pharmacology PEDS

GROWTH HORMONES somatropin (recombinant) (soe-ma-troe-pin) Genotropin, Humatrope, Norditropin, Nutropin, Nutropin AQ, Omnitrope, Saizen, Serostim, Tev-Tropin, Zorbtive Classification Therapeutic: hormones Pharmacologic: growth hormones Pregnancy Category B (Omnitrope, Serostim, and Zorbtive) , C (all others)

Indications: Growth failure in children due to chronic renal insufficiency. Growth failure in children due to deficiency of growth hormone. Short stature associated with Turner's syndrome. Short stature associated with or Noonan's syndrome (Norditropin only). Children with short stature born small for gestational age with no catch-up growth by age 2-4 yr (Norditropin only). Growth hormone deficiency in adults (Humatrope, Nutropin, Norditropin, Omnitrope). Idiopathic short stature syndrome (Genotropin, Humatrope, Nutropin, Nutropin AQ). AIDS wasting or cachexia (Serostim only). Increases spinal bone density in childhood-onset growth hormone-deficient patients (somatropin). As part of a comprehensive treatment program for Short Bowel Syndrome (Zorbtive). Action Produce growth (skeletal and cellular). Metabolic actions include:: Increased protein synthesis,, Increased carbohydrate metabolism,, Lipid mobilization,, Retention of sodium, phosphorus, and potassium. Somatropin has the same amino acid sequence as naturally occurring growth hormone; somatrem has 1 additional amino acid. Both are produced by recombinant DNA techniques. Growth hormone enhances GI tract mucosal transport of water, electrolytes, and nutrients. Therapeutic Effects: Increased skeletal growth in children with growth hormone deficiency. Replacement of somatropin in deficient adults. Decreased wasting in patients with AIDS. Increased bone density in adult growth hormone-deficient patients. Enhanced GI absorption of water, electrolytes and nutrients in short bowel syndrome. Pharmacokinetics Absorption: Well absorbed. Distribution: Localize to highly perfused organs (liver, kidneys). Metabolism and Excretion: Broken down in renal cells to amino acids that are recirculated; some liver metabolism. Half-life: Subcut—3.8 hr; IM—4.9 hr. TIME/ACTION PROFILE (growth) ROUTE ONSET PEAK DURATION IM, subcut within 3 mo unknown 12-48 hr Contraindications/Precautions Contraindicated in: Closure of epiphyses; Active neoplasia; Hypersensitivity to growth hormone, m-cresol or glycerin (somatropin) or benzyl alcohol (Zorbtive); Acute critical illness (therapy should not be initiated) or respiratory failure; Diabetic retinopathy; Prader-Willi syndrome with obesity and respiratory impairment (risk of fatal complications; can be used only if growth hormone deficiency is documented); OB: Use only if clearly needed. Use Cautiously in: Growth hormone deficiency due to intracranial lesion; Coexisting adrenocorticotropic hormone (ACTH) deficiency; Diabetes (may cause insulin resistance); Thyroid dysfunction; Lactation: Safety not established; Geri: ↑ sensitivity, ↑ risk of adverse reactions; use lower starting dose and smaller dose increments. Adverse Reactions/Side Effects (CAPITALS indicate life-threatening; underlines indicate most frequent.) CV: edema of the hands and feet. Endo: hyperglycemia, hypothyroidism, insulin resistance. GI: PANCREATITIS. Local: pain at injection site. MS: arthralgiaSerostim only: carpal tunnel syndrome, musculoskeletal pain. Interactions Drug-Drug: Excessive corticosteroid use (equivalent to 10-15 mg/m2/day) may ↓ response to somatropin. Route/Dosage Somatrem (Protropin) IM, Subcut (Children): Up to 0.3 mg (0.9 unit)/kg weekly; subcut route is preferred. Somatropin (Genotropin) Subcut (Children): 0.16-0.48 mg/kg/wk divided in 6-7 daily doses. Subcut (Adults): 0.04-0.8 mg/kg/wk divided in 6-7 daily doses. Somatropin (Humatrope) Subcut (Adults): 0.018 unit/kg/day (up to 0.0375 unit/kg/day). IM, Subcut (Children): 0.18 mg/kg (0.54 unit/kg)/wk given in divided doses on 3 alternating days or 6 times weekly (up to 0.3 mg/kg or 0.9 unit/kg/wk). Somatropin (Nutropin/Nutropin AQ) Subcut (Children): Growth hormone inadequacy—0.3 mg/kg. Chronic renal insufficiency—0.35 mg/kg (1.05 units/kg)/wk given as daily injections. Turner's syndrome—≤0.375 mg/kg (1.125 units/kg)/wk in 3-7 divided doses. Subcut (Adults): <0.006 mg/kg daily; may be ↑ to 0.025 mg/kg/day in patients <35 yrs or 0.0125 mg/kg in patients >35 yrs. Somatropin (Norditropin) Subcut (Adults): 0.004 mg/kg/day, may be increased to 0.016 mg/kg/day after 6 wk or 0.2 mg/day starting dose (without consideration of body weight) then gradually increase by 0.1-0.2 mg/day q 1-2 mo until clinical response achieved. Subcut (Children): Growth hormone inadequacy—0.024-0.034 mg/kg 6-7 times weekly; Short stature associated with Noonan's syndrome—Up to 0.066 mg/kg/day; Short stature associated with Turner's syndrome or short stature born small for gestational age—Up to 0.067 mg/kg/day. Somatropin (Omnitrope) Subcut (Adults): 0.04 mg/kg/wk given in 7 divided doses; may be ↑ at 4-8 wk intervals (up to 0.08 mg/kg/wk). Subcut (Children): 0.16-0.24 mg/kg/wk given in 6-7 divided doses. Somatropin (Saizen) Subcut, IM (Children): 0.06 mg (0.18 unit/kg) 3 times weekly. Somatropin (Serostim) Subcut (Adults): >55 kg—6 mg once daily; 45-55 kg—5 mg once daily; 35-45 kg—4 mg once daily; <35 kg—0.1 mg/kg once daily. Somatropin (Tev-Tropin) Subcut (Children): up to 0.1 mg/kg 3 times weekly. Somatropin (Zorbtive) Subcut (Adults): 0.1 mg/kg/day for 4 wk (not to exceed 8 mg/dose), dose may be stopped for 5 days and resumed at half dose for fluid retention or arthalgias. Availability Genotropin Powder for injection: 1.5-mg intra-mix cartridge (delivers 1.3 mg), 5.8-mg intra-mix cartridge (delivers 5 mg), 5.8-mg intra-mix cartridge (delivers 5 mg) as Pen 5 system, 13.8-mg intra-mix cartridge (delivers 12 mg), 13.8-mg intra-mix cartridge (delivers 12 mg) as Pen 12 system, MiniQuick system 0.2 mg, MiniQuick system 0.4 mg, MiniQuick system 0.6 mg, MiniQuick system 0.8 mg, MiniQuick system 1 mg, MiniQuick system 1.4 mg, MiniQuick system 1.6 mg, MiniQuick system 1.8 mg, MiniQuick system 2 mg. Humatrope Powder for injection: 5-mg/vial. Norditropin Cartridges for injection (using Nordipen): 5 mg/1.5 mL (orange), 15 mg/1.5 mL (green). Prefilled pens for injection (Nordiflex): 5 mg/1.5 mL (orange), 10 mg/1.5 mL (blue), 15 mg/1.5 mL (green), 30 mg/3 mL (purple). Prefilled pens for injection (FlexPro): 5 mg/1.5 mL (orange), 10 mg/1.5 mL (blue), 15 mg/1.5 mL (green). Nutropin Powder for injection: 5-mg (13 units)/vial, 10-mg (26 units)/vial. Nutropin AQ Solution for injection (AQ): 5 mg (15 units)/mL in 2-mL vial. Omnitrope Powder for injection: 1.5 mg/vial, 5.8 mg/vial. Cartridges for injection (using Omnitrope Pen 5 or 10): 5 mg/1.5 mL, 10 mg/1.5 mL. Saizen Powder for injection: 5-mg (15 units)/vial, 8.8-mg (26.4 units)/vial. Serostim Powder for injection: 4-mg (12 units)/vial, 5-mg (15 units)/vial, 6-mg (18 units)/vial. Tev-Tropin Powder for injection: 5-mg (15 units)/vial. Zorbtive Powder for injection: 8.8-mg multidose vials. NURSING IMPLICATIONS Assessment Assess for fluid retention (edema, arthralgia, carpal tunnel syndrome) especially in adults. May occur frequently; reduce dose as necessary. Growth Failure: Monitor bone age annually and growth rate determinations, height, and weight every 3-6 mo during therapy. AIDS Wasting/Cachexia: Re-evaluate treatment in patients who continue to lose weight in first 2 wk of treatment. Lab Test Considerations: Monitoring serum insulin-like growth factor I (IGF-I) levels may be useful during dose titration.. Monitor thyroid function prior to and during therapy. May ↓ T4, radioactive iodine uptake, and thyroxine-binding capacity. Hypothyroidism necessitates concurrent thyroid replacement for growth hormone to be effective. Serum inorganic phosphorus, alkaline phosphatase, and parathyroid hormone may ↑ with somatropin therapy.. Monitor blood glucose periodically during therapy. Diabetic patients may require ↑ insulin dose.. Monitor for development of neutralizing antibodies if growth rate does not exceed 2.5 cm/6 mo.. Monitor alkaline phosphatase closely in patients with adult growth hormone deficiency. Potential Nursing Diagnoses Disturbed body image (Indications) Implementation Rotate injection sites with each injection. Somatropin: Reconstitute 5-mg vial with 1.5-5 mL of sterile water for injection provided by manufacturer (contains preservative m-cresol), aiming the liquid against glass vial wall. Do not shake; swirl gently to dissolve. Solution is clear; do not use solutions that are cloudy or contain a precipitate. Stable for 14 days when refrigerated; do not freeze.. Genotropin intra-mix: Dissolve powder with solution provided with 2-chamber cartridge as directed. Gently tip cartridge upside down a few times until contents are completely dissolved. The 1.5-mg cartridge is stable following dilution for 24 hr if refrigerated. The 5.8-mg and 13.8-mg cartridges contain preservatives and are stable for 14 days if refrigerated.. Genotropin Pen: Prepare and administer as directed in patient instruction insert. Store in the refrigerator.. Genotropin MiniQuick: For single use only. Inject immediately after reconstitution; may be refrigerated for 24 hr after reconstitution. Follow directions on patient package insert for reconstitution and administration.. Humatrope: Reconstitute each 5-mg vial with 1.5-5 mL of diluent provided. Stable for 14 days if refrigerated.. Norditropin: Reconstitute each 4-mg or 8-mg vial with 2 mL of diluent. Use reconstituted vials within 14 days. If using cartridges for the Nordipen, each cartridge has a corresponding color-coded pen which is graduated to deliver the appropriate dose based on the concentration of norditropin in the cartridge. Color coding of cartridge and pen must match. Nordiflex prefilled pens contain multiple doses. After initial injection, use within 4 weeks if stored in refrigerator or within 3 weeks if stored at room temperature.. Nutropin/Nutropin AQ: Reconstitute 5-mg vial with 1-5 mL and 10-mg vial with 1-10 mL of bacteriostatic water for injection. Reconstituted vials are stable for 14 days (Nutropin) or 28 days (Nutropin AQ) if refrigerated.. Omnitrope Pen: Insert cartridge into corresponding Omnitrope Pen 5 delivery system. Follow instructions in booklet provided by manufacturer. Solution is light sensitive; store in carton in refrigerator for up to 21 days.. Omnitrope vials: Reconstitute with provided Sterile Water for Injection diluent. Do not shake. Do not administer solutions that are cloudy or contain a precipitate. 1.5 mg vial may be stored in refrigerator for 24 hr after reconstitution. 5.8 mg vial may be stored in carton in refrigerator up to 3 wk.. Saizen: Reconstitute each 5-mg vial with 1-3 mL of bacteriostatic water for injection. Reconstituted vials are stable for 14 days if refrigerated. To use cool.click needle-free injector, wind the device to energize the spring, and draw medication into the Crystal Check nozzle. Using firm pressure at the injection site, hold the injector at a 90° angle and press the blue actuator button.. Serostim: Reconstitute each vial with 1 mL of sterile water for injection. Use within 24 hr of reconstitution.. Tev-tropin: Reconstitute with 1-5 mL or 0.9% NaCl. May be cloudy if refrigerated. Allow to warm to room temperature. If remains solution cloudy or contains particulate matter, do not use.. Zorbtive: Reconstitute each 4-, 5-, or 6-mg vial with 0.5-1 mL of sterile water for injection and each 8.8-mg vial with 1 or 2 mL bacteriostatic water for injection. Solution should be clear upon reconstitution. Do not administer if cloudy upon reconstitution (4-, 5-, or 6-mg vials) or after refrigeration (8.8-mg vial). After refrigeration may contain small particles which should disappear when allowed to warm to room temperature. Solution reconstituted with bacteriostatic water is stable for 14 days if refrigerated. Subcut: Injection volume for somatropin should not exceed 1 mL. Patient/Family Teaching Instruct patient and parents on correct procedure for reconstituting medication, site selection, technique for IM or subcut injection, and disposal of needles and syringes. Review dose schedule. Parents should report persistent pain or edema at injection site. Explain rationale for prohibition of use for increasing athletic performance. Administration to persons without growth hormone deficiency or after epiphyseal closure may result in acromegaly (coarsening of facial features; enlarged hands, feet, and internal organs; increased blood glucose; hypertension). Emphasize need for regular follow-up with endocrinologist to ensure appropriate growth rate, to evaluate lab work, and to determine bone age by x-ray exam. Assure parents and child that these dose forms are synthetic and therefore not capable of transmitting Creutzfeldt-Jakob disease, as was the original somatropin, which was extracted from human cadavers. Evaluation/Desired Outcomes Child's attainment of adult height in growth failure secondary to pituitary growth hormone deficiency. Therapy is limited to period before closure of epiphyseal plates (approximately up to 14-15 yr in girls, 15-16 yr in boys). Failure to increase growth rate, particularly during the first year of therapy, indicates the need for close assessment of compliance and evaluation for other causes of growth failure (hypothyroidism, undernutrition, advanced bone age, antibodies to recombinant human GH). Replacement of somatropin in deficient adults. Decreased wasting in patients with AIDS. Enhanced GI absorption of water, electrolytes and nutrients in short bowel syndrome.

captopril (kap-toe-pril) Capoten Classification Therapeutic: antihypertensives Pharmacologic: ACE inhibitors Pregnancy Category C , (first trimester) , D , (second and third trimesters)

Indications Alone or with other agents in the management of hypertension. Management of heart failure. Reduction of risk of death, heart failure-related hospitalizations, and development of overt heart failure following myocardial infarction. Treatment of diabetic nephropathy in patients with Type 1 diabetes mellitus and retinopathy. Action 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. Therapeutic Effects: Lowering of BP in patients with hypertension. Improved survival and reduced symptoms in patients with heart failure. Improved survival and reduced development of overt heart failure after myocardial infarction. Decreased progression of diabetic nephropathy with decreased need for transplantation or dialysis. Pharmacokinetics Absorption: 60-75% absorbed following oral administration (decreased by food). Distribution: Crosses the placenta; enters breast milk in small amounts. Metabolism and Excretion: 50% metabolized by the liver to inactive compounds, 50% excreted unchanged in urine. Half-life: Infants with HF: 3.3 hr (range 1.2-12.4 hr); Children: 1.5 hr (range 0.98-2.3 hr); Adults: 1.9 hr (↑ to 20-40 hr in renal impairment); Adults with HF: 2.1 hr. TIME/ACTION PROFILE (effect on BP—single dose†) ROUTE ONSET PEAK DURATION PO 15-60 min 60-90 min 6-12 hr †Full effects may not be noted for several weeks Contraindications/Precautions Contraindicated in: Hypersensitivity; History of angioedema with previous use of ACE inhibitors; OB: Can cause injury or death of fetus - if pregnancy occurs, discontinue immediately; Lactation: Appears in breast milk; patient must discontinue drug or provide alternate to breast milk. Use Cautiously in: Patients with collagen vascular disease, renal impairment, hypovolemia, hyponatremia, and concurrent diuretic therapy; Surgery/anesthesia (hypotension may be exaggerated); Black patients (monotherapy for hypertension less effective, may require additional therapy; higher risk of angioedema); Women of childbearing potential; Geri: Initial dose ↓ recommended. Exercise Extreme Caution in: History of angioedema. Adverse Reactions/Side Effects (CAPITALS indicate life-threatening; underlines indicate most frequent.) CNS: dizziness, fatigue, headache, insomnia. Resp: cough . CV: hypotension, chest pain, palpitations, tachycardia. GI: taste disturbances, abdominal pain, anorexia, constipation, diarrhea, nausea, vomiting. GU: proteinuria, impaired renal function. Derm: ANGIOEDEMA, rash, pruritis. F and E hyperkalemia. Hemat: AGRANULOCYTOSIS, neutropenia. Misc: fever. Interactions Drug-Drug: Excessive hypotension may occur with concurrent use of diuretics. Additive hypotension with other antihypertensives. ↑ risk of hyperkalemia with concurrent use ofpotassium supplements, potassium-sparing diuretics, potassium-containing salt substitutes, or angiotensin II receptor antagonists. NSAIDs and selective COX-2 inhibitors may blunt the antihypertensive effect and ↑ the risk of renal dysfunction. ↑ levels and may ↑ the risk of lithium toxicity. Drug-Natural: Avoid natural licorice (causes sodium and water retention and increases potassium loss). Drug-Food: Food significantly ↓ absorption. Administer captopril 1 hr before meals. Route/Dosage Note: Use lower doses (1/2 of those listed) in patients who are sodium and water depleted due to diuretics.. Hypertension PO (Adultsand Adolescents): 12.5-25 mg 2-3 times daily, may be ↑ at 1-2 wk intervals up to 150 mg 3 times daily (initiate therapy with 6.25-12.5 mg 2-3 times daily in patients receiving diuretics). Heart Failure PO (Adults): 25 mg 3 times daily (6.25-12.5 mg 3 times daily in patients who have been vigorously diuresed); titrated up to target dose of 50 mg 3 times daily (max dose = 450 mg/day). PO (Children): 0.3 mg/kg—0.5 mg/kg/dose 3 times daily, titrate up to a maximum of 6 mg/kg/day in 2-4 divided doses; Older Children:6.25-12.5 mg/dose q 12-24 hr, titrate up to a maximum of 6 mg/kg/day in 2-4 divided doses. PO (Infants): 0.15-0.3 mg/kg/dose, titrate up to a maximum of 6 mg/kg/day in 1-4 divided doses. PO (Neonates): 0.05-0.1 mg/kg/dose q 8-24 hr, may ↑ as needed up to 0.5 mg/kg q 6-24 hr; Premature neonates: 0.01 mg/kg/dose q 8-12 hr. Left Ventricular Dysfunction Post-MI PO (Adults): 6.25-mg test dose, followed by 12.5 mg 3 times daily, may be ↑ up to 50 mg 3 times daily. Diabetic Nephropathy PO (Adults): 25 mg 3 times daily. Renal Impairment PO (Adults): ClCr 10-50 mL/min: Administer 75% of dose; ClCr < 10 mL/min: Administer 50% of dose. Availability (generic available) Tablets: 12.5 mg, 25 mg, 50 mg, 100 mg. In combination with: hydrochlorothiazide (Capozide). See Appendix B. NURSING IMPLICATIONS Assessment Hypertension: Monitor BP 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). Lab Test Considerations: Monitor renal function. May cause ↑ BUN and serum creatinine. If ↑ BUN or serum creatinine concentrations occur, may require dose reduction or withdrawal.. May cause hyperkalemia.. May cause ↑ AST, ALT, alkaline phosphatase, and serum bilirubin.. Assess urine protein prior to and periodically during therapy for up to 1 yr in patients with renal impairment or those receiving > 150 mg/day of captopril. If excessive or increasing proteinuria occurs, re-evaluate ACE inhibitor therapy.. May cause positive antinuclear antibody (ANA) titer.. Monitor CBC with differential prior to initiation of therapy, every 2 wk for the first 3 mo, and periodically for up to 1 yr in patients at risk for neutropenia (patients with renal impairment, or collagen-vascular disease) or at first sign of infection. Discontinue therapy if neutrophil count is <1000/mm3.. May cause false-positive test results for urine acetone. Potential Nursing Diagnoses Decreased cardiac output (Indications, Side Effects) Noncompliance (Patient/Family Teaching) Implementation Do not confuse captopril with carvedilol. Correct volume depletion, if possible, before initiation of therapy due to possible precipitous drop in BP during first 1-3 hr following first dose. Risk of hypotension may be decreased by discontinuing diuretics or cautiously increasing salt intake 2-3 days prior to beginning captopril. Monitor BP closely. Resume diuretics if BP is not controlled. PO: Administer 1 hr before meals or 2 hr after meals. May be crushed if patient has difficulty swallowing. Tablets may have a sulfurous odor.. An oral solution may be prepared by crushing the tablets. Patient/Family Teaching Instruct patient to take captopril 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. See Appendix M. 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. Instruct patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products being taken and consult health care professional before taking any new medications, especially cough, cold, or allergy remedies. May cause dizziness. Caution patient to avoid driving and other activities requiring alertness until response to medication is known. Advise patient to inform health care professional of medication regimen prior to treatment or surgery. Advise patient that medication may cause impairment of taste that generally resolves within 8-12 wk, even with continued therapy. Instruct patient to notify health care professional if rash; mouth sores; sore throat; fever; swelling of hands or feet; irregular heart beat; chest pain; dry cough; hoarseness; swelling of face, eyes, lips, or tongue; difficulty swallowing or breathing occurs; or if taste impairment or skin rash persists. Persistent dry cough may occur and may not subside until medication is discontinued. Consult health care professional if cough becomes bothersome. Also notify health care professional if nausea, vomiting, or diarrhea occurs and continues. Advise women of childbearing age to use contraception and notify health care professional of pregnancy is planned or suspected. Emphasize the importance of follow-up examinations to evaluate effectiveness of medication. Hypertension: Encourage patient to comply with additional interventions for hypertension (weight reduction, low sodium diet, discontinuation of smoking, moderation of alcohol consumption, regular exercise, and stress management). Medication controls but does not cure hypertension.. Instruct patient and family on correct technique for monitoring BP. Advise them to check BP at least weekly and to report significant changes to health care professional. Evaluation/Desired Outcomes Decrease in BP without appearance of excessive side effects. Improvement in survival and reduction of symptoms in heart failure. Reduction of risk of death or development of heart failure following myocardial infarction. Decrease in progression of diabetic nephropathy.

bacitracin (bas-i-tray-sin) BACiiM, Baciject, Bacitin Classification Therapeutic: anti-infectives Pharmacologic: none assigned Pregnancy Category UK See Appendix C for ophthalmic use

Indications IM: Treatment of infants with pneumonia and empyema caused by susceptible Staphylococci. Topical, Ophth: Treatment of localized infections due to susceptible organisms. Action Inhibits bacterial cell wall synthesis by preventing transfer of mucopeptides into growing cell wall. Therapeutic Effects: Bactericidal action. Spectrum: Notable for activity against: : Staphylococci, Streptococci . Pharmacokinetics Absorption: Well absorbed after IM administration. Poorly absorbed from mucous membranes. Distribution: Poor penetration into CSF. Metabolism and Excretion: 10-40% excreted in urine within 24 hr. Half-life: Unknown. TIME/ACTION PROFILE (blood levels) ROUTE ONSET PEAK DURATION IM unknown 1-2 hr unknown Contraindications/Precautions Contraindicated in: Hypersensitivity; Renal impairment. Use Cautiously in: Dehydration; OB/Lactation: Safety and effectiveness unknown. Adverse Reactions/Side Effects (CAPITALS indicate life-threatening; underlines indicate most frequent.) Derm: rash. GI: PSEUDOMEMBRANOUS COLITIS, nausea, vomiting. GU: renal failure. Local: pain at injection site. Interactions Drug-Drug: ↑ incidence of nephrotoxicity with other nephrotoxic drugs; avoid concurrent use. Route/Dosage Topical (Adults and Children): Apply 1-5 times daily. IM (Infants>2.5 kg): 1000 units/kg/day in 2-3 divided doses. IM (Infants≤2.5 kg): 900 units/kg/day in 2-3 divided doses. Availability Powder for injection (for reconstitution): 50,000 units/vial. Topical ointment: 500 units/g. NURSING IMPLICATIONS Assessment IM: Monitor signs and symptoms of infection (fever, chills, respiratory status, mucous secretions) prior to and periodically during therapy. Topical: Assess lesions prior to and periodically during therapy. Monitor bowel function. Diarrhea, abdominal cramping, fever, and bloody stools should be reported to health care professional promptly as a sign of pseudomembranous colitis. May begin up to several weeks following cessation of therapy. Lab Test Considerations: Monitor CBC periodically during therapy.. Monitor renal function prior to and daily during IM therapy. Potential Nursing Diagnoses Risk for infection (Indications) Implementation IM: Reconstitute with 0.9% NaCl containing 2% procaine hydrochloride. Do not use diluents containing parabens. Store in refrigerator.Concentration: Not less than 5,000 U/mL or more than 10,000 U/mL. Topical: Apply small amount of ointment to affected area; may be covered with a sterile bandage. Patient/Family Teaching Instruct patient to use only as long as prescribed; prolonged use may cause overgrowth of resistant organisms. Caution patient to notify health care professional if fever and diarrhea occur, especially if stool contains blood, pus, or mucus. Advise patient not to treat diarrhea without consulting health care professional. May occur up to several weeks after discontinuation of medication. Topical: Advise patient to only for use on minor cuts or burns. Do not use on animal bites, puncture wounds, serious burns, or deep cuts.. Inform patient that topical form may cause contact dermatitis or pruritus. Evaluation/Desired Outcomes Resolution of infection.

permethrin (per-meth-rin) Acticin, Elimite, Nix Classification Therapeutic: pediculocides Pregnancy Category B

Indications: 1% lotion: Eradication of Pediculus humanus capitis (head lice and their eggs):: Prevention of infestation of head lice during epidemics. 5% cream: Eradication of Sarcoptes scabiei (scabies). Contraindications/Precautions Contraindicated in: Hypersensitivity to permethrin, pyrethrins (insecticides or veterinary pesticides), chrysanthemums, or isopropyl alcohol; Lactation: Lactation. Use Cautiously in: OB: Use only if clearly needed; Pedi: Children <2 yr (1% lotion); Children <2 mo (5% cream). Adverse Reactions/Side Effects (CAPITALS indicate life-threatening; underlines indicate most frequent.) Derm: burning, itching, rash, redness, stinging, swelling. Neuro: numbness, tingling. Route/Dosage Head Lice (Treatment and Prevention) Topical (Adults and Children >2 yr): 1% lotion applied to the hair, left on for 10 min, then rinsed, for 1 application. Scabies Topical (Adults and Children): Massage 5% cream into all skin surfaces. Leave on for 8-14 hr, then wash off. Topical (Infants >2 mo): Massage 5% cream into hairline, scalp, neck, temple, and forehead. Leave on for 8-14 hr, then wash off.

deferoxamine (de-fer-ox-a-meen) Desferal Classification Therapeutic: antidotes Pharmacologic: heavy metal antagonists Pregnancy Category C

Indications: Acute toxic iron ingestion. Secondary iron overload syndromes associated with multiple transfusion therapy. Contraindications/Precautions Contraindicated in: Severe renal disease; Anuria; OB: Early pregnancy or childbearing potential (however, may be used safely in pregnant patients with moderate-to-severe acute iron intoxication). Use Cautiously in: Pedi: Children <3 yr (safety not established). Adverse Reactions/Side Effects (CAPITALS indicate life-threatening; underlines indicate most frequent.) EENT: blurred vision, cataracts, ototoxicity. CV: hypotension, tachycardia. GI: abdominal pain, diarrhea. GU: red urine. Derm: erythema, flushing, urticaria. Local: induration at injection site, pain at injection site. MS: leg cramps. Misc: allergic reactions, fever, shock after rapid IV administration. Route/Dosage Acute Iron Ingestion IM, IV (Adults and Children ≥3 yr): 1 g, then 500 mg q 4 hr for 2 doses. Additional doses of 500 mg q 4-12 hr may be needed (not to exceed 6 g/24 hr). Chronic Iron Overload IM, IV (Adults and Children ≥3 yr): 500 mg-1 g daily IM; additional doses of 2 g should be given IV for each unit of blood transfused (not to exceed 1 g/day in absence of transfusions; 6 g/day if patient receives transfusions). Subcut (Adults and Children ≥3 yr): 1-2 g/day (20-40 mg/kg/day) infused over 8-24 hr.

levalbuterol (leev-al-byoo-ter-ole) Xopenex, Xopenex HFA Classification Therapeutic: bronchodilators Pharmacologic: adrenergics Pregnancy Category C

Indications: Bronchospasm due to reversible airway disease (short-term control agent). Action R-enantiomer of racemic albuterol. Binds to beta-2 adrenergic receptors in airway smooth muscle leading to activation of adenylcyclase 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 bronchial smooth muscle. Therapeutic Effects: Relaxation of airway smooth muscle with subsequent bronchodilation. Relatively selective for beta-2 (pulmonary) receptors. Pharmacokinetics Absorption: Some absorption occurs following inhalation. Distribution: Unknown. Metabolism and Excretion: Metabolized in the liver to an inactive sulfate and 3-6% excreted unchanged in the urine. Half-life: 3.3-4 hr. TIME/ACTION PROFILE (bronchodilation) ROUTE ONSET PEAK DURATION Inhaln 10-17 min 90 min 5-6 hr Contraindications/Precautions Contraindicated in: Hypersensitivity to levalbuterol or albuterol. Use Cautiously in: Cardiovascular disorders (including coronary insufficiency, hypertension, and arrhythmias); History of seizures; Hypokalemia; Hyperthyroidism; Diabetes mellitus; Unusual sensitivity to adrenergic amines; OB/Lactation/Pedi: Pregnancy, lactation, or children <6 yr (for nebulized solution) or <4 yr (for metered-dose inhaler) (safety not established). Exercise Extreme Caution in: Concurrent use or use within 2 weeks of tricyclic antidepressants or MAO inhibitors (may ↑ risk of adverse cardiovascular reactions). Adverse Reactions/Side Effects (CAPITALS indicate life-threatening; underlines indicate most frequent.) CNS: anxiety, dizziness, headache, nervousness. Resp: PARADOXICAL BRONCHOSPASM (EXCESSIVE USE OF INHALERS), increased cough, turbinate edema. CV: tachycardia. GI: dyspepsia, vomiting. Endo: hyperglycemia. F and E hypokalemia. Neuro: tremor. Interactions Drug-Drug: Concurrent use or use within 2 weeks of tricyclic antidepressants or MAO inhibitors may ↑ risk of adverse cardiovascular reactions (use with extreme caution). Beta blockers block the beneficial pulmonary effects of adrenergic bronchodilators (choose cardioselective beta blockers if necessary and with caution). May ↑ risk of hypokalemia from potassium-losing diuretics. May ↓ serum digoxin levels. May ↑ risk of arrhythmias with hydrocarbon inhalation anesthetics or cocaine. Drug-Natural: Use with caffeine-containing herbs (guarana, tea, coffee) ↑ stimulant effect. Route/Dosage Inhaln (Adults and Children≥4 yr): 2 inhalations q 4-6 hr; some patients may respond to 1 inhalation q 4 hr. Inhaln (Adults and Children >12 yr): 0.63 mg via nebulization 3 times daily (every 6-8 hr); may be ↑ to 1.25 mg 3 times daily (every 6-8 hr). Inhaln (Children 6-11 yr): 0.31 mg via nebulization 3 times daily (not to exceed 0.63 mg 3 times daily). Availability (generic available) Metered-dose inhaler: 45 mcg/actuation in 15-g (200 metered actuations) canisters. Inhalation solution: 0.31 mg/3 mL in green foil pouch containing 12 vials, 0.63 mg/3 mL in yellow foil pouch containing 12 vials, 1.25 mg/3 mL in red foil pouch containing 12 vials, 1.25 mg/0.5 mL in unit-dose vials. NURSING IMPLICATIONS Assessment Assess lung sounds, pulse, and BP before administration and during peak of medication. Note amount, color, and character of sputum produced. Closely monitor patients on higher dose for adverse effects. Monitor pulmonary function tests before initiating therapy and periodically during course to determine effectiveness of medication. Observe for paradoxical bronchospasm (wheezing, dyspnea, tightness in chest). If condition occurs, withhold medication and notify health care provider immediately. Lab Test Considerations: May cause ↑ serum glucose and ↓ serum potassium. Potential Nursing Diagnoses Ineffective airway clearance (Indications) Implementation Inhaln: Allow at least 1 min between inhalations of aerosol medication.. For nebulization, levalbuterol solution does not require dilution prior to administration. Once the foil pouch is opened, vials must be used within 2 weeks; open vials may be stored for 1 week. Discard vial if solution is not clear or colorless. Patient/Family Teaching Instruct patient in the proper use of metered-dose inhaler and nebulizer (see Appendix D) and to take levalbuterol as directed. Caution patient not to exceed recommended dose; may cause adverse effects, paradoxical bronchospasm, or loss of effectiveness of medication. 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 or alcoholic beverages concurrently with this therapy. Caution patient also to avoid smoking and other respiratory irritants. Instruct patient to contact health care professional immediately if shortness of breath is not relieved by medication or is accompanied by diaphoresis, dizziness, palpitations, or chest pain. Advise patients to use levalbuterol first if using other inhalation medications, and allow 5 min to elapse before administering other inhalant medications unless otherwise directed. Advise patient to rinse mouth with water after each inhalation dose to minimize dry mouth. Instruct patient to notify health care professional if no response to the usual dose of levalbuterol. Evaluation/Desired Outcomes Prevention or relief of bronchospasm.

alprostadil (systemic) (al-pross-ta-dil) Prostaglandin E1, Prostin VR Pediatric, Prostin VR Classification Therapeutic: ductus arteriosus patency adjuncts Pharmacologic: prostaglandins Pregnancy Category UK

Indications: IV: Temporary maintenance of patent ductus arteriosus in neonates who depend on patency until surgery can be performed. Contraindications/Precautions Contraindicated in: Respiratory distress syndrome. Use Cautiously in: Pedi: Neonates with bleeding tendencies. Adverse Reactions/Side Effects (CAPITALS indicate life-threatening; underlines indicate most frequent.) CNS: SEIZURES, cerebral bleeding, irritability, jitteriness, lethargy. Resp: APNEA, altered respiratory rate (slow and fast), hypercapnia, respiratory depression, wheezing. CV: arrhythmia, bradycardia, edema, heart block, heart failure, hypotension, tachycardia. GI: diarrhea, gastric regurgitation, hyperbilirubinemia, peritonitis. GU: anuria, hematuria. Derm: flushing. F and E hypokalemia. Hemat: disseminated intravascular coagulation, anemia, bleeding, thrombocytopenia. Metab: hypoglycemia. MS: neck hyperextension, stiffness. Misc: fever, hypothermia, sepsis. Route/Dosage IV, IA (Neonates): 0.05-0.1 mcg/kg/min initially; may be increased up to 0.4 mcg/kg/min until satisfactory response, then decrease to maintenance dose by halving infusion rate. In some patients lower doses (0.01 mcg/kg/min) may be sufficient.

vancomycin (van-koe-mye-sin) Vancocin Classification Therapeutic: anti-infectives Pregnancy Category C

Indications: IV: Treatment of potentially life-threatening infections when less toxic anti-infectives are contraindicated. Particularly useful in staphylococcal infections, including:: Endocarditis,, Meningitis,, Osteomyelitis,, Pneumonia,, Septicemia,, Soft-tissue infections in patients who have allergies to penicillin or its derivatives or when sensitivity testing demonstrates resistance to methicillin. PO: Treatment of staphylococcal enterocolitis or pseudomembranous colitis due to Clostridium difficile. IV: Part of endocarditis prophylaxis in high-risk patients who are allergic to penicillin. Contraindications/Precautions Contraindicated in: Hypersensitivity. Use Cautiously in: Renal impairment (dosage reduction required if CCr ≤80 mL/min); Hearing impairment; Intestinal obstruction or inflammation (↑ systemic absorption when given orally); OB/Lactation: Safety not established. Adverse Reactions/Side Effects (CAPITALS indicate life-threatening; underlines indicate most frequent.) EENT: ototoxicity. CV: hypotension. GI: nausea, vomiting. GU: nephrotoxicity. Derm: rashes. Hemat: eosinophilia, leukopenia. Local: phlebitis. MS: back and neck pain. Misc: HYPERSENSITIVITY REACTIONS INCLUDING ANAPHYLAXIS, chills, fever, "red man" syndrome (with rapid infusion), superinfection. Route/Dosage Serious Systemic Infections IV (Adults): 500 mg q 6 hr or 1 g q 12 hr (up to 4 g/day). IV (Children >1 mo): 40 mg/kg/day divided q 6-8 hr Staphylococcal CNS infection—60 mg/kg/day divided q 6 hr, maximum dose: 1 g/dose. IV (Neonates 1 wk-1 mo): <1200 g: 15 mg/kg/day q 24 hr. 1200-2000 g: 10-15 mg/kg/dose q 8-12 hr. >2000 g: 15-20 mg/kg/dose q 8 hr. IV (Neonates <1 wk): <1200 g: 15 mg/kg/day q 24 hr. 1200-2000 g: 10-15 mg/kg/dose q 12-18 hr. >2000 g: 10-15 mg/kg/dose q 8-12 hr. IT (Adults): 20 mg/day. IT (Children): 5-20 mg/day. IT (Neonates): 5-10 mg/day. Endocarditis Prophylaxis in Penicillin-Allergic Patients IV (Adults and Adolescents): 1-g single dose 1-hr preprocedure. IV (Children): 20-mg/kg single dose 1-hr preprocedure. Pseudomembranous Colitis PO (Adults): 125-500 mg q 6 hr. PO (Children): 40 mg/kg/day divided q 6 hr for 7-10 days (not to exceed 2 g/day). Renal Impairment IV (Adults): An initial loading dose of 750 mg-1 g (not less than 15 mg/kg); serum level monitoring is optimal for choosing maintenance dose in patients with renal impairment; these guidelines may be helpful. CCr 50-80 mL/min—1 g q 1-3 days; CCr 10-50 mL/min—1 g q 3-7 days; CCr <10 mL/min—1 g q 7-14 days.

hydrocortisone (hye-droe-kor-ti-sone) Cortef, Cortenema, Hycort, Solu-CORTEF Classification Therapeutic: anti-inflammatories (steroidal) Pharmacologic: corticosteroids Pregnancy Category C

Indications: Management of adrenocortical insufficiency; chronic use in other situations is limited because of mineralocorticoid activity. Used systemically and locally in a wide variety of disorders including: : Inflammatory, , Allergic, , Hematologic, , Neoplastic, , Autoimmune disorders, , Septic shock. Action In pharmacologic doses, suppresses inflammation and the normal immune response. Has numerous intense metabolic effects (see Adverse Reactions and Side Effects). Suppresses adrenal function at chronic doses of 20 mg/day. Replaces endogenous cortisol in deficiency states. Also has potent mineralocorticoid (sodium-retaining) activity. Therapeutic Effects: Replacement therapy in adrenal insufficiency. Suppression of inflammation and modification of the normal immune response. Pharmacokinetics Absorption: Well absorbed following oral administration. Sodium succinate salt is rapidly absorbed following IM administration. Absorption from local sites (intra-articular, intralesional) is slow but complete. Distribution: Widely distributed, crosses the placenta, and probably enters breast milk. Metabolism and Excretion: Metabolized mostly by the liver. Half-life: 1.5-2 hr (plasma), 8-12 hr (tissue); adrenal suppression lasts 1.25-1.5 days. TIME/ACTION PROFILE (anti-inflammatory activity) ROUTE ONSET PEAK DURATION PO unknown 1-2 hr 1.25-1.5 days IM rapid 1 hr variable IV rapid unknown unknown Contraindications/Precautions Contraindicated in: Active untreated infections (may be used in patients being treated for tuberculous meningitis or septic shock); Lactation: Avoid chronic use; Known alcohol, bisulfite, or tartrazine hypersensitivity or intolerance (some products contain these and should be avoided in susceptible patients). Use Cautiously in: Chronic treatment (will lead to adrenal suppression; use lowest possible dose for shortest period of time); Pedi: Chronic use will result in ↓ growth; use lowest possible dose for shortest period of time; Hypothyroidism; Cirrhosis; Ulcerative colitis; Stress (surgery, infections); supplemental doses may be needed; Potential infections may mask signs (fever, inflammation); OB: Safety not established. Adverse Reactions/Side Effects (CAPITALS indicate life-threatening; underlines indicate most frequent.) Adverse reactions/side effects are much more common with high-dose/long-term therapy CNS: depression, euphoria, headache, ↑ intracranial pressure (children only), personality changes, psychoses, restlessness. EENT: cataracts, ↑ intraocular pressure. CV: hypertension. GI: PEPTIC ULCERATION, anorexia, nausea, vomiting. Derm: acne, ↓ wound healing, ecchymoses, fragility, hirsutism, petechiae. Endo: adrenal suppression, hyperglycemia. F and E fluid retention (long-term high doses), hypokalemia, hypokalemic alkalosis. Hemat: THROMBOEMBOLISM, thrombophlebitis. Metab: weight gain, weight loss. MS: muscle wasting, osteoporosis, avascular necrosis of joints, muscle pain. Misc: HYPERSENSITIVITY REACTIONS INCLUDING ANAPHYLAXIS, cushingoid appearance (moon face, buffalo hump), ↑ susceptibility to infection. Interactions Drug-Drug: Additive hypokalemia with thiazide and loop diuretics, or amphotericin B. Hypokalemia may ↑ the risk of digoxin toxicity. May ↑ requirement for insulin or oral hypoglycemic agents. Phenytoin,phenobarbital, and rifampin ↑ metabolism; may ↓ effectiveness. Oral contraceptives may ↓ metabolism. ↑ risk of adverse GI effects with NSAIDs (includingaspirin ). At chronic doses that suppress adrenal function, may ↓ antibody response to and ↑ risk of adverse reactions from live-virus vaccines. Route/Dosage PO (Adults and Children > 12 yr): 20-240 mg/day in 1-4 divided doses. PO (Children): Physiologic replacement—0.5-0.75 mg/kg/day or 20-25 mg/m2/day divided q 6 hr.Anti-inflammatory or immunosuppressive—2.5-10 mg/kg/day or 75-300 mg/m2/dayin 3-4 divided doses. PO (Neonates): Congenital adrenal hyperplasia—10-20 mg/m2/day in 3 divided doses. PO, IV (Neonates): Refractory hypoglycemia—5 mg/kg/day divided q 8-12 hr or 1-2 mg/kg/dose q 6 hr. Rect (Adults): Retention enema—100 mg nightly for 21 days or until remission occurs. IM, IV (Adults): 100-500 mg q 2-6 hr (range 100-8000 mg/day). IM, IV (Childrenand Infants): Adrenocortical insufficiency—1-2 mg/kg/dose bolus, then 25-250 mg/day in divided doses q 6-8 hr. Anti-inflammatory or immunosuppressive— 1-5 mg/kg/day or 30-150 mg/m2/day divided q 12-24 hr; Physiologic replacement—0.25-0.35 mg/kg/day or 12-15 mg/m2/day once daily;Shock—50 mg/kg bolus then 50 mg/kg as a 24 hr infusion. IV (Neonates): Bronchopulmonary dysplasia prevention in preterm neonates with prenatal inflammatory exposure- 1 mg/kg/day divided q 12 hr during the first 2 weeks of life; Refractory hypotension—3 mg/kg/day divided q 8 hr x 5 days. Availability (generic available) Tablets: 5 mg, 10 mg, 20 mg. Enema: 100 mg/60 mL. Powder for injection (sodium succinate): 100 mg/vial, 250 mg/vial, 500 mg/vial, 1 g/vial. NURSING IMPLICATIONS Assessment Indicated for many conditions. Assess involved systems prior to and periodically during therapy. Assess patient for signs of adrenal insufficiency (hypotension, weight loss, weakness, nausea, vomiting, anorexia, lethargy, confusion, restlessness) prior to and periodically during therapy. Monitor intake and output ratios and daily weights. Observe patient for peripheral edema, steady weight gain, rales/crackles, or dyspnea. Notify health care professional should these occur. Children should have periodic evaluations of growth. Rect: Assess symptoms of ulcerative colitis (diarrhea, bleeding, weight loss, anorexia, fever, leukocytosis) periodically during therapy. Lab Test Considerations: Systemic—Monitor serum electrolytes and glucose. May cause hyperglycemia, especially in persons with diabetes. May cause hypokalemia. Monitor hematologic values, serum electrolytes, and serum and urine glucose routinely in patients on prolonged therapy. May cause ↓ WBC counts. May cause ↓ serum potassium and calcium and ↑ serum sodium concentrations.. Guaiac test stools. Promptly report presence of guaiac-positive stools.. May cause elevated serum cholesterol and lipid values. May cause ↓ uptake of thyroid 123I or 131I.. Suppresses reactions to allergy skin tests.. Periodic adrenal function tests may be ordered to assess degree of hypothalamic-pituitary-adrenal axis suppression in systemic and chronic topical therapy. Potential Nursing Diagnoses Risk for infection (Side Effects) Disturbed body image (Side Effects) Implementation Do not confuse hydrocortisone with hydrocodone. Do not confuse Solu-Cortef with Solu-Medrol (methylprednisolone).. If dose is ordered daily or every other day, administer in the morning to coincide with the body's normal secretion of cortisol. Periods of stress, such as surgery, may require supplemental systemic corticosteroids. PO: Administer with meals to minimize GI irritation.. Tablets may be crushed and administered with food or fluids for patients with difficulty swallowing. IM: IM doses should not be administered when rapid effect is desirable. Do not dilute with other solution or admix. IV Administration pH: 7.0-8.0. Direct IV: Reconstitute with provided solution (i.e., Act-O-Vials) or 2 mL of bacteriostatic water or saline for injection. Rate: Administer each 100 mg over at least 30 sec. Doses ≥500 mg should be infused over at least 10 min. Intermittent Infusion: Diluent: May be added to 50-1000 mL of D5W or 0.9% NaCl. Concentration: Usual 1-5 mg/mL. Adults who are fluid restricted may received up to 60 mg/mL. Rate: Administer over 20-30 min Y-Site Compatibility: acyclovir, alemtuzumab, alfentanil, allopurinol, amifostine, amikacin, aminocaproic acid, aminophylline, amphotericin B cholesteryl, amphotericin B lipid complex, amphotericin B liposome, amsacrine, anidulafungin, argatroban, ascorbic acid, atracurium, atropine, aztreonam, benztropine, bivalirudin, bleomycin, bumetanide, buprenorphine, butorphanol, carboplatin, carmustine, caspofungin, cefazolin, cefepime, cefoperazone, cefotaxime, cefotetan, cefoxitin, ceftaroline, ceftazidime, ceftriaxone, cefuroxime, chloramphenicol, chlorpromazine, cisatracurium, cisplatin, cladribine, clindamycin, cyanocobalamin, cytarabine, clindamycin, cyanocobalamin, cyclophosphamide, cyclosporine, cytarabine, dactinomycin, daptomycin, dexamethasone, dexmedetomidine, digoxin, docetaxel, dopamine, doripenem, doxacurium, doxorubicin hydrochloride, doxorubicin liposome, droperidol, edrophonium, enalaprilat, ephedrine, epinephrine, epirubicin, epoetin alfa, eptifibitide, ertapenem, erythromycin, etoposide, famotidine, fenoldopam, fentanyl, filgrastim, fluconazole, fludarabine, fluorouracil, folic acid, foscarnet, furosemide, gemcitabine, glycopyrrolate, granisetron, heparin, hetastarch, hydromorphone, ifosfamide, imiepnem/cilastatin, indomethacin, insulin, irinotecan, isoproterenol, kanamycin, ketamine, ketorolac, levofloxacin, lidocaine, linezolid, lorazepam, mannitol, mechlorethamine, melphalan, metaraminol, methotrexate, methoxamine, methyldopate, methylergonovine, metoclopramide, metoprolol, metronidazole, milrinone, mitoxantrone, morphine, multivitamins, nafcillin, naloxone, neostigmine, nesiritide, nicardipine, nitroglycerin, nitroprusside, norepinephrine, octreotide, ondansetron, oxacillin, oxaliplatin, oxytocin, paclitaxel, palonosetron, pamidronate, pancuronium, pantoprazole, pemetrexed, penicillin G, pentobarbital, phenobarbital, phentolamine, phenylephrine, phytonadione, piperacillin/tazobactam, potassium acetate, potassium chloride, procainamide, prochlorperazine, propofol, propranolol, pyridostigmine, ranitidine, remifentanil, rituximab, scopolamine, sodium acetate, sodium bicarbonate, streptokinase, succinylcholine, sufentanil, tacrolimus, telavancin, teniposide, theophylline, thiotepa, ticarcillin/clavulanate, tigecycline, tirofiban, trastuzumab, trimetaphan, vasopressin, vecuronium, verapamil, vincristine, vinorelbine, voriconazole, zoledronic acid Y-Site Incompatibility: amphotericin B colloidal, azathioprine, calcium chloride, ciprofloxacin, dacarbazine, dantrolene, diazepam, diazoxide, dobutamine, doxycycline, ganciclovir, haloperidol, idarubicin, labetalol, mycophenolate, nalbuphine, pentamidine, phenytoin, protamine, pyridoxime, quinapristin/dalfopristin, rocuronium, sargramostim, thiamine, trimethoprim/sulfamethoxazole Rect: Position patient on left side and administer nightly for 21 days. Enema should be retained for at least 1 hr and preferrably all night. May use sedatives and antidiarrheals to facilitate retention. Patient/Family Teaching Instruct patient on correct technique of medication administration. Advise patient to take medication as directed. Take missed doses as soon as remembered unless almost time for next dose. Do not double doses. Stopping the medication suddenly may result in adrenal insufficiency (anorexia, nausea, weakness, fatigue, dyspnea, hypotension, hypoglycemia). If these signs appear, notify health care professional immediately. This can be life-threatening.. Corticosteroids cause immunosuppression and may mask symptoms of infection. Instruct patient to avoid people with known contagious illnesses and to report possible infections immediately. Caution patient to avoid vaccinations without first consulting health care professional. Review side effects with patient. Instruct patient to inform health care professional promptly if severe abdominal pain or tarry stools occur. Patient should also report unusual swelling, weight gain, tiredness, bone pain, bruising, nonhealing sores, visual disturbances, or behavior changes. Advise patient to notify health care professional of medication regimen prior to treatment or surgery. Discuss possible effects on body image. Explore coping mechanisms. Instruct patient to inform health care professional if symptoms of underlying disease return or worsen. Advise patient to carry identification describing disease process and medication regimen in the event of emergency in which patient cannot relate medical history. Explain need for continued medical follow-up to assess effectiveness and possible side effects of medication. Periodic lab tests and eye exams may be needed. Long-term Therapy: Encourage patient to eat a diet high in protein, calcium, and potassium, and low in sodium and carbohydrates (see Appendix M). Alcohol should be avoided during therapy.. If rectal dose used >21 days, decrease to every other night for 2-3 weeks to decrease gradually. Evaluation/Desired Outcomes Decrease in presenting symptoms with minimal systemic side effects. Suppression of the inflammatory and immune responses in autoimmune disorders, allergic reactions, and neoplasms. Management of symptoms in adrenal insufficiency. Improvement in symptoms of ulcerative colitis. Clinical symptoms usually improve in 3-5 days. Mucosal appearance may require 2-3 mo to improve.

clindamycin (klin-da-mye-sin) Cleocin, Cleocin T, Clinda-Derm, Clindagel, Clindesse, Clindets, Dalacin C, Dalacin T, Evoclin Classification Therapeutic: anti-infectives Pregnancy Category B

Indications: PO, IM, IV: Treatment of:: Skin and skin structure infections,, Respiratory tract infections,, Septicemia,, Intra-abdominal infections,, Gynecologic infections,, Osteomyelitis,, Endocarditis prophylaxis. Topical: Severe acne. Vag: Bacterial vaginosis. Unlabelled Use: PO, IM, IV: Treatment of Pneumocystis carinii pneumonia, CNS toxoplasmosis, and babesiosis. Contraindications/Precautions Contraindicated in: Hypersensitivity; Previous pseudomembranous colitis; Severe liver impairment; Diarrhea; Known alcohol intolerance (topical solution, suspension). Use Cautiously in: OB: Safety not established for systemic and topical; approved for vaginal use in 3rd trimester of pregnancy; Lactation: Has been used safely but appears in breast milk and exposes infant to drug and its side effects. Adverse Reactions/Side Effects (CAPITALS indicate life-threatening; underlines indicate most frequent.) CNS: dizziness, headache, vertigo. CV: arrhythmias, hypotension. GI: PSEUDOMEMBRANOUS COLITIS, diarrhea, bitter taste (IV only), nausea, vomiting. Derm: rashes. Local: phlebitis at IV site. Route/Dosage PO (Adults): Most infections—150-450 mg q 6 hr. P. carinii pneumonia—1200-1800 mg/day in divided doses with 15-30 mg Primaquine/day (unlabeled). CNS toxoplasmosis—1200-2400 mg/day in divided doses with pyrimethamine 50-100 mg/day (unlabeled); Bacterial endocarditis prophylaxis—600 mg 1 hr before procedure. PO (Children>1 mo): 10-30 mg/kg/day divided q 6-8 hr; maximum dose 1.8 g/day. Bacterial endocarditis prophylaxis—20 mg/kg 1 hr before procedure. IM, IV (Adults): Most infections—300-600 mg q 6-8 hr or 900 mg q 8 hr (up to 4.8 g/day IV has been used; single IM doses of >600 mg are not recommended). P. carinii pneumonia—2400-2700 mg/day in divided doses with Primaquine (unlabeled). Toxoplasmosis—1200-4800 mg/day in divided doses with pyrimethamine. Bacterial endocarditis prophylaxis—600 mg 30 min before procedure. IM, IV (Children >1 mo): 25-40 mg/kg/day divided q 6-8 hr; maximum dose: 4.8 g/day. Bacterial endocarditis prophylaxis—20 mg/kg 30 min before procedure; maximum dose: 600 mg. IM, IV (Infants <1 mo and <2 kg): 5 mg/kg q 8-12 hr ≥2 kg—20-30 mg/kg/day divided q 6-8 hr. Vag (Adults and Adolescents): Cleocin, Clindamax—1 applicatorful (5 g) at bedtime for 3 or 7 days (7 days in pregnant patients); Clindesse—one applicatorful (5 g) single dose; or 1 suppository (100 mg) at bedtime for 3 nights. Topical (Adults and Adolescents): Solution—1% solution/suspension applied twice daily (range 1-4 times daily). Foam, gel—1% foam or gel applied once daily.

desmopressin (des-moe-press-in) DDAVP, DDAVP Rhinal Tube, DDAVP Rhinyle Drops, Stimate Classification Therapeutic: hormones Pharmacologic: antidiuretic hormones Pregnancy Category B

Indications: PO, Subcut, IV, Intranasal: Treatment of central diabetes insipidus caused by a deficiency of vasopressin. IV, Intranasal: Controls bleeding in certain types of hemophilia and von Willebrand's disease. PO: Primary nocturnal enuresis. Contraindications/Precautions Contraindicated in: Hypersensitivity; Hypersensitivity to chlorobutanol; Patients with severe type I, type IIB or platelet-type (pseudo) von Willebrand's disease, hemophilia A with factor VIII levels <5% or hemophilia B; Renal impairment (CCr < 50 mL/min); Hyponatremia. Use Cautiously in: Angina pectoris; Hypertension; Patients at risk for hyponatremia; OB/Lactation: Safety not established. Adverse Reactions/Side Effects (CAPITALS indicate life-threatening; underlines indicate most frequent.) CNS: SEIZURES, drowsiness, headache, listlessness. EENT: intranasal: nasal congestion, rhinitis. Resp: dyspnea. CV: hypertension, hypotension, tachycardia (large IV doses only). GI: mild abdominal cramps, nausea. GU: vulval pain. Derm: flushing. F and E water intoxication/hyponatremia. Local: phlebitis at IV site. Route/Dosage Primary Nocturnal Enuresis PO (Adults and Children≥6 yr): 0.2 mg at bedtime; may be titrated up to 0.6 mg at bedtime to achieve desired response. Diabetes Insipidus PO (Adults and Children): 0.05 mg twice daily; adjusted as needed (usual range: 0.1-1.2 mg/day for adults or 0.1-0.8 mg/day for children in 2-3 divided doses). Intranasal (Adultsand Children ≥ 12 yr): DDAVP-5-40 mcg (0.0.05-0.4 mL)in 1-3 divided doses. Intranasal (Children 3 mo-12 yr): DDAVP-5-30 mcg (0.05-0.3 mL) in 1-2 divided doses. Subcut, IV (Adults and Children≥12 yr): 2-4 mcg/day in 2 divided doses. Subcut, IV (Children< 12 yr): 0.1-1 mcg/day in 1-2 divided doses. Hemophilia A/von Willebrand's disease Intranasal (Adults and Children>50 kg): Stimate—1 spray (150 mcg) in each nostril. Intranasal (Adults and Children≤50 kg): Stimate—1 spray (150 mcg) in one nostril. IV (Adults and Children >3 mo): 0.3 mcg/kg, repeated as needed.

IRON SUPPLEMENTS carbonyl iron (100%), (kar-bo-nil eye-ern) Feosol, Icar ferrous fumarate (33% elemental iron), (fer-us fyoo-ma-rate) Femiron, Feostat, Fumasorb, Fumerin, Hemocyte, Neo-Fer, Nephro-Fer, Novofumar, Palafer, Span-FF ferrous gluconate (12% elemental iron), (fer-us gloo-koe-nate) Apo-Ferrous Gluconate, Fergon, Ferralet, Fertinic, Novoferrogluc, Simron ferrous sulfate (30% elemental iron), (fer-us sul-fate) Apo-Ferrous Sulfate, ED-IN-SOL, Fe50, Feosol, Feratab, Fer-gen-sol, Fer-In-Sol, Fer-Iron, Fero-Grad, Novoferrosulfa, PMS Ferrous Sulfate, Slow FE iron dextran (eye-ern dex-tran) DexFerrum, InFeD iron polysaccharide (eye-ern poll-ee-sak-a-ride) Hytinic, Niferex, Nu-Iron iron sucrose (eye-ern su-krose) Venofer sodium ferric gluconate complex (so-dee-yum ferr-ic gloo-ko-nate) Ferrlecit Classification Therapeutic: antianemics Pharmacologic: iron supplements Pregnancy Category A (ferrous gluconate, ferrous sulfate, iron polysaccharide) , B (sodium ferric gluconate, iron sucrose) , C (iron dextran)

Indications: PO: Prevention/treatment of iron-deficiency anemia. IM, IV: Iron dextran—Treatment of iron-deficiency anemia in patients who cannot tolerate or receive oral iron. Sodium ferric gluconate complex—Treatment of iron deficiency in patients undergoing chronic hemodialysis or peritoneal dialysis who are concurrently receiving erythropoietin. Treatment of iron-deficiency anemia in patients with chronic kidney disease including patients who are not on dialysis (with or without erythropoietin) and patients dependent on dialysis (with erythropoietin). Action An essential mineral found in hemoglobin, myoglobin, and many enzymes. Enters the bloodstream and is transported to the organs of the reticuloendothelial system (liver, spleen, bone marrow), where it is separated out and becomes part of iron stores. Therapeutic Effects: Prevention/treatment of iron deficiency. Pharmacokinetics Absorption: 5-10% of dietary iron is absorbed (up to 30% in deficiency states). Therapeutically administered PO iron may be 60% absorbed via an active and passive transport process. Well absorbed following IM administration. Distribution: Remains in the body for many months. Crosses the placenta; enters breast milk. Protein Binding: ≥90%. Metabolism and Excretion: Mostly recycled; small daily losses occurring via desquamation, sweat, urine, and bile. Half-life: Iron dextran, iron sucrose—6 hr. TIME/ACTION PROFILE (effects on erythropoiesis) ROUTE ONSET PEAK DURATION PO 4 days 7-10 days 2-4 mo IM, IV 4 days 1-2 wk wk-mos Contraindications/Precautions Contraindicated in: Hemochromatosis, hemosiderosis, or other evidence of iron overload; Anemias not due to iron deficiency; Some products contain alcohol, tartrazine, or sulfites and should be avoided in patients with known intolerance or hypersensitivity. Use Cautiously in: Peptic ulcer; Ulcerative colitis or regional enteritis (condition may be aggravated); Alcoholism; Severe hepatic impairment; Severe renal impairment (oral products); Pre-existing cardiovascular disease (iron dextran) (may be exacerbated by adverse reactions to this drug); Significant allergies or asthma (iron dextran); History of drug allergy or multiple drug allergies (iron dextran) (may be at ↑ risk for anaphylactic reaction); Rheumatoid arthritis (iron dextran) (may have exacerbation of joint swelling); OB/Lactation: Pregnancy or lactation (safety of some parenteral products not established); Pedi: Safety not established for infants <4 mo (iron dextran) or children <6 yr (sodium ferric gluconate complex); safety may not be established for other products in the pediatric population. Adverse Reactions/Side Effects (CAPITALS indicate life-threatening; underlines indicate most frequent.) CNS: IM, IV: SEIZURES, dizziness, headache, syncope. CV: IM, IV: hypotension, hypertension, tachycardia. GI: nausea PO: constipation, dark stools, diarrhea, epigastric pain, GI bleedingIM, IV: taste disorder, vomiting. Derm: IM, IV: flushing, urticaria. Resp: IV: cough, dyspnea. Local: pain at IM site (iron dextran), phlebitis at IV site, skin staining at IM site (iron dextran). MS: IM, IV: arthralgia, myalgia. Misc: PO: staining of teeth (liquid preparations)IM, IV: ALLERGIC REACTIONS INCLUDING ANAPHYLAXIS, fever, lymphadenopathy, sweating. Interactions Drug-Drug: Oral iron supplements ↓ absorption of tetracyclines, bisphosphonates, fluoroquinolones, levothyroxine, mycophenolate mofetil, and penicillamine (simultaneous administration should be avoided). ↓ absorption of and may ↓ effects of levodopa and methyldopa. Concurrent administration of H2 antagonists, proton pump inhibitors, and cholestyramine may ↓ absorption of iron. Doses of ascorbic acid ≥200 mg may ↑ absorption of iron up to ≥30%. Chloramphenicol and vitamin E may ↓ hematologic response to iron therapy. ACE inhibitors may ↑ risk of anaphylactic reaction with iron dextran. Drug-Food: Iron absorption is ↓ 33-50% by concurrent administration of food. Route/Dosage Oral Iron Dosage for Iron Deficiency (expressed as mg elemental iron, note individual salt forms, multiple ones exist—see approximate equivalent doses below for dose conversions). Approximate Equivalent Doses (mg of iron salt): Ferrous fumarate—197; Ferrous gluconate—560; Ferrous sulfate—324; Ferrous sulfate, exsiccated—217. PO (Adults): Deficiency—120—240 mg/day (2-3 mg/kg/day) in 2-4 divided doses. Prophylaxis—60-100 mg/day. PO (Infantsand Children): Severe deficiency—4-6 mg/kg/day in 3 divided doses. Mild to moderate deficiency—3 mg/kg/day in 1-2 divided doses. Prophylaxis—1-2 mg/kg/day in 1-2 divided dose (maximum: 15 mg/day). PO (Neonates, premature): 2-4 mg/kg/day in 1-2 divided doses, maximum: 15 mg/day. Iron Dextran IM, IV (Adults and Children): Test dose of 0.5 mL (25 mg) is given 1 hr prior to therapy. IM, IV (Infants): Test dose of 0.25 mL (12.5 mg) is given 1 hr prior to therapy. IM, IV (Adults and Children >15 kg): Iron deficiency—Total dose (mL) = 0.0442 ×(desired Hgb− actual Hgb) × lean body weight (kg) + [0.26 × lean body weight (kg)]. Divided up and given in small daily doses until total is reached; not to exceed 100 mg/day. Total dose IV infusion—Total dose may be diluted and infused over 4-5 hr following a test dose of 10 drops (unlabeled). IM, IV (Adults): Blood loss—Dose (mL) = (Blood loss [mL] × hematocrit) × 0.02. IM, IV (Children 5-15 kg): Iron deficiency—Total dose (mL) = 0.042 (desried Hgb− actual Hgb) × weight (kg) + [0.26 × weight (kg)]. Divided up and given in small daily doses until total is reached; not to exceed 25 mg/day in children <5 kg; 50 mg/day in children 5-10 kg; or 100 mg/day in children > 10 kg. Iron Polysaccharide Complex PO (Adults): 50-100 mg twice daily of tablets/elixir or 150-300 mg/day of the capsules. PO (Children >6yr): 50-100 mg/day (may be given in divided doses). PO (Infants): 1-2 mg/kg/day. PO (Adults—Pregnant Women): 30-60 mg/day. Iron Sucrose IV (Adults): Hemodialysis dependent patients—100 mg (5 mL) during each dialysis session for 10 doses (total of 1000 mg) additional smaller doses may be necessary; Peritoneal dialysis dependent patients—300 mg (15 mL) infusion, followed by another 300 mg (15 mL) infusion 14 days later, followed by 400 mg (20 mL) infusion 14 days later; Non-dialysis dependent patients—200 mg (10 mL) on 5 different days within a 14 day period to a total of 1000 mg, may also be given as infusion of 500 mg on day 1 and day 14. Sodium Ferric Gluconate Complex IV (Adults): 10 mL (125 mg elemental iron) repeated during 8 sequential dialysis treatments to a total cumulative dose of 1 g. IV (Children >6 yr): 0.12 mL/kg (not to exceed 125 mg/dose) repeated during 8 sequential dialysis treatments. Availability Carbonyl Iron (100% Iron) Tablets: 50 mgOTC. Oral suspension: 15 mg/1.25 mLOTC. Ferrous Fumarate (33% Elemental Iron) (generic available) Tablets: 63 mgOTC, 195 mgOTC, 200 mgOTC, 324 mgOTC, 325 mgOTC. Chewable tablets: 100 mgOTC. Controlled-release capsules: 325 mgOTC. Suspension (butterscotch flavor): 100 mg/5 mLOTC, 300 mg/5 mLOTC. Drops: 45 mg/0.6 mLOTC, 60 mg/1 mLOTC. Ferrous Gluconate (11.6% Elemental Iron) (generic available) Tablets: 300 mgOTC, 320 mgOTC, 325 mgOTC. Sustained-release tablets: 320 mgOTC. Soft gelatin capsules: 86 mgOTC. Elixir: 300 mg/5 mLOTC. Syrup: 300 mg/5 mLOTC. Ferrous Sulfate (20-30% Elemental Iron) Tablets: 195 mgOTC, 300 mgOTC, 325 mgOTC. Capsules: 150 mgOTC, 250 mgOTC. Timed-release tablets: 525 mgOTC. Syrup: 90 mg/5 mLOTC. Elixir: 220 mg/5 mLOTC. Drops: 75 mg/0.6 mLOTC, 125 mg/1 mLOTC. Iron Dextran Injection: 50 mg/mL. Iron Polysaccharide (mg Iron) Capsules: 150 mgOTC. Elixir: 100 mg/5 mLOTC. Tablets: 50 mgOTC. Iron Sucrose Aqueous complex for injection: 20 mg/mL. Sodium Ferric Gluconate Complex (generic available) Injection: 62.5 mg/5 mL. NURSING IMPLICATIONS Assessment Assess nutritional status and dietary history to determine possible cause of anemia and need for patient teaching. Assess bowel function for constipation or diarrhea. Notify health care professional and use appropriate nursing measures should these occur. Iron Dextran, Iron Sucrose, and Sodium Ferric Gluconate Complex: Monitor BP and heart rate frequently following IV administration until stable. Rapid infusion rate may cause hypotension and flushing. Assess patient for signs and symptoms of anaphylaxis (rash, pruritus, laryngeal edema, wheezing) for at least 30 min following injection. Notify health care professional immediately if these occur. Keep epinephrine and resuscitation equipment close by in the event of an anaphylactic reaction. Lab Test Considerations: Monitor hemoglobin, hematocrit, and reticulocyte values prior to and every 3 wk during the first 2 mo of therapy and periodically thereafter. Serum ferritin and iron levels may also be monitored to assess effectiveness of therapy.. Occult blood in stools may be obscured by black coloration of iron in stool. Guaiac test results may occasionally be false-positive.. Iron Dextran: Monitor hemoglobin, hematocrit, reticulocyte values, transferrin, ferritin, total iron-binding capacity, and plasma iron concentrations periodically during therapy. Serum ferritin levels peak in 7-9 days and return to normal in 3 wk. Serum iron determinations may be inaccurate for 1-2 wk after therapy with large doses; therefore, hemoglobin and hematocrit are used to gauge initial response.. May impart a brownish hue to blood drawn within 4 hr of administration. May cause false ↑ in serum bilirubin and false decrease in serum calcium values.. Prolonged PTT may be calculated when blood sample is anticoagulated with citrate dextrose solution; use sodium citrate instead.. Iron Sucrose: Monitor hemoglobin, hematocrit, serum ferritin, and transferritin saturation prior to and periodically during therapy. Transferrin saturation values increase rapidly after IV administration; therefore, serum iron values may be reliably obtained 48 hr after IV administration. Withhold iron therapy if evidence of iron overload occurs.. May cause ↑ liver enzymes. Toxicity and Overdose: Early symptoms of overdose include stomach pain, fever, nausea, vomiting (may contain blood), and diarrhea. Late symptoms include bluish lips, fingernails, and palms; drowsiness; weakness; tachycardia; seizures; metabolic acidosis; hepatic injury; and cardiovascular collapse. Patient may appear to recover prior to the onset of late symptoms. Hospitalization continues for 24 hr after patient becomes asymptomatic to monitor for delayed onset of shock or GI bleeding. Late complications of overdose include intestinal obstruction, pyloric stenosis, and gastric scarring.. If patient is comatose or seizing, gastric lavage with sodium bicarbonate is performed. Deferoxamine is the antidote. Additional supportive treatments to maintain fluid and electrolyte balance and correction of metabolic acidosis are also indicated.. If signs of overdose occur during IV administration of iron sucrose, treatment includes IV fluids, corticosteroids, and/or antihistamines. Administering at a slower rate usually relieves symptoms. Potential Nursing Diagnoses Activity intolerance (Indications) Implementation Discontinue oral iron preparations prior to parenteral administration.. Sodium ferric gluconate and iron sucrose are for IV use only. PO: Oral preparations are most effectively absorbed if administered 1 hr before or 2 hr after meals. If gastric irritation occurs, administer with meals. Take tablets and capsules with a full glass of water or juice. Do not crush or chew enteric-coated tablets and do not open capsules.. Liquid preparations may stain teeth. Dilute in water or fruit juice, full glass (240 mL) for adults and 1/2 glass (120 mL) for children, and administer with a straw or place drops at back of throat.. Avoid using antacids, coffee, tea, dairy products, eggs, or whole-grain breads with or within 1 hr after administration of ferrous salts. Iron absorption is decreased by 33% if iron and calcium are given with meals. If calcium supplementation is needed, calcium carbonate does not decrease absorption of iron salts if supplements are administered between meals. Iron Dextran: The 2-mL ampule may be used for IM or IV administration.. Prior to initial IM or IV dose, a test dose of 25 mg should be given by the same route as the dose will be given, to determine reaction. The IV test dose should be administered over 5 min. The IM dose should be administered in the same injection site and by same technique as the therapeutic dose. The remaining portion may be administered after 1 hr, if no adverse symptoms have occurred. IM: Inject deeply via Z-track technique into upper outer quadrant of buttock, never into arm or other exposed areas. Use a 2-3 in., 19- or 20-gauge needle. Change needles between withdrawal from container and injection to minimize staining of subcut tissues. Stains are usually permanent. IV Administration IV: Iron Dextran: Following IV administration, patient should remain recumbent for at least 30 min to prevent orthostatic hypotension. Direct IV: Diluent: May administer undiluted or dilute in 0.9% NaCl or D5W.Concentration: 50 mg/mL. Rate: Administer slowly at a rate of 50 mg (1 mL) over at least 1 min. Intermittent Infusion: May be diluted in 200-1000 mL of 0.9% NaCl or D5W; 0.9% NaCl is the preferred diluent; dilution in D5W increases incidence of pain and phlebitis. Rate: Administer over 1-6 hr following a test dose of 10 drops/min for 10 min. Flush line with 10 mL of 0.9% NaCl at completion of infusion. Y-Site Incompatibility: Discontinue other IV solutions during infusion. Additive Incompatibility: Manufacturers recommend that iron dextran not be mixed with other solutions; however, iron dextran has been added to total parenteral nutrition solutions. Sodium Ferric Gluconate Complex: Diluent: Dilute test dose in 50 mL of 0.9% NaCl and administer IV over 60 min.Concentration: 12.5 mg/mL.. To administer therapeutic dose of 10 mL (125 mg of elemental iron) dilute in 100 mL of 0.9% NaCl. Dialysis patients frequently require a cumulative dose of 1 g of elemental iron, administered over 8 sessions of sequential dialysis. Rate: Administer at a maximum rate of 12.5 mg/min. Iron Sucrose: Each 5-mL vial contains 100 mg of elemental iron.. Hemodialysis—Most patients require a minimum cumulative dose of 1000 mg of elemental iron, administered over 10 sequential dialysis sessions, to achieve a favorable hemoglobin or hematocrit response.. Solution is brown. Inspect for particulate matter or discoloration. Do not administer solutions that contain particulate matter or are discolored. Direct IV: May be administered undiluted by slow injection into dialysis line. Rate: Administer at a rate of 1 mL undiluted solution per minute, not to exceed one vial per injection. Discard any unused portion. Intermittent Infusion: May also be administered via infusion, into dialysis line for hemodialysis patients. May reduce risk of hypotensive episodes. Diluent: Each vial must be diluted in a maximum of 100 mL of 0.9% NaCl immediately prior to infusion. Unused diluted solution should be discarded.Concentration: 1-2 mg/mL. Rate: Infuse at a rate of 100 mg of iron over at least 15 min, large doses (500 mg) should be given over 3.5-4 hr. Intermittent Infusion: For Peritoneal Dialysis Patients—Diluent: Dilute each dose in a maximum of 250 mL of 0.9% NaCl. Rate: Administer doses of 300 mg over 1.5 hr and doses of 400 mg over 2.5 hr. Direct IV: For Non-dialysis dependent patients—May be administered as a slow injection of 200 mg undiluted. Rate: Administer over 2-5 min. Intermittent Infusion: Dilute 500 mg in 250 mL 0.9% NaCl. Rate: Infuse over 3.5-4 hr on days 1 and 14. May cause hypotension; monitor closely. Additive Incompatibility: Do not mix iron sucrose with other medications or add to parenteral nutrition solutions for IV infusion. Patient/Family Teaching Explain purpose of iron therapy to patient. Encourage patient to comply with medication regimen. Take missed doses as soon as remembered within 12 hr; otherwise, return to regular dosing schedule. Do not double doses. Advise patient that stools may become dark green or black and that this change is harmless. Instruct patient to follow a diet high in iron (see Appendix M). Discuss with parents the risk of children's overdosing on iron. Medication should be stored in the original childproof container and kept out of reach of children. Do not refer to vitamins as candy. In the event of a suspected overdose, parents or guardians should contact the poison control center (1-800-222-1222) or emergency medical services (911) immediately. Iron Dextran: Delayed reaction may occur 1-2 days after administration and last 3-4 days if IV route used, 3-7 days with IM route. Instruct patient to contact physician if fever, chills, malaise, muscle and joint aches, nausea, vomiting, dizziness, and backache occur. Iron sucrose and sodium ferric gluconate complex: Instruct patient to immediately report symptoms of hypersensitivity reaction to health care professional. Evaluation/Desired Outcomes Increase in hemoglobin, which may reach normal parameters after 1-2 mo of therapy. May require 3-6 mo for normalization of body iron stores. Improvement in iron deficiency anemia or anemia of chronic renal failure.

baclofen (bak-loe-fen) Gablofen, Lioresal Classification Therapeutic: antispasticity agents, skeletal muscle relaxants (centrally acting) Pregnancy Category C

Indications: PO: Treatment of reversible spasticity due to multiple sclerosis or spinal cord lesions. IT: Treatment of severe spasticity of cerebral or spinal origin (should be reserved for patients who do not respond or are intolerant to oral baclofen) (should wait at least one year in patients with traumatic brain injury before considering therapy). Unlabelled Use: Management of pain in trigeminal neuralgia. Action Inhibits reflexes at the spinal level. Therapeutic Effects: Decreased muscle spasticity; bowel and bladder function may also be improved. Pharmacokinetics Absorption: Well absorbed after oral administration. Distribution: Widely distributed; crosses the placenta. Metabolism and Excretion: 70-80% eliminated unchanged by the kidneys. Half-life: 2.5-4 hr. TIME/ACTION PROFILE (effects on spasticity) ROUTE ONSET PEAK DURATION PO hr-wk unknown unknown IT 0.5-1 hr 4 hr 4-8 hr Contraindications/Precautions Contraindicated in: Hypersensitivity. Use Cautiously in: Patients in whom spasticity maintains posture and balance; Patients with epilepsy (may ↓ seizure threshold); Renal impairment (↓ dose may be required); OB/Lactation: Safety not established; Pedi: Children <12 yr (oral) or <4 yr (intrathecal) (safety not established); Geri: Geriatric patients are at ↑ risk of CNS side effects. Adverse Reactions/Side Effects (CAPITALS indicate life-threatening; underlines indicate most frequent.) 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. Interactions Drug-Drug: ↑ CNS depression with other CNS depressants including alcohol, antihistamines, opioid analgesics, and sedative/hypnotics. Use with MAO inhibitors may lead to ↑ CNS depression or hypotension. Drug-Natural: Concomitant use of kava-kava, valerian, or chamomile can ↑ CNS depression. Route/Dosage PO (Adults): 5 mg 3 times daily. May increase q 3 days by 5 mg/dose up to 80 mg/day (some patients may have a better response to 4 divided doses). IT (Adults): 100-800 mcg/day infusion; dose is determined by response during screening phase. IT (Children≥4 yr): 25-1200 mcg/day infusion (average 275 mcg/day); dose is determined by response during screening phase. Availability (generic available) Tablets: 10 mg, 20 mg. Intrathecal injection: 50 mcg/mL, 500 mcg/mL, 2000 mcg/mL. NURSING IMPLICATIONS Assessment Assess muscle spasticity before and periodically during therapy.. Observe patient for drowsiness, dizziness, or ataxia. May be alleviated by a change in dose. IT: Monitor patient closely during test dose and titration. Resuscitative equipment should be immediately available for life-threatening or intolerable side effects. Lab Test Considerations: May cause ↑ in serum glucose, alkaline phosphatase, AST, and ALT levels. Potential Nursing Diagnoses Impaired wheelchair mobility (Indications) Risk for injury (Adverse Reactions) Implementation PO: Administer with milk or food to minimize gastric irritation. IT: For screening phase, dilute for a concentration of 50 mcg/mL with sterile preservative-free NaCl for injection. Test dose should be administered over at least 1 min. Observe patient for a significant decrease in muscle tone or frequency or severity of spasm. If response is inadequate, 2 additional test doses, each 24 hr apart, 75 mcg/1.5 mL and 100 mcg/2 mL respectively, may be administered. Patients with an inadequate response should not receive chronic IT therapy.. Dose titration for implantable IT pumps is based on patient response. If no substantive response after dose increase, check pump function and catheter patency. Patient/Family Teaching Instruct patient to take baclofen as directed. Take a missed dose within 1 hr; do not double doses. Caution patient to avoid abrupt withdrawal of this medication because it may precipitate an acute withdrawal reaction (hallucinations, increased spasticity, seizures, mental changes, restlessness). Discontinue baclofen gradually over 2 wk or more. May cause dizziness and drowsiness. Advise patient to avoid driving or other activities requiring alertness until response to drug is known. Instruct patient to change positions slowly to minimize orthostatic hypotension. Advise patient to avoid concurrent use of alcohol or other CNS depressants while taking this medication. Instruct patient to notify health care professional if frequent urge to urinate or painful urination, constipation, nausea, headache, insomnia, tinnitus, depression, or confusion persists. Advise patient to report signs and symptoms of hypersensitivity (rash, itching) promptly. IT: Caution patient and caregiver not to discontinue IT therapy abruptly. May result in fever, mental status changes, exaggerated rebound spasticity, and muscle rigidity. Advise patient not to miss scheduled refill appointments and to notify health care professional promptly if signs of withdrawal occur. Evaluation/Desired Outcomes Decrease in muscle spasticity and associated musculoskeletal pain with an increased ability to perform activities of daily living. Decreased pain in patients with trigeminal neuralgia. May take weeks to obtain optimal effect.

pancrelipase (pan-kre-li-pase) Creon, Pancreaze, Zenpep Classification Therapeutic: digestive agent Pharmacologic: pancreatic enzymes Pregnancy Category C

Indications: Pancreatic insufficiency associated with:: Chronic pancreatitis,, Pancreatectomy,, Cystic fibrosis,, GI bypass surgery,, Ductal obstruction secondary to tumor. Contraindications/Precautions Contraindicated in: Hypersensitivity to hog proteins. Use Cautiously in: Gout, renal impairment, or hyperuricemia (may ↑ uric acid levels); OB/Lactation: Safety not established. Adverse Reactions/Side Effects (CAPITALS indicate life-threatening; underlines indicate most frequent.) EENT: nasal stuffiness. Resp: dyspnea, shortness of breath, wheezing. GI: FIBROSING COLONOPATHY (HIGH DOSES ONLY), abdominal pain (high doses only), diarrhea, nausea, stomach cramps, oral irritation. GU: hematuria. Derm: hives, rash. Metab: hyperuricemia. Misc: allergic reactions. Route/Dosage PO (Adults and Children≥4 yr): Initiate with 500 lipase units/kg/meal; dose should be adjusted based on weight, clinical symptoms, and stool fat content; maximum dose = 2500 lipase units/kg/meal (or 10,000 lipase units/kg/day). PO (Children>1 yr and <4 yr): Initiate with 1000 lipase units/kg/meal; dose should be adjusted based on weight, clinical symptoms, and stool fat content; maximum dose = 2500 lipase units/kg/meal (or 10,000 lipase units/kg/day). PO (Children≤1 yr): 2000-4000 lipase units per 120 mL of formula or breast milk.

filgrastim (fil-gra-stim) Neupogen, G-CSF, granulocyte colony stimulating factor Classification Therapeutic: colony-stimulating factors Pregnancy Category C

Indications: Prevention of febrile neutropenia and associated infection in patients who have received bone marrow-depressing antineoplastics for the treatment of nonmyeloid malignancies. Reduction of time for neutrophil recovery and duration of fever in patients undergoing induction and consolidation chemotherapy for acute myelogenous leukemia. Reduction of time to neutrophil recovery and sequelae of neutropenia in patients with nonmyeloid malignancies undergoing myeloablative chemotherapy followed by bone marrow transplantation. Mobilization of hematopoietic progenitor cells into peripheral blood for collection by leukapheresis. Management of severe chronic neutropenia. Unlabelled Use: Neutropenia associated with HIV infection. Neonatal neutropenia. Contraindications/Precautions Contraindicated in: Hypersensitivity to filgrastim or Escherichia coli-derived proteins. Use Cautiously in: Malignancy with myeloid characteristics; Pre-existing cardiac disease; OB: Use only if potential benefit justifies potential risk to fetus; Lactation: Unlikely to adversely affect breastfed infant. Adverse Reactions/Side Effects (CAPITALS indicate life-threatening; underlines indicate most frequent.) Hemat: excessive leukocytosis. Local: pain, redness at subcut site. MS: medullary bone pain. Route/Dosage After Myelosuppressive Chemotherapy IV, Subcut (Adultsand Children): 5 mcg/kg/day as a single injection daily for up to 2 wk. Dosage may be increased by 5 mcg/kg during each cycle of chemotherapy, depending on blood counts. After Bone Marrow Transplantation IV, Subcut (Adults): 10 mcg/kg/day as a 4- or 24-hr IV infusion or as a continuous subcut infusion; initiate at least 24 hr after chemotherapy and at least 24 hr after bone marrow transplantation. Subsequent dosage is adjusted according to blood counts. Peripheral Blood Progenitor Cell Collection and Therapy Subcut (Adults): 10 mcg/kg/day as a bolus or continuous infusion for at least 4 days before first leukapheresis and continued until last leukapheresis; dosage modification suggested if WBC >100,000 cells/mm3. Severe Chronic Neutropenia Subcut (Adults): Congenital neutropenia—6 mcg/kg twice daily. Idiopathic/cyclical neutropenia—5 mcg/kg daily (decrease if ANC remains >10,000/mm3). Neonatal neutropenia IV, Subcut (Neonates): 5-10 mcg/kg/day once daily for 3-5 days.

lidocaine/prilocaine (lye-doe-kane/pri-loe-kane) EMLA, Oraqix Classification Therapeutic: anesthetics (topical/local) Pregnancy Category B

Indications: Produces local anesthesia prior to minor painful procedures including:: Insertion of cannulae or needles,, Arterial/venous/lumbar puncture,, Intramuscular injections,, Subcutaneous injections,, Dermal procedures,, Laser treatments,, Circumcision. When applied to genital mucous membranes in preparation for superficial minor surgery or as preparation for infiltration anesthesia. Produces localized anesthesia in periodontal pockets during scaling and/or root planing (Oraqix only). Contraindications/Precautions Contraindicated in: Hypersensitivity to lidocaine, prilocaine, or any other amide-type local anesthetic; Hypersensitivity to any other product in the formulation; Should not be applied to middle ear, mucous membranes, or broken/inflamed skin; Pedi: Congenital or idiopathic methemoglobinemia; Infants <1 mo if gestational age is <37 weeks; Infants <12 mo receiving methemoglobin-inducing agents. Use Cautiously in: Repeated use or use on large areas of skin (more likely to result in systemic absorption); Acutely ill, or debilitated patients (↑ risk of absorption and systemic effects); Severe liver disease; Any conditions associated with methemoglobinemia (including glucose-6-phosphate dehydrogenase deficiency); OB: Use only if clearly needed; Lactation: Usually compatible with breastfeeding (AAP); Pedi: Area/duration of treatment should be limited in neonates and children <20 kg or 37 weeks gestation (↑ susceptibility to methemoglobinemia); Geri: May have ↑ absorption and risk of systemic effects. Adverse Reactions/Side Effects (CAPITALS indicate life-threatening; underlines indicate most frequent.) Local: blanching, redness, alteration in temperature sensation, edema, itching, rash, hyperpigmentation. Misc: ALLERGIC REACTIONS INCLUDING ANAPHYLAXIS. Route/Dosage EMLA Topical (Adults and Children): Minor dermal procedures including venipuncture and IV cannulation—2.5 g (½ of the 5-g tube) applied to 20-25 cm2 (2 in. by 2 in") area of skin, covered with an occlusive dressing applied for at least 1 hr. Major dermal procedures including split-thickness skin graft harvesting—2 g/10 cm2 area of skin, covered with an occlusive dressing for at least 2 hr. Adult male genital skin—as an adjunct prior to local anesthetic infiltration, apply a thick layer (1 g/10 cm2) to skin surface for 15 min; local infiltration anesthesia should be performed immediately after removal of cream. Adult female genital mucous membranes—apply a thick layer (5-log) for 5-10 min. Topical (Children 7-12 yr and >20 kg): Dose should not exceed 20 g over more than 200 cm2 for more than 4 hr. Topical (Children 1-6 yr and >10 kg): Dose should not exceed 10 g over more than 100 cm2 for more than 4 hr. Topical (Children 3 mo-12 mo and >5 kg): Dose should not exceed 2 g over more than 20 cm2 for more than 4 hr. Topical (Children 0-3 mo or <5 kg): Dose should not exceed 1 g over more than 10 cm2 for more than 1 hr. Oraqix Topical (Adults): Apply on gingival margin around the selected teeth using the blunt-tipped applicator included in package; wait 30 seconds, then fill the periodontal pockets with gel using the blunt-tipped applicator until the gel becomes visible at the gingival margin; wait another 30 seconds before starting treatment; maximum recommended dose at one treatment session is 5 cartridges (8.5 g).

naloxone (nal-ox-one) Narcan Classification Therapeutic: antidotes (for opioids) Pharmacologic: opioid antagonists Pregnancy Category B

Indications: Reversal of CNS depression and respiratory depression because of suspected opioid overdose. Unlabelled Use: Opioid-induced pruritus (low dose IV infusion). Management of refractory circulatory shock. Contraindications/Precautions Contraindicated in: Hypersensitivity. Use Cautiously in: Cardiovascular disease; Patients physically dependent on opioids (may precipitate severe withdrawal); OB: May cause acute withdrawal syndrome in mother and fetus if mother is opioid dependent; Lactation: Safety not established; Pedi: May cause acute withdrawal syndrome in neonates of opioid-dependent mothers. Adverse Reactions/Side Effects (CAPITALS indicate life-threatening; underlines indicate most frequent.) CV: VENTRICULAR ARRHYTHMIAS, hypertension, hypotension. GI: nausea, vomiting. Route/Dosage Postoperative Opioid-Induced Respiratory Depression IV (Adults): 0.02-0.2 mg q 2-3 min until response obtained; repeat q 1-2 hr if needed. IV (Children): 0.01 mg/kg; may repeat q 2-3 min until response obtained. Additional doses may be given q 1-2 hr if needed. IM, IV, Subcut (Neonates): 0.01 mg/kg; may repeat q 2-3 min until response obtained. Additional doses may be given q 1-2 hr if needed. Opioid-Induced Respiratory Depression During Chronic (>1 wk) Opioid Use IV, IM, Subcut (Adults >40 kg): 20-40 mcg (0.02-0.04 mg) given as small, frequent (q min) boluses or as an infusion titrated to improve respiratory function without reversing analgesia. IV, IM, Subcut (Adults and Children <40 kg): 0.005-0.02 mg/dose given as small, frequent (q min) boluses or as an infusion titrated to improve respiratory function without reversing analgesia. Overdose of Opioids IV, IM, Subcut (Adults): Patients not suspected of being opioid dependent—0.4 mg (10 mcg/kg); may repeat q 2-3 min (IV route is preferred). Some patients may require up to 2 mg. Patients suspected to be opioid dependent—Initial dose should be ↓ to 0.1-0.2 mg q 2-3 min. May also be given by IV infusion at rate adjusted to patient's response. IV, IM, Subcut (Children> 5 yr or > 20 kg): 2 mg/dose, may repeat q 2-3 min. IV, IM, Subcut (Infantsup to 5 yr or 20 kg): 0.1 mg/kg, may repeat q 2-3 min. Opioid-Induced Pruritus IV (Children): 2 mcg/kg/hr continuous infusion, may ↑ by 0.5 mcg/kg/hr every few hours if pruritus continues.

pimecrolimus (pi-me-cro-li-mus) Elidel Classification Therapeutic: immunosuppressants (topical)

Indications: Short-term and intermittent long-term management of mild to moderate atopic dermatitis unresponsive to or in patients intolerant of conventional treatment. Action Inhibits T-cell and mast cell activation by interfering with production of inflammatory cytokines. Therapeutic Effects: Decreased severity of atopic dermatatis. Pharmacokinetics Absorption: Minimally absorbed through intact skin. Distribution: Local distribution after topical administration. Metabolism and Excretion: Systemic metabolism and excretion is negligible with local application. Half-life: Not applicable. TIME/ACTION PROFILE (improvement in symptoms) ROUTE ONSET PEAK DURATION topical within 6 days unknown unknown Contraindications/Precautions Contraindicated in: Hypersensitivity; Should not be applied to areas of active cutaneous viral infections (↑ risk of dissemination); Concurrent use of occlusive dressings; Netherton's syndrome (↑ absorption of pimecrolimus); Lactation: Discontinue breastfeeding. Use Cautiously in: Possible risk of cancer. Do not use as first-line therapy; Clinical infection at treatment site (infection should be treated/cleared prior to use); Skin papillomas (warts); allow treatment/resolution prior to use; Natural/artificial sunlight (minimize exposure); OB: Use only if clearly needed; Pedi: Children <2 yr (safety not established); use only if other treatments have failed. Adverse Reactions/Side Effects (CAPITALS indicate life-threatening; underlines indicate most frequent.) Local: burning. Misc: ↑ risk of lymphoma/skin cancer. Interactions Drug-Drug: None significant as systemic absorption is negligible. Route/Dosage Topical (Adults and Children≥2 yr): Apply thin film twice daily; rub in gently and completely. Availability Cream: 1%. NURSING IMPLICATIONS Assessment Assess skin lesions prior to and periodically during therapy. Discontinue therapy after signs and symptoms of atopic dermatitis have resolved. Resume treatment at the first signs and symptoms of recurrence. Potential Nursing Diagnoses Impaired skin integrity (Indications) Implementation Topical: Apply a thin layer to affected area twice daily and rub in gently and completely. May be used on all skin areas including head, neck, and intertriginous areas. Do not use with occlusive dressings. Patient/Family Teaching Instruct patient on correct technique for application. Apply only as directed to external areas. Wash hands following application, unless hands are areas of application. Advise patient to read Medication Guide before starting and with each Rx refill in case of changes. Caution patient to avoid exposure to natural or artificial sunlight, including tanning beds, while using cream. Advise patient that pimecrolimus may cause skin burning. This occurs most commonly during first few days of application, is of mild to moderate severity, and improves within 5 days or as atopic dermatitis resolves. Advise patient to notify health care provider if no improvement is seen following 6 wk of treatment or at any time if condition worsens. Evaluation/Desired Outcomes Resolution of signs and symptoms of atopic dermatitis.

ranitidine (ra-ni-ti-deen) Acid Reducer, Zantac, Zantac EFFERdose, Zantac 75, Zantac 150 Classification Therapeutic: antiulcer agents Pharmacologic: histamine H2 antagonists Pregnancy Category B

Indications: Short-term treatment of active duodenal ulcers and benign gastric ulcers. Maintentance therapy for duodenal and gastric ulcers after healing of active ulcer(s). Management of gastric hypersecretory states (Zollinger-Ellison syndrome). Treatment of and maintenace therapy for erosive esophagitis. Treatment of gastroesophageal reflux disease (GERD). Heartburn, acid indigestion, and sour stomach (OTC use). IV: Prevention and treatment of stress-induced upper GI bleeding in critically ill patients. Action Inhibits the action of histamine at the H2-receptor site located primarily in gastric parietal cells, resulting in inhibition of gastric acid secretion. Therapeutic Effects: Healing and prevention of ulcers. Decreased symptoms of gastroesophageal reflux. Decreased secretion of gastric acid. Pharmacokinetics Absorption: 50% absorbed after PO administration. Distribution: Enters breast milk and cerebrospinal fluid. Metabolism and Excretion: Metabolized by the liver, mostly on first pass; 30% excreted unchanged by the kidneys after parenteral administration. Half-life: Neonates (on ECMO): 6.6 hr; Infants: 3.5 hr; Children: 1.8-2 hr; Adults: 2-2.5 hr (↑ in renal impairment to 4.8 hr). TIME/ACTION PROFILE ROUTE ONSET PEAK DURATION PO unknown 1-3 hr 8-12 hr IM unknown 15 min 8-12 hr IV unknown 15 min 8-12 hr Contraindications/Precautions Contraindicated in: Hypersensitivity; Syrup contains alcohol and should be avoided in patients with known intolerance. Use Cautiously in: Phenylketonuric patients (effervescent tablets and granules contain phenylalanine); Geri: Geriatric patients are more susceptible to adverse CNS reactions including dizziness and confusion; dosage ↓ recommended; Renal impairment (more susceptible to adverse CNS reactions; ↑ dose interval recommended if CCr <50 mL/min); Hepatic impairment; Acute porphyria (may precipitate an attack); OB: Pregnancy; Lactation: Passes into breast milk and can cause ↓ stomach acid in the infant. Adverse Reactions/Side Effects (CAPITALS indicate life-threatening; underlines indicate most frequent.) CNS: confusion, dizziness, drowsiness, hallucinations, headache. CV: ARRHYTHMIAS. GI: constipation, diarrhea, nausea. GU: ↓ sperm count, erectile dysfunction. Endo: gynecomastia. Hemat: AGRANULOCYTOSIS, APLASTIC ANEMIA, anemia, neutropenia, thrombocytopenia. Local: pain at IM site. Misc: hypersensivity reactions, vasculitis. Interactions Drug-Drug: May ↓ absorption of ketoconazole, itraconazole, atazanavir, delavirdine, and geftinib. May ↑ absorption of triazolam and glipizide. May ↑ procainamide levels. May ↑ the effects of warfarin. Route/Dosage PO (Adults): Short-term treatment of active ulcers—150 mg twice daily or 300 mg once daily at bedtime. Duodenal ulcer prophylaxis—150 mg once daily at bedtime. GERD—150 mg twice daily. Erosive esophagitis—150 mg 4 times daily initially, then 150 mg twice daily as maintenance.Gastric hypersecretory conditions—150 mg twice daily initially; up to 6 g/day have been used. OTC use—75 mg when symptoms occur (up to twice daily). PO (Children1 mo-16 yr): Treatment of active ulcers—2-4 mg/kg/day divided twice daily, maximum 300 mg/day. GERD and Erosive esophagitis—4-10 mg/kg/day divided twice daily, maximum 300 mg/day for GERD, 600 mg/day for erosive esophagitis. PO (Neonates): 2 mg/kg/day divided q 12 hr. IV, IM (Adults): 50 mg q 6-8 hr (not to exceed 400 mg/day). Continuous IV infusion—6.25 mg/hr. Gastric hypersecretory conditions—1 mg/kg/hr; may be ↑ by 0.5 mg/kg/hr (not to exceed 2.5 mg/kg/hr). IV, IM (Children1 mo—16 yr): Treatment of active ulcers—2-4 mg/kg/day divided q 6-8 hr, maximum 200 mg/day.Continuous infusion—1 mg/kg/dose followed by 0.08-0.17 mg/kg/hr. IV (Neonates): 1.5 mg/kg/dose load, then in 12 hr start maintenance of 1.5-2 mg/kg/day divided q 12 hr Continuous IV infusion-1.5 mg/kg/dose load followed by 0.04-0.08 mg/kg/hr infusion. Renal Impairment PO (Adults): CCr10-50 mL/min—↓ dose to 50% of dose recommended for indication; CCr<10 mL/min—↓ dose to 25% of dose recommended for indication; further reductions may be necessary if there is coexistent hepatic impairment. Availability (generic available) Tablets: 75 mgOTC, 150 mg, 300 mg. Effervescent tablets (EFFERdose): 25 mg, 150 mg. Capsules: 150 mg, 300 mg. Syrup (peppermint flavor): 15 mg/mL. Solution for injection: 25 mg/mL. Premixed infusion: 50 mg/50 mL 0.45% NaCl. NURSING IMPLICATIONS Assessment Assess patient for epigastric or abdominal pain and frank or occult blood in the stool, emesis, or gastric aspirate. Assess geriatric and debilitated patients routinely for confusion. Lab Test Considerations: CBC with differential should be monitored periodically during therapy.. Antagonizes effects of pentagastrin and histamine during gastric acid secretion testing. Avoid administration for 24 hr preceding the test.. May cause false-negative results in skin tests using allergenic extracts. Histamine antagonists should be discontinued 24 hr before the test.. May cause an ↑ in serum transaminases and serum creatinine.. May cause false-positive results for urine protein; test with sulfosalicylic acid. Potential Nursing Diagnoses Acute pain (Indications) Implementation Do not confuse Zantac (ranitidine) with Xanax (alprazolam) or Zyrtec (cetirizine).. If antacids or sucralfate are used concurrently for relief of pain, avoid administration of antacids within 30 min-1 hr of ranitidine and take sucralfate 2 hr after ranitidine; may decrease the absorption of ranitidine. PO: Administer with meals or immediately afterward and at bedtime to prolong effect.. Doses administered once daily should be administered at bedtime to prolong effect.. Shake oral suspension before administration. Discard unused suspension after 30 days.. Remove foil from ranitidine effervescent tablets or granules and dissolve in 6-8 oz water before drinking. IV Administration pH: 6.7-7.3. Direct IV: Diluent: Dilute each 50 mg in 20 mL of 0.9% NaCl or D5W for injection. Concentration: 2.5 mg/mL. Rate: Administer over at least 5 min at a maximum of 10 mg/min. Rapid administration may cause hypotension and arrhythmias. Intermittent Infusion: Diluent: Dilute each 50 mg in 100 mL of 0.9% NaCl or D5W. Diluted solution is stable for 48 hr at room temperature. Do not use solution that is discolored or that contains precipitate. Concentration: 0.5 mg/mL. Rate: Administer over 15-20 min. Continuous Infusion: Diluent: D5W. Concentration: 150 mg/250 mL (no greater than 2.5 mg/mL for Zollinger-Ellison patients). Rate: Administer at a rate of 6.25 mg/hr. In patients with Zollinger-Ellison syndrome, start infusion at 1 mg/kg/hr. If gastric acid output is >10 mEq/hr or patient becomes symptomatic after 4 hr, adjust dose by 0.5 mg/kg/hr increments and remeasure gastric output. Y-Site Compatibility: acyclovir, aldesleukin, alfentanil, allopurinol, amifostine, amikacin, aminocaproic acid, aminophylline, amphotericin B lipid complex, amphotericin B liposome, amsacrine, anikinra, anidulafungin, argatroban, ascorbic acid, atracurium, atropine, aztreonam, benztropine, bivalirudin, bleomycin, bumetanide, buprenorphine, butorphanol, calcium chloride, calcium gluconate, carboplatin, carmustine, cefazolin, cefepime, cefoperazone, cefotaxime, cefotetan, cefoxitin, ceftaroline, ceftazidime, ceftriaxone, cefuroxime, chloramphenicol, chlorpromazine, ciprofloxacin, cisatracurium, cisplatin, cladribine, clindamycin, cyanocobalamin, cyclophosphamide, cyclosporine, cytarabine, dactinomycin, daptomycin, dexamethasone, dexmedetomidine, digoxin, diltiazem, diphenhydramine, dobutamine, docetaxel, dopamine, doripenem, doxacurium, doxapram, doxorubicin hydrochloride, doxorubicin liposome, doxycycline, enalaprilat, ephedrine, epinephrine, epirubicin, epoetin alfa, eptifibatide, ertapenem, erythromycin, esmolol, etoposide, etoposide phosphate, famotidine, fenoldopam, fentanyl, filgrastim, fluconazole, fludarabine, fluorouacil, folic acid, foscarnet, furosemide, ganciclovir, gemcitabine, gentamicin, glycopyrrolate, granisetron, heparin, hydrocortisone, hydromorphone, idarubicin, ifosfamide, imipenem/cilastatin, indomethacin, irinotecan, isoproterenol, ketamine, ketorolac, labetalol, levofloxacin, lidocaine, linezolid, lorazepam, magnesium sulfate, mannitol, mechlorethamine, melphalan, meperidine, metaraminol, methotrexate, methoxamine, methyldopate, methylprednisolone, metoclopramide, metoprolol, metronidazole, midazolam, milrinone, mitoxantrone, morphine, multivitamins, mycophenolate, nafcillin, nalbuphine, naloxone, nesiritide, nicardipine, nitroglycerin, nitroprusside, norepinephrine, octreotide, ondansetron, oxacillin, oxaliplatin, oxytocin, paclitaxel, palonosetron, pamidronate, pancuronium, papaverine, pemetrexed, penicillin G, pentamidine, pentazocine, pentobarbital, phenobarbital, phentolamine, phenylephrine, phytonadione, piperacillin/tazobactam, potassium acetate, potassium chloride, procainamide, prochlorperazine, promethazine, propofol, propranolol, protamine, pyridoxime, remifentanil, rituximab, rocuronium, sargramostim, sodium acetate, sodium bicarbonate, strepotkinase, succinylcholine, sufentanil, tacrolimus, telavancin, teniposide, theophylline, thiamine, thiopental, thiotepa, ticarcillin/clavulanate, tigecycline, tirofiban, tobramycin, tolazoline, trastuzumab, trimetaphan, vancomycin, vasopressin, vecuronium, verapamil, vincristine, vinorelbine, warfarin, zidovudine, zoledronic acid Y-Site Incompatibility: amphotericin B cholesteryl, caspofungin, dantrolene, diazepam, diazoxide, pantoprazole, phenytoin, quinupristin/dalfopristin, trimethoprim/sulfamethoxazole Patient/Family Teaching Instruct patient to take medication as directed for the full course of therapy, even if feeling better. Take missed doses as soon as remembered but not if almost time for next dose. Do not double doses.. Advise patients taking OTC preparations not to take the maximum dose continuously for more than 2 wk without consulting health care professional. Notify health care professional if difficulty swallowing occurs or abdominal pain persists. Inform patient that smoking interferes with the action of histamine antagonists. Encourage patient to quit smoking or at least not to smoke after last dose of the day. May cause drowsiness or dizziness. Caution patient to avoid driving or other activities requiring alertness until response to the drug is known. Advise patient to avoid alcohol, products containing aspirin or NSAIDs, excessive amounts of caffeine, and foods that may cause an increase in GI irritation. Inform patient that increased fluid and fiber intake and exercise may minimize constipation. Advise patient to report onset of black, tarry stools; fever; sore throat; diarrhea; dizziness; rash; confusion; or hallucinations to health care professional promptly. Evaluation/Desired Outcomes Decrease in abdominal pain. Prevention of gastric irritation and bleeding. Healing of duodenal ulcers can be seen by x-rays or endoscopy. Therapy is continued for at least 6 wk in treatment of ulcers but not usually longer than 8 wk. Decreased symptoms of esophageal reflux.

dextromethorphan (dex-troe-meth-or-fan) Balminil DM, Benylin Adult, Benylin Pediatric, Broncho-Grippol-DM, Calmylin #1, Children's Hold, Creo-Terpin, Delsym, DexAlone, DM Syrup, Drixoral Liquid Cough Caps, ElixSure Children's Cough Syrup, Hold, Koffex, Little Colds Cough Formula Drops, Mediquell, Neo-DM, Ornex·DM, PediCare Infant's Long Acting Cough Drops, Pertussin Cough Suppressant, Pertussin CS, Pertussin ES, Robidex, Robitussin Cough Calmers, Robitussin CoughGels, Robitussin Maximum Strength Cough Suppressant, Robitussin Pediatric, Sedatuss, Simply Cough, Sucrets Cough Control Formula, TheraFlu Thin Strips Long Acting Cough, Triaminic Thin Strips Long Acting Cough, Vicks 44 Cough Relief, Vicks Formula 44 Pediatric Formula Classification Therapeutic: allergy, cold, and cough remedies, antitussives Pregnancy Category C

Indications: Symptomatic relief of coughs caused by minor viral upper respiratory tract infections or inhaled irritants. Most effective for chronic nonproductive cough. A common ingredient in nonprescription cough and cold preparations. Contraindications/Precautions Contraindicated in: Hypersensitivity; Patients taking MAO inhibitors or SSRIs; Should not be used for chronic productive coughs; Some products contain alcohol and should be avoided in patients with known intolerance. Use Cautiously in: Cough that lasts more than 1 wk or is accompanied by fever, rash, or headache—health care professional should be consulted; History of drug abuse or drug-seeking behavior (capsules have been abused resulting in deaths); Diabetes (some products contain sucrose); OB: Pregnancy (has been used safely); Lactation: Lactation; Pedi: Children <4 yr (OTC cough and cold products containing this medication should be avoided). Adverse Reactions/Side Effects (CAPITALS indicate life-threatening; underlines indicate most frequent.) CNS: high dose—dizziness, sedation. GI: nausea. Route/Dosage PO (Adults and Children >12 yr): 10-20 mg q 4 hr or 30 mg q 6-8 hr or 60 mg of extended-release preparation bid (not to exceed 120 mg/day). PO (Children 6-12 yr): 5-10 mg q 4 hr or 15 mg q 6-8 hr or 30 mg of extended-release preparation q 12 hr (not to exceed 60 mg/day). PO (Children 4-6 yr): 2.5-5 mg q 4 hr or 7.5 mg q 6-8 hr or 15 mg of extended-release preparation q 12 hr (not to exceed 30 mg/day).

mupirocin (myoo-peer-oh-sin) Bactroban, Bactroban Nasal Classification Therapeutic: anti-infectives Pregnancy Category B

Indications: Topical: Treatment of:: Impetigo,, Secondarily infected traumatic skin lesions (up to 10 cm in length or 100 cm2 area) caused by Staphylococcus aureus and Streptococcus pyogenes. Intranasal: Eradicates nasal colonization with methicillin-resistant S. aureus. Action Inhibits bacterial protein synthesis. Therapeutic Effects: Inhibition of bacterial growth and reproduction. Spectrum: Greatest activity against gram-positive organisms, including:: S. aureus,, Beta-hemolytic streptococci. Resolution of impetigo. Eradication of S. aureus carrier state. Pharmacokinetics Absorption: Minimal systemic absorption. Distribution: Remains in the stratum corneum after topical use for prolonged periods of time (72 hr). Metabolism and Excretion: Metabolized in the skin, removed by desquamation. Half-life: 17-36 min. TIME/ACTION PROFILE (anti-infective effect) ROUTE ONSET PEAK DURATION Nasal unknown unknown 12 hr Topical† unknown 3-5 days 72 hr †Resolution of lesions Contraindications/Precautions Contraindicated in: Hypersensitivity to mupirocin or polyethylene glycol. Use Cautiously in: Renal impairment; Burn patients; OB/Lactation: Safety not established. Adverse Reactions/Side Effects (CAPITALS indicate life-threatening; underlines indicate most frequent.) CNS: nasal only: headache. EENT: nasal only: cough, itching, pharyngitis, rhinitis, upper respiratory tract congestion. GI: nausea nasal only: altered taste. Derm: topical only: burning, itching, pain, stinging. Interactions Drug-Drug: Nasal mupirocin should not be used concurrently with other nasal products. Route/Dosage Topical (Adults and Children ≥2 mo): Ointment: Apply 3-5 times daily for 5-14 days. Topical (Adults and Children≥3 mo): Cream: Apply small amount 3 times/day for 10 days. Intranasal (Adults and Children ≥1 yr): Apply small amount nasal ointment to each nostril 2-4 times/day for 5-14 days. Availability (generic available) Ointment: 2% Cost: Generic-- $37.99/22 g. Cream: 2% Cost: $64.99/15 g, $96.99/30 g. Nasal ointment: 2% in 1-g single-use tubes Cost: $18.99/1 g. NURSING IMPLICATIONS Assessment Assess lesions before and daily during therapy. Potential Nursing Diagnoses Impaired skin integrity (Indications) Risk for infection (Indications, Patient/Family Teaching) Implementation Topical: Wash affected area with soap and water and dry thoroughly. Apply a small amount of mupirocin to the affected area 3 times daily and rub in gently. Treated area may be covered with gauze if desired. Nasal: Apply one half of the ointment from the single-use tube to each nostril twice daily (morning and evening) for 5 days. After application, close nostrils by pressing together and releasing sides of the nose repeatedly for 1 min. Patient/Family Teaching Instruct patient on the correct application of mupirocin. Advise patient to apply medication exactly as directed for the full course of therapy. If a dose is missed, apply as soon as possible unless almost time for next dose. Avoid contact with eyes. Topical: Teach patient and family appropriate hygienic measures to prevent spread of impetigo.. Instruct parents to notify school nurse for screening and prevention of transmission. Patient should consult health care professional if symptoms have not improved in 3-5 days. Evaluation/Desired Outcomes Healing of skin lesions. If no clinical response is seen in 3-5 days, condition should be re-evaluated. Eradication of methicillin-resistant S. aureus carrier state in patients and health care workers during institutional outbreaks.

methylphenidate (oral) (meth-ill-fen-i-date) Biphentin, Concerta, Metadate CD, Metadate ER, Methylin, Methylin ER, Ritalin, Ritalin LA, Ritalin SR methylphenidate (transdermal) Daytrana Classification Therapeutic: central nervous system stimulants Schedule II Pregnancy Category C

Indications: Treatment of ADHD (adjunct). Oral: Symptomatic treatment of narcolepsy. Unlabelled Use: Management of some forms of refractory depression. Action 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. Pharmacokinetics Absorption: Slow and incomplete after oral administration; absorption of sustained or extended-release tablet (SR) is delayed and provides continuous release; well absorbed from skin. Metadate CD, Concerta, Ritalin LA—provides initial rapid release followed by a second continuous release (biphasic release). Distribution: Unknown. Metabolism and Excretion: Mostly metabolized (80%) by the liver. Half-life: 2-4 hr. TIME/ACTION PROFILE (CNS stimulation) ROUTE ONSET PEAK DURATION PO unknown 1-3 hr 4-6 hr PO-ER unknown 4-7 hr 3-12 hr† Transdermal unknown unknown 12 hr †Depends on formulation Contraindications/Precautions Contraindicated in: 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. Use Cautiously in: History of cardiovascular disease (sudden death has occurred in children with structural cardiac abnormalities or other serious heart problems); Hypertension; Diabetes mellitus; History of contact sensitization with transdermal product (may be at ↑ risk for systemic sensitization reactions with oral products); Geri: Geriatric or debilitated patients; Continual use (may result in psychological or physical dependence); Seizure disorders (may lower seizure threshold); Concerta product should be used cautiously in patients with esophageal motility disorders or severe GI narrowing (may ↑ the risk of obstruction); OB/Lactation: Safety not established; Pedi: Growth suppression may occur in children with long term use; children <6 yr (transdermal only). Adverse Reactions/Side Effects (CAPITALS indicate life-threatening; underlines indicate most frequent.) CNS: hyperactivity, insomnia, restlessness, tremor, behavioral disturbances, dizziness, hallucinations, headache, irritability, mania, thought disorder. EENT: blurred vision. CV: SUDDEN DEATH, hypertension, palpitations, tachycardia, hypotension. GI: anorexia, constipation, cramps, diarrhea, dry mouth, metallic taste, nausea, vomiting. Derm: contact sensitization (erythema, edema, papules, vesicles) (transdermal), erythema, rashes. Metab: growth suppression, weight loss (may occur with prolonged use). Neuro: akathisia, dyskinesia, tics. Misc: fever, hypersensitivity reactions, physical dependence, psychological dependence, tolerance. Interactions Drug-Drug: ↑ sympathomimetic effects with other adrenergics, including vasoconstrictors, decongestants, and halogenated anesthetics. Use with MAO inhibitors or vasopressors may result in hypertensive crisis (concurrent use or use within 14 days of MAO inhibitors is contraindicated). Metabolism of warfarin, phenytoin, phenobarbital, primidone, phenylbutazone, selective serotonin reuptake inhibitors, and tricyclic antidepressants may be ↓ and effects ↑. Avoid concurrent use with pimozide (may mask cause of tics). May ↓ the effectiveness of antihypertensives. Drug-Natural: Use with caffeine-containing herbs (guarana, tea, coffee) ↑ stimulant effect. St. John's wort may ↑ serious side effects (concurrent use is NOT recommended). Drug-Food: Excessive use of caffeine-containing foods or beverages (coffee, cola, tea) may cause ↑ CNS stimulation. Route/Dosage PO (Adults): ADHD—5-20 mg 2-3 times daily as prompt-release tablets. When maintenance dose is determined, may change to extended-release formulation. Narcolepsy—10 mg 2-3 times/day; maximum dose 60 mg/day. PO (Children >6 yr): Prompt release tablets—0.3 mg/kg/dose or 2.5-5 mg before breakfast and lunch; ↑ by 0.1 mg/kg/dose or by 5-10 mg/day at weekly intervals (not to exceed 60 mg/day or 2 mg/kg/day). When maintenance dose is determined, may change to extended-release formulation. Ritalin SR, Metadate ER—may be used in place of the prompt-release tablets when the 8-hour dosage corresponds to the titrated 8-hour dosage of the prompt-release tablets; Ritalin LA—can be used in place of twice daily regimen given once daily at same total dose, or in place of SR product at same dose; Concerta (patients who have not taken methylphenidate previously)—18 mg once daily in the morning initially, may be titrated as needed up to 54 mg/day. Concerta (patients are currently taking other forms of methylphenidate)—18 mg once daily in the morning if previous dose was 5 mg 2-3 times daily or 20 mg daily as SR product, 36 mg once daily in the morning if previous dose was 10 mg 2-3 times daily or 40 mg daily as SR product, 54 mg once daily in the morning if previous dose was 15 mg 2-3 times daily or 60 mg once daily as SR product. Metadate CD—20 mg once daily. Dosage may be adjusted in weekly 20-mg increments to a maximum of 60 mg/day taken once daily in the morning. Transdermal (Children6-17 yr): Apply one 10-mg patch initially (should be applied 2 hr before desired effect and removed 9 hr after application); may be titrated based on response and tolerability; may ↑ to 15-mg patch after 1 week, and then to 20-mg patch after another week, and then to 30-mg patch after another week. Availability (generic available) Immediate-release tablets: 5 mg, 10 mg, 20 mg Cost: Generic-- 5 mg $149.95/100, 10 mg $79.96/100, 20 mg $104.95/100. Extended-release tablets (Metadate ER, Methylin ER): 10 mg, 20 mg Cost: 10 mg $159.95/100, 20 mg $244.36/100. Extended-release tablets (Concerta): 18 mg, 27 mg, 36 mg, 54 mg Cost: 18 mg $539.95/90, 27 mg $602.94/90, 36 mg $585.94/90, 54 mg $634.93/90. Sustained-release tablets (Ritalin SR): 20 mg Cost: Generic-- $161.95/90. Extended-release capsules (Metadate CD): 10 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg Cost: 10 mg $445.93/90, 20 mg $299.99/90, 30 mg $299.95/90$34.68/30. Extended-release capsules (Ritalin LA): 10 mg, 20 mg, 30 mg, 40 mg Cost: 10 mg $299.97/90, 20 mg $445.44/90, 30 mg $445.44/90, 60 mg $730.90/90. Chewable tablets (Methylin) (grape flavor): 2.5 mg, 5 mg, 10 mg Cost: 5 mg $69.95/100, 10 mg $69.95/100. Oral solution (Methylin) (grape flavor): 5 mg/5 mL, 10 mg/5 mL. Transdermal system: releases 10 mg/9 hr, releases 15 mg/9 hr, releases 20 mg/9 hr, releases 30 mg/9 hr Cost: 10 mg/9 hr $554.94/90, 15 mg/9 hr $538.95/90, 20 mg/9 hr $546.65/90, 30 mg/9 hr $540.98/90. NURSING IMPLICATIONS Assessment 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.. Pedi: 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.. Methylphenidate has high dependence and abuse potential. Tolerance to abuse of medication occurs rapidly; do not increase dose. ADHD: Assess children for attention span, impulse control, and interactions with others. Therapy may be interrupted at intervals to determine whether symptoms are sufficient to continue therapy. Narcolepsy: Observe and document frequency of episodes. Transdermal: Assess skin for signs of contact sensitization (erythema with edema, papules, or vesicles that does not improve within 48 hr or spreads beyond patch site) during therapy. May lead to systemic sensitization to other forms of methylphenidate (flare-up of previous dermatitis or prior positive patch-test sites, generalized skin eruptions, headache, fever, malaise, arthralgia, diarrhea, vomiting). If contact sensitization develops and oral methylphenidate is instituted, monitor closely. Lab Test Considerations: Monitor CBC, differential, and platelet count periodically in patients receiving prolonged therapy. Potential Nursing Diagnoses Disturbed thought process (Side Effects) Implementation Do not confuse Metadate ER/CD (methylphenidate), or methylphenidate with methadone. Do not confuse Metadate CD with Metadate ER. Do not confuse Ritalin LA with Ritalin SR. 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. Concerta may be administered without regard to food, but must be taken with water, milk, or juice. 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 hr before desired effect and remove 9 hr after applied; effects last several more hours. Do not apply or reapply with dressings, tape, or other adhesives. Do not cut patches.. If difficulty in separating patch from release liner, tearing, or other damage occurs during removal from liner, discard patch and apply a new patch. Inspect release liner to ensure no adhesive containing medication has transferred to liner; if transfer has occurred, discard patch. Avoid touching adhesive during application; wash hands immediately after application.. If patch does not fully adhere or partially detaches, remove and replace with another patch. Wear patched for a total of 9 hr, regardless of number used. Exposure to water during bathing, swimming, or showering may affect patch adherence.. Patches may be removed earlier before decreasing dose if an unacceptable loss of appetite or insomnia occurs.. Store patches at room temperature in a safe place to prevent abuse and misuse; do not refrigerate or freeze.. To remove patch, peel off slowly. An oil-based product (petroleum jelly, olive oil, mineral oil) may be applied gently to facilitate removal. Upon removal, fold so that adhesive side of patch adheres to itself and flush down toilet or dispose of in an appropriate lidded container. Patient/Family Teaching 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 Concerta 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. Advise patient and/or parents to notify health care professional of behavioral changes. 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. Inform patient that health care professional may order periodic holidays from the drug to assess progress and to decrease dependence. Emphasize the importance of routine follow-up exams to monitor progress. Transdermal: Encourage parent or caregiver to use the administration chart included in package to monitor application and removal time and disposal method.. Caution patient to avoid exposing patch to direct external heat sources (hair dryers, heating pads, electric blankets, heated water beds, etc). May increase rate and extent of absorption. Inform parent/caregiver that skin redness, itching and small bumps on the skin are common. If swelling or blistering occurs, the patch should not be worn and health care professional notified. Caution parent/caregiver not to apply hydrocortisone or other solutions, creams, ointments, or emollients prior to application. Advise patient referred for MRI test to discuss patch with referring health care professional and MRI facility to determine if removal of patch is necessary prior to test and for directions for replacing patch. Home Care Issues: Pedi: Advise parents to notify school nurse of medication regimen. Evaluation/Desired Outcomes Improved attention span and social interactions in ADHD. Decreased frequency of narcoleptic symptoms.

ceFAZolin (sef-a-zoe-lin) Ancef Classification Therapeutic: anti-infectives Pharmacologic: first-generation cephalosporins Pregnancy Category B

Indications: Treatment of the following infections due to susceptible organisms: : Skin and skin structure infections (including burn wounds), , Pneumonia, , Urinary tract infections, , Biliary tract infections, , Genital infections, , Bone and joint infections, , Septicemia, , Bacterial endocarditis prophylaxis for dental and upper respiratory procedures. Perioperative prophylaxis. Not suitable for the treatment of meningitis. Action Binds to bacterial cell wall membrane, causing cell death. Therapeutic Effects: Bactericidal action against susceptible bacteria. Spectrum: Active against many gram-positive cocci including: : Streptococcus pneumoniae, , Group A beta-hemolytic streptococci, , Penicillinase-producing staphylococci. Not active against: : Methicillin-resistant staphylococci, , Bacteroides fragilis, , Enterococcus. Active against some gram-negative rods including: : Proteus mirabilis, , Escherichia coli. Pharmacokinetics Absorption: Well absorbed after IM administration. Distribution: Widely distributed. Penetrates bone and synovial fluid well. Crosses the placenta and enters breast milk in low concentrations. Minimal CSF penetration. Protein Binding: 74—86%. Metabolism and Excretion: Excreted almost entirely unchanged by the kidneys. Half-life: Neonates: 3-5 hrs; Adults: 90-150 min (↑ in renal impairment). TIME/ACTION PROFILE (blood levels) ROUTE ONSET PEAK DURATION IM rapid 0.5-2 hr 6-12 hr IV rapid 5 min 6-12 hr Contraindications/Precautions Contraindicated in: Hypersensitivity to cephalosporins; Serious hypersensitivity to penicillins. Use Cautiously in: Renal impairment (dose ↓ and/or ↑ dosing interval recommended if CCr <30 mL/min); Hepatic impairment; History of GI disease, especially colitis; OB: Half-life is shorter and blood levels lower during pregnancy; has been used safely.Lactation: Low concentrations of drug appear in breast milk; Geri: Dose adjustment due to age-related ↓ in renal function may be necessary. Adverse Reactions/Side Effects (CAPITALS indicate life-threatening; underlines indicate most frequent.) CNS: SEIZURES (HIGH DOSES). GI: PSEUDOMEMBRANOUS COLITIS, diarrhea, nausea, vomiting, cramps. Derm: STEVENS-JOHNSON SYNDROME, rash, pruritis, urticaria. Hemat: leukopenia, neutropenia, thrombocytopenia. Local: pain at IM site, phlebitis at IV site. Misc: allergic reactions including anaphylaxis and serum sickness, superinfection. Interactions Drug-Drug: Probenecid ↓ excretion and ↑ blood levels of renally excreted cephalosporins. Route/Dosage IM, IV (Adults): Moderate-to-severe infections—500 mg-2 g every 6-8 hr; maximum 12 g/day. Mild infections with Gram-positive cocci-250-500 mg every 8 hr.Uncomplicated urinary tract infection—1 g every 12 hr.Pneumococcal pneumonia—500 mg every 12 hr.Infective endocarditis or septicemia—1-1.5 g every 6 hr.Perioperative prophylaxis—1 g within 30-60 min prior to incision (an additional 500 mg-1 g should be given for surgeries ≥ 2 hr). 500 mg-1 g should then be given for all surgeries every 6-8 hr for 24 hr following the surgery. IM, IV (Children and Infants >1 mo): 50-100 mg/kg/day divided every 8 hr; maximum: 6 g/dayBacterial endocarditis prophylaxis in penicillin-allergic patients:-25 mg/kg 30 minutes prior to procedure; maximum dose: 1 g. IM, IV (Neonates≤ 7 days): 40 mg/kg/day divided q 12 hr. IM, IV (Neonates> 7 days and ≤ 2 kg): 40 mg/kg/day divided q 12 hr. IM, IV (Neonates> 7 days and > 2 kg): 60 mg/kg/day divided q 8 hr. Renal Impairment IM, IV (Adults): CCr 10-30 mL/min— Administer dose every 12 hr; CCr ≤10 mL/min—Administer every 24 hr. Availability (generic available) Powder for injection: 500 mg/vial, 1 g/vial, 10 g/vial, 20 g/vial. Premixed containers: 1 g/50 mL D5W. NURSING IMPLICATIONS Assessment Assess for infection (vital signs; appearance of wound, sputum, urine, and stool; WBC) at beginning of and throughout therapy. Before initiating therapy, obtain a history to determine previous use of and reactions to penicillins or cephalosporins. Persons with a negative history of penicillin sensitivity may still have an allergic response. Obtain specimens for culture and sensitivity before initiating therapy. First dose may be given before receiving results. Observe patient for signs and symptoms of anaphylaxis (rash, pruritus, laryngeal edema, wheezing). Discontinue drug and notify health care professional immediately if these problems occur. Keep epinephrine, an antihistamine, and resuscitation equipment close by in case of an anaphylactic reaction. Monitor bowel function. Diarrhea, abdominal cramping, fever, and bloody stools should be reported to health care professional promptly as a sign of pseudomembranous colitis. May begin up to several weeks following cessation of therapy. Assess patient for skin rash frequently during therapy. Discontinue at first sign of rash; may be life-threatening. Stevens-Johnson syndrome may develop. Treat symptomatically; may recur once treatment is stopped. Lab Test Considerations: May cause positive results for Coombs' test in patients receiving high doses or in neonates whose mothers were given cephalosporins before delivery.. May cause ↑ serum AST, ALT, alkaline phosphatase, bilirubin, LDH, BUN, and creatinine.. May rarely cause leukopenia, neutropenia, thrombocytopenia, and eosinophilia. Potential Nursing Diagnoses Risk for infection (Indications, Side Effects) Diarrhea (Adverse Reactions) Implementation Do not confuse cefazolin with cefotetan, cefoxitin, ceftazidime, or ceftriaxone. IM: Reconstitute IM doses with 2 mL or 2.5 mL of with sterile water for injection to a achieve a final concentration of 225-330 mg/mL.. Inject deep into a well-developed muscle mass; massage well. IV Administration pH: 4.5-7.0. IV: Monitor site frequently for thrombophlebitis (pain, redness, swelling). Change sites every 48-72 hr to prevent phlebitis.. Do not use solutions that are cloudy or contain a precipitate.. If aminoglycosides are administered concurrently, administer in separate sites, if possible, at least 1 hr apart. If second site is unavailable, flush line between medications. Direct IV: Diluent: Dilute with sterile water for injection. Do not use preparations containing benzyl alcohol for neonates. Concentration: ≤100 mg/mL. Rate: Administer slowly over 3-5 min. Intermittent Infusion: Diluent: Reconstituted solution may be further diluted with 0.9% NaCl, D5W, D10W, D5/0.25% NaCl, D5/0.45% NaCl, D5/09% NaCl, D5/LR, or LR solution. Solution is stable for 24 hr at room temperature and 10 days if refrigerated. Concentration: ≤20 mg/mL. Rate: Administer over 30-60 min. Y-Site Compatibility: acyclovir, alfentanil, allopurinol, alprostadil, amifostine, aminocaproic acid, aminophylline, amphotericin B lipid complex, amphotericin B liposome, anidulafungin, argatroban, ascorbic acid, atracurium, atropine, aztreonam, benztropine, bivalirudin, bleomycin, bumetanide, buprenorphine, butorphanol, calcium gluconate, carboplatin, carmustine, cefoperazone, cefotetan, cefoxitin, ceftazidime, ceftriaxone, cefuroxime, chlorampheniocol, cisplatin, clindamycin, cyanocobalamin, cyclophosphamide, cyclosporine, cytarabine, dactinomycin, daptomycin, dexamethasone, dexmedetomidine, digoxin, diltiazem, docetaxel, doxacurium, doxapram, doxorubicin liposome, enalaprilat, ephedrine, epinephrine, epirubicin, epoetin alfa, eptifibatide, esmolol, etoposide, etoposide phosphate, fenoldopam, fentanyl, filgrastim, fluconazole, fludarabine, fluorouracil, folic acid, foscarnet, gemcitabine, glycopyrrolate, granisetron, heparin, hydrocortisone, ifosfamide, imipenem/cilastatin, indomethacin, insulin, irinotecan, isoproterenol, ketamine, ketorolac, lidocaine, linezolid, lorazepam, mannitol, mechlorethamine, melphalan, meperidine, metaraminol, methotrexate, methoxamine, methyldopate, methylprednisolone, metoclopramide, metoprolol, metronidazole, midazolam, milrinone, morphine, multivitamins, nafcillin, nalbuphine, naloxone, nesiritide, nicardipine, nitroglycerin, nitroprusside, norepinephrine, octreotide, ondansetron, oxacillin, oxaliplatin, oxytocin, paclitaxel, palonosetron, pamidronate, pancuronium, pantoprazole, penicillin G, perphenazine, phenobarbital, phenylephrine, phytonadione, potassium acetate, potassium chloride, procainamide, propofol, propranolol, ranitidine, remifentanil, rituximab, sargramostim, sodium acetate, sodium bicarbonate, streptokinase, succinylcholine, sufentanil, tacrolimus, teniposide, theophylline , thiamine, thiotepa, ticarcillin/clavulanate, tigecycline, tirofiban, tolazoline, trastuzumab, trimetaphan, vasopressin, vecuronium, verapamil, vincristine, vitamin B complex with C, voriconazole, warfarin, zoledronic acid Y-Site Incompatibility: alemtuzumab, amphotericin B cholesteryl, azathioprine, calcium chloride, caspofungin, cefotaxime, chlorpromazine, dantrolene, diazepam, diazoxide, diphenhydramine, dobutamine, dopamine, doxorubicin hydrochloride, doxycycline, erythromycin, ganciclovir, haloperidol, hydralazine, hydroxyzine, idarubicin, levofloxacin, mitoxantrone, mycophenolate, papaverine, pemetrexed, pentamidine, pentazocine, pentobarbital, phentolamine, phenytoin, prochlorperazine, promethazine, protamine, quinupristin/dalfopristin, sodium citrate, tobramycin, trimethoprim/sulfamethoxazole, vinorelbine. Patient/Family Teaching Advise patient to report signs of superinfection (furry overgrowth on the tongue, vaginal itching or discharge, loose or foul-smelling stools) and allergy. Instruct patient to notify health care professional if rash, or fever and diarrhea develop, especially if diarrhea contains blood, mucus, or pus. Advise patient not to treat diarrhea without consulting health care professional. Evaluation/Desired Outcomes Resolution of signs and symptoms of infection. Length of time for complete resolution depends on the organism and site of infection. Decreased incidence of infection when used for prophylaxis.

cefTRIAXone (sef-try-ax-one) Rocephin Classification Therapeutic: anti-infectives Pharmacologic: third-generation cephalosporins Pregnancy Category B

Indications: Treatment of: : Skin and skin structure infections, , Bone and joint infections, , Complicated and uncomplicated urinary tract infections, , Uncomplicated gynecological infections including gonorrhea, , Lower respiratory tract infections, , Intra-abdominal infections, , Septicemia, , Meningitis, , Otitis media. Perioperative prophylaxis. Action Binds to the bacterial cell wall membrane, causing cell death. Therapeutic Effects: Bactericidal action against susceptible bacteria. Spectrum: Similar to that of second-generation cephalosporins, but activity against staphylococci is less, while activity against gram-negative pathogens is greater, even for organisms resistant to first- and second-generation agents. Notable is increased action against: : Acinetobacter, , Enterobacter, , Haemophilus influenzae (including β-lactamase-producing strains), , Haemophilus parainfluenzae, , Escherichia coli, , Klebsiella pneumoniae, , Morganella morganii, , Neisseria, , Proteus, , Providencia, , Serratia, , Moraxella catarrhalis. Has some activity against anaerobes, includingBacteroides fragilis. Not active against methicillin-resistant staphylococci or enterococci. Pharmacokinetics Absorption: Well absorbed following IM administration; IV administration results in complete bioavailability. Distribution: Widely distributed. CSF penetration better than with first- and second-generation agents. Crosses the placenta; enters breast milk in low concentrations. Protein Binding: ≥90%. Metabolism and Excretion: 33-67% excreted in urine as unchanged drug; remainder excreted in feces. Half-life: 6-9 hr. TIME/ACTION PROFILE ROUTE ONSET PEAK DURATION IM rapid 1-2 hr 12-24 hr IV rapid end of infusion 12-24 hr Contraindications/Precautions Contraindicated in: Hypersensitivity to cephalosporins; Serious hypersensitivity to penicillins; Pedi: Neonates ≤28 days (use in hyperbilirubinemic neonates may lead to kernicterus); Pedi: Neonates ≤28 days requiring calcium-containing IV solutions (↑ risk of precipitation formation). Use Cautiously in: Combined severe hepatic and renal impairment (dose reduction/↑ dosing interval recommended); History of GI disease, especially colitis; OB/Lactation: Pregnancy and lactation. Adverse Reactions/Side Effects (CAPITALS indicate life-threatening; underlines indicate most frequent.) CNS: SEIZURES (HIGH DOSES). GI: PSEUDOMEMBRANOUS COLITIS, diarrhea, cholelithiasis, gallbladder sludging. Derm: rashes, urticaria. Hemat: bleeding, eosinophilia, hemolytic anemia, leukopenia, thrombocytosis. Local: pain at IM site, phlebitis at IV site. Misc: ALLERGIC REACTIONS INCLUDING ANAPHYLAXIS, superinfection. Interactions Drug-Drug: Should not be administered concomitantly with any calcium-containing solutions. Route/Dosage IM, IV (Adults): Most infections—1-2 g every 12-24 hr Gonorrhea—250 mg IM (single dose). Meningitis—2 g every 12 hr.Perioperative prophylaxis-1 g 0.5-2 hr before surgery (single dose). IM, IV (Children): Most infections—50-75 mg/kg/day (not to exceed 2 g/day) divided every 12-24 hr. Meningitis—100 mg/kg/day (not to exceed 4 g/day) divided every 12-24 hr or Uncomplicated gonorrhea—125 mg IM (single dose).Acute otitis media—50 mg/kg (not to exceed 1 g) IM single dose. Availability (generic available) Powder for injection: 250 mg/vial, 500 mg/vial, 1 g/vial, 2 g/vial, 10 g/vial. Premixed containers: 1 g/50 mL, 2 g/50 mL. NURSING IMPLICATIONS Assessment Assess for infection (vital signs; appearance of wound, sputum, urine, and stool; WBC) at beginning of and throughout therapy. Before initiating therapy, obtain a history to determine previous use of and reactions to penicillins or cephalosporins. Persons with a negative history of penicillin sensitivity may still have an allergic response. Obtain specimens for culture and sensitivity before initiating therapy. First dose may be given before receiving results. Pedi: Assess newborns for jaundice and hyperbilirubinemia; can increase bilirubinemia and should not be administered to jaundiced neonates, especially premature neonates. Observe patient for signs and symptoms of anaphylaxis (rash, pruritus, laryngeal edema, wheezing). Discontinue the drug and notify health care professional immediately if these symptoms occur. Keep epinephrine, an antihistamine, and resuscitation equipment close by in the event of an anaphylactic reaction. Monitor bowel function. Diarrhea, abdominal cramping, fever, and bloody stools should be reported to health care professional promptly as a sign of pseudomembranous colitis. May begin up to several weeks following cessation of therapy. Lab Test Considerations: May cause positive results for Coombs' test.. May cause increased serum AST, ALT, alkaline phosphatase, bilirubin, LDH, BUN, and creatinine.. May rarely cause leukopenia, neutropenia, agranulocytosis, thrombocytopenia, eosinophilia, lymphocytosis, and thrombocytosis. Potential Nursing Diagnoses Risk for infection (Indications, Side Effects) Diarrhea (Adverse Reactions) Implementation Do not confuse ceftriaxone with cefazolin, cefoxitin, cefotetan, or ceftazidime. IM: Reconstitute IM doses with sterile water for injection, or 0.9% NaCl for injection. May be diluted with lidocaine to minimize injection discomfort.. Inject deep into a well-developed muscle mass; massage well. IV Administration pH: 6.6-6.7. IV: Monitor injection site frequently for phlebitis (pain, redness, swelling). Change sites every 48-72 hr to prevent phlebitis.. If aminoglycosides are administered concurrently, administer in separate sites, if possible, at least 1 hr apart. If second site is unavailable, flush lines between medications. Intermittent Infusion: Diluent: Reconstitute each 250-mg vial with 2.4 mL, each 500-mg vial with 4.8 mL, each 1-g vial with 9.6 mL, and each 2-g vial with 19.2 mL of sterile water for injection, 0.9% NaCl, or D5W for a concentration of 100 mg/mL. Solution should be further diluted in 50-100 mL of 0.9% NaCl, D5W, D10W, D5/0.45% NaCl, or D5/0.9% NaCl. Solution may appear light yellow to amber. Solution is stable for 3 days at room temperature . Rate: Infuse over 30 min. Y-Site Compatibility: acyclovir, alfentanil, allopurinol, amifostine, aminocaproic acid, aminophylline, amiodarone, amphotericin B lipid complex, amphotericin B liposome, anidulafungin, argatroban, atracurium, atropine, aztreonam, benztropine, bivalirudin, bumetanide, buprenorphine, butorphanol, carboplatin, carmustine, cefazolin, cefonocid, cefoperazone, cefotaxime, cefotetan, cefoxitin, ceftazidime, cefuroxime, cisatracurium, cisplatin, cyanocobalamin, cyclophosphamide, cyclosporine, cytarabine, dactinomycin, daptomycin, dexamethasone, dexmedetomidine, digoxin, diltiazem, docetaxel, dopamine, doxacurium, doxorubicin liposome, doxycycline, enalaprilat, ephedrine, epinephrine, epoetin alfa, epitifibitide, erythromycin, esmolol, etoposide, etoposide phosphate, fenoldopam, fentanyl, fludarabine, fluorouracil, folic acid, foscarnet, furosemide, gemcitabine, glycopyrrolate, granisetron, heparin, hetastarch, hydrocortisone, hydromorphone, ifosfamide, indomethacin, insulin, isoproterenol, ketorolac, levofloxacin, lidocaine, linezolid, lorazepam, mannitol, mechlorethamine, melphalan, meperidine, metaraminol, methotrexate, methoxamine, methyldopate, methylprednisolone, metoclopramide, metoprolol, metronidazole, midazolam, milrinone, morphine, multivitamins, nafcillin, nalbuphine, naloxone, nesiritide, nitroglycerin, nitroprusside, norepinephrine, octreotide, oxacillin, oxaliplatin, oxytocin, paclitaxel, palonosetron, pamidronate, pantoprazole, pemetrexed, penicillin G, phenobarbital, phentolamine, phenylephrine, phytonadione, potassium acetate, potassium chloride, procainamide, propofol, propranolol, pyridoxime, ranitidine, remifentanil, rituxumab, rocuronium, sargramostim, sodium acetate, sodium bicarbonate, streptokinase, succinylcholine, sufentanil, tacrolimus, telavancin, teniposide, theophylline, thiamine, thiotepa, ticarcillin/clavulanate, tigecycline, tirofiban, tolazoline, trastuzumab, trimethaphan, vasopressin, vecuronium, verapamil, vincristine, voriconazole, warfarin, zidovudine, zoledronic acis Y-Site Incompatibility: alemtuzumab, amphotericin B cholesteryl, amsacrine, ascorbic acid, azathioprine, azithromycin, calcium chloride, calcium gluconate, caspofungin, chloramphenicol, chlorpromazine, clindamycin, dantrolene, diazepam, diazoxide, diphenhydramine, dobutamine, doxorubicin hydrochloride, epirubicin, filgrastim, ganciclovir, haloperidol, hetastarch, hydralazine, hydroxyzine, idarubicin, imipenem/cilastatin, irinotecan, labetalol, magnesium sulfate, mitoxantrone, mycophenolate, pentamidine, pentazocine, pentobarbital, phenytoin, prochlorperazine, promethazine, protamine, quinupristin/dalfopristin, tobramycin, trimethoprim/sulfamethoxazole, vinorelbine, Calcium-containing solutions, including parenteral nutrition, should not be mixed or co-administered, even via different infusion lines at different sites in patients <28 days old. In older patients, flush line thoroughly between infusions Patient/Family Teaching Advise patient to report signs of superinfection (furry overgrowth on the tongue, vaginal itching or discharge, loose or foul-smelling stools) and allergy. Instruct patient to notify health care professional if fever and diarrhea develop, especially if diarrhea contains blood, mucus, or pus. Advise patient not to treat diarrhea without consulting health care professional. Evaluation/Desired Outcomes Resolution of the signs and symptoms of infection. Length of time for complete resolution depends on the organism and site of infection. Decreased incidence of infection when used for prophylaxis.

OXYBUTYNIN (ox-i-byoo-ti-nin) oxybutynin (oral) Ditropan, Ditropan XL oxybutynin (gel) Gelnique oxybutynin (transdermal system) Oxytrol Classification Therapeutic: urinary tract antispasmodics Pharmacologic: anticholinergics Pregnancy Category B

Indications: Urinary symptoms that may be associated with neurogenic bladder including:: Frequent urination,, Urgency,, Nocturia,, Urge incontinence. Overactive bladder with symptoms of urge incontinence, urgency, and frequency. Action Inhibits the action of acetylcholine at postganglionic receptors. Has direct spasmolytic action on smooth muscle, including smooth muscle lining the GU tract, without affecting vascular smooth muscle. Therapeutic Effects: Increased bladder capacity. Delayed desire to void. Decreased urge incontinence, urinary urgency, and frequency and decreased number of urinary accidents associated with overactive bladder. Pharmacokinetics Absorption: Rapidly absorbed following oral administration, but undergoes extensive first-pass metabolism; XL tablets provide extended release. Transdermal absorption occurs by passive diffusion through intact skin and bypasses the first-pass effect. Distribution: Widely distributed. Metabolism and Excretion: Extensively metabolized by the liver (CYP3A4 enzyme system); one metabolite is pharmacologically active; metabolites are renally excreted with negligible (<0.1%) excretion of unchanged drug. Half-life: 7-8 hr (oral and patch); 64 hr (gel). TIME/ACTION PROFILE (urinary spasmolytic effect) ROUTE ONSET PEAK DURATION PO 30-60 min 3-6 hr 6-10 hr (up to 24 hr with XL tablet) TD-patch within 24 hr 36 hr 3-4 days TD-gel unknown unknown 24 hr Contraindications/Precautions Contraindicated in: Hypersensitivity; Uncontrolled angle-closure glaucoma; Intestinal obstruction or atony; Urinary retention. Use Cautiously in: Hepatic/renal impairment; Bladder outflow obstruction; Ulcerative colitis; Benign prostatic hyperplasia; Cardiovascular disease; Reflux esophagitis or gastrointestinal obstructive disorders; Patients with dementia receiving acetylcholinesterase inhibitors; Myasthenia gravis; OB/Lactation: Pregnancy or lactation; Pedi: Oral: Safety not established in children <5 yr; Patch and gel: Safety not established in children <18 yr; Geri: Appears on Beers list. Poorly tolerated due to anticholinergic effects. Initiate treatment at lower doses. Adverse Reactions/Side Effects (CAPITALS indicate life-threatening; underlines indicate most frequent.) CNS: dizziness, drowsiness, agitation, confusion, hallucinations, headache. EENT: blurred vision. CV: tachycardia. GI: constipation, dry mouth, nausea, abdominal pain, diarrhea. GU: urinary retention. Derm: ↓ sweating, transdermal only: application site reactions, pruritus. Metab: hyperthermia. Misc: ANAPHYLAXIS, ANGIOEDEMA. Interactions Drug-Drug: ↑ anticholinergic effects with other agents having anticholinergic properties, including amantadine, antidepressants, phenothiazines, disopyramide, and haloperidol. Additive CNS depression with other CNS depressants, including alcohol, antihistamines, antidepressants, opioids, and sedative/hypnotics. Ketoconazole, itraconazole, erythromycin, and clarithromycin may ↑ effects. Route/Dosage PO (Adults): Immediate-release tablets—5 mg 2-3 times daily (not to exceed 5 mg 4 times daily) (may start with 2.5 mg 2-3 times daily in elderly). Extended-release tablets—5-10 mg once daily; may ↑, as needed, (in 5-mg increments) up to maximum dose of 30 mg/day. PO (Children >5 yr): Immediate-release tablets—5 mg 2-3 times daily (not to exceed 15 mg/day). Extended-release tablets (children ≥6 yr)—5 mg once daily; may ↑, as needed, (in 5-mg increments) up to maximum dose of 20 mg/day. PO (Children1-5 yr): 0.2 mg/kg/dose 2-3 times daily. Transdermal (Adults): Patch—Apply one 3.9 mg system twice weekly (every 3-4 days); Gel—Apply contents of one sachet (100 mg/g) once daily. Availability (generic available) Tablets: 5 mg. Extended-release tablets: 5 mg, 10 mg, 15 mg. Syrup: 5 mg/5 mL. Gel: 1 g unit dose (sachet) contains 100 mg/g (10%). Transdermal system: 3.9 mg/day system. NURSING IMPLICATIONS Assessment Monitor voiding pattern and intake and output ratios, and assess abdomen for bladder distention prior to and periodically during therapy. Catheterization may be used to assess postvoid residual. Cystometry is usually performed to diagnose type of bladder dysfunction prior to prescription of oxybutynin. Geri: Assess geriatric patients for anticholinergic effects (sedation and weakness). Potential Nursing Diagnoses Impaired urinary elimination (Indications) Acute pain (Indications) Implementation Do not confuse Ditropan (oxybutynin) with Diprivan (propofol). PO: Immediate release tabs should be administered on an empty stomach; XL tablets may be given with or without food. XL tablets should be swallowed whole; do not break, crush, or chew. Transdermal patch: Apply patch on same two days each week (Sunday/Wednesday, Monday/Thursday) to hip, abdomen, or buttock in an area that is clean, dry, and without irritation. Patch should be worn continuously. Transdermal gel: Apply clear, colorless gel once daily to intact skin on abdomen (avoid area around navel), upper arms/shoulders, or thighs until dry. Rotate sites; do not use same site on consecutive days. Patient/Family Teaching Instruct patient to take oxybutinin as directed. Take missed doses as soon as remembered unless almost time for next dose. Advise patient to read Information for the Patient prior to beginning therapy and with each Rx refill in case of new information. May cause drowsiness or blurred vision. Advise patient to avoid driving and other activities requiring alertness until response to medication is known. Advise patient to avoid concurrent use of alcohol and other CNS depressants while taking this medication. Instruct patient that frequent rinsing of mouth, good oral hygiene, and sugarless gum or candy may decrease dry mouth. Health care professional should be notified if mouth dryness persists >2 wk. Advise patient to stop taking oxybutinin and notify health care professional immediately if signs of angioedema and/or anaphylaxis (swelling of face, tongue, or throat; rash; dyspnea). Inform patient that oxybutynin decreases the body's ability to perspire. Avoid strenuous activity in a warm environment because overheating may occur. Advise patient to notify health care professional if urinary retention occurs or if constipation persists. Discuss methods of preventing constipation, such as increasing dietary bulk, increasing fluid intake, and increasing mobility. Advise patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products being taken and to consult with health care professional before taking other medications. Advise patient to notify health care professional if pregnancy is planned or suspected or if breastfeeding. Discuss need for continued medical follow-up. Periodic cystometry may be used to evaluate effectiveness. Ophthalmic exams should be performed periodically to detect glaucoma, especially in patients over 40 yr of age. Transdermal patch: Instruct patient on correct application and disposal of patch. Open pouch by tearing along arrows; apply immediately. Apply 1/2 patch to skin by removing 1/2 protective cover and applying firmly to skin. Apply second half by bending in half and rolling patch onto skin while removing protective liner. Press patch firmly in place.. Remove slowly; fold in half, sticky sides together, and discard. Wash site with mild soap and water or a small amount of baby oil. Advise patient referred for MRI to remove patch prior to test and give directions for replacing patch. Transdermal gel: Instruct patient on correct application of oxybutynin gel. Do not apply to recently shaved skin, skin with rashes, or areas treated with lotions, oils, or powders; may be used with sunscreen. Wash area with mild soap and water and dry completely before applying. Tear packet open just before use and squeeze entire contents into hand or directly onto application site. Amount of gel will be size of a nickel on the skin. Gently rub into skin until dry. Wash hands immediately following application. Avoid application near open fire or when smoking; medication is flammable. Do not shower, bathe, swim, exercise, or immerse the application site in water within 1 hr after application. Cover application site with clothing if close skin-to-skin contact at application site is anticipated. Evaluation/Desired Outcomes Relief of bladder spasm and associated symptoms (frequency, urgency, nocturia, and incontinence) in patients with a neurogenic or overactive bladder.

prednisoLONE (pred-niss-oh-lone) Flo-Pred, Orapred, Orapred ODT, Pediapred, Prelone Classification Therapeutic: anti-inflammatories (steroidal) (intermediate-acting), immune modifiers Pregnancy Category C

indications: Used systemically and locally in a wide variety of chronic diseases including: : Inflammatory, , Allergic, , Hematologic, , Neoplastic, , Autoimmune disorders. Suitable for alternate-day dosing in the management of chronic illness. Replacement therapy in adrenal insufficiency. Unlabelled Use: Adjunctive therapy of hypercalcemia. Adjunctive management of nausea and vomiting from chemotherapy. Action In pharmacologic doses, suppresses inflammation and the normal immune response. Has numerous intense metabolic effects (see Adverse Reactions and Side Effects). Suppresses adrenal function at chronic doses of 5 mg/day. Has minimal mineralocorticoid activity. Therapeutic Effects: Suppression of inflammation and modification of the normal immune response. Replacement therapy in adrenal insufficiency. Pharmacokinetics Absorption: Well absorbed following oral administration. Distribution: Widely distributed, crosses the placenta, and probably enters breast milk. Metabolism and Excretion: Metabolized mostly by the liver. Half-life: 2.1-3.5 hr (plasma), 18-36 hr (tissue); adrenal suppression lasts 1.25-1.5 days. TIME/ACTION PROFILE (anti-inflammatory activity) ROUTE ONSET PEAK DURATION PO unknown 1-2 hr 1.25-1.5 days Contraindications/Precautions Contraindicated in: Active untreated infections (may be used in patients being treated for tuberculous meningitis); Lactation: Avoid chronic use; Known alcohol or bisulfite hypersensitivity or intolerance (some products contain these; avoid in susceptible patients). Use Cautiously in: Chronic treatment (leads to adrenal suppression; use lowest possible dose for shortest period of time); Pedi: Chronic use will result in ↓ growth; use lowest possible dose for shortest period of time; Stress (surgery, infections); supplemental doses may be needed; Potential infections may mask signs (fever, inflammation); Pedi: Neonates (oral solution and syrup contains benzoic acid, a metabolite of benzyl alcohol, which can cause potentially fatal gasping syndrome); OB: Safety not established. Adverse Reactions/Side Effects (CAPITALS indicate life-threatening; underlines indicate most frequent.) Adverse reactions/side effects are much more common with high-dose/long-term therapy CNS: depression, euphoria, headache, ↑ intracranial pressure (children only), personality changes, psychoses, restlessness. EENT: cataracts, ↑ intraocular pressure. CV: hypertension. GI: PEPTIC ULCERATION, anorexia, nausea, vomiting. Derm: acne, ↓ wound healing, ecchymoses, fragility, hirsutism, petechiae. Endo: adrenal suppression, hyperglycemia. F and E fluid retention (long-term high doses), hypokalemia, hypokalemic alkalosis. Hemat: THROMBOEMBOLISM, thrombophlebitis. Metab: weight gain, weight loss. MS: muscle wasting, osteoporosis, avascular necrosis of joints, muscle pain. Misc: cushingoid appearance (moon face, buffalo hump), ↑ susceptibility to infection. Interactions Drug-Drug: Additive hypokalemia with thiazide and loop diuretics, amphotericin B, piperacillin, or ticarcillin. Hypokalemia may ↑ risk of digoxin toxicity. May ↑ requirement for insulin or oral hypoglycemic agents. Phenytoin, phenobarbital, and rifampin stimulate metabolism; may ↓ effectiveness. Oral contraceptives may ↓ metabolism. ↑ risk of adverse GI effects withNSAIDs (including aspirin ). At chronic doses that suppress adrenal function, may ↓ antibody response to and ↑ risk of adverse reactions from live-virus vaccines. May ↑ risk of tendon rupture from fluoroquinolones. Route/Dosage PO (Adults): Most uses—5-60 mg/day as a single dose or in divided doses. Multiple sclerosis—200 mg/day for 7 days, then 80 mg every other day for 1 mo. Asthma exacerbations—120-180 mg/day in divided doses 3-4 times/day for 48 hr, then 60-80 mg/day in 2 divided doses. PO (Children): Anti-inflammatory/Immunosuppressive—0.1-2 mg/kg/day in 1-4 divided doses. Nephrotic syndrome—2 mg/kg/day (60 mg/m2/day) in 1-3 divided doses daily (maximum dose: 80 mg/day) until urine is protein free for 4-6 weeks, followed by 2 mg/kg/dose (40 mg/m2/dose) every other day in the morning, gradually taper off over 4-6 weeks. Asthma exacerbations—1 mg/kg q 6 hr for 48 hr, then 1-2 mg/kg/day (maximum: 60 mg/day) divided twice daily. Availability (generic available) Tablets: 5 mg. Orally disintegrating tablets (grape flavor): 10 mg, 15 mg, 30 mg. Oral solution: 5 mg/5 mL, 10 mg/5 mL, 15 mg/5 mL, 20 mg/5 mL. Oral suspension: 15 mg/5 mL. NURSING IMPLICATIONS Assessment Indicated for many conditions. Assess involved systems prior to and periodically during therapy. Assess patient for signs of adrenal insufficiency (hypotension, weight loss, weakness, nausea, vomiting, anorexia, lethargy, confusion, restlessness) prior to and periodically during therapy. Monitor intake and output ratios and daily weights. Observe patient for peripheral edema, steady weight gain, rales/crackles, or dyspnea. Notify health care professional should these occur. Pedi: Children should have periodic evaluations of growth. Lab Test Considerations: Monitor serum electrolytes and glucose. May cause hyperglycemia, especially in persons with diabetes. May cause hypokalemia. Patients on prolonged therapy should routinely have hematologic values, serum electrolytes, and serum and urine glucose evaluated. May ↓ WBC counts. May ↓ serum potassium and calcium and increase serum sodium concentrations.. Guaiac test stools. Promptly report presence of guaiac-positive stools.. May ↑ serum cholesterol and lipid values. May ↓ uptake of thyroid 123I or 131I.. Suppresses reactions to allergy skin tests.. Periodic adrenal function tests may be ordered to assess degree of hypothalamic-pituitary-adrenal axis suppression in systemic and chronic topical therapy. Potential Nursing Diagnoses Risk for infection (Side Effects) Disturbed body image (Side Effects) Deficient knowledge , related to medication regimen (Patient/Family Teaching) Implementation If dose is ordered daily or every other day, administer in the morning to coincide with the body's normal secretion of cortisol. Periods of stress, such as surgery, may require supplemental systemic corticosteroids. PO: Administer with meals or milk to minimize GI irritation.. Tablets may be crushed and administered with food or fluids for patients with difficulty swallowing.. Orally disintegrating tablets: Remove tablet from blister just prior to dosing. Peel blister pack open, and place orally disintegrating tablet on tongue. Tablets may be swallowed whole or allowed to dissolve in mouth, with or without water. Do not cut, split, or break.. Use calibrated measuring device to ensure accurate dose of liquid forms. Patient/Family Teaching Instruct patient on correct technique of medication administration. Advise patient to take medication as directed. Take missed doses as soon as remembered unless almost time for next dose. Do not double doses. Stopping the medication suddenly may result in adrenal insufficiency (anorexia, nausea, weakness, fatigue, dyspnea, hypotension, hypoglycemia). If these signs appear, notify health care professional immediately. This can be life-threatening.. Glucocorticoids cause immunosuppression and may mask symptoms of infection. Instruct patient to avoid people with known contagious illnesses and to report possible infections immediately. Prelone syrup should not be refrigerated, Pediapred solution may be refrigerated, Orapred solution should be refrigerated. Caution patient to avoid vaccinations without first consulting health care professional. Review side effects with patient. Instruct patient to inform health care professional promptly if severe abdominal pain or tarry stools occur Patient should also report unusual swelling, weight gain, tiredness, bone pain, bruising, nonhealing sores, visual disturbances, or behavior changes. Advise patient to notify health care professional of medication regimen prior to treatment or surgery. Discuss possible effects on body image. Explore coping mechanisms. Instruct patient to inform health care professional if symptoms of underlying disease return or worsen. Advise patient to carry identification describing disease process and medication regimen in the event of emergency in which patient cannot relate medical history. Explain need for continued medical follow-up to assess effectiveness and possible side effects of medication. Periodic lab tests and eye exams may be needed. Long-term Therapy: Encourage patient to eat a diet high in protein, calcium, and potassium, and low in sodium and carbohydrates (see Appendix M). Alcohol should be avoided during therapy. Evaluation/Desired Outcomes Decrease in presenting symptoms with minimal systemic side effects. Suppression of the inflammatory and immune responses in autoimmune disorders, allergic reactions, and neoplasms. Management of symptoms in adrenal insufficiency.