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LPN IV Series: IV Pharmacology

5.00 Contact Hours   -   1.00 CCU
A score of 80% correct answers on a test is required to successfully complete any course and attain a certificate of completion.
Authors:    Wesley Hunter () , Julia Tortorice (RN, MBA, MSN, NEA-BC, CPHQ)

Outcomes

100% of participants will safely administer IV medications.

Objectives

After completing this course the participant will be able to:

  • Identify medication classes
  • Discuss IV medication
  • Identify specific medication precautions
  • Describe the use of technology
  • Identify high-risk medication

Antibiotics (Anti-infective)

Antibiotics are a diverse group of medications used to fight infection. They are classified by action as bacteriostatic or bactericidal. Bacteriostatic action inhibits growth and bactericidal kill bacteria. This is accomplished thru various mechanisms including inhibiting cell wall synthesis, alteration of cell permeability, prohibiting cell protein synthesis, changes in nucleic acid metabolism of the cell, blocking metabolic steps of the cell, blocking DNA synthesis.1
Class of agents includes:

  • Beta-lactam
  • Macrolide
  • Penicillin
  • Cephalosporin, multiple generations
  • Tetracycline
  • Carbapenem β-lactam
  • Fluoroquinolone
  • Nitroimidazole
  • Rifamycin
  • Glycylcycline
  • Glycopeptide

The effectiveness of an antibiotic can be altered by the manner in which it is taken. Antibiotics should be taken at regular intervals to maintain appropriate concentrations.

It is good practice to culture the suspected bacteria first.1 This will allow for a definitive treatment of an antibiotic that the organism is susceptible to. However, if treatment is required sooner, guidelines for the specific medication should be adhered to. It is also important to assess the severity of the illness.1 This will be a factor in how aggressively to treat and for how long to treat.

Allergic reactions can occur even in patients who have not previously shown sensitivity to the medication. It is important to observe the patient closely while the medication is being administered. Reactions may be rapid in onset or may not occur for days or weeks following the initiation of the therapy. Allergic reactions vary in intensity from a mild rash to difficulty breathing.

An important complication is that of a superinfection. These superinfections occur due to the resistance of the bacteria to the antibiotic. For example, women may get a vaginal yeast infection from antibiotic treatment

Adverse effects are different from allergic reactions. They are often considered expected side effects of the medications. Common adverse effects of antibiotics are nausea, vomiting, and diarrhea. Serious adverse reactions include bone marrow suppression and anaphylaxis. Some antibiotics have very specific and severe adverse effects and contraindications.

Many IV antibiotics have a short half-life once mixed. They may come in a bag that has a medication vial attached. The bag allows you to pop the top of the medication vial and mix thoroughly with the IV solution without contaminating the solution.

Medication2Adult IV DosageNotes
Ampicillin (Omnipen, Polycillin, Principen)1-2 gm IV every 4-6 hours 
Ampicillin-sulbactam (Unasyn)1.5-3 gm IV every 6-8 hours 
Azithromycin (Zithromax)500 mg 1 time a dayDiluted in 250 mL NS
Aztreonam (Azactam)1-2 gm 3 times a day 
Cefotaxime (Claforan)1-3 gm every 3 hoursdiluted in 50-100 mL NS
20 mL syringe for IVP over 5-10 minutes
Ceftaroline Fosamil (Teflaro)600 mg 1 or 2 times a day 
Ceftriaxone (Rocephin)1-2 gm 1-2 times a dayDiluted in 50-100 NS
Ciprofloxacin (Cipro)400 mg 2 times a day 
Clindamycin (Cleocin)600-900 mg every 8-12 hoursDiluted in 50-100 NS
Doxycycline (Vibramycin, Doxychel)100-400 mg 1 time a day 
Ertapenem (Invanz)1 gm 1 time a day 
Imipenem-cilastain(Primaxin)1 gm every 8-12 hours 
Levofloxacin (Levaquin)500 mg 1 time a day 
Meropenem (Merrem)1 gm every 8-12 hours 
Metronidazole (Flagyl)500 mg up to 3 times a day 
Moxifloxacin (Avelox)400 mg 1 time a day 
Rifampin (Rifadin)300 mg 2 times a day or 600 mg 1 time a dayDiluted in 500 mL NS
Tigecycline (Tygacil)100 mg loading dose then 50 mg 2 times a day 
Vancomycin (Vancocin)Given 1-2 times a dayDiluted in 250-500 mL NS
Weekly labs for kidney function. Must be drawn as ordered to get correct peak and trough
Zosyn (Piperacillin/Tazobactam3.37-4.5 gm every 6 hoursDiluted in 50-150 mL

Nursing Consideration and Patient Education:

  • Antibiotics may interfere with oral contraceptives.
  • The patient should take the medication exactly as ordered since the timing of some antibiotics is crucial to maintaining therapeutic levels.
  • Superinfections caused by the overgrowth of nonsusceptible organisms, like yeast, may occur with antibiotic use. Symptoms may be diarrhea, anogenital itching, vaginal discharge or stomatitis.
  • Encourage the patient to increase fluid intake, especially water, if it is not contraindicated

Anticoagulants

Anticoagulants are used to treat or prevent blood clots caused by strokes, MI, DVT, and PE. This group of medications slows down bleeding times thus delaying the clotting process. The goal is to promote anticoagulation while minimizing hemorrhagic issues. 1 Medications, such as heparin, are used in more serious disease processes and are therefore administered via injection or IV.

The most commonly prescribed medications in this class are Warfarin (Coumadin) and Heparin. Low Molecular Weight Heparin Therapy or LMWH, has a longer duration and does not need aPTT checked. Differences in LMWH include a more predictable effect on clotting. The use of the LMWH has a lower incidence of heparin-induced thrombocytopenia and possibly lowers bleeding risks.1 LMWH medications include dalteparin (Fragmin), enoxaparin (Lovenox), fondaparinux (Arixtra), and tinzaparin (Innohep). The most common side effect for anticoagulant medications is an increased risk of hemorrhaging. Also, renal excretion must be taken into consideration as these medications are excreted mostly in the urine.1

It should be noted that the Joint Commission has listed anticoagulant therapy as a patient safety goal. Check with your facility to review the patient safety plan.

Anticoagulants are used for the following conditions:

  • Prophylaxis and treatment of venous thrombosis
  • Preventing thromboembolic complications arising from cardiac surgery, vascular surgery, and frostbite
  • Treatment of disseminated intravascular clotting syndrome
  • Treatment of atrial fibrillation with embolization
  • Anticoagulant during dialysis
  • Heart surgery
  • Treatment of acute stroke or prevention of stroke
  • Treatment of acute MI

Before administering an anticoagulant, coagulation test values must be checked. The tests vary per medication. Below is a chart depicting the most common coagulation tests and medication prescribed. Note that each facility or laboratory may vary.Wear identification stating use of heparin

Warfarin (Coumadin)

Inhibits Vitamin K synthesis which impacts Factors VII, IX, X, and II. At a therapeutic level, Warfarin inhibits the liver's production of vitamin K which is what creates the therapeutic range. Although therapeutic ranges may be achieved in 1-2 hours, the full effect is not achieved for 4-5 days until Factor II is depleted.1 It is important to draw the INR on time and prior to administering the medication. The INR is one way to determine the dose of the medication. INR is typically checked every three days until the therapeutic range is achieved. The INR is checked periodically. INR should also be checked seven days after starting or changing the dose of a new medication.3

Warfarin has a black box warning as it can cause major bleeding. Bleeding is more likely to occur during the start of the treatment. It is important to monitor INR carefully as well as completing a full assessment of the patient.3 Warfarin also interacts with several other medications and foods. Be sure to check all medications for interactions and assess the patient’s diet and make sure to ask about any herbals or vitamins taken.

Warfarin can be given IV.

IndicationInternational Normalization Ratio (INR) Therapeutic Range
Venous thrombosis
Pulmonary Embolism
Prevention of systemic embolism
Tissue heart values
Acute MI
Atrial Fibrillation
2.3-3.0
Recurrent embolism
Mechanical heart valve
2.5-3.5

Warfarin may impact other laboratory tests3

ALT, ASTIncrease
INR, PT, PTTIncrease
theophyllineFalse decrease

Foods and supplements that impact Warfarin

  • Grapefruit and Cranberry products
  • Green leafy vegetables must be kept consistent in the diet
  • Garlic
  • Ginger
  • Gingko Biloba
  • Feverfew
  • Fish oil
  • Turmeric
  • St John’s Wort
  • Chondroitin sulfate
  • Vitamin supplements

Be sure to assess alcohol intake and vegetable intake especially vegetables high in vitamin K such as kale, parsley, collards, spinach, turnip greens, mustard greens, collard greens and beet greens.

Heparin

Unfractionated heparin (UFH) is an older form that has been used in clot prevention for many years. It is usually used in the hospital setting as a treatment for acute issues such as DVT, PE, MI, stroke, or atrial occlusion. This can also be given prophylactically prior to surgery. Check with your institution as to the proper procedural use. Side effects are more significant with UFH and include an increased chance of bleeding as well as pain and bruising at the injection site. Patients will usually get switched to an LMWH due to the high side effect profile of UFH. Monitoring aPTT begins 3-4 hours after initiation and doses adjusted accordingly.1

Heparin and LMWH can be given IV. Heparin is usually started with an IV push bolus followed by a continuous infusion. The dosage is going to vary based on the condition being treated and the weight of the patient.

What to monitor3,4
Laboratory TestWhat it measuresResults
Activated partial prothrombin time - aPTTMonitors intrinsic pathway of thrombin, factor Xa, used in Heparin therapyNormal is 25-41
On Heparin results may be 1.5 -2 times normal
Prothrombin time - PTMonitors extrinsic pathway and Vitamin K dependent clotting Factors VII, X, and II. Used in Warfarin therapy.Reported at INR
International Normalization Ratio - INRMathematical equation used to measure PT test and the time it takes blood to clot. Used in Warfarin therapy.2-3.5 if taking anticoagulants
Heparin TypeMonitoring
Parenteral Heparin
IV,
Full dose
Subcutaneous
aPTT every 6 hours
Daily platelets for HIT
Daily Hemoglobin for hemorrhage
Check stool for occult blood
Subcutaneous Heparin
All low dose UFH
CBC with platelets if side effects occur
Assess for ecchymosis, purpura, CNS changes, headache, stool for occult blood
Subcutaneous Heparin
Standard UFH; fixed doses, IV
aPTT
Platelets every 2-3 days from day 4 until 14 or until discontinued
LMWHDoes not affect aPTT
The Heparins1
SUBCLASSGENERIC NAMETRADE NAME
Heparinheparin sodiumgeneric
LMWHenoxaparin sodiumLovenox
 dalteparinFragmin
 tinzaparinInnohep
HeparinoidsdanaparoidOrgaran
 fondaparinuxArixtra
Use of Heparin1
HeparinPrevent VTE during surgery, prophylaxis and treatment of PE, atrial fibrillation with embolism, acute and chronic DIC, prevent clotting during surgery, prevention of arterial embolism, anticoagulant in blood transfusions, anticoagulant in blood transfusions, extracorporeal circulation, dialysis procedures, Not recommended for acute ischemic stroke
LMWH, fondaparinuxPrevention of VTE in surgery, PE and acute coronary syndrome, bridge therapy for anticoagulant patient preoperative, revascularization therapy, recent warfarin therapy with subtherapeutic INR.

Keep in mind that warfarin (Coumadin) takes several days to reach therapeutic concentration. It is important to remember to start warfarin prior to discontinuing heparin therapy. Warfarin is gradually adjusted until the INR of 2:3 is reached. The target range may be higher for certain disorders.1

Nursing Considerations for Heparin:

  • SQ Inject between iliac crests in lower abdomen into the fat layer
  • Do not massage area
  • Alternate sites every 12 hours
  • Draw blood for PTT 4-6 hours after administration (Therapeutic level is 1 ½- 2 ½ times the baseline)
  • Monitor platelet count
  • Assess patient for bruising, bleeding, petechiae, nosebleed, melena, tarry stool, hematuria, and hematemesis
  • Monitor for agranulocytosis, leukopenia, eosinophilia, thrombocytopenia, tissue irritation and sloughing, and site reactions. Patients should be monitored for signs and symptoms of hemorrhage, like a drop in BP or rapid pulse.
    Monitor vital signs
  • Do not check for blood return
  • Apply gentle pressure for 5-10 seconds

Patient Education

  • Instruct patient or caregiver to watch for bleeding or bruising
  • Avoid OTC medications containing aspirin or salicylates
  • Avoid herbal supplements
  • Encourage smoking cessation as nicotine decreases the effect of heparin
  • Monitor CBC in menstruating females (May see excessive bleeding)
  • Use a soft toothbrush
  • Use an electric razor
  • Wear identification stating use of heparin

Anticonvulsants

Anticonvulsants are used to control seizure activity and inhibit the spread of the seizure at the motor cortex.

Common agents include:

  • phenytoin (Dilantin)
  • carbamazepine (Tegretol)
  • phenobarbital (Luminal)
  • divalproex Sodium (Depakote)
  • valproic acid (Depakene)

When giving an anticonvulsant IV, frequently observe for signs of infiltration at the IV site since these medications can destroy soft tissue. Continuously monitor vital signs closely during IV infusion and for 1 hour following completion. A cardiac monitor should be used. Watch for respiratory depression.3

Adverse effects include drowsiness, ataxia, headache, dizziness, blurred vision, nausea and vomiting, anorexia, constipation, diarrhea, rash, bone marrow depression, blood dyscrasias, hypocalcemia and rickets.3

IV Anticonvulsant5DosageNotes
Briviact (Brivaracetam)100 mg twice a day initiallyInject over 2-15 minutes
Compatible with NS, D5W and LR
Carnexiv (Carbamazepine)
7-26 mL every 6 hours
Piggyback over 30 minutes
Must be diluted in 100 mL
Compatible with NS, D5W and LR
Valium (Diazepam)2-20 mL every 3-4 hoursInject at 1 mL per minute
Do not dilute
Fosphenytoin sodium15 to 20 mg PE/kgInject at 100 to 150 mg PE/min.
For short-term IV use
Requires dilution concentration ranging from 1.5 to 25 mg PE/mL
Compatible with NS and D5W
Vimpat (lacosamide)50 mg twice a dayCompatible with NS, D5W and LR
Levetiracetam500 mg twice a day initiallyPiggyback 100 mL over 15 minutes
Comes premixed in 100 mL or 500 mL
Do not dilute
Ativan (Lorazepam)Depends on condition being treated 
Phenobarbital100-320 mg 
Dilantin (phenytoin)10-20 mg/kgMaximum infusion rate 50 mg/min
Recommended infusion 40-50 mg/min
Elderly infusion rate 20-25 mg/min
Depocon, Depakene, Depakote (Valproic acid)Depends on condition being treated60-minute infusion (n style="background:white"> 20 mg/minute) 

Adverse effects include drowsiness, ataxia, headache, dizziness, blurred vision, nausea and vomiting, anorexia, constipation, diarrhea, rash, bone marrow depression, blood dyscrasias, hypocalcemia and rickets.3

Patient Education:

  • To avoid danger, patients on these medications should not drive or participate in activities requiring alertness.
  • Patients with a seizure history should carry an ID card or medic alert bracelet that includes the medications they take.
  • Patients should take the medication with food or milk to decrease GI symptoms.
  • Patients on prolonged therapy should have an adequate intake of Vitamin D foods and sufficient exposure to sunlight.
  • Anticonvulsants may turn the patient's urine pink, red or red-brown.
  • Since some anticonvulsants are metabolized by the liver, caution the patient to report any jaundice immediately.
  • Caution the patient to take the medication as prescribed. Abrupt discontinuation may precipitate seizures and status epilepticus.
  • Alcohol intake may increase Dilantin levels leading to toxicity. When taking barbiturates, the patient should abstain from alcohol or psychotropic medications unless directed by a physician.

Nursing Considerations

  • Be sure to check required laboratory tests
  • Monitor the patient for changes in behavior
  • Monitor for hepatotoxicity
  • Monitor therapeutic range

Antihypertensive Medications

Antihypertensive medications are used to treat elevations of the systolic blood pressure, diastolic blood pressure or both. According to the Eighth Joint National Committee on Prevention, Detection, Evaluations and Treatment of High Blood Pressure, there are several classes of antihypertensives shown to be moderately effective for treatment.7 The report further states that personal data such as ethnicity, race, and environmental conditions need to be assessed and taken into consideration when treating high blood pressure. For example, the report states that various classes of antihypertensives such as angiotensin-converting enzyme inhibitors, angiotensin receptor blockers calcium channel blockers, or thiazide-type diuretics are recommended for non-black persons with hypertension. However, in black patients with hypertension including those with diabetes, a calcium channel blocker, or a thiazide-type diuretic is recommended for treatment.1

Angiotensin-Converting Enzyme Inhibitors (ACE)

ACE Inhibitors work by interrupting the conversion of renin-angiotensin I to angiotensin II. This causes dilation of the arterial and venous vessels and as result blood pressure drops.

Common ACE inhibitor agents include:

  • Benazepril (Lotensin)
  • Captopril (Captopril)
  • Enalapril (Vasotec)
  • Fosinopril (Monopril)

Ace inhibitors are absorbed in the gut and metabolized mostly in the liver. The kidneys excrete these medications. Careful monitoring of renal function and liver stability is imperative. Ace inhibitors stop the conversion of angiotensin I into becoming angiotensin II.4 Angiotensin II is a peripheral vasoconstrictor that causes excretion of aldosterone that in turn causes sodium and water retention. If angiotensin II is not allowed to work, peripheral vascular resistance is reduced, and the lack of aldosterone promotes the excretion of sodium and water. This reduces the amount of blood going through the heart, which will reduce blood pressure.1, 4

Ace inhibitors can be used in conjunction with other medications to treat hypertension. Most commonly they are prescribed with beta-adrenergic blockers or diuretics. Some Ace inhibitors such as lisinopril and captopril are also used in heart failure in certain instances, in particular for left ventricular dysfunction to improve mortality and morbidity.1

Enalapril (Vasotec) initial IV dose is 1.25 mg/dose, given over 5 minutes every 6 hours; doses as high as 5 mg/dose every 6 hours have been tolerated for up to 36 hours.32

Nursing Considerations

  1. These medications can become less effective when used with NSAIDs and antacids.
  2. Ace inhibitors enhance the hypotensive effect of diuretics and beta-adrenergic blockers
  3. They can increase serum lithium levels
  4. Food decreases absorption of Ace inhibitors
  5. Adverse reactions include: headache, fatigue, GI reactions, cough, and throat irritation are the most common.
  6. Ace inhibitors can also cause an increase in serum potassium and an elevation of BUN and creatinine levels
  7. Monitor vital signs regularly
  8. Check for adverse reactions
  9. Monitor weight, electrolytes and fluid status.
  10. Instruct the patient to take with food or at bedtime
  11. Instruct the patient to get up slowly as orthostatic hypotension can occur when rising.
  12. Help the patient maintain a diet and exercise program

Several medication interactions can occur. Care should be taken to review all medications taken with Ace inhibitors. For example, NSAIDs reduce the medication’s effectiveness, potassium supplements and cause hyperkalemia, and lithium levels may be increased when taken with Ace inhibitors.4

B-adrenergic blockers (beta blockers)

B-adrenergic (beta) blockers reduce blood pressure by blocking effects of epinephrine. This helps the heart relax. The beats slower, the left ventricle fills more completely, vessels become more open, and the heart uses less force to work.4 Cardiac output is reduced causing a decrease in peripheral vascular resistance and a decrease in renin activity.6

Common agents include:

  • Acebutolol (Sectral)
  • Atenolol (Tenormin)
  • Metoprolol (Lopressor)
  • Labetalol (Trandate)
  • Propranolol (Inderal)
  • Bisoprolol (Zebeta)
  • Nadolol (Corgard)

Beta-blockers are, for the most part, absorbed in the GI tract, metabolized by the liver and excreted through the renal system. Some beta-blockers such as propranolol and metoprolol are more highly bound to protein than the others in this class.6

It is important to note that several medications interact with beta-blockers:

  • Antacids can delay absorption
  • NSAIDs can decrease the hypotensive effects
  • Lidocaine toxicity can occur
  • Diabetic medications may need to be altered

Also, adverse reactions include bradycardia, angina, heart failure, arrhythmias, fainting, fluid retention, peripheral edema, nausea and vomiting, diarrhea, and difficulty breathing due to bronchiole constriction.3

Atenolol (Tenormin) initial IV dosage is 1.25 to 5 mg every 6-12 hours have been used in short-term management of patients unable to take oral tabs. MI early treatment: 5 mg slow IV over 5 minutes; may repeat in 10 minutes. If both doses are tolerated, may start oral atenolol 50 mg every 12 hours or 100 mg/day for 6-9 days post myocardial infarction. Oral: Follow IV dose with 100 mg/day or 50 mg twice daily for 6 to 9 days post myocardial infarction.5

Esmolol (Brevibloc) used for supraventricular tachycardia or gradual control of postoperative tachycardia/hypertension IV loading dose: 500 mcg/kg over 1 minute; follow with a 50 mcg/kg/minute infusion for 4 minutes; response to this initial infusion rate may be a rough indication of the responsiveness of the ventricular rate. Infusion may be continued at 50 mcg/kg/minute or, if the response is inadequate, titrated upward in 50 mcg/kg/minute increments (increased no more frequently than every 4 minutes) to a maximum of 200 mcg/kg/minute.5

To achieve more rapid response, following the initial loading dose and 50 mcg/kg/minute infusion, re-bolus with a second 500 mcg/kg loading dose over 1 minute, and increase the maintenance infusion to 100 mcg/kg/minute for 4 minutes. If necessary, a third (and final) 500 mcg/kg loading dose may be administered, prior to increasing to an infusion rate of 150 mcg/minute. After 4 minutes of the 150 mcg/kg/minute infusion, the infusion rate may be increased to a maximum rate of 200 mcg/kg/minute (without a bolus dose).5

Supraventricular tachycardias (SVT) IV dose range: Usual dosage range is 50-200 mcg/kg/minute with average dose of 100 mcg/kg/minute.5

Labetalol (Normodyne) use in hypertensive emergency dose is 20mg IV slow injection, then 40-80 mg IV every 10 minutes as needed. (up to 300 mg total dose) until desired BP is reached or start continuous infusion: 2 mg/min (range: 1 to 3 mg/min)–titrate to BP.

Metoprolol (Lopressor) use in Hypertension/ventricular rate control IV dose(in patients having nonfunctioning GI tract): Initial: 1.25-5 mg every 6-12 hours; titrate initial dose to response. Initially, low doses may be appropriate to establish response; however, up to 15 mg every 3-6 hours has been employed. Use in MI, initial IV dose 5 mg every 2 minutes for 3 doses in early treatment of myocardial infarction; thereafter give 50 mg orally every 6 hours 15 minutes after last IV dose and continue for 48 hours; then administer a maintenance dose of 100 mg twice daily. When administered acutely for cardiac treatment, monitor ECG and blood pressure. 5

Propranolol (Inderal) use in life-threatening arrhythmia dose is usually 1- 3 mg (maximum rate: 1 mg/min)-may dilute in 50 mL D5W. May repeat 1 mg dose every 5 minutes to maximum of 5 mg total. Subsequent doses no sooner than 4 hours. May start IV infusion: usual rate: 2 to 3 mg/hr. Titrate to HR/BP.5

Nursing Consideration

  1. Check apical pulse. Some medications such as metoprolol should be held if the apical pulse is less than 60 beats/minute
  2. Educate the patient not to stop this medication suddenly. This can cause angina, arrhythmia, and MI
  3. Monitor renal and liver laboratory results
  4. Assess for adverse reactions
  5. Educate the patient on medication interactions

Calcium Channel Blockers

Calcium channel blockers act on three calcium channels in the heart that control contractility and heart rate; the peripheral vascular system to control blood pressure, and the brain’s vascular system. The medication prevents calcium from entering these areas resulting in an increase of oxygen to the heart and decreased contractility.4 The medications also slow the heart rate by suppressing the sinoatrial node and the atrioventricular node. Some of the medications in this category also dilate the peripheral vascular system and some also stop vasospasms in the brain.  Because these medications cause vasodilation, headache is the most common complaint. Hypotension can also be common along with dizziness, headache, dysrhythmias, edema, fatigue, drowsiness and flushing.1, 4

Common agents include:

  • Diltiazem (Cardizem, Tiazac)
  • Felodipine (Plendil)
  • Nifedipine (Procardia)

Diuretics

Diuretics cause increased excretion of fluid through the kidneys thus reducing the circulating blood volume and ultimately reducing blood pressure.7 They inhibit the reabsorption of electrolytes such as sodium back into the circulatory system. There are three classes of diuretics; loop diuretics, thiazide diuretics, and potassium-sparing diuretics. Each type works at a different site within the kidney. Although these medications are widely used and cost-effective, care should be taken with special populations such as the elderly. Side effects can include electrolyte problems especially hypokalemia, problems with sodium, potassium, hydrogen and magnesium. Careful management through laboratory tests needs to be maintained.1, 7

Class of DiureticSite of ActionExamplesNotes
LoopAscending limb of the loop of Henlefurosemide, bumetanide, TorasemideMost powerful
Thiazide and Thiazide-likeDistal convoluted tubulebendroflumethiazide, indapamide, Metolazone, ChlortalidonePreferred for hypertension
Potassium-sparingCollecting tubules; block loss of potassiumSpironolactone, Eplerenone, Amiloride, TriamtereneSome inhibit aldosterone; slower acting but effects last longer

Acetazolamide (Diamox) for glaucoma the IV dose is 250-500 mg, may repeat in 2-4 hours to a maximum of 1 g/day. For edema, the IV dose is 250-375 mg once daily.

Bumetanide (Bumex) for edema associated with congestive heart failure, hepatic and renal disease, including the nephrotic syndrome IV bolus dose is 0.5-1 mg/dose over 1-2 minutes; may repeat in 2-3 hours for up to 2 doses if needed (maximum dose: 10 mg/day). Continuous infusion rate is0.9 to 1 mg/hour.

Chlorothiazide (Diuril) IV dose is 500 mg to 1 g once or twice daily.

Ethacrynic Acid (Edecrin) IV dose is 50mg x 1 (0.5-1 mg/kg/dose). Maximum is 100 mg/dose. Usually, only one dose has been necessary; occasionally a second dose may be required. Use a new injection sit for the second dose, to avoid possible thrombophlebitis, A single intravenous dose not exceeding 100 mg has been used in critical situations. Dilute in D5W or NS (1 mg/mL) and infuse over several minutes.5

Furosemide (Lasix) for edema/CHF initial IV bolus is 20-40 mg over 1-2 min. May repeat in 1 to 2 hours or may be increased by 20 mg until desired response. This individually determined dose may be given once or twice daily. For acute pulmonary edema, the initial IV bolus is 40 mg IV over 1-2 minutes. If not adequate, may increase dose to 80 mg. Continuous infusion initial IV bolus dose of 0.1 mg/kg followed by continuous IV infusion doses of 0.1 mg/kg/hour doubled every 2h to a maximum of 0.4 mg/kg/hour if urine output is <1 ml/kg/hour. Other studies have used a rate of 4 mg/minute as a continuous IV infusion. For the elderly, initial IV dose is 20 mg/day; increase slowly to desired response. For acute renal failure high doses (up to 1-3 g/day) have been used to initiate desired response. Avoid use in oliguric states. Replace parenteral therapy with oral therapy as soon as possible.5

Torsemide (Demadex) for CHF initial IV bolus is10-20 mg daily. Edema (liver disease) initial IV bolus is 5-10 mg. Edema (renal failure) initial IV bolus is 20 mg daily. May increase by doubling the dose. Maximum: 200 mg daily.

Nursing Considerations

  1. Diuretics should be taken early in the day to prevent nocturia.
  2. Monitor blood pressure, pulse, weight
  3. Monitor patients for lupus-like syndrome. (sore throat, fever, muscle ache, joint aches, rash)
  4. Assess for dizziness, orthostatic hypotension, general malaise, muscle or joint pain, chest pain. Use diuretics with caution in the elderly because electrolyte disturbances and dehydration can occur rapidly.
  5. The nursing assessment should include a daily weight, intake and output, and a check of skin turgor for dehydration.
  6. Monitor for signs of metabolic alkalosis including drowsiness and restlessness.
  7. Monitor for signs of hypokalemia including postural hypotension, malaise, fatigue, tachycardia, leg cramps and weakness., confusion, anuria,
  8. Monitor electrolytes
  9. Thiazide can exacerbate diabetes and gout 8
  10. Avoid potassium supplements with potassium-sparing diuretic
  11. Avoid Ace inhibitors with potassium-sparing diuretics

Centrally Acting Alpha 2 Antagonists

Centrally acting alpha 2 antagonists are used to treat mild hypertension and are generally the second line of defense when other medications are not effective.4 However, methyldopa is the first line medication for hypertension in pregnancy. These medications work by activating the alpha 2 receptors with inhibits the cardio acceleration and vasoconstriction process in the brain. This reduction in sympathetic function, in turn, causes a decrease in peripheral norepinephrine and decrease peripheral resistance, renal vascular resistance, heart rate and blood pressure. These medications can cause sodium retention and are often given with a diuretic1, 4

Common agents include:

  • lonidine (Catapres)
  • Guanabenz (Wytensin)
  • Guanfacine (Tenex, Intuniv)
  • Methyldopa
  • Clonidine/chlorthalidone (Clorpres) includes a thiazide diuretic.

Clonidine is absorbed via the GI tract and the skin. It is also lipid soluble and enters the brain from circulation. Guanabenz and guanfacine are also absorbed this way. However, methyldopa is only absorbed by about 50% in the GI tract. This medication enters the brain through amino acid transporters. Metabolism occurs in the liver and is excreted in urine.4

IV Methyldopate (Aldomet) add the desired dose to 100 mL of D5W. Alternatively, the desired dose may be given in D5W in a concentration of 100 mg/10 mL. Give this intravenous infusion slowly over a period of 30 to 60 minutes. Adult IV dosage is 250 mg to 500 mg at six-hour intervals as required. The maximum recommended intravenous dose is 1 gram every six hours.

Nursing Considerations

  1. Review liver and renal function laboratory tests
  2. Assess for side effects including drowsiness, dry mouth, constipation, urinary tract infection, impotence, nightmare and insomnia with Clonidine.
  3. Assess for hypotension, chest pain, bradycardia,
  4. GI symptoms are associated with guanabenz including nausea, vomiting, anorexia, abdominal pain
  5. Assess for gynecomastia with guanabenz and clonidine
  6. Assess for pruritic rash
  7. Review medications for interactions such as beta blockers.

Peripherally acting antiadrenergic

Peripherally acting antiadrenergic inhibit sympathetic vasoconstriction by inhibiting release of norepinephrine and/or depleting norepinephrine stores in adrenergic nerve endings.1,4

Common agents include:

  • Prazosin (Minipress)
  • Reserpine
  • Terazosin (Hytrin)
  • Nursing Considerations

  1. Assess blood pressure and pulse
  2. Be aware that the elderly are more sensitive to hypotensive effects
  3. Assess for dizziness, dry mouth, suddenly standing,
  4. Monitor liver and renal functions in laboratory tests
  5. Review medication list for medication interactions. Diuretics may cause increase dizziness.
  6. Review any herbs or over the counter medications used.

Peripheral Vasodilators

Peripheral vasodilators act with direct relaxation and dilation of the arteriolar smooth muscle. This reduces the peripheral vascular pressure and increases the pulse and cardiac output.1, 4

Common agents include:

Diazoxide (Hyperstat IV)

Hydralazine (Apresoline)

Minoxidil (Loniten)

Fenoldopam Mesylate (corlopam) starting dose of 0.1 to 0.3 mcg/kg/minute, the dose is titrated at 15-minute intervals, depending on the BP response. May be increased in increments of 0.05 to 0.1 mcg/kg/minute every 15 minutes until target blood pressure is reached. Maximal infusion rate reported in clinical studies: 1.6 mcg/kg/minute. Onset/duration: 5-10 minutes/~ 1 hour.5

Hydralazine (Apresoline) Initial (Acute hypertension): 10 mg slow IV bolus (maximum dose being 20 mg) every 4 to 6 hours as needed. May increase to 40 mg/dose (generally speaking – do not exceed 20mg/dose). Change to oral therapy as soon as possible. The fall in blood pressure begins within 10 to 30 minutes and lasts 2 to 4 hours.5

Nesiritide (Natrecor) IV bolus of 2 mcg/kg (over 1 minute) followed by a continuous infusion of 0.01 mcg/kg/min. Withdraw bolus dose from the infusion bag. Higher initial dosages are not recommended. At intervals of 3 hours, the dosage may be increased by 0.005 mcg/kg/minute (preceded by a bolus of 1 mcg/kg), up to a maximum of 0.03 mcg/kg/minute.5

Nicardipine (Cardene) The initial dose is 5 mg/hour and can be increased to a maximum of 15 mg/hour. Effects seen within 15 minutes. Initial dose of 5 mg/hr can be increased by 2.5 mg/hour every 15 minutes to the previously listed maximum of 15 mg/hour. Consider reduction to 3 mg/hour after response is achieved. Monitor and titrate to lowest dose necessary to maintain stable blood pressure. Preparation: Dilute to 0.1 mg/ml (25 mg in D5W 250 ml).5

Nipride (nitroprusside) is considered the most effective parenteral medication for most hypertensive emergencies, except myocardial ischemia or renal impairment. The initial IV dose is 0.3-0.5 mcg/kg/minute. Increase in increments of 0.5 mcg/kg/minute, titrating to the desired hemodynamic effect or the appearance of headache or nausea. The usual dose is 3 mcg/kg/minute. Maximum dosage is 10 mcg/kg/minute.5

Other Antihypertensives

Epoprostenol (PGI2, prostacyclin) is used for long-term intravenous treatment of primary pulmonary hypertension and pulmonary hypertension associated with the scleroderma. 5

The initial IV dose is 2 ng/kg/min IV, titrate upward in increments of 2 ng/kg/min every 15 min or longer until dose-limiting pharmacological effects are elicited or until tolerance develops. Reconstitute only with supplied diluent; do not give with other parenteral medications. Infuse continuous chronic infusion via a central venous catheter with an ambulatory infusion pump. Epoprostenol may be administered peripherally until a central catheter established. Avoid abrupt withdrawal. Anticipate need for periodic dose adjustments. 5

Anti-inflammatories (Nonsteroidal)

These medications, also known as NSAIDs, are used to relieve the pain of low to moderate intensity, for various inflammatory conditions related to arthritic conditions, and to reduce fever in selected infectious conditions. NSAIDs are also used to treat inflammation.4 Although the exact action is not known, it is thought that NSAIDs inhibit cyclooxygenase and prostaglandin synthesis that is part of the cascade involved in inflammation. They are also used as an antipyretic and may help to suppress the rheumatoid factor. There are two cyclooxygenase enzymes or COX -1 and COX-2. COX-1 works to protect the stomach and supports platelets. When NSAIDs are given, the COX enzymes are blocked, especially in long-term use, stomach ulcers and bleeding can occur.4 NSAIDs are metabolized by the liver and excreted through the kidney.

Acetaminophen is an analgesic and an antipyretic as well. These medications have limited anti-inflammatory properties. The mechanism of action is not well known. However, it is believed that it inhibits the central and peripheral prostaglandin synthesis. Acetaminophen is metabolized by the liver and excreted through the kidney. However, when taken in large doses or long-term use, in the liver, acetaminophen binds to sulfate and glucuronide molecules. Too much of the medication can saturate these pathways. When this happens, the medication is processed via the cytochrome P-450 pathway. This pathway produces NAPQI, which is toxic. Normally the glutathione system will detoxify NAPQI. However, the glutathione system becomes saturated by NAPQI in the presence of acetaminophen and causes damage to the liver.9

Common agents include:

  1. Aspirin (Acetylsalicylic acid, Ecotrin)
  2. Ibuprofen (Motrin, Advil)
  3. Sulindac (Clinoril)
  4. Naproxen (Napron, Aleve, Ananprox, Naprosyn)
  5. Oxaprozin (Daypro)
  6. Ketorolac (Toradol) can be given IV bolus 30 mg x 1 or 30 mg q6h (maximum daily dose: 120 mg).

Nursing Considerations and Patient Education

  1. When these medications are administered for their antipyretic effect, the temperature must be rechecked an hour following administration.
  2. In adults, sensations of fullness in the ears, tinnitus and a decreased or muffled hearing are the most common symptoms associated with chronic overdosage
  3. Because of the possible association of Aspirin usage with Reye's Syndrome, do not give aspirin to children or teens with symptoms of chickenpox or influenza-like illnesses without consulting a physician.
  4. Adverse effects include nausea, dizziness, drowsiness, GI bleeding, and prolonged bleeding time. Severe adverse effects include nephrotoxicity, blood dyscrasias and cholestatic hepatitis
  5. Review renal and liver function periodically
  6. Assess for GI ulceration and bleed such as tarry stool blood in urine or vomit, coffee-ground vomit
  7. Assess for cardiovascular history or current symptoms
  8. Educate patient that full effect may not be for 1-2 weeks for inflammation and 2-4 weeks for arthritis
  9. NSAIDS intake should not exceed 1.2g daily for adults and no more than 30mg/kg daily for children 11 and under. NSAIDs should not be used for children under 6 months of age.

Acetaminophen effects the following laboratory tests: may decrease glucose and hemoglobin levels, neutrophils, WBC, RBC, and platelet counts. May cause a false-positive result for urinary 5-hydroxyindoleacetic acid. May also decrease glucose levels with home monitoring systems.

Antineoplastic (Chemotherapy)

There are several classes of antineoplastic medications all of which are aimed at destroying the malignant cells by inhibiting the reproduction process. Alkylating class of medications damage the DNA and interfere with replication.3 They are non-specific in the cell cycle. The class of antimetabolites interferes with the metabolism of the malignant cells. Antimetabolites work in the S phase of the cell cycle. Antitumor Antibiotics work by altering the DNA inside the cell and prevents any replication. A subcategory of this class is anthracyclines, which interfere with the DNA replication and work in all cell cycles. Anthracyclines are used for a variety of cancers. However, these medications can cause permanent heart damage in high doses.4 Therefore there are lifetime limits placed on dosages. Hormone therapy involves sex hormones or hormone-like medications that change the action of male or female hormones.

Cancers such as prostate, breast cancer, endometrial cancers grow in response to hormones. Hormone treatment does not work like chemotherapy. Instead, this class of medications work by not allowing the malignant cell to use the hormones they need to propagate.1

  1. Alkylating medications
    1. Busulfan (Myleran)
    2. Carboplatin (Paraplatin)
    3. Cisplatin (Platinol-AQ)
    4. Melphalan (Alkeran)
    5. Streptozocin (Zanosar)
  2. Antimetabolites
    1. Capecitabine (Xeloda)
    2. Floxuridine (FUDR)
    3. Hydroxyurea (Hydrea)
  3. Antitumor Antibiotics
    1. Bleomycin (Blenoxane)
    2. Actinomycin
    3. Plicamycin (Mithracin)
    4. Anthracyclines: Daunorubicin, Doxorubicin, Epirbicin, Idarubicin
  4. Hormone balance altering
    1. Anastrozole (Arimidex)
    2. Nilutamide (Nilandron)
    3. Megestrol acetate (Megace)
    4. Tamoxifen (Nolvadex)

The bone marrow suppression caused by these medications can severely inhibit white blood cell production, particularly the neutrophils, thus causing neutropenia. Neutropenia is known to significantly increase the risk of infection and the complications of infections. The risk of infection increases with the severity and duration of the neutropenia. Normally neutrophils comprise about 50%-70% of the total WBC count. Neutrophils are WBCs that fight infections by engulfing “invaders.”

Other side effects or adverse reactions include anemia, nausea, vomiting, and hair loss. Some antineoplastics can cause hepatotoxicity, nephrotoxicity and cardiotoxicity.

Some antineoplastics require special handling by the nurse. Be sure to read accompanying material and/or check with the dispensing pharmacist to protect patients, nurses and family members.

IV administration of antineoplastics can only be done by a nurse who is specially trained or certified. Antineoplastics are very toxic to the patient and potentially to the staff. Some require pre and post administration medications to reduce reactions. Administration protocols vary widely.

Nursing Considerations and Patient Education

  1. Assess for signs of infection, like fever, sore throat and malaise.
  2. Assess for anemia, fatigue, headache, irritability, shortness of breath
  3. Evaluate for abnormal bleeding ( patient should not use razors)
  4. Educate the patient on potential hair loss, nausea and vomiting while in treatment
  5. Monitor laboratory tests such as CBC including differential
  6. Monitor liver function and assess for jaundice
  7. Avoid OTC products containing NSAIDs and aspirin
  8. Some of the medications in the category require special handling

Antipsychotics

Antipsychotic medications are used to treat mainly schizophrenia. However, more approvals by the FDA is allowing this class of medications to be used for Bipolar disorder as well as for depression. There are two subclasses of antipsychotic, typical and atypical. The typicals are the older medications such as

  1. Chlorpromazide (Thorazine),
  2. Haloperidol (Haldol),
  3. Fluphenazine (Prolixin)
  4. Clozapine (Clozaril)

However, these older medications come with more side effects and lasting reactions when used over long periods of time or in high doses. The new, atypical antipsychotics have fewer side effects. These medications are9:

  1. Risperidone (Risperdal)
  2. Brexpiprazole (Rexulti)
  3. Aripiprazole (Abilify)
  4. Paliperidone (Invega)
  5. Ziprasidone (Geodon)
  6. Olanzapine (Zyprexa)

The typical or older antipsychotics can have additional adverse side effects such as extrapyramidal reactions (Parkinson-like symptoms), Tardive Dyskinesia and Neuroleptic Malignant Syndrome. Most antipsychotics have side effects that can include dry mouth, photosensitivity, sore throat and drowsiness, nausea, weight gain, constipation and diarrhea. Severe adverse reactions include hypotension, agranulocytosis, laryngospasm and cardiac arrest. It is important to monitor patients closely for all adverse reactions.9

IV Medication5IV Adult DosageNotes
Chlorpromazine (Thorazine)25 mg
may repeat (25-50 mg) in 1-4 hours – gradually increase to a maximum of 400 mg/dose every 4-6 hours until patient is controlled
Infuse 1 mg or portion thereof over 1 minute
Haloperidol (Haldol)Unlabeled use, ICU delirium treatment
0.5mg – __? Mg
may repeat bolus doses every 20-30 minutes until calm then administer 25% of the maximum dose every 6 hours
HALDOL INJECTION IS NOT APPROVED FOR INTRAVENOUS ADMINISTRATION
Monitor ECG and QTc interval

Nursing Considerations and Patient Education

  1. Inform patients on home therapy not to alter or discontinue their medication. These medications should be tapered gradually to discontinue treatment.
  2. Educate patient to wear sunscreen when outside, rise slowly from a lying or sitting position, avoid hot tubs
  3. Monitor blood pressure
  4. Evaluate for Extrapyramidal symptoms such as akathisia, dystonia, pseudo-Parkinsonism, and dyskinesia.
  5. Change from a sitting or lying position slowly to avoid orthostatic hypotension. Avoid hot tubs and bathing in very hot water.
  6. Wear sunscreen or protective clothing to prevent sunburns.
  7. Take extra precautions during hot weather to avoid heat stroke.
  8. Drowsiness or impaired mental and motor activity occurs during the first two weeks of taking the medication but tends to decrease over time.
  9. The sudden appearance of sores in the mouth or a sore throat may indicate agranulocytosis. The patient should contact the prescribing physician if this occurs.

Antivirals

Antivirals are used to treat and manage viral infections including influenza, HIV, herpes simplex and herpes zoster. Unlike antibiotics, antivirals are specific to a particular virus. There are several classes of antivirals each working at a different stage of the viral life cycle. The exact mechanism of action is different for each disease and particular virus. The most common side effects for any antiviral medication are diarrhea, nausea, vomiting dizziness, sleep issues, and headaches.3 However, there are additional side effects and serious reactions with each type of antiviral classification.

HIV

Entry inhibitors keep the virus from attaching to the outside of the host cell preventing infection of the virus.1

  1. Fusion inhibitors stop the virus cell from fusing with the host cell
  2. Reverse transcription inhibitors prevent single strand viruses from becoming a double strand virus. There are two types1,10:
    1. Nucleoside RT inhibitors stop virus DNA synthesis by adding a false DNA strand.
    2. Non-nucleoside RT inhibitors interfere with the ability to convert RNA to DNA
  3. Integrase Inhibitors blocks the enzyme integrase that the virus uses to insert itself into a host cell
  4. Protease Inhibitors interfere with the enzyme protease, which normally works on the viral proteins to help create new viral cells10
  5. Multi-class Combination is combinations of these classes to prevent mutant and resistant viruses.

 

Antivirals for HIVSide effects
Abacavir (Ziagen)Rash, fever, headache, insomnia, anxiety, depression, fatigue, dizziness, ENT, infections, anorexia, diarrhea, nausea, vomiting, Alcohol use decreases elimination. Black Box Warnings: Patients who carry the HLA-B5701 allele may be more sensitive to reactions, high risk of hepatotoxicity with patients who have compromised liver.
Fosamprenavir(Lexiva)Depression, fatigue, oral parenthesis, headache, GI upset, diarrhea, nausea, rash, pruritis, hyperglycemia, hypercholesterolemia
Lamivudine (Epivir)Black Box warning: Lactic acidosis and severe hepatomegaly have been reported. Pancreatitis, other side effects are nausea, vomiting, dizziness, fatigue, fever, headache, diarrhea, anorexia, joint pain, anemia. More severe side effects: neutropenia, thrombocytopenia,
Delavirdine (Rescriptor)Black Box Warning: tend to see resistant viruses when used. Side effects include: asthenia, fatigue, headache, depression, fever, pain, sleep disturbances, pharyngitis, nausea, abdominal cramps, epididymitis, hematuria, erectile dysfunction, polyuria, proteinuria, renal calculi, vaginal candidiasis, cough, rash, flu-like symptoms
Ritonavir (Norvir)Generalized clonic-tonic can be life-threatening, asthenia, confusion, depression, dizziness, fever, malaise, pain, diarrhea, nausea, taste perversion, pancreatitis, pseudomembranous, leukopenia, thrombocytopenia, hepatitis, Diabetic Mellitus, myalgia, sweating.
Efavirenz (Sustiva)Approved for children. Erythema multiforme, Steven-Johnson Syndrome, toxic epidermal are life-threatening. Other side effects are: dizziness, abnormal dreams, agitation, euphoria, fever, fatigue, nervousness, poor concentration, GI upset, vomiting, sweating, pruritus.
Nelfinavir (Viracept)Approved for children. Seizures, suicidal thoughts, pancreatitis, leukopenia, thrombocytopenia, hepatitis, hypoglycemia, diabetes mellitus are more serious reactions. Other side effects are nausea, dehydration, hyperlipidemia, hyperuricemia, rash, and redistribution of body fat.

Herpes Simplex 1 and 21

Antivirals for Herpes
Acyclovir (Zovirax)

Mucocutaneous herpes simplex: IV: 5 mg/kg/dose every 8 hours x 5-10 days.

Encephalitis: 10mg/kg/dose IV every 8 hours.5
Encephalopathic changes, tremors, confusion, hallucinations, agitation seizures, acute renal failure, angioedema, anaphylaxis are more serious. Other side effects include GI upset, thrombocytosis, rash, pruritis, pain, burning at injection site

 

Famciclovir (Famvir)Headache, fatigue, dizziness, somnolence, GI upset, pruritis
Valacyclovir (Valtrex)GI upset, headache, dizziness, depression, dysmenorrhea, arthralgia

Influenza1

Antivirals for InfluenzaSide effects
Oseltamivir (Tamiflu) - oralDizziness, fatigue, headache, insomnia, epistaxis, conjunctivitis, GI upset, cough, lymphedema and dermatitis in children
Zanamivir (Relenza) - inhaledHives, difficulty breathing, swelling of the face, lips, tongue, or throat are potentially life-threatening. Other side effects include headache, dizziness, GI upset, joint pain, chills, fever, stuffy nose, sneezing, and sore throat.
Peramivir (Rapivab) -intravenous
IV 600 mg administered over 15 to 30 minutes5
Abnormal Liver function test, decrease neutrophils, erythema multiform, Stevens-Johnson Syndrome, skin rash and sloughing are severe reactions. Other side effects include GI upset, high blood pressure, increase glucose reading, rash.

Nursing Considerations and Patient Education

  1. Monitor for side effects and complete regular assessments
  2. Educate patients on side effects
  3. Oral contraceptives may be rendered ineffective
  4. Antacids should be taken at least an hour prior to taking an antiviral medication
  5. Review laboratory work

 

Cardiac Medications

Antiarrhythmic

Antiarrhythmic medications are used to treat disturbances in normal heart rhythms. Careful monitoring must be observed as these medications can worsen conditions with the heart. There are 4 classes of antiarrhythmic. The desired endpoint of this therapy includes eliminating the dysrhythmias, controlling the heart rate and preventing the dysrhythmias from returning. Monitoring EKGs and the heart rate are integral parts of the therapy.1, 4

Common adverse effects are faintness, syncope, hypotension, nausea, vomiting, diarrhea and abdominal pain. Symptoms of overdosage are hypokalemia, seizures and tachydysrhythmias.3

Class 1A

This class includes Quinidine, disopyramide phosphate (Norpace), and procainamide hydrochloride (Pronestyl). These medications are quickly absorbed and metabolized. There are extended release versions to prolong their effects. Quinidine does cross the blood-brain barrier. All are metabolized by the living and excreted thru the kidneys. Class 1A Antiarrhythmic work by blocking sodium channels, which changes the impulses along cardiac cells. This effect occurs during different phases of the heart action potential. They also block parasympathetic stimulation of the Sinoatrial and AV nodes, which increases conduction of the AV node. These medications increase action potential duration and the refractory period and slow the conduction velocity. Class 1A medications are used to treat premature ventricular contractions, ventricular tachycardia, atrial fibrillation, atrial flutter, and paroxysmal atrial tachycardia. Side effects particular to this class of medications are GI symptoms and a bitter taste.1, 6

IV Quinidine 80 mg/mL should be diluted to 50 mL (16 mg/mL) with D5W.  An infusion of quinidine must be delivered slowly with a pump, no faster than 0.25 mg/kg/min (1 mL/kg/hour). During the first few minutes of the infusion, the patient should be monitored especially closely for possible hypersensitive or idiosyncratic reactions. Most arrhythmias that will respond to intravenous quinidine will respond to a total dose of less than 5 mg/kg, but some patients may require as much as 10 mg/kg. If conversion to sinus rhythm has not been achieved after infusion of 10 mg/kg, then the infusion should be discontinued.5

Class 1B

This class of medications includes mexiletine (Mexiletine) and lidocaine. These medications work by blocking the influx of sodium during the depolarization phase, especially in the Purkinje fiber system. This results in a decrease refractory period and reduces the risk of arrhythmia. Class 1B medication is used only on ventricular arrhythmias. Side effects seen with this class of medications are drowsiness, light-headedness, parenthesis, hypotension, and bradycardia. Particular to mexiletine are AV block, confusion, ataxia, double vision, nausea, vomiting, and tremors. Lidocaine can cause seizures as well as respiratory and cardiac arrest.1

Lidocaine (Xylocaine) for ventricular arrhythmia 1-1.5 mg/kg IV bolus over 2-3 minutes; may repeat doses of 0.5-0.75 mg/kg in 5-10 minutes up to a total of 3 mg/kg; continuous infusion: 1-4 mg/minute.5

Prevention of ventricular fibrillation IV bolus: 0.5 mg/kg; repeat every 5-10 minutes to a total dose of 2 mg/kg. Refractory ventricular fibrillation: Repeat 1.5 mg/kg bolus may be given 3-5 minutes after initial dose.5

Class 1C

Class 1C antiarrhythmics are used to treat severe, resistant ventricular arrhythmias. Medications include flecainide acetate (Tambocor), propafenone (Rythmol). These medications slow the conduction rate but do not have much of an effect on action potential. Side effects include development of new arrhythmias and aggravation of current arrhythmia, palpitations, shortness of breath, chest pain, heart failure and cardiac arrest.1

Class II

Class II antiarrhythmics are beta-adrenergic blockers. These medications block beta-adrenergic receptors on the conduction system of the heart. This slows the firing of the SA Node and the AV Node, which decreases conductivity. These medications also reduce the strength of the contractions so less force is needed with each beat and therefore less oxygen is required.  Class II medications are used for atrial flutter, atrial fibrillation, and paroxysmal atrial tachycardia. Medications include Propanolol, Timolol, Metoprolol, and Atenolol. Side effects include arrhythmia, bradycardia, heart failure, hypotension, GI reactions, bronchoconstriction and fatigue1

IV administration is discussed under antihypertensive section.

Class III

Class III medications treat ventricular arrhythmias. These medications bind and block the potassium channels for phase 3 repolarization. This delays repolarization and increases action potential time in the effective refractory period. Medications in this class are amiodarone (Cordarone), sotalol (Betapace), bretylium tosylate (Bretylium) ibutilide (Corvert). Side effects include aggravation of current arrhythmia, hypotension, bradycardia, nausea, anorexia. Amiodarone can cause vision issues. Ibutilide may sustain QT interval and sotalol may cause AV block, bradycardia, bronchospasm and hypotension.

Amiodarone IV first 24 hours:5

  1. Rapid infusion of 150 mg over 10 minutes (15 mg/min). Add 3 ml of Amiodarone (150 mg) to 100 ml D 5 W. Infuse 100 ml over 10 minutes.
  2. Followed by Slow: 360 mg over the NEXT 6 hours (1 mg/min). Add 18 ml of Amiodarone IV (900 mg) to 500 ml D 5 W (conc = 1.8 mg/ml).
  3. Maintenance infusion: 540 mg over the remaining 18 hours (0.5 mg/min).

After the first 24 hours, the maintenance infusion rate of 0.5 mg/min (720 mg/24 hours) should be continued utilizing a concentration of 1 to 6 mg/ml. In the event of breakthrough episodes of VF or hemodynamically unstable VT, give 150-mg/100 ml D5W over 10 minutes to minimize potential for hypotension. The rate of the maintenance infusion may be increased to achieve effective arrhythmia suppression. The initial infusion rate should not exceed 30 mg/min.5

Amiodarone IV concentrations greater than 2 mg/ml should be administered via a central venous catheter.

Bretylium tosylate for immediate life-threatening ventricular arrhythmias, ventricular fibrillation, unstable ventricular tachycardia IV bolus 5 mg/kg the shock. Repeat in 5 minutes at 10 mg/kg (maximum total: 30 to 35 mg/kg). Side effects: Bradycardia, hypotension, N&V. Continuous infusion: 1 to 2 mg/min (Range: 0.5 to 4 mg/min). Add 1 gram to 250ml of D5W or normal saline.5
Ibutilide for acute termination of A-flutter/A-fib infuse 1mg IV over 10min. May repeat one time in 10 minutes if needed. May be an alternative to cardioversion. Monitor ECG for at least 4hr . Effective in @30% of patients.5

For major adverse reactions: proarrhythmic events: VT, PVC’s, BC, AV block, torsades de pointes, etc. IV piggyback 0 to 1 mg/50 ml D5W or NS over 10 minutes. If patient is < 60kg give 0.01 mg/kg over 10 minutes. May repeat once.5

Class IV

Class IV medications are calcium channel blockers and used to treat supraventricular arrhythmias. These medications block calcium ions in cardiac and smooth muscle cells, which decreases contractility. This decreases oxygen requirements and dilates coronary arteries and arterioles. Examples of Class IV medications are verapamil (Calan, Covera-HS, Verelan) and diltiazem (Cardizem).1

IV administration is discussed under antihypertensive section.

Nursing Considerations and Patient Education

  1. Monitor EEG, vital signs and apical pulse
  2. Monitor medication levels when indicated
  3. Monitor liver function and renal function laboratory results
  4. Assess for adverse reaction
  5. Educate patients on side effects
  6. Monitor weight as required
  7. Monitor fluid intake and output when indicated

Cardiac Glycosides

Cardiac glycosides are used to treat heart failure. The main ingredient is Digitalis purpurea. Digitalis (Lanoxin) cardiac works by increasing muscle contraction and slowing the heart rate. Because it is a heart stimulant, digoxin acts indirectly as a diuretic by promoting greater perfusion of blood through the kidneys. Furthermore, Digoxin acts on the central nervous system to slow heart rate.

Adverse side effects of cardiac glycosides include dysrhythmias, anorexia, nausea, vomiting, bradycardia and headache.1, 4

Digoxin getting once daily IV maintenance doses can be treated on a regular unit. IV loading regimens (multiple doses) are restricted to patients on a monitor in critical care area.

loading doses:5
CHF: 8-12 mcg/ Normally, give 50% of the total digitalizing dose in the initial dose, then give 25% of the total dose in each of the two subsequent doses at 8 to 12 hr intervals. Obtain an EKG 6 hours after each dose to assess potential toxicity. Infuse IV Bolus over at least 5 min.

Renal insufficiency dose 6 to 10 mcg/kg IBW.

A-fib: 10 to 15 mcg/kg ideal body weight (IBW) kg in divided doses (every 4-8h) over 12 to 24 hours.

PSVT, for patients not on digoxin, give 0.25 to 0.5 mg IV. May follow with 0.125 to 0.25 mg IV every 2-6h until 0.75 to 1.5 mg is given over 24 hours. Digoxin is considered to be a 3rd line medication in stable patients who fail to respond to adenosine/verapamil/esmolol. Not the preferred medication for PSVT because it may take up to 60 minutes to be effective.

Digoxin maintenance dose depends on digoxin clearance, monitoring by maintaining blood samples at least 4 hours after IV dose.

Nursing Consideration and Patient Education

Prior to giving every dose of Digoxin, an apical heart rate must be taken. If the heart rate has slowed, or a change in rhythm is detected, the dose should be withheld, and the physician should be notified. A heart rate of 60 or below is usually used to decide to hold the medication.

Antianginals

Antianginal agents reduce oxygen demand, increasing the oxygen to the heart or both. At therapeutic doses, they reduce systolic, diastolic and mean arterial blood pressures and improve coronary circulation. There are three classes of these medications; they are nitrates, Calcium channel blockers and beta-adrenergic blockers.1, 4

Nitrates decrease peripheral vascular resistance or afterload and decrease preload. They also cause vasodilation and are typically used for acute angina as they have a rapid onset. Side effects are typically a headache, dizziness, orthostatic hypotension, flushing, and palpitations. Medications in this class are amyl nitrate, isosorbide dinitrate, isosorbide mononitrate, and nitroglycerin. These medications are given sublingually, chewable or as an aerosol.1, 4

IV administration is discussed under antihypertensive section except for nitroglycerin.

IV nitroglycerin is caustic to normal plastic. Use glass bottles or specially made bags, Excel® or PAB®. Initial infusion rate is 5 mcg/min. May increase by 5 mcg/min every 3 to 5 minutes until response. If 20 mcg/minute is inadequate, increase by 10 to 20 mcg/min every 3 to 5 minutes. Maximum dose: 400 mcg/minute. Nitroglycerine is not for direct bolus, it must be diluted with D5W or NS.

Beta-adrenergic medications are used for long-term prevention of angina. These include atenolol, metoprolol, nadolol, and propranolol. These medications reduce oxygen demand as it causes a decrease in heart rate and reduces the contraction force. Side effects include fainting, fluid retention, peripheral edema, GI disturbances, and constriction of bronchioles.

IV administration is discussed under antihypertensive section.

Calcium channel blockers are used to prevent angina that doesn’t respond to the other antianginal medications. These medications include amlodipine, diltiazem, nifedipine and verapamil. These medications block the calcium ions from entering the cell membrane and smooth muscle cells causing dilation or peripheral and coronary arteries. The heart decreases the contraction force of the heart and decreases afterload; increasing the oxygen supply. Side effects include orthostatic hypotension, dizziness, headache, weakness flushing, peripheral edema, hypotension, bradycardia, and AV block.3

IV administration is discussed under antihypertensive section.

Nursing Considerations and Patient Education

  1. Assess for adverse reactions
  2. Assess apical pulse and vital signs
  3. Monitor serum medication levels
  4. Monitor liver function and renal function laboratory tests
  5. Monitor ECG as required
  6. Educate patient to change positions slowly, avoid alcohol and report side effects

Corticosteroids

Corticosteroids are a class of medications that include glucocorticoids and mineralocorticoids. Glucocorticoids decrease inflammation, increase capillary permeability and modify the body's immune response. Mineralocorticoids act by increasing reabsorption of sodium by increasing excretion of hydrogen and potassium.4

Glucocorticoids are used to treat asthma, allergic reactions and in conjunction with antineoplastic agents. Mineralocorticoids are used to treat adrenal insufficiency. Side effects include suppression of the immune response euphoria, insomnia, GI irritation, hypokalemia, hyperglycemia, carbohydrate intolerance and sodium and fluid retention. The salt or sodium retention properties of mineralocorticoids are counter-balanced by increased potassium excretion. Thus, electrolyte imbalances may occur, and patients need to be monitored for sodium retention and potassium depletion.1, 4

These medications include:

  • Hydrocortisone (Cortef)
  • Prednisone (Sterapred)
  • Dexamethasone (Decadron)
  • Methylprednisolone (Depo-Medrol)

Common mineralocorticoids include:

  • Fludrocortisone (Florinef)

IV dexamethasone5

Spinal cord compression: 10 to 100mg IV bolus, followed by 4 to 24 mg IV every 6 hours. Use larger doses (e.g. up to 100mg) in patients with profound neurologic injury and lower doses in patients with mild or equivocal signs.

Antiemetic prophylaxis given as sodium phosphate IV 10-20 mg 15-30 minutes before treatment. Mildly emetogenic therapy IV 4 mg every 4-6h.

Treatment of shock: Addisonian crisis/shock given as sodium phosphate IV 4-10 mg one time, which may be repeated if necessary.

Unresponsive shock given as sodium phosphate 1-6 mg/kg as a single IV dose or up to 40 mg initially followed by repeat doses every 2-6 hours while shock persists.

Physiological replacement given as sodium phosphate IV 0.03-0.15 mg/kg/day or 0.6-0.75 mg/m2/day in divided doses every 6-12 hours.

Nursing Considerations and Patient Education

  1. Monitor weight daily, blood pressure and electrolyte status
  2. Monitor for adverse effects
  3. Assess for cushingoid effect, moon face, buffalo hump, central obesity, thinning hair, hypertension and increased susceptibility to infections.
  4. Assess for adrenal insufficiency (fatigue, muscle weakness, joint pain fever, anorexia nausea, shortness of breath, dizziness, and fainting.

Hydrocortisone (Cortef, Solu-Cortef) for IV bolus dilute to 50 mg/mL and administer over 30 seconds to several minutes. For IV intermittent infusion dilute to 1 mg/mL and administer over 20-30 minutes.

Condition5Adult IV Dosage
Acute adrenal insufficiently100 mg IV Succinate bolus, then 300 mg/day in divided doses every 8 hours or as a continuous infusion for 48 hours; once patient is stable change to oral and tapers off.
Anti-inflammatory or immunosuppressiveIV Succinate 15 to 240 mg every 12 hours.
ShockIV 500 mg to 2 g every 2 to 6 hours
Status asthmaticusIV Succinate 1-2 mg/kg/dose every 6 hours for 24 hours, then maintenance of 0.5-1 mg/kg every 6 hours

Methylprednisolone sodium succinate IV bolus administer over one to several minutes

Condition5Adult Dose
Acute spinal cord injury30 mg/kg over 15 minutes, followed in 45 minutes by a continuous infusion of 5.4 mg/kg/hour for 23 hours
Anti-inflammatory or immunosuppressive10 to 40 mg over a period of several minutes and repeated IV or I.M. at intervals depending on clinical response; when high dosages are needed, give 30 mg/kg over a period >/= 30 minutes and may be repeated every 4 to 6 hours for 48 hours.
Status asthmaticusLoading dose: 2 mg/kg/dose, then 0.5-1 mg/kg/dose every 6 hours for up to 5 days
High-dose therapy for acute spinal cord injuryIV bolus: 30 mg/kg over 15 minutes, followed 45 minutes later by an infusion of 5.4 mg/kg/hour for 23 hours
Lupus nephritis1 g/day for 3 days
Aplastic anemia1 mg/kg/day or 40 mg/day (whichever dose is higher), for 4 days. After 4 days, change to oral and continue until day 10 or until symptoms of serum sickness resolve, then rapidly reduce over approximately 2 weeks.
Pneumocystis pneumonia in AIDs patients:40-60 mg every 6 hours for 7-10 days

Diabetic Medications (Insulin and Hypoglycemics)

Diabetic patients may be treated with injectable insulin or oral hypoglycemics, depending on the pathophysiology of their disease.

Injection of insulin serves as a replacement for the patient's own insulin and is used in insulin-dependent diabetes (IDDM or Type I.) These patients cannot produce much, if any insulin, so they need an exogenous source of insulin.

Insulin Activity after SQ Injection1,4
Type InsulinExample Brands/Common NameOnsetPeakDuration
Lispro 15 minutes prior to meal or immediately afterHumalog15 min.0.5-1.5 hr.6 – 8 hrs.
Regular 30-60 min prior to mealsHumulin-R0.5 –1 hr.2-3 hr.8-12 hrs.
Isophane SuspensionNPH1-2 hr.4-12 hr.18-24 hrs.
Isophane suspension and RegularHumulin 10/90 Humulin 70/3030 min.4-8 hr.12-24 hrs.
Zinc suspensionSemilente1-1.5 hr5-10 hr.12-16 hr.
Zinc SuspensionLente1-2.5 hr.7-15 hr12-24 hr.
Zinc Suspension ExtendedUltralente4-8 hr.10-30 hr.36 hr.

Animal source insulin (beef or pork) carries a danger of contamination and immunologic reactions, and their use is rapidly decreasing and replaced with synthetic “human” insulin. Synthetic insulin comes in different forms that can be mixed to suit the patient's glucose pattern and lifestyle.

Insulin vials currently being used should be stored at room temperature. Unopened vials should be stored in the refrigerator but never frozen.

All insulin preparations except short-acting insulin should be rolled between the palms to be mixed. Insulin should never be vigorously shaken.

Regular, short-acting insulin should always be drawn up in the syringe first when it is mixed in the same syringe with another type of insulin. Otherwise, a small amount of long-acting insulin may contaminate the regular insulin delaying its action.1, 4

To save money, some patients prefer to reuse their syringes until the needle becomes dull. The ADA states that syringe reuse can be safe and practical for patients who maintain good personal hygiene. The syringe should be carefully recapped and stored in a safe place at room temperature.

Administration of IV insulin is dependent on accurate bedside glucose monitoring. IV insulin therapy is no longer recommended as routine treatment in the ICU. It should be reserved for patients who undergo open cardiac surgery and diabetic patients with suboptimal glucose control as a result of their underlying diabetes, infection or treatment that fails to be controlled with conventional subcutaneous insulin regimens. IV insulin administration varies. Multiple intensive insulin protocols have been developed to manage hyperglycemia; however, no singular protocol has been universally accepted. Significant similarities in strategy exist among the various protocols, and the differences relate to bolus amounts, infusion rates, and target glucose goals. 11

Oral hypoglycemics are used to manage mild to moderate, non-insulin dependent diabetes (NIDDM or Type II) that cannot be controlled by diet and weight reduction alone. The action of these medications is to lower the blood glucose by stimulating the pancreatic beta cells to synthesize and release insulin.1, 4

Common agents include:

  • Glipizide (Glucatrol)
  • Glipizide (Glucatrol)
  • Chlorpropamide (Diabinese)
  • Glimepiride (Amaryl)
  • Glyburide (Micronase)
  • Metformin (Glucophage)
  • Rosiglitazone (Avandia)

Adverse effects of insulin or oral hypoglycemic medications are hypoglycemia, blood dyscrasias, hepatotoxicity and, rarely, anaphylaxis, bloating, gas, GI disturbances.3

Nursing Considerations

  1. Educate patient on how to inject themselves and when to take medication
  2. Educate patient on how to measure medication
  3. Educate patient on to obtain and read glucose levels
  4. Assess patient for rash, shortness of breath, wheezing, hypotension, excess sweating.
  5. Monitor injection sites
  6. Asses for hypoglycemia and hyperglycemia
  7. Assess for diabetic nerve disease
  8. Review renal and liver function laboratory reports
  9. Monitor patient closely if they have a fever, are under stress, surgery or trauma.

Narcotic Analgesics (Opioid Analgesics)

Narcotic analgesics are used to relieve pain, cause numbness or induce unconsciousness. These medications work by binding to opioid receptors or G-proteins, which either facilitate potassium channels or block calcium channels. The outcome is that the neurons are less excitable in the pain pathway. These medications can cause tolerance and dependence. They are available as a pill, liquid suckers, injections, patch and suppository. Side effects include tolerance and addiction, trouble breathing, swelling of face, lips or tongue, hives, increase sweating, constipation, lightheaded ness, nausea and vomiting.3

Common agents include:

  • Codeine
  • Fentanyl (Duragesic)
  • Hydrocodone (Lortab)
  • Hydromorphone (Dilaudid)
  • Meperidine (Demerol)
  • Morphine
  • Oxycodone (Percodan, Tylox)

The intravenous route is the route of choice with acute pain only until oral intake is tolerated. Once oral intake is tolerated, the route should be changed to oral. Intramuscular administration of narcotic analgesics is not recommended for treatment of any type of pain. Absorption of medication is variable with the intramuscular route and IM injections hurt!

Medication5IV Adult DosageNotes
Propofol (Diprivan)Induction: Healthy adults <55 yrs: IV: 2-2.5 mg/kg (40 mg every10 sec). Elderly, debilitated: 1-1.5 mg/kg (20 mg every10 sec).
ICU sedation: 5 mcg/kg/min ( 0.3 mg/kg/hour); increase by 5-10 mcg/kg/min (or 0.3-0.6 mg/kg/hour) every 5-10 min desired sedation. Usual maintenance range: 5-50 mcg/kg/min (or 0.3-3 mg/kg/hr).
Provided in ready to use emulsion.
Do not use if there is evidence of separation of the phases of the emulsion.
Compatible with D5W, lactated ringers, D5W and 0.45% sodium chloride, and D5W and .02% sodium chloride
Hydromorphone (Dilaudid)IV: (opiate naive) Start: 0.2 – 0.6 mg slow IV bolus over 2-3 min every 2-3 hours prn. Pain, acute: 1-2 mg every 3 hours prn.
Mechanically-ventilated: 0.7 – 2 mg every 1-2 hours prn or start infusion: 0.5 – 1 mg/hr
Patient controlled analgesia (PCA): Usual concentration: 0.2 mg/ml. Demand dose (usual): 0.1 – 0.2 mg (range: 0.05 – 0.5mg). Lockout: 5-15 min. 4-hour limit: 4-6 mg.
Compatible with D5W and NS
Pancuronium (Pavulon)Intermittent dosing: 0.1 to 0.2 mg/kg (usual: 0.1) every 1-3h (range: 0.04 to 0.2)
Continuous infusion: Loading dose: 0.04 to 0.10 mg/kg , followed by 1 to 1.7 mcg/kg/min or 0.06 to 0.1 mg/kg/hr
neuromuscular blocking agent used in anesthesia and managing ventilated patient in ICU
Compatible with D5W, NS
 
Morphine SulfateIV 2.5 to 20 mg every 2-6h prn. Usual: 10mg every 4h prn.
IV continuous infusion: 0.8 – 10 mg/hr. Titrate to response. Usual range: up to 80mg/hr.
 
CodeinePain: IV 30 mg (15-60mg) every 4-6h prn. (Max 360mg/day) 
FentanylSedation for minor procedures/analgesia: IV 0.5-1 mcg/kg/dose; higher doses are used for major procedures
Premedication: slow IV 50-100 mcg/dose 30-60 minutes prior to surgery.
 
Levorphanol (Levo-Dromoran)Slow IV Initial: Opiate-naive: Up to 1 mg/dose every 3-6 hours as needed; patients with prior opiate exposure may require higher initial doses 
Meperidine (Demerol)Preoperatively: 50-100 mg given 30-90 minutes before the beginning of anesthesia
Slow IV Initial: 5-10 mg every 5 minutes as needed
>PCA: Usual concentration: 10 mg/mL
Initial dose: 10 mg
Demand dose: 1-5 mg range 5-25 mg
Lockout interval: 5-10 minutes
 
Methadone (Dolophine)IV initial: 2.5-10 mg every 8-12 hours in opioid-naive patients; titrate slowly to effect 
Buprenorphine (Buprenex)Slow IV initial: Opiate-naive: 0.3 mg every 6-8 hours as needed; initial dose (up to 0.3 mg) may be repeated once in 30-60 minutes after the initial dose if needed 
Butorphanol (Stadol)IV initial: 1 mg, may repeat every 3-4 hours as needed; usual range: 0.5-2 mg every 3-4 hours as needed. 
Dezocine (Dalgan)2.5 to 10 mg IV every 2 to 4 hours 
Nalbuphine (Nubain)IV 10 mg/70 kg every 3-6 hours; maximum single dose: 20 mg; maximum daily dose: 160 mg 
Pentazocine (Talwin)IV 30 mg every 3-4 hours (maximum: 360 mg/day) 

The optimal dose is the minimal dose repeated often enough to produce the desired pain relief and yet be free of side effects. Implicit in the determination of the optimal dose is the continued observation of the patient. One of the major principles of pain management that guide the nurse's practice is that the patient is the authority on his pain experience. A pain scale should be used to allow the patient to describe the impact of the medication.1, 4

Timing is important. Anticipate the patient's need for pain medication and do not force undue waiting, as the therapeutic effect will then take longer to occur.

Never assume the pain is just from one source. Reassess the site, severity and type of pain each time the patient requires the medication. Always return to the patient within 30 minutes or less to assess the results. The results of the therapy should be documented each time. Remember that the time of the assessment is directly related to the route used for the analgesic.3

Tolerance to narcotic analgesics may develop, and patients or healthcare providers may fear a problem with addiction. The actual number of people who become addicted is very small. So, full and adequate doses of analgesic medications should seldom be withheld simply because of the fear of medication dependence.

Narcotic analgesics are controlled substances and must be signed out appropriately. Narcotics that are wasted must be signed and witnessed by two licensed nurses.

Nausea and vomiting are occasionally associated with the initial doses of morphine or Meperidine. If this becomes a problem, the use of an antiemetic such as Phenergan may help. The major hazard of narcotic analgesics is respiratory depression and to a lesser degree, circulatory depression. Check the respiratory rate and depth frequently. Also, be aware that these medications can cause decreased intestinal motility and the patient may need to be treated for constipation.3

Nursing Considerations and Patient Education

  1. Monitor for overdose (cold, clammy skin, confusion, severe nervousness, restlessness, dizziness, drowsiness, slow breathing, seizures)
  2. Monitor for signs of withdrawal (nausea vomiting, cramps, fever, faintness, anorexia, hallucinations)
  3. Educate patient not to use alcohol, not to participate in activities that require alertness
  4. Monitor vital signs
  5. Educate patient on side effects such as constipation and dry mouth and provide instruction for relief such as drinking water or chewing gum.
  6. Monitor the ability to urinate

Narcotic Antagonists (Reversal Agents)

>Medication5IV Adult DosageNotes
Nalmefene (Revex)Reversal of postoperative opioid depression: Blue labeled product (100 mcg/mL) Titrate to reverse the undesired effects of opioids; initial dose for nonopioid dependent patients: 0.25 mcg/kg followed by 0.25 mcg/kg incremental doses at 2-5-minute intervals; after a total dose >1 mcg/kg,
Management of known/suspected opioid overdose: Green labeled product (1000 mcg/mL): Initial dose: 0.5 mg/70 kg; may repeat with 1 mg/70 kg in 2-5 minutes
If IV access is lost, give IM or SQ
Naloxone (Narcan)Narcotic overdose: Adults: IV 0.4-2 mg every 2-3 minutes as needed; may need to repeat doses every 20-60 minutes, if no response is observed after 10 mg, question the diagnosis.
Adults: Continuous infusion, calculate dosage/hour based on effective intermittent dose used and duration of adequate response seen, titrate dose 0.25-6.25 mg/hour (short-term infusions as high as 2.4 mg/kg/hour have been tolerated in adults during treatment for septic shock); alternatively, continuous infusion utilizes 2 /3 of the initial naloxone bolus on an hourly basis; add 10 times this dose to each liter of D5W and infuse at a rate of 100 mL/hour; 1 /2 of the initial bolus dose should be re-administered 15 minutes after initiation of the continuous infusion to prevent a drop in naloxone levels; increase infusion rate as needed to assure adequate ventilation
Use 0.1-0.2 mg increments in patients who are opioid dependent and in postoperative patients to avoid large cardiovascular changes.
If IV access is lost, give IM or SQ

Thyroid Hormones

Thyroid hormones are used as replacement therapy for diminished or absent thyroid function related to atrophy of the gland, surgery, excessive radiation or congenital defect (hypothyroidism).1,4 The hormone increases cellular metabolism which is related to growth tissue development, brain function, and temperature regulation. The oral route mostly gives thyroid hormone replacement. Side effects are irritability, insomnia, weight loss, change in appetite, palpitations, angina, dysrhythmias, or tachycardia.3

Common agents include:

  • Levothyroxine (Levothroid, Synthroid)
  • Norfloxacin (Noroxin)

Medication5IV Adult DoseNotes
Levothyroxine (Synthroid)5 mL IV bolusCompatible with NS only
Reconstitute with 5 mL of NS
Shake vial to ensure complete mixing.
Use Immediately after reconstitution.

Nursing considerations and Patient Education

  • Monitor for overdose (chest pain, increase heart rate and pulse, nervousness, excessive sweating, heat intolerance, insomnia, GI disturbances.
  • Assess for angina, coronary inclusion
  • Review history with patients who are diagnosed with diabetes, heart conditions, taking anticoagulants
  • Educate patient to report any unusual bleeding or bruising.
  • Monitor vital signs

Educate patient to avoid food with iodine, soybeans, tofu, turnips and seafood

Medication Errors

Medication errors account for over 98,000 deaths per year and are a very large part of health care costs.12 It is estimated that preventable adverse reactions account for more than 3.5 billion dollars annually for hospitals.12 The Institute of Medicine report To Err is Human: Building a Safer Health Care System revealed the seriousness of these errors and found that most were preventable.13 Dosing errors are the most common form of medication errors. Other errors occur during ordering and administration and often include the wrong dose, wrong prescription, allergy, wrong time, wrong route, or missed dose. Although several reasons have been found for the error’s communication has been shown to be a common thread.

Another area of concern is that of handoffs or transitions. As continuity of care is disrupted, the risk for error is higher. This can happen with changes of providers such as shift change or when the patient is moved to a different facility or unit. Communication is again the key component. The Joint Commission National Patient Safety Goals requires a standardized handoff procedure include discussion of patient information. As several errors can occur during handoff including, background noise, inconsistent information, incomplete care responsibility, conflicting communication needs and expectations, and inability to listen.13

Handoff tools such as SBAR (Situation, Background, Assessment, Recommendation) are a way to standardize the information that is passed between providers and facilities.13 The situation is described and includes present illness, and reason for transfer, contact information of referring provider, and patient identification. Background information includes diagnosis, past medication history, surgical history, medications, allergies, vital signs, laboratory results, code status, significant events during hospitalization, physical exam findings. The assessment is patient-centered and includes patient-specific needs, concerns, cardiovascular stability, complications, and cultural factors. The recommendation includes information pertaining to the treatment plan, discharge plan, and case management.13

There are also more specific tools for intrahospital transfers (The Ticket Ride Tool) and surgical tools (Postoperative Handover Assessment Tool) for example. Other information can also be included for specific purposes such as mental examinations, barriers, diet, or required patient positioning.12

Nurses find themselves as the last link in the chain of medication management. Nurses are habitually blamed for medication errors when in fact there are multiple people and tasks involved in medication errors, and most medication errors are discovered by nurses.15 Studies reveal that several factors are involved in medication errors that can lead to adverse reaction and sentinel events. Causes identified specifically to nursing care are unsafe practices, misidentification of the patient or medication, lack of knowledge, violation of policy and procedures, calculation errors, faulty checking procedures, equipment deficits, and not following medication directions.15

The use of technology in medication administration has been somewhat successful in reducing medication errors. Barcoding medication for administration, computerized order entry, education, and electronic medication distribution systems have been helpful to nurses and other health care staff in catching and reducing medication errors.

Recommendations to Reduce Errors

The Institute of Medicine recommends the following12:

  1. Routinely reconcile medication at admission, discharge or patient transfer
  2. Avoid verbal orders except in emergencies
  3. Assess all medications the patient is currently using
  4. Keep medication record accurate and up-to-date
  5. Assess for allergic reactions
  6. Educate patients in all medications prescribed
  7. Assess refill history and compliance
  8. Review all side effects
  9. Prescribe electronically when possible
  10. Use read back with any orders
  11. Avoid abbreviations
  12. State patient age and weight if required for dosing
  13. Nurses, pharmacists and prescribers should work as a team
  14. Adhere to formularies and clinical guidelines
  15. Use precautions as indicated with high-risk medications
  16. Consult electronic reference for the most up-to-date evidence-based practices
  17. Standardize patient transfers between units and facilities
  18. Monitor patient for responses to medication changes
  19. Minimize the use of samples

Charts of medication information are usually available on a unit or by internet. Critical care areas usually have charts very specific to critical medications. Newer IV pumps have medication specific information pre-programmed.

High-Alert Medications

A meta-analysis of high-risk medications revealed that approximately 47% of all serious medication errors were caused by seven medications or classes. These medications are methotrexate, warfarin, nonsteroidal anti-inflammatory medications (NSAIDs), digoxin, opioids, acetylic salicylic acid, and beta-blockers.24 It is estimated that over 70% of all medications identified were involved in fatal events. 24

The Institute for Safe Medication Practices reports the medications that are considered Look-Alike-Sound-Alike as well as high-risk medications.  The list is extensive and should be review periodically. The Institute recommends that the review included storage and dispensing procedures to help in decreasing sentinel events that involve medication errors (Institutional high alert meds). The most recent list can be found at https://www.ismp.org/tools/institutionalhighAlert.asp

The following is the list of high-risk IV medications16

  • adrenergic agonists, IV (e.g., Epinephrine, phenylephrine, norepinephrine)
  • adrenergic antagonists, IV (e.g., propranolol, metoprolol, labetalol)
  • anesthetic agents, general, inhaled and IV (e.g., propofol, ketamine)
  • antiarrhythmics, IV (e.g., lidocaine, amiodarone)
  • anticoagulants (e.g., warfarin, low molecular weight heparin, unfractionated heparin)
  • chemotherapeutic agents
  • dextrose, hypertonic, 20% or greater
  • dialysis solutions
  • moderate sedation agents, IV (e.g., dexmedetomidine, midazolam, Lorazepam)
  • opioids
  • neuromuscular blocking agents (e.g., succinylcholine, rocuronium, vecuronium)
  • parenteral nutrition preparations
  • sodium chloride for injection, hypertonic, greater than 0.9% concentration
  • sterile water for injection, inhalation and irrigation (excluding pour bottles) in containers of 100 mL or more

 

Computerization of the Medication Administration Process

Automation in pharmacy and nursing unit medication dispensing appears to decrease the number of medication errors. The evidence to support a computerized entry system as the ideal way to decrease medication error is marginal at best.13 Nevertheless, health care systems have moved to a more automated method of patient care including computerized order entry, automated clinical decision support systems, and electronic health records.17 Barcoding systems for medication administration help to identify the right patient, medication, dose, route, and time. This system has lowered the errors that occur in the administration phase15. However, the transcription phase must be correct for the barcode to be effective.

Some physicians' orders are still handwritten and then manually transcribed to a medication administration record. This leaves a lot of opportunity for errors. A computerized physician order entry, in which the physician must enter all orders by computer, eliminates handwriting and transcription errors but still may not reduce administration errors13,17 It also makes it possible to automatically check doses, medication interactions, allergies and significant patient data, like impaired renal function. Automation is very dependent upon each phase being correct. If one step is missed or is incorrect due to human inaccuracy, the risk of an adverse effect due to a medication error is significantly increased.

Automated systems can present several problems. There is a significant expense that smaller facilities may not be able to afford. Cost prohibitions or lack of space may limit the number of PCs to the point that practitioners have long wait times for computer access. It also seems slow and inconvenient at times. In addition, physicians who are less computer savvy may be resistant to implement the system fully. Human error is also a factor. Education and communication are again the keys to decreasing medication errors.

References

  1. Edmunds, M., & Mayhew, M. (2013). Pharmacology for the primary care provider (Fourth ed.). St. Louis, MO: Elsevier Mosby.
  2. Infuserve America. Intraveneous Antibiotics, retrieved 10/13/18 (Visit Source).
  3. Nursing 2016 drug handbook (36th ed.). (2016). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.
  4. Woo, T., & Wynne, A. (2011). Pharmacotherapeutics for nurse practitioner prescribers (3rd ed.). Philadelphia, PA: F.A. Davis.
  5. Global RxPh, The Clinician’s ultimate Reference. Retrieved 10/17/18 (Visit Source).
  6. Zisaki, A., Miskovic, L., & Hatzimanikatis, V. (2015). Antihypertensive Drugs Metabolism: An Update to Pharmacokinetic Profiles and Computational Approaches. Current Pharmaceutical Design, 21(6), 806–822. doi:10.2174/1381612820666141024151119
  7. Kaufman, G. (2014). Diuretics: how they work, cautions and contraindications. Nursing & Residential Care, 16(2), 83-86.
  8. Joint Formulary Committee (2013) British National Formulary. No 66. BMJ Group and RPS Publishing, London
  9. Stahl, S. M., & Grady, M. M. (2011). Stahl's essential psychopharmacology: The prescriber's guide (4th ed.). Cambridge, UK ; New York: Cambridge University Press.
  10. HIV/AIDS. (2013, September 1). Retrieved July 26, 2015, (Visit Source).
  11. Medscape, Intravenous Insulin Therapy. Retrieved 10/20/18 (Visit Source).
  12. Pham, J. C., Aswani, M. S., Rosen, M., Lee, H., Huddle, M., Weeks, K., & Pronovost, P. J. (2012). Reducing medical errors and adverse events. Annual review of medicine, 63, 447-463.
  13. Radley, D. C., Wasserman, M. R., Olsho, L. E., Shoemaker, S. J., Spranca, M. D., & Bradshaw, B. (2013). Reduction in medication errors in hospitals due to adoption of computerized provider order entry systems. Journal of the American Medical Informatics Association, 20(3), 470-476.
  14. Keers, R. N., Williams, S. D., Cooke, J., & Ashcroft, D. M. (2013). Causes of medication administration errors in hospitals: a systematic review of quantitative and qualitative evidence. Drug Safety, 36(11), 1045-1067. doi:10.1007/s40264-013-0090-2
  15. Saedder, E. A., Brock, B., Nielsen, L. P., Bonnerup, D. K., & Lisby, M. (2014). Identifying high-risk medication: a systematic literature review. European Journal Of Clinical Pharmacology, 70(6), 637-645. doi:10.1007/s00228-014-1668
  16. ISMP. High Alert Drugs in an Acute Care Setting. 8/23/18. Retrieved 10/20/18 from (Visit Source)
  17. Wolcott, J., Bootman, J. L., & Cronenwett, L. R. (2007). Preventing medication errors (pp. 367-408). Washington: National Academies Press.

This course is applicable for the following professions:

Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN)

Topics:

LPN IV Series


Last Updated: