) inhibitors block the conversion of angiotensin I to the vasoconstrictor angiotensin II. ACE inhibitors also prevent the degradation of bradykinin and other vasodilatory prostaglandins. ACE inhibitors also plasma renin levels and aldosterone levels. Net result is systemic vasodilation. Contraindications: Hypersensitivity, history of angioedema with previous use of ACE inhibitors, on current use with aliskiren in patients with diabetes or moderate to-severe renal impairment (CCr 60 mL/min); OB: Can cause injury or death of fetus - if pregnancy occurs, discontinue immediately; Lactation: Discontinue drug or use formula. Use Cautiously in patients with renal impairment, hypovolemia, hyponatremia, and concurrent diuretic therapy (initial dosage reduction recommended). Side Effects: Dizziness, fatigue, headache, weakness, cough, hypotension, chest pain, abdominal pain, diarrhea, nausea, vomiting, erectile dysfunction, impaired renal function, rashes, hyperkalemia and angioedema. Nursing Implications: Hypertension: monitor blood pressure and pulse frequently during initial dose adjustment and periodically during therapy. notify health care professional of significant changes. Monitor frequency of prescription refills to determine compliance. Assess patient for signs of angioedema (dyspnea, facial swelling). Heart failure: monitor weight and assess patient routinely for resolution of fluid overload (peripheral edema, rales/crackles, dyspnea, weight gain, jugular venous distention). Usual Dosage & Route: PO (Adults): 10 mg once daily, can be up to 20- 40 mg/day (initiate therapy at 5 mg/day in patients receiving diuretics). PO (Children 6 year): 0.07 mg/kg once daily (up to 5 mg/day), may be titrated every 1- 2 week up to 0.6 mg/kg/day (or 40 mg/day). Information Patient Needs: Instruct patient to take medication as directed at the same time each day, even if feeling well. Take missed doses as soon as remembered but not if almost time for next dose. Do not double doses. Warn patient not to discontinue ACE inhibitor therapy unless directed by health care professional. Caution patient to avoid salt substitutes containing potassium or foods containing high levels of potassium or sodium unless directed by health care professional. Caution patient to change positions slowly to minimize orthostatic hypotension. Use of alcohol, standing for long periods, exercising, and hot weather may increase orthostatic hypotension.

Trade Name/Generic Name: Catapres (clonidine)*

Classification: Therapeutic: antihypertensives. Pharmacologic: adrenergics(centrally acting). Uses/Actions: Decreased BP, decreased pain, improvement in ADHD symptoms, management of opioid withdrawal. Adjunctive treatment of neuropathic pain. Action Stimulates alpha-adrenergic receptors in the CNS, which results in decreased sympathetic outflow inhibiting cardio acceleration and vasoconstriction centers. Prevents pain signal transmission to the CNS by stimulating alpha-adrenergic receptors in the spinal cord. Contraindications: Hypersensitivity; Epidural—injection site infection, anticoagulant therapy, or bleeding problems. Use Cautiously in serious cardiac or cerebrovascular disease; Renal insufficiency; Pediatrics: Safety and efficacy not established for ADHD in children 6 year; evaluation for cardiac disease should precede initiation of therapy for ADHD in children. Side Effects: drowsiness, depression, dizziness, hallucinations, nervousness, nightmares, dry eyes, AV block, bradycardia, hypotension (with epidural), palpitations, dry mouth, constipation, nausea, vomiting, erectile dysfunction, rash, sweating, sodium retention, weight gain, and paresthesia. Nursing Implications: Hypertension: Monitor intake and output ratios and daily weight, and assess for edema daily, especially at beginning of therapy. Monitor BP and pulse prior to starting, frequently during initial dose adjustment and dose increases and periodically throughout therapy. Titrate slowly in patients with cardiac conditions or those taking other sympatholytic drugs. Report significant changes. Pain: Assess location, character, and intensity of pain prior to, frequently during first few days, and routinely throughout administration. Usual Dosage & Route: PO, transdermal, and epidural. PO: 0.1 mg PO twice daily. Increase by 0.1 mg/day at weekly intervals until desired effect is achieved (usual range: 0.2 to 0.6 mg/day). Transdermal: apply one Catapres TTS-1 (delivers 0.1 mg/24 hours) patch to an intact area of hairless skin on the upper arm or torso, once every 7 days. Adjust dose every 1 to 2 weeks by changing or combining dosage systems. Epidural: 30 mcg/hour by continuous epidural infusion in combination with opioid analgesics. Information Patient Needs: Instruct patient to take clonidine at the same time each day, even if feeling well. Take missed dosed as soon as remembered. If dose of extended-release product is missed; omit dose and take next dose as scheduled. Do not take more than the prescribed daily dose in any 24 hr. If more than 1 oral dose in a row is missed or if transdermal system is late in being changed by 3 or more days, consult health care professional. All routes of clonidine should be gradually discontinued over 2- 4 days to prevent rebound hypertension. May cause drowsiness, which usually diminishes with continued use. Advise patient to avoid driving or other activities requiring alertness until response to medication is known.

Trade Name/ Generic Name: Cardura (doxazosin)*

Classification: Therapeutic: antihypertensives. Pharmacologic: peripherally acting antiadrenergics Uses/ Actions: Hypertension (alone or with other agents) (immediate-release only). Symptomatic benign prostatic hyperplasia (BPH). Action Dilates both arteries and veins by blocking postsynaptic alpha1-adrenergic receptors. Therapeutic Effects: lowering of BP. Increased urine flow and decreased symptoms of BPH. Contraindications: Hepatic dysfunction; Gastrointestinal narrowing; Geri: Appears on Beers list. Geriatric patients are at risk for hypotension; Lactation, Pedi: safety not established; Patients undergoing cataract surgery (risk of intraoperative floppy iris syndrome). Side Effects: dizziness, headache, depression, drowsiness, fatigue, nervousness, weakness, abnormal vision, blurred vision, conjunctivitis, epistaxis, intraoperative floppy iris syndrome, dyspnea, first-dose orthostatic hypotension, arrhythmias, chest pain, edema, palpitations, abdominal discomfort, constipation, diarrhea, dry mouth, flatulence, nausea, vomiting, sexual dysfunction, flushing, rash, urticarial, arthralgia, arthritis, gout, myalgia. Nursing Implications: Monitor BP and pulse 2- 6 hour after first dose, with each increase in dose, and periodically during therapy. Report significant changes. Assess for first-dose orthostatic hypotension and syncope. Incidence may be dose related. Observe patient closely during this period and take precautions to prevent injury. Monitor intake and output ratios and daily weight, and assess for edema daily, especially at beginning of therapy. Report weight gain or edema. Usual Dosage & Route: PO 1mg once daily, may gradually increase at a two-week interval to 2-16mg/day. Information Patient Needs: Emphasize the importance of continuing to take this medication, even if feeling well. Instruct patient to take medication at the same time each day. Take missed doses as soon as remembered unless almost time for next dose. Do not double doses. May cause drowsiness or dizziness. Advise patient to avoid driving or other activities requiring alertness until response to medication is known. Caution patient to change positions slowly to decrease orthostatic hypotension. May cause syncopal episodes, especially within first 24 hours of therapy, with dose increase, and with resumption of therapy after interruption.

Trade Name/ Generic Name: Seroquel (quetiapine)*

Classification: Therapeutic: antipsychotics, mood stabilizers Uses/ Actions: This medication is used to treat certain mental/mood conditions (such as schizophrenia, bipolar disorder, sudden episodes of mania or depression associated with bipolar disorder). Quetiapine is known as an anti-psychotic drug (atypical type). It works by helping to restore the balance of certain natural substances (neurotransmitters) in the brain. Contraindications: Hypersensitivity, lactation, concurrent use of agents that prolong the QT interval, including dofetilide, sotalol, quinidine, disopyramide, amiodarone, dronedarone, thioridazine, chlorpromazine, droperidol, moxifloxacin, mefloquine, pentamidine, arsenic trioxide, dolasetron, tacrolimus, ziprasidone, erythromycin, citalopram, escitalopram, and clarithromycin (risk of serious arrhythmias); History of arrhythmias, including bradycardia; Hypokalemia or hypomagnesemia (risk of serious arrhythmias); Congenital long QT syndrome (risk of serious arrhythmias). Side Effects: Neuroleptic malignant syndrome, seizures, dizziness, cognitive impairment, extrapyramidal symptoms, sedation, tardive dyskinesia, ear pain, rhinitis, pharyngitis, cough, dyspnea, palpitations, peripheral edema, postural hypotension, pancreatitis, anorexia, constipation, dry mouth, dyspepsia, stevens-johnson syndrome, sweating, phemoglobin, leukopenia, weight gain, hyperglycemia, hyperlipidemia, hyperprolactinemia, hypertriglyceridemia, hypothyroidism and flu-like syndrome. Nursing Implications: Monitor mental status (mood, orientation, behavior) before and periodically during therapy. Assess for suicidal tendencies, especially during early therapy. Restrict amount of drug available to patient. Risk may be increased in children, adolescents, and adults 24 years old. Assess weight and BMI initially and throughout therapy. Monitor BP (sitting, standing, lying) and pulse before and frequently during initial dose titration. If hypotension occurs during dose titration, return to the previous dose. Observe patient carefully when administering to ensure medication is swallowed and not hoarded or cheeked. Usual Dosage & Route: Dosage depends on reason why patient is receiving. Depression: 50 mg once daily. Schizophrenia PO (Adults): Immediate-release— 25 mg twice daily. PO: May be administered without regard to food. Extended-release tablets should be swallowed whole, do not break, crush, or chew. Information Patient Needs: Instruct patient to take medication as directed. Take missed doses as soon as remembered unless almost time for next dose; do not double doses. Consult health care professional prior to stopping quetiapine; should be discontinued gradually. Stopping abruptly may cause insomnia, nausea and vomiting. Advise patient and caregiver that quetiapine should not be given to elderly patients with dementia-related psychosis; risk of death. Inform patient of the possibility of extrapyramidal symptoms. Instruct patient to report symptoms immediately to health care professional.

Trade Name/Generic Name: Lipitor (atorvastatin)*

Classification: Therapeutic: lipid-lowering agents Pharmacologic: HMG-CoA reductase inhibitors Uses/Actions: Adjunctive management of primary hypercholesterolemia and mixed dyslipidemia. Primary prevention of coronary heart disease (myocardial infarction, stroke, angina, and coronary revascularization) in asymptomatic patients with increased total and low-density lipoprotein (LDL) cholesterol and decreased high-density lipoprotein (HDL) cholesterol. Contraindications: Contraindicated in: Hypersensitivity; Active liver disease or unexplained persistent elevations in AST and ALT; OB: Potential for fetal anomalies; Lactation:May appear in breast milk. Use Cautiously in: History of liver disease; Alcoholism; Renal impairment; Concurrent use of gemfibrozil, azole antifungals, erythromycin, clarithromycin, protease inhibitors, niacin, or cyclosporine (higher risk of myopathy/rhabdomyolysis); OB: Women of childbearing age; Pedi: Children 10 yr (safety not established). Side Effects: CNS: amnesia, confusion, dizziness, headache, insomnia, memory loss, weakness. EENT: rhinitis. Resp: bronchitis. CV: chest pain, peripheral edema. GI: abdominal cramps, constipation, diarrhea, flatus, heartburn, altered taste, drug-induced hepatitis, dyspepsia,qliver enzymes, nausea, pancreatitis. Endo: hyperglycemia. GU:erectile dysfunction.Derm:rashes, pruritus.MS: RHABDOMYOLYSIS,arthralgia, arthritis, immune-mediated necrotizing myopathy, myalgia, myositis. Misc: hypersensitivity reactions including ANGIONEUROTIC EDEMA. Nursing Implications: Obtain a diet history, especially with regard to fat consumption. Lab Test Considerations: Evaluate serum cholesterol and triglyceride levels before initiating, after 2- 4 wk of therapy, and periodically thereafter. Monitor liver function tests prior to initiation of therapy and as clinically indicated. If symptoms of serious liver injury, hyperbilirubinemia, or jaundice occurs discontinue atorvastatin and do not restart. May also causeqalkaline phosphatase and bilirubin levels. If patient develops muscle tenderness during therapy, CPK levels should be monitored. If CPK levels are 10 times the upper limit of normal or myopathy occurs, therapy should be discontinued. Monitor for signs and symptoms of immune-mediated necrotizing myopathy (IMNM) (proximal muscle weakness andqserum creatine kinase), persisting despite discontinuation of statin therapy. Perform muscle biopsy to diagnose; shows necrotizing myopathy without significant inflammation. Treat with immunosuppressive agents. Usual Dosage and Route: PO (Adults): 10- 20 mg once daily initially; (may start with 40 mg/day if LDL-C needs to bepby 45%); may beqevery 2- 4 wk up to 80 mg/day; Concurrent nelfinavir therapy—Dose should not exceed 40 mg/day; Concurrent clarithromycin, itraconazole, saquinavir/ritonavir, darunavir/ritonavir, fosamprenavir, or fosamprenavir/ritonavir therapy—Dose should not exceed 20 mg/day. Information Patient Needs: Instruct patient to take medication as directed. Take missed doses as soon as remembered more than 12 hrs since missed dose; omit and take next scheduled dose. Do not double up on missed doses. Advise patient to avoid drinking more than one quart of grapefruit juice per day during therapy. Medication helps control but does not cure elevated serum cholesterol levels. Advise patient that this medication should be used in conjunction with diet restrictions (fat, cholesterol, carbohydrates, alcohol), exercise, and cessation of smoking. Instruct patient to notify health care professional if unexplained muscle pain, tenderness, or weakness occurs, especially if accompanied by fever or malaise. Instruct patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products being taken and consult health care professional before taking any new medications. Advise patient to notify health care professional of medication regimen prior to treatment or surgery. Instruct female patients to notify health care professional promptly if pregnancy is planned or suspected, or if breast feeding. Emphasize the importance of follow-up exams to determine effectiveness and to monitor for side effects.

Trade Name/Generic Name: Zetia (ezetimbe)*

Classification: Therapeutic: lipid-lowering agents Pharmacologic:cholesterol absorption inhibitors Uses/Actions: Alone or with other agents (HMG-CoA reductase inhibitors) in the management of dyslipidemias including primary hypercholesterolemia, homozygous familial hypercholesterolemia and homozygous sitosterolemia Contraindications: Contraindicated in: Hypersensitivity; Acute liver disease or unexplained laboratory evidence of liver disease (when used with HMG-CoA reductase inhibitor); Moderate or severe hepatic impairment; Concurrent use of fibrates; OB: May cause fetal harm by interfering with cholesterol synthesis and, possibly, biologically active substances derived from cholesterol; Lactation: Potential for adverse effects in nursing infant. Side Effects: GI: cholecystitis, cholelithiasis, increase liver enzymes (with HMG-CoA reductase inhibitors), nausea, pancreatitis.Derm:rash.Misc: ANGIOEDEMA Nursing Implications: Obtain a diet history, especially with regard to fat consumption. Lab Test Considerations: Evaluate serum cholesterol and triglyceride levels before initiating, after 2- 4 wk of therapy, and periodically thereafter. May cause increase liver transaminases when administered with HMG-CoA reductase inhibitors. Monitor liver enzymes prior to initiation and during therapy according to recommendations of HMG-CoA reductase inhibitor. Elevations are usually asymptomatic and return to baseline with continued therapy. Usual Dosage and Route: PO (Adults): 10 mg once daily Information Patient Needs: Instruct patient to take medication as directed, at the same time each day, even if feeling well. Take missed doses as soon as remembered, but do not take more than 1 dose/day. Medication helps control but does not cure elevated serum cholesterol levels. Advise patient that this medication should be used in conjunction with diet restrictions (fat, cholesterol, carbohydrates, alcohol), exercise, and cessation of smoking. Ezetimibe does not assist with weight loss. Instruct patient to notify health care professional if unexplained muscle pain, tenderness, or weakness occur. Risk may increase when used with HMG CoA reductase inhibitors. Instruct patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products being taken and to consult health care professional before taking any other Rx, OTC, or herbal products. Advise patient to notify health care professional of medication regimen prior to treatment or surgery. Instruct female patients to notify health care professional promptly if pregnancy is planned or suspected or if breast feeding. If regimen includes HMG-CoA reductase inhibitors, they are contraindicated in pregnancy. Emphasize the importance of follow-up exams to determine effectiveness and to monitor for side effects.

Trade Name/Generic Name: Niaspan (niacin)*

Classification: Therapeutic: lipid-lowering agents, vitamins Pharmacologic: water soluble vitamins Uses/Actions: Treatment and prevention of niacin deficiency (pellagra). Adjunctive therapy in certain hyperlipidemias (niacin only). Decreased blood lipids (niacin only). Supplementation in deficiency states. Contraindications: Contraindicated in: Hypersensitivity to niacin; Some products may contain tartrazine and should be avoided in patients with known hypersensitivity; Alcohol intolerance (Nicotinex only). Use Cautiously in:Liver disease; Arterial bleeding; History of peptic ulcer disease; Gout; Glaucoma; Diabetes mellitus. Side Effects: Adverse reactions and side effects refer to doses used to treat hyperlipidemia CNS: dizziness, nervousness, panic. EENT: blurred vision, loss of central vision, proptosis, toxic amblyopia. CV: orthostatic hypotension. GI: HEPATOTOXICITY, GI upset, bloating, diarrhea, dry mouth, flatulence, heartburn, hunger pains, nausea, peptic ulceration.Derm: flushing of the face and neck, pruritus, burning, dry skin, hyperpigmentation, increase sebaceous gland activity, rashes, stinging or tingling of skin. Metab: glycosuria, hyperglycemia, hyperuricemia.MS:myalgia. Nursing Implications: Vitamin Deficiency: Assess patient for signs of niacin deficiency (pellagra— dermatitis, stomatitis, glossitis, anemia, nausea and vomiting, confusion, memory loss, and delirium) prior to and periodically during therapy. Hyperlipidemia: Obtain a diet history, especially with regard to fat consumption. Lab Test Considerations: Monitor serum glucose and uric acid levels and hepatic function tests periodically during prolonged high-dose therapy. Notify health care professional if AST, ALT, or LDH becomes elevated. Mayqprothrombin times andpserum albumin. High-dose therapy may causeqserum glucose and uric acid levels. When niacin is used as a lipid-lowering agent, serum cholesterol and triglyceride levels should be monitored prior to and periodically during therapy. Usual Dosage and Route: PO (Adults and Children): Dietary supplement—10- 20 mg/day. Dietary deficiency—Up to 500 mg/day in divided doses. Hyperlipidemias- Niacin only—Immediate-release: 250 mg once daily;qdose every 4- 7 days to desired response (usual dose 1.5- 2 g/day in 2- 3 divided doses); after 2- 3 mo, mayqat 2- 4 wk intervals to1g3 times daily; Extended-release: 500 mg at bedtime for 4 wk, then 1 g at bedtime for 4 wk; may thenqdose every 4 wk by 500 mg/day to maximum of 2 g/ day. Information Patient Needs: Inform patient that cutaneous flushing and a sensation of warmth, especially in the face, neck, and ears; itching or tingling; and headache may occur within the first 2 hr after taking the drug. These effects are usually transient and subside with continued therapy. If flushing is distressing or persistent, aspirin 300 mg given 30 min before each dose or slow upward titration of dose may decrease flushing. Advise patient to change positions slowly to minimize orthostatic hypotension. Instruct patients taking long-term OTC extended-release niacin to report signs of hepatotoxicity (darkening of urine, light gray-colored stool, loss of appetite, severe stomach pain, yellow eyes or skin) to health care professional. Emphasize the importance of follow-up examinations to evaluate progress. Vitamin Deficiency: Encourage patient to comply with dietary recommendations of health care professional. Explain that the best source of vitamins is a well-balanced diet with foods from the four basic food groups. Foods high in niacin include meats, eggs, milk, and dairy products; little is lost during ordinary cooking. Patients self-medicating with vitamin supplements should be cautioned not to exceed RDA. The effectiveness of megadoses for treatment of various medical conditions is unproved and may cause side effects. Hyperlipidemia: Advise patient that this medication should be used in conjunction with dietary restrictions (fat, cholesterol, carbohydrates, alcohol), exercise, and cessation of smoking.

Trade Name/Generic Name: Anectine (succinylcholine)*

Classification: Therapeutic: neuromuscular blocking agents-depolarizing Uses/Actions: depolarizes skeletal muscle to relax muscle, used to relax muscles during cesarean section, prevents neuromuscular transmission by blocking the effect of acetylcholine at the myoneural junction. Has agonist activity initially, producing fasciculation. Causes the release of histamine. Has no analgesic or anxiolytic effects. Contraindications: drugs that enhance effects: Lidocaine, Beta-blockers. Can cause lethal hyperkalemia in patients with: burns, crush injuries, adbdominal infections, tetanus, muscle disorders Side Effects:. Most adverse reactions to succinylcholine are extensions of pharmacologic effects Resp: APNEA, bronchospasm. CV:arrhythmias, bradycardia, hypotension. F and E: HYPERKALEMIA. MS: RHABDOMYOLYSIS, muscle fasciculation. Misc: ANAPHYLAXIS, MALIGNANT HYPERTHERMIA, myoglobinemia (qin children), myoglobinuria (increase in children), tachyphylaxis. Nursing Implications: Assess respiratory status continuously, monitor neuromuscular response, monitor ECG, heart rate, and BP, assess patient for history of malignant hyperthermia Usual Dosage and Route: short surgery IV 0.3- 1.1 mg/kg for adults, long surgery IV 2.5- 4.3 mg/min adult Information Patient Needs: reassure patient that communication abilities will return as the medication wears off

Trade Name/ Generic Name: Urecholine (bethanechol)*

Classification: Therapeutic: urinary tract stimulants. Pharmacologic: cholinergics. Uses/ Actions: Stimulates cholinergic receptors. Effects include: Contraction of the urinary bladder, decreased bladder capacity, increased frequency of ureteral peristaltic waves, increased tone and peristalsis in the GI tract, increased pressure in the lower esophageal sphincter, increased gastric secretions. Therapeutic Effects: Bladder emptying. Contraindications: Hypersensitivity; mechanical obstruction of the GI or GU tract. use cautiously in: history of asthma; ulcer disease; cardiovascular disease; epilepsy; hyperthyroidism; sensitivity to cholinergic agents or effects. Side Effects: Headache, malaise, lacrimation, miosis, bronchospasm, heart block, syncope/cardiac arrest, bradycardia, hypotension, abdominal discomfort, diarrhea, nausea, salivation, vomiting, urgency, flushing, sweating, hypothermia. Nursing Implications: Monitor blood pressure, pulse, and respirations before administering and for at least 1 hour after subcutaneous administration. Monitor intake and output ratios, palpate abdomen for bladder distention, notify physician or other health care professional if drug fails to relieve condition for which it was prescribed. Usual Dosage/ Route: PO (Adults): 25- 50 mg 3 times daily. PO (Children): 0.2 mg/kg 3 times daily or 0.15 mg/kg 4 times daily. Subcutaneous (Adults): 5 mg 3- 4 times daily. Subcutaneous (Children): 0.06 mg/kg 3 times daily or 0.05 mg/kg 4 times daily. Information Patient Needs: Instruct patient to take medication exactly as directed. missed doses should be taken as soon as possible within 2 hours; otherwise, return to regular dosing schedule. do not double doses. Caution patient to change positions slowly to minimize orthostatic hypotension. Advise patient to report abdominal discomfort, salivation, sweating, or flushing to health care professional.

Trade Name/ Generic Name: Imitrex (sumatriptan)*

Classification: Therapeutic: vascular headache suppressants. Pharmacologic: 5-HT1 agonists. Uses/ Actions: Acts as a selective agonist of 5-HT1 at specific vascular serotonin receptor sites, causing vasoconstriction in large intracranial arteries. Therapeutic Effects: Relief of acute attacks of migraine. Contraindications: Hypersensitivity; Ischemic heart disease or signs and symptoms of ischemic heart disease, Prinzmetal's angina, or uncontrolled hypertension; Stroke or transient ischemic attack; Peripheral vascular disease (including, but not limited to, ischemic bowel disease); Concurrent MAO inhibitor therapy; Hemiplegic or basilar migraine; Concurrent use of (within 24 hour) ergotamine-containing or ergot-type drugs or other 5HT1 agonists; Severe hepatic impairment; Geri: Excessive risk of cardiovascular complications. Side Effects: All adverse reactions are less common after oral administration, dizziness, vertigo, anxiety, drowsiness, fatigue, feeling of heaviness, feeling of tightness, headache, malaise, strange feeling, tight feeling in head, weakness, alterations in vision, nasal sinus discomfort, throat discomfort, MI, angina, chest pressure, chest tightness, coronary vasospasm, ECG changes, transient hypertension, abdominal discomfort, dysphagia. Nursing Implications: Assess pain location, intensity, duration, and associated symptoms (photophobia, phono phobia, nausea, vomiting) during migraine attack. Give initial subcutaneous dose under observation to patients with potential for coronary artery disease including postmenopausal women, men 40 year, patients with risk factors for coronary artery disease such as hypertension, hypercholesterolemia, obesity, diabetes, smoking, or family history. Monitor BP before and for 1 hour after initial injection. If angina occurs, monitor ECG for ischemic changes. Usual Dosage & Route: PO: Tablets should be swallowed whole; do not crush, break, or chew. Tablets are film-coated to prevent contact with tablet contents, which have an unpleasant taste and may cause nausea and vomiting. Subcut: Administer as a single injection just below the skin. Solution is clear and colorless or pale yellow; do not use dark-colored or cloudy or if beyond expiration date. Intranasal: 10-mg dose may be administered as 2 sprays of 5 mg in one nostril or 1 spray in each nostril. Transdermal: Apply to dry, non-irritated, intact skin of upper arm or thigh. Site must be relatively free of hair and without scars, tattoos, abrasions, eczema, psoriasis, melanoma, or contact dermatitis. Information Patient Needs: Inform patient that sumatriptan should be used only during a migraine attack. It is meant to be used for relief of migraine attacks but not to prevent or reduce the number of attacks. Instruct patient to administer sumatriptan as soon as symptoms of a migraine attack appear, but it may be administered at any time during an attack. If migraine symptoms return, a second injection may be used. Allow at least 1 hour between doses, and do not use more than two injections in any 24-hour period. Additional sumatriptan doses are not likely to be effective, and alternative medications may be used.

Trade Name/Generic Name: Xylocaine (lidocaine)*

Classification: Therapeutic:anesthetics (topical/local), antiarrhythmics (class IB) Uses/Actions: used parenterally to treat acute, life-threatening ventricular arrhythmias. stop itching and pain from certain skin conditions (e.g., scrapes, minor burns, eczema, insect bites, hemorrhoids. *shingles treatment* works by causing temporary numbness/loss of feeling in the skin and mucous membranes. Contraindications: Broken skin/infection, heart disease, liver disease, Hypersensitivity; cross-sensitivity may occur; Third-degree heart block. Use Cautiously in: Liver disease, HF, patients weighing 50 kg, and geriatric patients (pbolus and/or maintenance dose); Respiratory depression; Shock; Heart block; OB, Lactation:Safety not established; Pedi:Safety not established for transdermal patch. Side Effects: hypotension, edema, redness at injection site, small red or purple spots on skin, constipation, nausea. Nursing Implications: constant EKG monitoring, effects increased by beta-blockers, use caution in pregnant women Usual Dosage and Route: 1-1.5 mg/kg slow IV and 10-20mg/100mL Injectable. Information Patient Needs: nausea, constipation, vomiting are normal side effects, consult doctor immediately if labored breathing occurs

Trade Name/Generic Name: Coumadin (warfarin)*

Classification: Therapeutic:anticoagulants; Pharmacologic:coumarins Uses/Actions: Prophylaxis and treatment of: Venous thrombosis, Pulmonary embolism, Atrial fibrillation with embolization. Management of myocardial infarction: Decreases risk of death, Decreases risk of subsequent MI, Decreases risk of future thromboembolic events. Prevention of thrombus formation and embolization after prosthetic valve placement. Contraindications: Contraindicated in: Uncontrolled bleeding; Open wounds; Active ulcer disease; Recent brain, eye, or spinal cord injury or surgery; Severe liver or kidney disease; Uncontrolled hypertension; OB: Crosses placenta and may cause fatal hemorrhage in the fetus. May also cause congenital malformation. Use Cautiously in: Malignancy; Patients with history of ulcer or liver disease; History of poor compliance; Women with childbearing potential; Asian patients or those who carry the CYP2C9*2 allele and/or the CYP2C9*3 allele, or with the VKORC1 AA genotype (qrisk of bleeding with standard dosing; lower initial doses should be considered); Pedi: Has been used safely but may require more frequent PT/INR assessments; Geri: Due to greater than expected anticoagulant response, initiate and maintain at lower doses. Side Effects: GI:cramps, nausea.Derm: dermal necrosis.Hemat: BLEEDING.Misc: fever. Nursing Implications: Assess for signs of bleeding and hemorrhage (bleeding gums; nosebleed; unusual bruising; tarry, black stools; hematuria; fall in hematocrit or BP; guaiac-positive stools, urine, or nasogastric aspirate). Assess for evidence of additional or increased thrombosis. Symptoms depend on area of involvement. Geri: Patients over 60 yr exhibit greater than expected PT/INR response. Monitor for side effects at lower therapeutic ranges. Pedi: Achieving and maintaining therapeutic PT/INR ranges may be more difficult in pediatric patients. Assess PT/INR levels more frequently. Usual Dosage and Route: PO, IV (Adults): 2- 5 mg/day for 2- 4 days; then adjust daily dose by results of INR. Initiate therapy with lower doses in geriatric or debilitated patients or in Asian patients or those with CYP2C9*2 and/or CYP2C9*3 alleles or VKORC1 AA genotype Information Patient Needs: Instruct patient to take medication as directed. Take missed doses as soon as remembered that day; do not double doses. Inform health care professional of missed doses at time of checkup or lab tests. Inform patients that anticoagulant effect may persist for 2- 5 days following discontinuation. Advise patient to read Medication Guide before starting therapy and with each Rx refill. Review foods high in vitamin K. Patient should have consistent limited intake of these foods, as vitamin K is the antidote for warfarin, and alternating intake of these foods will cause PT levels to fluctuate. Advise patient to avoid cranberry juice or products during therapy Caution patient to avoid IM injections and activities leading to injury. Instruct patient to use a soft toothbrush, not to floss, and to shave with an electric razor during warfarin therapy. Advise patient that venipunctures and injection sites require application of pressure to prevent bleeding or hematoma formation. Advise patient to report any symptoms of unusual bleeding or bruising (bleeding gums; nosebleed; black, tarry stools; hematuria; excessive menstrual flow) and pain, color, or temperature change to any area of your body to health care professional immediately. Patients with a deficiency in protein C and/or S mediated anticoagulant response may be at greater risk for tissue necrosis. Instruct patient not to drink alcohol or take other Rx, OTC, or herbal products, especially those containing aspirin or NSAIDs, or to start or stop any new medications during warfarin therapy without advice of health care professional. Advise patient to notify health care professional if pregnancy is planned or suspected or if breast feeding. Instruct patient to carry identification describing medication regimen at all times and to inform all health care personnel caring for patient on anticoagulant therapy before lab tests, treatment, or surgery. Emphasize the importance of frequent lab tests to monitor coagulation factors.

Trade Name/Generic Name: Hydrodiuril (hydrochlorothiazide)*

Classification: Therapeutic:antihypertensives, diuretics; Pharmacologic: thiazide diuretics Uses/Actions: Management of mild to moderate hypertension. Treatment of edema associated with: HF, Renal dysfunction, Cirrhosis, Glucocorticoid therapy, Estrogen therapy. Contraindications: Contraindicated in: Hypersensitivity (cross-sensitivity with other thiazides or sulfonamides may exist); Some products contain tartrazine and should be avoided in patients with known intolerance; Anuria; Lactation:Lactation. Use Cautiously in: Renal or hepatic impairment; OB: Jaundice or thrombocytopenia may be seen in the newborn. Side Effects: CNS: dizziness, drowsiness, lethargy, weakness. CV: hypotension. GI: anorexia, cramping, hepatitis, nausea, vomiting. Derm: STEVENS JOHNSON SYNDROME, photosensitivity, rash. EENT:acute angle-closure glaucoma, acute myopia. Endo: hyperglycemia. F and E: hypokalemia, dehydration, hypercalcemia, hypochloremic alkalosis, hypomagnesemia, hyponatremia, hypophosphatemia, hypovolemia. Hemat: blood dyscrasias. Metab: hyperuricemia, hypercholesterolemia. MS: muscle cramps.Misc: pancreatitis. Nursing Implications: Monitor BP, intake, output, and daily weight and assess feet, legs, and sacral area for edema daily. Assess patient, especially if taking digoxin, for anorexia, nausea, vomiting, muscle cramps, paresthesia, and confusion. Notify health care professional if these signs of electrolyte imbalance occur. Patients taking digitalis glycosides are at risk of digitalis toxicity because of the potassium-depleting effect of the diuretic. If hypokalemia occurs, consideration may be given to potassium supplementation or decreasing dose of diuretic. Assess patient for allergy to sulfonamides.Assess patient for skin rash frequently during therapy. Discontinue diuretic at first sign of rash; may be life-threatening. Stevens-Johnson syndrome may develop. Treat symptomatically; may recur once treatment is stopped. Hypertension:Monitor BP before and periodically throughout therapy. Monitor frequency of prescription refills to determine compliance. Lab Test Considerations: Monitor electrolytes (especially potassium), blood glucose, BUN, serum creatinine, and uric acid levels before and periodically during therapy. May causeqserum and urine glucose in diabetic patients. May causeqserum bilirubin, calcium, creatinine, and uric acid, andpserum magnesium, potassium, sodium, and urinary calcium concentrations. May causeqserum cholesterol, low-density lipoprotein, and triglyceride concentrations. Potential Nursing Diagnoses Excess fluid volume (Indications) Risk for deficient fluid volume (Side Effects) Deficient knowledge, related to medication regimen (Patient/Family Teaching). Administer in the morning to prevent disruption of sleep cycle. Intermittent dose schedule may be used for continued control of edema. PO: May give with food or milk to minimize GI irritation. Tablets may be crushed and mixed with fluid to facilitate swallowing Usual Dosage and Route: When used as a diuretic in adults, generally given daily, but may be given every other day or 2- 3 days/week. PO (Adults): 12.5- 100 mg/day in 1- 2 doses (up to 200 mg/day; not to exceed 50 mg/day for hypertension; doses above 25 mg are associated with greater likelihood of electrolyte abnormalities). Information Patient Needs: Instruct patient to take this medication at the same time each day. Take missed doses as soon as remembered but not just before next dose is due. Do not double doses. Instruct patient to monitor weight biweekly and notify health care professional of significant changes. Caution patient to change positions slowly to minimize orthostatic hypotension. This may be potentiated by alcohol. Advise patient to use sunscreen and protective clothing to prevent photosensitivity reactions. Instruct patient to discuss dietary potassium requirements with health care professional. Instruct patient to notify health care professional of medication regimen before treatment or surgery. Advise patient to report rash, muscle weakness, cramps, nausea, vomiting, diarrhea, or dizziness to health care professional. Emphasize the importance of routine follow-up exams. Hypertension: Advise patients to continue taking the medication even if feeling better. Medication controls but does not cure hypertension. Encourage patient to comply with additional interventions for hypertension (weight reduction, low-sodium diet, regular exercise, smoking cessation, moderation of alcohol consumption, and stress management). Instruct patient and family in correct technique for monitoring weekly BP. Instruct patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products being taken and to consult health care professional before taking other Rx, OTC, or herbal products, especially cough or cold preparations.

Trade Name/Generic Name: Lioresal (baclofen)*

Classification: Therapeutic:antispasticity agents, skeletal muscle relaxants (centrally acting) Uses/Actions: Polyethylene glycol (PEG) in solution acts as an osmotic agent, drawing water into the lumen of the GI tract. Therapeutic Effects: Evacuation of the GI tract without water or electrolyte imbalance and treatment of reversible spasticity due to multiple sclerosis or spinal cord lesions/ inhibits reflexes at spinal level= decreased muscles spasms Contraindications: epilepsy patients, renal impairment, hypersensitivity Side Effects CNS: SEIZURES(IT), dizziness, drowsiness, fatigue, weakness, confusion, depression, headache, insomnia. EENT: nasal congestion, tinnitus. CV: edema, hypotension. GI: nausea, constipation. GU: frequency. Derm: pruritus, rash. Metab: hyperglycemia, weight gain.Neuro:ataxia.Misc: hypersensitivity reactions, sweating. Nursing Implications: monitor serum glucose levels, monitor closely during titration and test dose= have resuscitative equipment handy Usual Dosage and Route: PO 5 mg, 3x daily Information Patient Needs: report signs of hypersensitivity, may cause dizziness and drowsiness, avoid driving, do not double dose

Trade Name/ Generic Name: Ritalin (methylphenidate)*

Classification: Therapeutic:central nervous system stimulants Uses/ actions: Produces CNS and respiratory stimulation with weak sympathomimetic activity. Therapeutic Effects: Increased attention span in ADHD. Increased motor activity, mental alertness, and diminished fatigue in narcoleptic patients. Contraindications: Hypersensitivity; Hyperexcitable states; Hyperthyroidism; Patients with psychotic personalities or suicidal or homicidal tendencies; Personal or family history of Tourette's syndrome; Glaucoma; Motor tics; Concurrent use or use within 14 days of MAO inhibitors; Fructose intolerance, glucose-galactose malabsorption, or sucrose-isomaltase insufficiency; Surgery. Side effects: Abuse and dependence, known hypersensitivity to methylphenidate or other ingredients of Ritalin and Ritalin-SR, hypertensive crisis with concomitant use of Monoamine Oxidase Inhibitors, serious cardiovascular reactions, blood pressure and heart rate increases, psychiatric adverse reactions, peripheral vasculopathy, including Raynaud's phenomenon, and long-term suppression of growth. Nursing Implications: Monitor BP, pulse, and respiration before administering and periodically during therapy. Obtain a history (including assessment of family history of sudden death or ventricular arrhythmia), physical exam to assess for cardiac disease, and further evaluation (ECG and echocardiogram), if indicated. If exertional chest pain, unexplained syncope, or other cardiac symptoms occur, evaluate promptly. Monitor closely for behavior change. Monitor for signs and symptoms of peripheral vasculopathy (numbness and burning in fingers, digital changes). May require reduction in dose or discontinuation. Peds: Monitor growth, both height and weight, in children on long-term therapy. May produce a false sense of euphoria and well-being. Provide frequent rest periods and observe patient for rebound depression after the effects of the medication have worn off. Usual Dosage & Route: PO and transdermal. PO: Administer immediate and sustained-release tablets on an empty stomach (30- 45 min before a meal). Sustained-release tablets should be swallowed whole; do not break, crush, or chew. Medate CD and Ritalin LA capsules may be opened and sprinkled on cool applesauce; entire mixture should be ingested immediately and followed by a drink of water. Do not store for future use, may be administered without regard to food, but must be taken with water, milk, or juice. Shake extended-release oral suspension for 10 seconds before administering. May be given with or without food. Transdermal: Apply patch to a clean, dry site on the hip which is not oily, damaged, or irritated; do not apply to waistline where tight clothing may rub it. Press firmly in place with palm of hand for 30 seconds to make sure of good contact with skin, especially around edges. Alternate site daily. Apply patch 2 hour before desired effect and remove 9 hour after applied; effects last several more hours. Do not apply or reapply with dressings, tape, or other adhesives. Do not cut patches. Information Patient Needs: Instruct patient to take medication as directed. If an oral dose is missed, take the remaining doses for that day at regularly spaced intervals; do not double doses. Take the last dose before 6 PM to minimize the risk of insomnia. Instruct patient not to alter dose without consulting health care professional. Abrupt cessation of high doses may cause extreme fatigue and mental depression. Instruct parent/ caregiver to read the Medication Guide prior to use and with each Rx refill; new information may be available. Advise patient to check weight 2- 3 times weekly and report weight loss to health care professional. May cause dizziness or blurred vision. Caution patient to avoid driving or activities requiring alertness until response to medication is known. Inform patient and/or parents that shell of tablet may appear in the stool. This is no cause for concern. Advise patient to avoid using caffeine-containing beverages concurrently with this therapy. Advise patient to notify health care professional if nervousness, insomnia, palpitations, vomiting, skin rash, or fever occurs.

Trade Name/Generic Name: Aldactone (spirolactone)*

Classification: Therapeutic:diuretics, potassium-sparing diuretics Uses/Actions: Management of primary hyperaldosteronism. Management of edema associated with HF, cirrhosis and nephrotic syndrome. Management of essential hypertension. Treatment of hypokalemia (counteracts potassium loss caused by other diuretics). Contraindications: Contraindicated in: Hypersensitivity; Anuria; Acute renal insufficiency; Significant renal impairmen; SCr 2.5 m g/dL (for patients with heart failure); Hyperkalemia; Addison's disease; Concurrent use of eplerenone. Use Cautiously in: Hepatic dysfunction; Geriatric or debilitated patients or patients with diabetes mellitus (qrisk of hyperkalemia); OB, Lactation: May cause endocrine dysfunction in infants. Is tumorigenic and should not be given to nursing mothers. Alternative method of feeding should be used if spironolactone is essential. Side Effects: CNS: dizziness, clumsiness, headache, sedation. CV: arrhythmias. GI: GI irritation. GU: erectile dysfunction, dysuria. Endo: amenorrhea, gynecomastia (in males), breast tenderness, deepening of voice,qhair growth (in females), sexual dysfunction. F and E: hyperkalemia, hyponatremia, hyperchloremic metabolic acidosis. Hemat: agranulocytosis, thrombocytopenia. Derm: DRUG RASH WITH EOSINOPHILIA AND SYSTEMIC SYMPTOMS (DRESS), STEVENS-JOHNSON SYNDROME, TOXIC EPIDERMAL NECROLYSIS, alopecia, pruritis.MS:muscle cramps.Misc:allergic reactions. Nursing Implications: Monitor intake and output ratios and daily weight during therapy. If medication is given as an adjunct to antihypertensive therapy, BP should be evaluated before administering. Monitor response of signs and symptoms of hypokalemia (weakness, fatigue, U wave on ECG, arrhythmias, polyuria, polydipsia). Assess patient frequently for development of hyperkalemia (fatigue, muscle weakness, paresthesia, confusion, dyspnea, cardiac arrhythmias). Patients who have diabetes mellitus or kidney disease and elderly patients are at increased risk of developing these symptoms. Periodic ECGs may be recommended in patients receiving prolonged therapy. Assess patient for skin rash frequently during therapy. Discontinue diuretic 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: Evaluate serum potassium levels prior to and routinely during therapy. Withhold drug and notify health care professional if patient becomes hyperkalemic. Monitor BUN, serum creatinine, and electrolytes prior to and periodically during therapy. May causeqserum magnesium, uric acid, BUN, creatinine, potassium, plasma renin activity, and urinary calcium excretion levels. May also causepsodium levels. Discontinue potassium-sparing diuretics 3 days prior to a glucose tolerance test because of risk of severe hyperkalemia. PO: Administer in AMto avoid interrupting sleep pattern. Administer with food or milk to minimize gastric irritation and to increase bioavailability. Usual Dosage and Route: PO (Adults): 25- 400 mg/day as a single dose or 2 divided doses. HF—25- 50 mg/ day Information Patient Needs: Emphasize the importance of continuing to take this medication, even if feeling well. Instruct patient to take medication at the same time each day. Take missed doses as soon as remembered unless almost time for next dose. Do not double doses. Caution patient to avoid salt substitutes and foods that contain high levels of potassium unless prescribed by health care professional. May cause dizziness. Caution patient to avoid driving or other activities requiring alertness until response to medication is known. Instruct patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products being taken and to consult health care professional before taking any OTC medications concurrently with this therapy, especially OTC decongestants, cough or cold preparations, or appetite suppressantsdue to potential for increased BP. Instruct patient to notify health care professional of medication regimen prior to treatment or surgery. Advise patient to notify health care professional if rash, muscle weakness or cramps; fatigue; or severe nausea, vomiting, or diarrhea occurs. Advise female patients to notify health care professional if pregnancy is planned or suspected or if breast feeding. Emphasize the need for follow-up exams to monitor progress. Hypertension: Reinforce need to continue additional therapies for hypertension (weight loss, restricted sodium intake, stress reduction, moderation of alcohol intake, regular exercise, and cessation of smoking). Medication helps control but does not cure hypertension. Teach patient and family the correct technique for checking BP weekly.

Trade Name/Generic Name: Osmitrol (mannitol)*

Classification: Therapeutic:diuretics; Pharmacologic: osmotic diuretics Uses/Actions: V: Adjunct in the treatment of: Acute oliguric renal failure, Edema, Increased intracranial or intraocular pressure, Toxic overdose. GU irrigant During transurethral procedures (2.5- 5% solution only). Contraindications: Contraindicated in: Hypersensitivity; Anuria; Dehydration; Active intracranial bleeding; Severe pulmonary edema or congestion. Use Cautiouslyin: OB, Lactation,Safety not established). Side Effects: CNS:confusion, headache. EENT: blurred vision, rhinitis. CV: transient volume expansion, chest pain, HF, pulmonary edema, tachycardia.GI: nausea, thirst, vomiting. GU: renal failure, urinary retention. F and E: dehydration, hyperkalemia, hypernatremia, hypokalemia, hyponatremia. Local: phlebitis at IV site. Nursing Implications: Monitor vital signs, urine output, CVP, and pulmonary artery pressures (PAP) before and hourly throughout administration. Assess patient for signs and symptoms of dehydration (decreased skin turgor, fever, dry skin and mucous membranes, thirst) or signs of fluid overload (increased CVP, dyspnea, rales/crackles, edema). Assess patient for anorexia, muscle weakness, numbness, tingling, paresthesia, confusion, and excessive thirst. Report signs of electrolyte imbalance. Increased Intracranial Pressure: Monitor neurologic status and intracranial pressure readings in patients receiving this medication to decrease cerebral edema. Increased Intraocular Pressure: Monitor for persistent or increased eye pain or decreased visual acuity. Lab Test Considerations: Renal function and serum electrolytes should be monitored routinely throughout course of therapy. Potential Nursing Diagnoses Excess fluid volume (Indications) Risk for deficient fluid volume (Side Effects). Usual Dosage and Route: IV (Adults): Edema, oliguric renal failure—50- 100 g as a 5- 25% solution; may precede with a test dose of 0.2 g/kg over 3- 5 min. Reduction ofintracranial/intraocular pressure—0.25- 2 g/kg as 15- 25% solution over 30- 60 min (500 mg/kg may be sufficient in small or debilitated patients).Diuresis in drug intoxications— 50- 200 g as a 5- 25% solution titrated to maintain urine flow of 100- 500 mL/hr Information Patient Needs: You should not receive mannitol if you have severe kidney disease, lung swelling or congestion, severe dehydration, bleeding in your brain not caused by surgery, or if your kidneys have already shut down and you are unable to urinate.

Trade Name/Generic Name: 0.9% Sodium Chloride*

Classification: Therapeutic:mineral and electrolytereplacements/supplements Uses/Actions: IV: Hydration and provision of NaCl in deficiency states. Maintenance of fluid and electrolyte status in situations in which losses may be excessive (excess diuresis or severe salt restriction). 0.45% ("half-normal saline") solution is most commonly used for hydration and the treatment of hyperosmolar diabetes (hypotonic). 0.9% ("normal saline") solution is used for: Replacement, Treatment of metabolic alkalosis, A priming fluid for hemodialysis, To begin and end blood transfusions. Small volumes of 0.9% NaCl (preservative-free or bacteriostatic) are used to reconstitute or dilute other medications. Hypertonic solution (3%, 5%) may be required in situations in which rapid replacement of sodium is necessary: Hyponatremia, Hypochloremia, Renal failure, Heart failure. PO: Prevention of or management of volume depletion due to salt restriction or heat prostration when excessive sweating occurs during exposures to high temperatures.Irrigating Solutions: 0.9% and 0.45%may be used as irrigating solutions. Concentrated sodium chloride: Used as an additive to parenteral fluid therapy in very specific situations. Contraindications: Contraindicated in: Hypertonic (3%, 5%) solutions should not be used in patients with elevated, slightly decreased, or normal serum sodium; Fluid retention or hypernatremia. Use Cautiously in: Patients prone to metabolic, acid-base, or fluid and electrolyte abnormalities, including: geriatric patients, those with nasogastric suctioning, vomiting, diarrhea, diuretic therapy, glucocorticoid therapy, fistulas, HF, severe renal failure, severe liver diseases (additional electrolytes may be required); Pedi: NaCl preserved with benzyl alcohol should not be used in neonates; Inadequate hydration (water and other electrolytes must be replaced). Side Effects: Seen primarily during PO and IV use CV: HF, PULMONARY EDEMA, edema. F and E: hypernatremia, hypervolemia, hypokalemia. Local: IV— extravasation, irritation at IV site. Nursing Implications: Assess fluid balance (intake and output, daily weight, edema, lung sounds) throughout therapy. Assess patient for symptoms of hyponatremia (headache, tachycardia, lassitude, dry mucous membranes, nausea, vomiting, muscle cramps) or hypernatremia (edema, weight gain, hypertension, tachycardia, fever, flushed skin, mental irritability) throughout therapy. Sodium is measured in relation to its concentration to fluid in the body, and symptoms may change based on patient's hydration status. Lab Test Considerations: Monitor serum sodium, potassium, bicarbonate, and chloride concentrations and acid-base balance periodically for patients receiving prolonged therapy with sodium chloride. Monitor serum osmolarity in patients receiving hypertonic saline solutions. Potential Nursing Diagnoses Deficient fluid volume (Indications) Excess fluid volume (Side Effects) Implementation High Alert: Accidental administration of hypertonic sodium chloride solutions (greater than 0.9%) have resulted in serious electrolyte imbalances. Do not confuse vials of concentrated sodium chloride (23.4%) with vials of sodium chloride flush solution (0.9%). Dose of NaCl depends on patient's age, weight, condition, fluid and electrolyte balance, and acid-base balance. Do not administer bacteriostatic NaCl containing benzyl alcohol as a preservative to neonates. This should not be used to reconstitute or to dilute solutions or to flush intravascular catheters in neonates. Infusion of 0.45% NaCl is hypotonic, 0.9% NaCl is isotonic, and 3% and 5% NaCl are hypertonic. Usual Dosage and Route: IV (Adults): 0.9% NaCl (isotonic)—1 L (contains 150 mEq sodium/L), rate and amount determined by condition being treated. 0.45% NaCl (hypotonic)—1-2 L (contains 75 mEq sodium/L), rate and amount determined by condition being treated. 3%, 5% NaCl (hypertonic)—100 mL over 1 hr (3% contains 50 mEq sodium per 100 mL; 5% contains 83.3 mEq sodium per 100 mL). PO (Adults): 1- 2 g 3 times daily. Information Patient Needs: Explain to patient the purpose of the infusion. Advise patients at risk for dehydration due to exposure to extreme temperatures when and how to take NaCL tablets. Inform patients that undigested tablets may be passed in the stool; oral electrolyte solutions are preferable.

Trade Name/Generic Name: 5% Albumin*

Classification: Therapeutic:volume expanders; Pharmacologic: blood products, colloids Uses/Actions: Expansion of plasma volume and maintenance of cardiac output in situations associated with fluid volume deficit, including shock, hemorrhage, and burns. Temporary replacement of albumin in diseases associated with low levels of plasma proteins, such as nephrotic syndrome or end-stage liver disease, resulting in relief or reduction of associated edema. Contraindications: Contraindicated in: Allergic reactions to albumin; Severe anemia; HF; Normal or increased intravascular volume. Use Cautiously in:Severe hepatic or renal disease; Dehydration (additional fluids may be required); Patients requiring sodium restriction; Preterm neonates (infuse slowly due to increased risk of intravascular hemorrhage). Side Effects: CNS: headache. CV: PULMONARY EDEMA, fluid overload, hypertension, hypotension, tachycardia. GI: increased salivation, nausea, vomiting.Derm: rash, urticaria.MS: back pain.Misc:chills, fever, flushing Nursing Implications: Monitor vital signs, CVP, and intake and output before and frequently throughout therapy. If fever, tachycardia, or hypotension occurs, stop infusion and notify physician immediately. Antihistamines may be required to suppress this hypersensitivity response. Hypotension may also result from infusing too rapidly. May be given without regard to patient's blood group. Assess for signs of vascular overload (elevated CVP, rales/crackles, dyspnea, hypertension, jugular venous distention) during and after administration. Surgical Patients: Assess for increased bleeding after administration caused by increased BP and circulating blood volume. Albumin does not contain clotting factors. Hemorrhage: Monitor hemoglobin and hematocrit levels. These values may decreasee of hemodilution. Usual Dosage and Route: IV Route. Dose is highly individualized and depends on condition being treated; normally IV (Adults): 25 g (500 mL), may be repeated within 30 min. Information Patient Needs: Explain the purpose of this solution to the patient. Instruct patient to report signs and symptoms of hypersensitivity reaction

Trade Name/Generic Name: Sinemet (levodopa-carbidopa)*

Classification: anti-parkinsons drugs, dopamine precursors Uses/Actions: treats parkinson disease, does not cross blood-brain barrier, increases dopamine levels Contraindications: dyskinesia, cardia arrhythmias, cardiac disease, hypotension MI, narrow-angle glaucoma Side Effects: CNS: involuntary movements, anxiety, dizziness, hallucinations, memory loss, psychiatric problems, urges (gambling, sexual). EENT: blurred vision, mydriasis. GI: nausea, vomiting, anorexia, dry mouth, hepatotoxicity. Derm: melanoma. Hemat: hemolytic anemia, leukopenia.Misc: darkening of urine or sweat. Nursing Implications: monitor for side effects, mental stat assessment, may cuase false results in urine tests for sugar and ketones Usual Dosage and Route: PO 10-250mg Information Patient Needs: inform patient, sweat, urine, saliva may appear red, brown or black (common side effect), avoid high protein diet

Trade Name/Generic Name: Buspar (buspirone)*

Classification: antianxiety agent Uses/Actions: management of anxiety/ binds to serotonin and dopamine receptors, increase norep. metabolism Contraindications: other antianxiety meds, other psychotopics Side Effects: fatigue, insomnia, blurred vision, sore throat, altered taste or smell, urinary frequency, dry mouth Nursing Implications: assess degree and manifestations of anxiety, assess and possibly restrict amount of drug avail. to patients with substance tolerance or impaired control Usual Dosage and Route: PO 7.5mg daily increase by 5mg PRN Information Patient Needs: may cause drowsiness and dizziness, do not take alcohol

Trade Name/Generic Name: Valium (diazepam)*

Classification: antianxiety, anticonvulsant, sedative/hypnotics, skeletal muscle relaxant Uses/Actions: adjunct medication for anxiety, preoperative sedation, status epilepticus/ depresses CNS Contraindications: Contraindicated in: Hypersensitivity; Cross-sensitivity with other benzodiazepines may occur; Comatose patients; Myasthenia gravis; Severe pulmonary impairment; Sleep apnea; Severe hepatic dysfunction; Pre-existing CNS depression; Uncontrolled severe pain; Angle-closure glaucoma; Some products contain alcohol, propylene glycol, or tartrazine and should be avoided in patients with known hypersensitivity or intolerance;OB: risk of congenital malformations; Pedi: Children 6 mo (for oral; safety not established); Lactation: Recommend to discontinue drug or bottle-feed. Use Cautiously in: Severe renal impairment; History of suicide attempt or drug dependence; Debilitated patients (doseprequired); Patients with low albumin; Pedi: Metabolites can accumulate in neonates. Injection contains benzyl alcohol which can cause potentially fatal gasping syndrome in neonates; Geri: Long-acting benzodiazepines cause prolonged sedation in the elderly. Appears on Beers list and is associated withqrisk of falls (pdose required or consider short-acting benzodiazepine). Side Effects: blurred vision, slurred speech, depression, lethargy, drowsiness, dizziness Nursing Implications: monitor vitals, assess IV site periodically for phlebitis and venous thrombosis. Usual Dosage and Route: PO 2-10 mg, IM-IV 5-10 mg Information Patient Needs: sharing this med could be very dangerous, med may cause clumsiness, avoid alcohol or other CNS depressants

Trade Name/Generic Name: Dilantin (phenytoin)*

Classification: antiarrhythmic, anticonvulsant, hydantoin Uses/Actions: treatment of seizures, management of neuropathic pain Contraindications: alcohol intolerance, sinus bradycardia, renal disease, cardiac or resp. disease Side Effects: Most listed are for chronic use of phenytoin CNS: SUICIDAL THOUGHTS, ataxia, agitation, confusion, dizziness, drowsiness, dysarthria, dyskinesia, extrapyramidal syndrome, headache, insomnia, weakness. EENT: diplopia, nystagmus. CV: hypotension (q with IV phenytoin), tachycardia. GI: gingival hyperplasia, nausea, constipation, drug-induced hepatitis, vomiting.Derm: STEVENS-JOHNSON SYNDROME, TOXIC EPIDERMAL NECROLYSIS, hypertrichosis, rash, exfoliative dermatitis, pruritus, purple glove syndrome. Hemat: AGRANULOCYTOSIS, APLASTIC ANEMIA, leukopenia, megaloblastic anemia, thrombocytopenia. MS: osteomalacia, osteoporosis. Misc: fever, lymphadenopathy Nursing Implications: monitor for depression and changes in behavior that may harm patient, observe for rash & steven johnson syndrome Usual Dosage and Route: PO 7.5 mg-9mg/kg/day in 2-3 doses, IV 25-50mg/min Information Patient Needs: instruct patient that behavioral changes, skin rash should be reported, advise female patients to use additional nonhormonal method of contraception

Trade Name/Generic Name: Elavil (amitriptyline)*

Classification: antidepressant Uses/Actions: depression, anxiety/ potentiates effect of serotonin and norep in CNS Contraindications: angle--closure glaucoma, recent MI, prostatic hyperplasia Side Effects: CNS: SUICIDAL THOUGHTS, lethargy, sedation. EENT: blurred vision, dry eyes, dry mouth. CV: ARRHYTHMIAS, TORSADE DE POINTES, hypotension, ECG changes, QT interval prolongation. GI: constipation, hepatitis, paralytic ileus,qappetite, weight gain. GU: urinary retention,plibido. Derm: photosensitivity. Endo: changes in blood glucose, gynecomastia.Hemat: blood dyscrasias. Nursing Implications: obtain weight and BMI periodically, asses fasting glucose and cholesterol levels in overweight patients, monitor mental status, assess for suicidal tendencies Usual Dosage and Route: PO 75mg.day in divided doses for adults, only 10-25mg for geri patients Information Patient Needs: advise patient and caregivers to look for suicidality, orthostatic hypotension is normal at first= notify caregiver if persists, instruct patient to avoid alcohol

Trade Name/Generic Name: Zoloft (sertraline)*

Classification: antidepressant, SSRI Uses/Actions:major depressive disorder, panic disorder, OCD, PTSD, PMDD// inhibits neuronal uptake of serotonin in CNS Contraindications: hepatic or renal impairment, history of mania, suicide attempt, third trimester women, alcohol consumption Side Effects: CNS: NEUROLEPTIC MALIGNANT SYNDROME, SUICIDAL THOUGHTS, dizziness, drowsiness, fatigue, headache, insomnia, agitation, anxiety, confusion, emotional lability, impaired concentration, manic reaction, nervousness, weakness, yawning. EENT: pharyngitis, rhinitis, tinnitus, visual abnormalities. CV: chest pain, palpitations. GI: diarrhea, dry mouth, nausea, abdominal pain, altered taste, anorexia, constipation, dyspepsia, flatulence,qappetite, vomiting. GU: sexual dysfunction, menstrual disorders, urinary disorders, urinary frequency. Derm:qsweating, hot flashes, rash. Endo: diabetes. F and E: hyponatremia. MS: back pain, myalgia.Neuro: tremor, hypertonia, hypoesthesia, paresthesia, twitching. Misc: SEROTONIN SYNDROME, fever, thirst. Nursing Implications: assess for suicidal tendencies, assess for depression, assess frequency of panic attacks Usual Dosage and Route: PO 25mg-50mg depending of condition diagnosed Information Patient Needs: advise to avoid alcohol or other antidepressants, advise patient that sexual dysfunction is a side effect, encourage patient to participate in psychotherapy to improve coping skills

Trade Name/Generic Name: Cogentin (benztropine)

Classification: antiparkinson agent, anticholinergic Uses/Actions: adjunctive treatment of all form of parkinson's disease// blocks cholinergic activity in the CNS Contraindications: children <3 y/o, prostatic hyperplasia, seizure disorders, cardia arrthymias Side Effects: hallucinations, dry eyes, hypotension, dry mouth, decreased sweating Nursing Implications: assess bowel function daily, mental illness patients are high risk for exaggerated symptoms= monitor for behavioral changes Usual Dosage and Route: PO 1-2mg in divided doses BID- IM,IV 1-2mg + PO 1-2mg BID Information Patient Needs: avoid driving, operating machinery, caution patient this decreases sweating and overheating may occur, emphasize important of routine follow up

Trade Name/Generic Name: Eldepryl (selegiline)*

Classification: antiparkinson agent, monosamin oxidase type B inhibitor Uses/Actions: management of parkinsons disease/ MAO conversion agent= increased dopamine levels Contraindications: peptic ulcer disease, concurrent use with meperidine or other opioids Side Effects: CNS: confusion, dizziness, fainting, hallucinations, insomnia, urges (gambling, sexual), vivid dreams.Derm:melanoma.GI: nausea, abdominal pain, dry mouth. Nursing Implications: assess BP frequently, assess for tremors, ataxic gait Usual Dosage and Route: PO (Adults): 5 mg twice daily, with breakfast and lunch (some patients may require further dividing of doses— 2.5 mg 4 times daily). PO (Adults): Orally disintegrating tablets—1.25 mg once daily for at least 6 wk. After 6 wk, may increase to 2.5 mg if effect not achieved and patient is tolerating medication. Information Patient Needs: avoid large quantities of caffeine, OTC cough or cold medication, , instruct patient to change positions slowly to minimize orthostatic hypotension

Trade Name/Generic Name: Cozaar (losartan)*

Classifications: Angiotensin-II Receptor Blockers/ARBs Uses/Actions: For the treatment of hypertension, either alone or in combination with other antihypertensive agents. For stroke prophylaxis in hypertensive patients with left ventricular hypertrophy (LVH). NOTE: There is evidence that this benefit does not apply to Black patients. For the treatment of proteinuria or diabetic nephropathy. For the treatment of heart failure (off label). Contraindications: Losartan and active metabolite plasma concentrations are similar in elderly and young adults with hypertension. Plasma losartan concentrations are about twice as high in females versus males, but the plasma concentrations of the active metabolite are unchanged. However, blood pressure responses are similar, regardless of age or gender. According to the manufacturer, no dosage adjustment is necessary. Hepatic disease; Heart failure, renal artery stenosis; Hypotension, hypovolemia; Hyperkalemia; ACE-inhibitor induced angioedema, angioedema; Black patients; Pregnancy - Losartan is classified as FDA pregnancy risk category D; Breast-feeding; children under age of 6; prior to surgery Geriatric Greater sensitivity to the hypotensive effects of losartan is possible in geriatric patients due to an age-related decline in renal function Side Effects: diarrhea; stomach pain; muscle cramps; leg or back pain; dizziness; headache; sleep problems (insomnia); tiredness, and cold or flu symptoms such as stuffy nose, sneezing, sore throat, fever, and cough Nursing Implications: Avoid given first dose at night due to increase hypotensive risk; Monitor blood pressure and pulse frequently; Enquire the complete health history of patient specially any renal disease; Check patient s/s for angioedema; Monitor electrolytes specially sodium and potassium levels, uric acid levels and CBC. Usual Dosage and Route: Adults: Initially, 50 mg PO once daily; then increase the dosage to 100 mg PO once daily based on response. MAXIMUM DOSAGE for Adults 100 mg/day PO. Information Patient Needs: Get emergency medical help if you have signs of an allergic reaction:hives; difficult breathing; swelling of your face, lips, tongue, or throat. Avoid potassium rich diet and supplements when taken losartan; Do not breast feed when taken losartan; Inform patients the s/s of hypotension; Inform HP about pregnancy if conceived; Take plenty of water to avoid dehydration

Trade Name/Generic Name: Apresoline (hydralazine)*

Classifications: Antihypertensives and vasodilators Uses/Actions: Moderate to severe hypertension (with a diuretic). Unlabeled Use: HF unresponsive to conventional therapy with digoxin and diuretics. Contraindications: Contraindicated in: Hypersensitivity; Some products contain tartrazine and should be avoided in patients with known intolerance. Use Cautiously in: Cardiovascular or cerebrovascular disease; Severe renal and hepatic disease (dose modification may be necessary); OB, Lactation: Has been used safely during pregnancy. Side Effects: CNS: dizziness, drowsiness, headache. CV: tachycardia, angina, arrhythmias, edema, orthostatic hypotension. GI: diarrhea, nausea, vomiting. Derm: rash. F and E: sodium retention. MS: arthralgias, arthritis. Neuro: peripheral neuropathy.Misc: drug-induced lupus syndrome. Nursing Implications: Monitor BP and pulse frequently during initial dose adjustment and periodically during therapy. About 50- 65% of Caucasians, Black, South Indians, and Mexicans are slow acetylators at risk for toxicity, while 80- 90% of Eskimos, Japanese and Chinese are rapid acetylators at risk for decreased levels and treatment failure. Monitor frequency of prescription refills to determine adherence. Lab Test Considerations: Monitor CBC, electrolytes, LE cell prep, and ANA titer prior to and periodically during prolonged therapy. May cause a positive direct Coombs' test result. Potential Nursing Diagnoses Ineffective tissue perfusion (Indications) Noncompliance (Patient/Family Teaching) Implementation Do not confuse hydralazine with hydroxyzine. IM or IV route should be used only when drug cannot be given orally. May be administered concurrently with diuretics or beta blockers to permit lower doses and minimize side effects. PO: Administer with meals consistently to enhance absorption. Pharmacist may prepare oral solution from hydralazine injection for patients with difficulty swallowing. Usual Dosage and Route: PO (Adults): Hypertension—10 mg 4 times daily initially. After 2- 4 days mayqto 25 mg 4 times daily for the rest of the 1st week; may thenqto 50 mg 4 times daily (up to 300 mg/day). Once maintenance dose is established, twice-daily dosing may be used. HF—25- 37.5 mg 4 times daily; may bequp to 300 mg/day in 3- 4 divided doses. PO (Children 1 mo): Initial— 0.75- 1 mg/kg/day in 2- 4 divided doses, not to exceed 25 mg/dose; mayqgradually to 5 mg/kg/day in infants and 7.5 mg/kg/day in children (not to exceed 200 mg/day) in 2- 4 divided doses. IM, IV (Adults): Hypertension—5- 40 mg repeated as needed. Eclampsia—5 mg q 15- 20 min; if no response after a total of 20 mg, consider an alternative agent. IM, IV (Children 1 mo): Initial— 0.1- 0.2 mg/kg/dose (not to exceed 20 mg) q 4- 6 hr as needed, up 1.7- 3.5 mg/kg/day in 4- 6 divided doses. Information Patient Needs: Emphasize the importance of continuing to take this medication, even if feeling well. Instruct patient to take medication at the same time each day; last dose of the day should be taken at bedtime. Take missed doses as soon as remembered; do not double doses. If more than 2 doses in a row are missed, consult health care professional. Must be discontinued gradually to avoid sudden increase in BP. Hydralazine controls but does not cure hypertension. Encourage patient to comply with additional interventions for hypertension (weight reduction, low-sodium diet, smoking cessation, moderation of alcohol intake, regular exercise, and stress management). Instruct patient and family on proper technique for BP monitoring. Advise them to check BP at least weekly and report significant changes. Patients should weigh themselves twice weekly and assess feet and ankles for fluid retention. May occasionally cause drowsiness. Advise patient to avoid driving or other activities requiring alertness until response to medication is known. Caution patient to avoid sudden changes in position to minimize orthostatic hypotension. Advise patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products being taken and to consult with health care professional before taking other medications, especially cough, cold, or allergy remedies. Instruct patient to notify health care professional of medication prior to treatment or surgery. Advise patient to notify health care professional immediately if general tiredness; fever; muscle or joint aching; chest pain; skin rash; sore throat; or numbness, tingling, pain, or weakness of hands and feet occurs. Vitamin B6 (pyridoxine) may be used to treat peripheral neuritis.

Trade Name/Generic Name: Demerol (meperidine)*

Classifications: Opioid Uses/Actions: For the treatment of severe pain requiring an opioid analgesic and for which alternative treatments are inadequate. Contraindications: Meperidine is contraindicated for use in patients with significant respiratory depression and in patients with acute or severe asthma (e.g., status asthmaticus) in unmonitored care settings or in the absence of resuscitative equipment. Additionally, avoid coadministration with other CNS depressants when possible, as this significantly increases the risk for profound sedation, respiratory depression, coma, and death. Reserve concomitant prescribing of these drugs for use in patients for whom alternative treatment options are inadequate; if concurrent use is necessary, use the lowest effective dosages and minimum treatment durations needed. Monitor patients closely for signs or symptoms of respiratory depression and sedation. In patients with chronic obstructive pulmonary disease (COPD), cor pulmonale, decreased respiratory reserve, hypoxia, hypercapnia, respiratory insufficiency, upper airway obstruction, or preexisting respiratory depression, it is recommended that non-opioid analgesics be considered as alternatives to meperidine, as even usual therapeutic doses may decrease respiratory drive and cause apnea in these patient populations. Extreme caution should also be used in patients with chronic asthma, kyphoscoliosis (a type of scoliosis), hypoxemia, or paralysis of the phrenic nerve. Patients with advanced age, debilitation, or sleep apnea are at an increased risk for the development of respiratory depression associated with meperidine. Use with caution in patients with obesity as this is a risk factor for obstructive sleep-apnea syndrome and/or decreased respiratory reserve. Meperidine should not be used during impaired consciousness or coma, as significant decreases in respiratory drive may lead to adverse intracranial effects from carbon dioxide retention. Respiratory depression, if left untreated, may cause respiratory arrest and death. Symptoms of respiratory depression include a reduced urge to breathe, a decreased respiratory rate, or deep breaths separated by long pauses High addiction rate. Nursing Implications: Take apical pulse before administering. If <50 bpm or if arrhythmia occurs, withhold medication and notify, administer metoprolol with meals or directly after eating. Usual Dosage and Route: IM or SC (25 to 100 mg q3 to 4 hours ); IV direct 10 to 30 mg given over at least 1 minute, titrated every 6 to 10 minutes until analgesia achieved (usual maximum 60 mg/hour), or pill 50-150 mg every 3-4 hours PRN Information Patient Needs: High risk for addiction; get emergency help if signs of allergic reaction occur; opoid medicines can slow or stop breathing

Trade Name/Generic Name: Diamox (acetazolamide)*

Classifications: Therapeutic:anticonvulsants, antiglaucoma agents, diuretics, ocular hypotensive agen. Pharmacologic:carbonic anhydrase inhibitors Uses/Actions: Lowering of intraocular pressure in the treatment of glaucoma. Management of acute altitude sickness. Edema due to HF. Adjunct to the treatment of refractory seizures. Unlabeled Use: Reduce cerebrospinal fluid production in hydrocephalus. Prevention of renal calculi composed of uric acid or cystine. Contraindications: Contraindicated in: Hypersensitivity or cross-sensitivity with sulfonamides may occur; Hepatic disease or insufficiency; Concurrent use with ophthalmic carbonic anhydrase inhibitors (brinzolamide, dorzolamide) is not recommended; OB: Avoid during first trimester of pregnancy. Use Cautiously in: Chronic respiratory disease; Electrolyte abnormalities; Gout; Renal disease; STEVENS-JOHNSON SYNDROME, rashes. Endo: hyperglycemia. F and E: hyperchloremic acidosis, hypokalemia, growth retardation (in children receiving chronic therapy). Hemat: APLASTIC ANEMIA, HEMOLYTIC ANEMIA, LEUKOPENIA. Metab: weight loss, hyperuricemia. Neuro: paresthesias. Misc:allergic reactions including ANAPHYLAXIS. Nursing Implications: Observe for signs of hypokalemia (muscle weakness, malaise, fatigue, ECG changes, vomiting). Assess for allergy to sulfonamides. Intraocular Pressure: Assess for eye discomfort or decrease in visual acuity. Seizures: Monitor neurologic status in patients receiving acetazolamide for seizures. Initiate seizure precautions. Altitude Sickness: Monitor for decrease in severity of symptoms (headache, nausea, vomiting, fatigue, dizziness, drowsiness, shortness of breath). Notify health care professional immediately if neurologic symptoms worsen or if patient becomes more dyspneic and rales or crackles develop. Edema:Monitor intake and output ratios and daily weight during therapy. Lab Test Considerations: Serum electrolytes, complete blood counts, and platelet counts should be evaluated initially and periodically during prolonged therapy. May causeppotassium, bicarbonate, WBCs, and RBCs. May causeqserum chloride. May cause serum and urine glucose; monitor serum and urine glucose carefully in diabetic patients. May cause false-positive results for urine protein and 17-hydroxysteroid tests. May causeqblood ammonia, bilirubin, uric acid, urine urobilinogen, and calcium. Maypurine citrate. Potential Nursing Diagnoses Disturbed sensory perception (visual) (Indications) Implementation Do not confuse acetazolamide with acetohexamide. Do not confuse Diamox with Diabinese. Encourage fluids to 2000- 3000 mL/day, unless contraindicated, to prevent crystalluria and stone formation. A potassium supplement without chloride should be administered concurrently with acetazolamide. PO: Give with food to minimize GI irritation. Tablets may be crushed and mixed with fruit-flavored syrup to minimize bitter taste for patients with difficulty swallowing. Extended-release capsules may be opened and sprinkled on soft food, but do not crush, chew, or swallow contents dry. Extended-release capsules are only indicated for glaucoma and altitude sickness Usual Dosage and Route: PO (Adults): Glaucoma (open angle)—250- 1000 mg/day in 1- 4 divided doses (up to 250 mg q 4 hr) or 500-mg extended-release capsules twice daily. Epilepsy— 4- 16 mg/kg/day in 1- 4 divided doses (maximum 30 mg/kg/day or 1 g/day). Altitude sickness—250 mg 2- 4 times daily started 24- 48 hr before ascent, continued for 48 hr or longer to control symptoms. Antiurolithic—250 mg at bedtime. Edema—250- 375 mg/day. Urine alkalinization—5 mg/kg/dose repeated 2- 3 times over 24 hr. PO (Children): Glaucoma—8- 30 mg/kg (300- 900 mg/m2 /day) in 3 divided doses (usual range 10- 15 mg/kg/day). Edema—5 mg/kg/dose once daily. Epilepsy—4- 16 mg/kg/day in 1- 4 divided doses (maximum 30 mg/kg/day or 1 g/ day). PO (Neonates): Hydrocephalus—5 mg/kg/dose q 6 hrqby 25 mg/kg/day up to a maximum of 100 mg/kg/day. IV (Adults): Glaucoma (closed angle)—250- 500 mg, may repeat in 2- 4 hr to a maximum of 1 g/day. Edema—250- 375 mg/day. IV (Children): Glaucoma—5- 10 mg/kg q 6 hr, not to exceed 1 g/day. Edema— 5 mg/kg/dose once daily. IV (Neonates): Hydrocephalus—5 mg/kg/dose q 6 hrqby 25 mg/kg/day up to a maximum of 100 mg/kg/day.Information Patient Needs: Instruct patient to take as directed. Take missed doses as soon as possible unless almost time for next dose. Do not double doses. Patients on anticonvulsant therapy may need to gradually withdraw medication. Advise patient to report numbness or tingling of extremities, weakness, rash, sore throat, unusual bleeding or bruising, fever, or signs/symptoms of a sulfonamide adverse reaction (Stevens-Johnson syndrome [flu-like symptoms, spreading red rash, or skin/mucous membrane blistering], toxic epidermal necrolysis [widespread peeling/blistering of skin]) to health care professional. If hematopoietic reactions, fever, rash, hepatic, or renal problems occur, acetazolamide should be discontinued. May occasionally cause drowsiness. Caution patient to avoid driving and other activities that require alertness until response to the drug is known. Caution patient to use sunscreen and wear protective clothing to prevent photosensitivity reactions. Advise patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products being taken and to consult with health care professional before taking other medications.

Trade Name/Generic Name: Tylenol (acetaminophen)*

Classifications: Therapeutic:antipyretics, nonopioid analgesics Uses/Actions: acts on hypothalamus--->dilates peripheral blood vessels Contraindications: Hepatotoxic Side Effects: CNS: agitation ( children) (IV), anxiety (IV), headache (IV), fatigue (IV), insomnia (IV).Resp:atelectasis (children) (IV), dyspnea (IV).CV: hypertension (IV), hypotension (IV). GI: HEPATOTOXICITY (DOSES), constipation (children) (IV),qliver enzymes, nausea (IV), vomiting (IV). F and E: hypokalemia (IV). GU: renal failure (high doses/chronic use). Hemat: neutropenia, pancytopenia. MS: muscle spasms (IV), trismus (IV). Derm: acute generalized exanthematous pustulosis, Stevens-Johnson Syndrom, toxic epidermal, necroysis, rash, urticaria. Usual Route Dosage and Route: Baby Drops(babies), Liquids (children), tablet (adults) Information Patient Needs: do not drink alcohol, make sure patient isn't on anticoagulants

Trade Name/Generic Name: Lasix (furosemide)*

Classifications: Therapeutic:diuretics Pharmacologic: loop diuretics Uses/Actions: Edema due to heart failure, hepatic impairment or renal disease. Hypertension. Contraindications: Contraindicated in: Hypersensitivity; Cross-sensitivity with thiazides and sulfonamides may occur; Hepatic coma or anuria; Some liquid products may contain alcohol, avoid in patients with alcohol intolerance. Use Cautiously in: Severe liver disease (may precipitate hepatic coma; concurrent use with potassium-sparing diuretics may be necessary); Electrolyte depletion; Diabetes mellitus; Hypoproteinemia (qrisk of ototoxicity); Severe renal impairment (qrisk of ototoxicity); OB, Lactation:Safety not established; Pedi:qrisk for renal calculi and patent ductus arteriosis in premature neonates; Geri: May haveqrisk of side effects, especially hypotension and electrolyte imbalance, at usual doses. Side Effects: CNS: blurred vision, dizziness, headache, vertigo. EENT: hearing loss, tinnitus. CV: hypotension. GI: anorexia, constipation, diarrhea, dry mouth, dyspepsia,qliver enzymes, nausea, pancreatitis, vomiting. GU:qBUN, excessive urination, nephrocalcinosis.Derm: ERYTHEMA MULTIFORME, STEVENS-JOHNSON SYNDROME, TOXIC EPIDERMAL NECROLYSIS, photosensitivity, pruritis, rash, urticaria. Endo: hypercholesterolemia, hyperglycemia, hypertriglyceridemia, hyperuricemia. F and E: dehydration, hypocalcemia, hypochloremia, hypokalemia, hypomagnesemia, hyponatremia, hypovolemia, metabolic alkalosis. Hemat: APLASTIC ANEMIA, AGRANULOCYTOSIS, hemolytic anemia, leukopenia, thrombocytopenia. MS: muscle cramps. Neuro: paresthesia. Misc: fever. Nursing Implications: Assessment Assess fluid status. Monitor daily weight, intake and output ratios, amount and location of edema, lung sounds, skin turgor, and mucous membranes. Notify health care professional if thirst, dry mouth, lethargy, weakness, hypotension, or oliguria occurs. Monitor BP and pulse before and during administration. Monitor frequency of prescription refills to determine compliance in patients treated for hypertension. Geri: Diuretic use is associated with increased risk for falls in older adults. Assess falls risk and implement fall prevention strategies. Assess patients receiving digoxin for anorexia, nausea, vomiting, muscle cramps, paresthesia, and confusion. Patients taking digoxin are at increased risk of digoxin toxicity because of the potassium-depleting effect of the diuretic. Potassium supplements or potassium-sparing diuretics may be used concurrently to prevent hypokalemia. Assess patient for tinnitus and hearing loss. Audiometry is recommended for patients receiving prolonged high-dose IV therapy. Hearing loss is most common after rapid or high-dose IV administration in patients with decreased renal function or those taking other ototoxic drugs. Assess for allergy to sulfonamides. Assess patient for skin rash frequently during therapy. Discontinue furosemide at first sign of rash; may be life-threatening. Stevens-Johnson syndrome, toxic epidermal necrolysis, or erythema multiforme may develop. Treat symptomatically; may recur once treatment is stopped. Lab Test Considerations:Monitor electrolytes, renal and hepatic function, serum glucose, and uric acid levels before and periodically throughout therapy. Commonlypserum potassium. May causepserum sodium, calcium, and magnesium concentrations. May also causeqBUN, serum glucose, creatinine, and uric acid levels. Potential Nursing Diagnoses Excess fluid volume (Indications) Deficient fluid volume (Side Effects). Usual Dosage and Route: Edema PO (Adults): 20- 80 mg/day as a single dose initially, may repeat in 6- 8 hr; increase dose by 20- 40 mg q 6- 8 hr until desired response. Maintenance doses may be given once or twice daily (doses up to 2.5 g/day have been used in patients with HF or renal disease). Hypertension—40 twice daily initially (when added to regimen, decrease dose of other antihypertensives by 50%); adjust further dosing based on response; Hypercalcemia—120 mg/day in 1- 3 doses. IM, IV (Adults): 20- 40 mg, may repeat in 1- 2 hr increase 20 mg every 1- 2 hr until response is obtained, maintenance dose may be given q 6- 12 hr. For Hypertension PO (Adults): 40 twice daily initially (when added to regimen decrease of other antihypertensives by 50%); adjust further dosing based on response. Information Patient Needs: Instruct patient to take furosemide as directed. Take missed doses as soon as possible; do not double doses. Caution patient to change positions slowly to minimize orthostatic hypotension. Caution patient that the use of alcohol, exercise during hot weather, or standing for long periods during therapy may enhance orthostatic hypotension. Instruct patient to consult health care professional regarding a diet high in potassium. Advise patient to contact health care professional of weight gain more than 3 lbs in 1 day. Instruct patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products being taken and to consult health care professional before taking any OTC medications concurrently with this therapy. Instruct patient to notify health care professional of medication regimen before treatment or surgery. Caution patient to use sunscreen and protective clothing to prevent photosensitivity reactions. Advise patient to contact health care professional immediately if rash, muscle weakness, cramps, nausea, dizziness, numbness, or tingling of extremities occurs. Advise diabetic patients to monitor blood glucose closely; may cause increased blood glucose levels. Emphasize the importance of routine follow-up examinations. Geri: Caution older patients or their caregivers about increased risk for falls. Suggest strategies for fall prevention. Hypertension: Advise patients on antihypertensive regimen to continue taking medication even if feeling better. Furosemide controls but does not cure hypertension. Reinforce the need to continue additional therapies for hypertension (weight loss, exercise, restricted sodium intake, stress reduction, regular exercise, moderation of alcohol consumption, cessation of smoking). Instruct patient to take furosemide as directed. Take missed doses as soon as possible; do not double doses. Caution patient to change positions slowly to minimize orthostatic hypotension. Caution patient that the use of alcohol, exercise during hot weather, or standing for long periods during therapy may enhance orthostatic hypotension. Instruct patient to consult health care professional regarding a diet high in potassium. Advise patient to contact health care professional of weight gain more than 3 lbs in 1 day. Instruct patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products being taken and to consult health care professional before taking any OTC medications concurrently with this therapy. Instruct patient to notify health care professional of medication regimen before treatment or surgery. Caution patient to use sunscreen and protective clothing to prevent photosensitivity reactions. Advise patient to contact health care professional immediately if rash, muscle weakness, cramps, nausea, dizziness, numbness, or tingling of extremities occurs. Advise diabetic patients to monitor blood glucose closely; may cause increased blood glucose levels. Emphasize the importance of routine follow-up examinations. Geri: Caution older patients or their caregivers about increased risk for falls. Suggest strategies for fall prevention. Hypertension: Advise patients on antihypertensive regimen to continue taking medication even if feeling better. Furosemide controls but does not cure hypertension. Reinforce the need to continue additional therapies for hypertension (weight loss, exercise, restricted sodium intake, stress reduction, regular exercise, moderation of alcohol consumption, cessation of smoking).

Trade Name/Generic Name: Toprol (metoprolol)*

Classifications: antianginals, antihypertensives, beta-blockers Uses/Actions: Hypertension. Angina pectoris. Prevention of MI and decreased mortality in patients with recent MI. Management of stable, symptomatic (class II or III) heart failure due to ischemic, hypertensive or cardiomyopathc origin (may be used with ACE inhibitors, diuretics and/or digoxin; Toprol XL only). Unlabeled Use: Ventricular arrhythmias/tachycardia. Migraine prophylaxis. Tremors. Aggressive behavior. Druginduced akathisia. Anxiety. Contraindications: Contraindicated in: Uncompensated HF; Pulmonary edema; Cardiogenic shock; Bradycardia, heart block, or sick sinus syndrome (in absence of a pacemaker). Use Cautiously in: Renal impairment; Hepatic impairment; Geri:qsensitivity to beta blockers; initial dose reduction recommended; Pulmonary disease (including asthma; beta1 selectivity may be lost at higher doses); Diabetes mellitus (may mask signs of hypoglycemia); Thyrotoxicosis (may mask symptoms); Patients with a history of severe allergic reactions (intensity of reactions may be increased); Untreated pheochromocytoma (initiate only after alpha blocker therapy started); OB, Lactation, Pedi:Safety not established; all agents cross the placenta and may cause fetal/ neonatal bradycardia, hypotension, hypoglycemia, or respiratory depression. Side Effects: CNS: fatigue, weakness, anxiety, depression, dizziness, drowsiness, insomnia, memory loss, mental status changes, nervousness, nightmares. EENT: blurred vision, stuffy nose. Resp: bronchospasm, wheezing. CV: BRADYCARDIA, HF, PULMONARY EDEMA, hypotension, peripheral vasoconstriction. GI: constipation, diarrhea, druginduced hepatitis, dry mouth, flatulence, gastric pain, heartburn,qliver enzymes, nausea, vomiting. GU: erectile dysfunction,plibido, urinary frequency. Derm: rashes. Endo: hyperglycemia, hypoglycemia. MS: arthralgia, back pain, joint pain. Misc: drug-induced lupus syndrome. Nursing Implications: Monitor BP, ECG, and pulse frequently during dose adjustment and periodically during therapy. Monitor frequency of prescription refills to determine compliance. Monitor vital signs and ECG every 5-15 min during and for several hours after parenteral administration. If heart rate 40 bpm, especially if cardiac output is also decreased, administer atropine 0.25-0.5 mg IV. Monitor intake and output ratios and daily weights. Assess routinely for signs and symptoms of HF (dyspnea, rales/crackles, weight gain, peripheral edema, jugular venous distention). Angina: Assess frequency and characteristics of anginal attacks periodically during therapy. Potential Nursing Diagnoses Decreased cardiac output (Side Effects) Noncompliance (Patient/Family Teaching). High Alert: IV vasoactive medications are inherently dangerous. Before administering intravenously, have second practitioner independently check original order and dose calculations. High Alert: Do not confuse Toprol-XL (metoprolol) with Topamax (topiramate). Do not confuse Lopressor with Lyrica. Do not confuse metoprolol tartrate with metoprolol succinate. PO: Take apical pulse before administering. If 50 bpm or if arrhythmia occurs, withhold medication and notify health care professional. Administer metoprolol with meals or directly after eating. Extended-release tablets should be swallowed whole; do not break, crush, or chew. Usual Dosage and Route: When switching from immediate-release to extended-release product,the same total daily dose can be used PO (Adults): Antihypertensive/antianginal—25- 100 mg/day as a single dose initially or 2 divided doses; may beqq 7 days as needed up to 450 mg/day (immediate-release) or 400 mg/day (extended-release) (for angina, give in divided doses). Extended-release products are given once daily. MI—25- 50 mg (starting 15 min after last IV dose) q 6 hr for 48 hr, then 100 mg twice daily. Heart failure—12.5- 25 mg once daily (of extended-release), can be doubled every 2 wk up to 200 mg/ day.Migraine prevention—50- 100 mg 2- 4 times daily (unlabeled). IV (Adults):MI—5 mg q 2 min for 3 doses, followed by oral dosing Information Patient Needs: Instruct patient to take medication as directed, at the same time each day, even if feeling well; do not skip or double up on missed doses. Take missed doses as soon as possible up to 8 hr before next dose. Abrupt withdrawal may precipitate life-threatening arrhythmias, hypertension, or myocardial ischemia. Teach patient and family how to check pulse daily and BP biweekly and to report significant changes to health care professional. May cause drowsiness. Caution patient to avoid driving or other activities that require alertness until response to the drug is known. Advise patient to change positions slowly to minimize orthostatic hypotension. Caution patient that this medication may increase sensitivity to cold. Instruct patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products being taken and to consult health care professional be fore taking any Rx, OTC, or herbal products, especially cold preparations, concurrently with this medication. Patients on antihypertensive therapy should also avoid excessive amounts of coffee, tea, and cola. Diabetics should closely monitor blood glucose, especially if weakness, malaise, irritability, or fatigue occurs. Medication does not block sweating as a sign of hypoglycemia. Advise patient to notify health care professional if slow pulse, difficulty breathing, wheezing, cold hands and feet, dizziness, light-headedness, confusion, depression, rash, fever, sore throat, unusual bleeding, or bruising occurs. Instruct patient to inform health care professional of medication regimen before treatment or surgery. Advise patient to carry identification describing disease process and medication regimen at all times. Hypertension: Reinforce the need to continue additional therapies for hypertension (weight loss, sodium restriction, stress reduction, regular exercise, moderation of alcohol consumption, and smoking cessation). Medication controls but does not cure hypertension.

Trade Name/ Generic Name: Proventil (albuterol)*

Uses/Actions: Binds to beta2-adrenergic receptors in airway smooth muscle, leading to activation of adenyl cyclase and increased levels of cyclic-3, 5-adenosine monophosphate (cAMP). Increases in cAMP activate kinases, which inhibit the phosphorylation of myosin and decrease intracellular calcium. Decreased intracellular calcium relaxes smooth muscle airways. Relaxation of airway smooth muscle with subsequent bronchodilation. Relatively selective for beta2 (pulmonary) receptors. Therapeutic Effects: Bronchodilation. Contraindications: Cardiac disease; Hypertension; Hyperthyroidism; Diabetes; Glaucoma; Seizure disorders; Excess inhaler use may lead to tolerance and paradoxical bronchospasm; OB, Lactation, Pedi: Safety not established for pregnant women near term, breast-feeding women, and children less than 2 years' old. Side Effects: nervousness, restlessness, tremor, headache, insomnia (occurs more frequently in young children than adults), hyperactivity in children, paradoxical bronchospasm (excessive use of inhalers), chest pain, palpitations, angina, arrhythmias, hypertension, nausea, vomiting, hyperglycemia, and tremor. Nursing Implications: Assess lung sounds, pulse, and BP before administration and during peak of medication. Note amount, color, and character of sputum produced. Monitor pulmonary function tests before initiating therapy and periodically during therapy. Observe for paradoxical bronchospasm (wheezing). If condition occurs, withhold medication and notify health care professional immediately. Usual Dosage & Route: the usual dosage for adults and children 4 years of age and older is two inhalations repeated every 4 to 6 hours. More frequent administration or a larger number of inhalations is not recommended. In some patients, one inhalation every 4 hours may be sufficient. Each actuation of PROVENTIL HFA Inhalation Aerosol delivers 108 mcg of albuterol sulfate (equivalent to 90 mcg of albuterol base) from the mouthpiece. Proventil (albuterol sulfate) Inhalation Aerosol is supplied as a pressurized aluminum canister, with an attached dose indicator, a yellow plastic actuator and orange dust cap each in boxes of one. Each actuation delivers 120 mcg of albuterol sulfate from the valve and 108 mcg of albuterol sulfate from the mouthpiece (equivalent to 90 mcg of albuterol base). Canisters with a labeled net weight of 6.7 g contain 200 inhalations Information Patient Needs: Instruct patient to take albuterol as directed. If on a scheduled dosing regimen, take missed dose as soon as remembered, spacing remaining doses at regular intervals. Do not double doses or increase the dose or frequency of doses. Caution patient not to exceed recommended dose; may cause adverse effects, paradoxical bronchospasm (more likely with first dose from new canister), or loss of effectiveness of medication. Instruct patient to contact health care professional immediately if shortness of breath is not relieved by medication or is accompanied by diaphoresis, dizziness, palpitations, or chest pain. Instruct patient to prime unit with 4 sprays before using and to discard canister after 200 sprays.