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Pharmacology Current Practice

3 Contact Hours - 3 Pharmacology Hours
This course is applicable for the following professions:
Advanced Registered Nurse Practitioner (ARNP), Certified Registered Nurse Anesthetist (CRNA), Clinical Nurse Specialist (CNS), Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN), Nursing Student, Registered Nurse (RN)
This course will be updated or discontinued on or before Friday, April 30, 2021
Course Description
This course covers the major medications currently used in medicine. Those who complete this course will be able to discuss the legal rules in medication administration. They will be able to identify patients who call for special attention when receiving medication and discuss common agents in every medication category. They will also be able to list common medication errors and methods on avoiding errors.
CEUFast Inc. did not endorse any product, or receive any commercial support or sponsorship for this course. The Planning Committee and Authors do not have any conflict of interest.

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To earn of certificate of completion you have one of two options:
  1. Take test and pass with a score of at least 80%
  2. Reflect on practice impact by completing self-reflection, self-assessment and course evaluation.
    (NOTE: Some approval agencies and organizations require you to take a test and self reflection is NOT an option.)
Author:    Kelley Madick (MSN/ED, PMHNP)


The purpose of this course is to update the healthcare professional on currently available, major medications.


After completing the course, the learner will be able to:

  1. Relate the rules which serve as the standard for legal accountability in medication administration.
  2. Identify the types of patients who require special consideration when administering medications.
  3. Discuss the indications and adverse effects of each category of medication.
  4. Relate common agents included in each category of medication.
  5. Identify nursing considerations for each category of medication.
  6. List common medication errors that are avoidable and strategies to avoid them.
  7. Relate drug specific categories for prevention of medication errors.

Nurses' Accountability

Nurses have the largest role in medication safety. Studies show that nurses are responsible for 26-38% of medication administration errors6. Their results showed that at least one in four of the medication rights were regularly violated. The majority of these errors are preventable and according the Institute of Medicine Report, The Future of Nursing, nurses are pivotal in reducing medication errors5  Nurses should be diligent when administering medications and use the medication rights with every patient. The rights included in the list are only one version. Some lists have different rights or more rights.

Right Patient: Use two identifiers. The room number is not an identifier. Ask the patient to identify himself or herself, check the name on the order and the patient. If available, use technology such as bar coding. For patients not wearing ID bands or those that are not able to identify themselves, extra caution is a need. A system should be in place to identify patients without name bands or who are incompetent.

Right Medication:  Every medication administered must have an order from the provider. Compare the order with the medication administration record (MAR) for accuracy. Compare the label on the medication to the information on the MAR three times: 1) before removing the container from the drawer, 2) as the medication is removed from the container, and 3) at the bedside before administering to the patient. Do not prepare from unmarked medication containers or illegible containers. Be sure to verify medications at the patients’ bedside with the MAR and two identifiers21.

Right Dose: Have a second nurse check any calculations that need to be done. Use standard measuring devices such as syringes, graduated cups, scaled droppers. See if the pharmacists can split any required pills for safety21. If medications need to be crushed, be sure to clean the devices used before and after. Nurses should have access to information on therapeutic doses, therapeutic serum levels if applicable, and laboratory results when needed. If there is any doubt as to the doses on the order, on the MAR, or if there is a question on the medication, stop and verify all information before administering.

Right Route: Medication errors involving the wrong route of medication administration are common. Be sure to verify if there is any question as to the medication route. The nurse is responsible for knowing the appropriate route for the medication. Giving medications via the wrong route can cause serious harm to patients. If possible, when using a syringe or other device, label the appropriate route.

Right Time: Nurses need to understand why medications are given at certain times. Although some medication requires clinical judgment as to when to administer, such as a PRN sleeping medication, other medications are labeled as time-critical in some hospitals4. Studies show that giving medications at the incorrect time results in 30-40% of all medication errors3, 26, 1. Giving medication at the incorrect time can impact bioavailability and efficacy of the medication. Likewise, medications should not be prepared or mixed in advance for the same reason.6

Right Documentation: Document parameters i.e. blood pressure for hypertensive medication.

Right Action: It is important to understand the rationale for the medications prescribed. If the medication ordered is incongruent to the patient's diagnosis and rationale for its use is not apparent, it is appropriate to gather more information prior to administration.

Right Response: Document the effectiveness of the medication and the patient’s response i.e. allergic reaction, pain medication worked.

Right Form: Administration of the medication in the appropriate form (i.e. liquid versus tablet).

Special Considerations

The elderly, children, and pregnant women have physiologic differences that need to be considered when administering medication.

Due to physiological changes, particularly in hepatic metabolism and renal elimination, dosing in the elderly population can be challenging.16  The elderly may experience an increase in side effects or toxicity. This is particularly important as the majority of elderly patients are on more than one medication. Care should be taken when combining medications.

Pediatric doses are very different from adult doses. Differences in dosing are not merely due to body weight but must include physiological differences.17 Rates of renal clearance can be different in each age group. The liver and kidneys impact the pharmacokinetics of a child dose versus an adult dose. Body weight, which most medications are based on, does not give an indication of how organs are functioning. Therefore, developmental growth must also be considered when administering medications to this population.17

Pregnant women present another population where careful consideration must be taken when administering medications. The effect of the medication on the fetus may be detrimental. An understanding of how the fetus develops during pregnancy must be considered.1 The risks of not treating a disorder must be contemplated as well.

Major Categories of Medications

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.7

Common agents include:

  • Penicillin
  • Cephalosporin
  • Aminoglycoside (Gentamicin, Neomycin, Tobramycin)
  • Sulfonamide (Bactrim, Septra, Gantrisin)
  • Tetracycline
  • Monobactam
  • Macrolide (Erythromycin, Azithromycin)
  • Fluoroquinolones (Ciprofloxacin, Levofloxacin)

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. Some antibiotics must be taken on an empty stomach while others specifically must be taken with a meal. Most should be taken with a full glass of water, and some should not be taken with dairy products or close to the time dairy products are consumed.

It is good practice to culture the suspected bacteria first.7 This will allow for a definitive treatment with 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.7  This will be a factor in how aggressively to treat and 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 anaphylaxis

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

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

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 maintain therapeutic levels.
  • Do not stop the medication even if the patient feels better. The organism may not have been completely destroyed.
  • Patients should be instructed to contact their physician if the symptoms worsen or do not improve.
  • 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 are used to treat or prevent blood clots that cause strokes, MI, DVT, and PE. This group of medications increases bleeding times thus delaying the clotting process. The goal is to promote anticoagulation while minimizing hemorrhagic issues7. Medications, such as heparin, are used in more serious disease processes and are 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.7 LMWH medications include dalteparin (Fragmin), enoxaparin (Lovenox), fondaparinux (Arixtra), and tinzaparin (Innohep). The most common side effect for anticoagulant medications is an increased risk for hemorrhaging. Also renal excretion must be taken into consideration as these medications are excreted mostly in the urine.7

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.

Warfarin (Coumadin)

Inhibits Vitamin K synthesis which impacts Factors VII, IX, X, and II. At a therapeutic level, Warfarin inhibits the livers production of vitamin K which is what creates the therapeutic range. Although therapeutic ranges may be achieved in 1-2 hours, full effect is not achieved for 4-5 days until Factor II is depleted.7 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 a changing the dose or starting a new medication.19

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.19 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.

IndicationInternational Normalization Ratio (INR) Therapeutic Range
Venus thrombosis
Pulmonary Embolism
Prevention of systemic embolism
Tissue heart values
Acute MI
Atrial Fibrillation


Recurrent embolism
Mechanical heart valve


Warfarin may impact other laboratory tests19

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
  • Chondrotin 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.


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 the high side effect profile of UFH. Monitoring aPTT begins 3-4 hours after initiation and doses adjusted accordingly.7

What to monitor19, 28

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
Full dose
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
Platelets every 2-3 days from day 4 until 14 or until discontinued
LMWHDoes not effect aPTT

The Heparins7

Heparinheparin sodiumgeneric
LMWHenoxaparin sodiumLovenox

Use of Heparin7

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 subtherapuetic INR.

Nursing Considerations for Heparin:

  • Inject between iliac crests in lower abdomen into 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
  • Asses 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 Teaching for Heparin

  • 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


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.7


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.19

Adverse effects include drowsiness, ataxia, headache, dizziness, blurred vision, nausea and vomiting, anorexia, constipation, diarrhea, rash, bone marrow depression, blood dyscrasias, hypocalcemia and rickets.19

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.
  • Patients should use good oral hygiene, including flossing daily to control gingival hyperplasia.

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.14 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.7

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)
  • Lisinopril (Prinivil, Zestril)

Ace inhibitors are absorbed in the gut and metabolized mostly in the liver. The kidneys excrete these drugs. Careful monitoring of renal function and liver stability is imperative. Ace inhibitors stop the conversion of angiotensin I into becoming angiotensin II.28 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.7, 28

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.7

Nursing Considerations:

These medications can become less effective when used with NSAIDS and antacids

Ace inhibitors enhance the hypotensive effect of diuretics and bets-adrenergic blockers

They can increase serum lithium levels

Food decreases absorption of ACE inhibitors

Adverse reactions include: headache, fatigue, GI reactions, cough, and throat irritation are the most common

Ace inhibitors can also cause an increase serum potassium and an elevation of BUN and creatinine levels

  • Monitor vital signs regularly
  • Check for adverse reactions
  • Monitor weight, electrolytes and fluid status.
  • Instruct the patient to take with food or at bedtime
  • Instruct the patient to get up slowly as orthostatic hypotension can occur when rising.
  • Help the patient maintain a diet and exercise program

Several drug interactions can occur. Care should be taken to review all medications taken with ACE inhibitors. For example, NSAIDS reduce the drug’s effectiveness, potassium supplements can cause hyperkalemia, and lithium levels may be increased when taken with Ace inhibitors.28

B-adrenergic blockers (beta blockers)

B-adrenergic (beta) blockers block 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.28 Cardiac output is reduced causing a decrease in peripheral vascular resistance and a decrease in renin activity.29

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.29

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

  • Antacids can delay absorption
  • NSAIDS can decrease the hypotensive effects
  • Lidocaine toxicity can occur,
  • Diabetic medications may need 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.19

Nursing Considerations

  • Check apical pulse. Some drugs such as metoprolol should be held if the apical pulse is less than 60 beats/minute
  • Educate the patient not to stop this medication suddenly, This can cause angina, arrhythmia, and MI
  • Monitor renal and liver laboratory results
  • Assess for adverse reactions
  • Educate the patient on drug 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 drug prevents calcium from entering these areas resulting in an increase of oxygen to the heart and decreased contractility.28 The drugs also slow the heart rate by suppressing the Sinoatrial node and the Atrioventricular node. Some of the drugs in this category also dilate the peripheral vascular system and some also stop vasospasms in the brain.  Because these drug cause vasodilation, headache is the most common complaint.  Hypotension can also be common along with dizziness, headache, dysrhythmias, edema, fatigue, drowsiness and flushing.7, 28

Common agents include:

  • Diltiazem (Cardizem, Tiazac)
  • Felodipine (Plendil)
  • Nifedipine (Procardia)
  • Verapamil (Calan)
  • Amlodipine (Norvasc)

Interactions can occur when administered with beta-blockers since both types of medication interfere with the AV node resulting in bradycardia, heart block and asystole. Calcium channel blockers should not be taken with grapefruit juice or cimetidine (Tagamet), as this may lead to decrease cardiac output and hypotension. Furthermore, Dilantin and Tegretol may also interfere with the calcium channel blocker and may cause hypertension and angina. These medications may alter the effects of other drugs such as theophylline, digoxin and cyclosporine.28

Nursing Considerations

  • Monitor apical pulse. Report an irregular beat or a rate below 60 beats/minute
  • Assess for edema, crackles, dyspnea, weight gain, and jugular distention
  • Assess for hypotension and bradycardia
  • Educate the patient on orthostatic hypotension and how to rise slowly.
  • Review diet and exercise plan as sodium may need to be reduced
  • Assess blood pressure. If systolic is below 90mm HG, report to prescribing practitioner


Diuretics cause increased excretion of fluid through the kidneys thus reducing the circulating blood volume and ultimately reducing blood pressure.14 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 drugs 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.7, 14  

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

Nursing Considerations

  • Use diuretics with caution in the elderly because electrolyte disturbances and dehydration can occur rapidly
  • The nursing assessment should include a daily weight, intake and output, and a check of skin turgor for dehydration
  • Monitor for signs of metabolic alkalosis including drowsiness and restlessness
  • Monitor for signs of hypokalemia including postural hypotension, malaise, fatigue, tachycardia, leg cramps and weakness, confusion, anuria
  • Monitor electrolytes
  • Thiazide can exacerbate diabetes and gout 13
  • Avoid potassium supplements with potassium-sparing diuretic
  • 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 drugs are not effective.28 However, methyldopa is the first line drug for hypertension in pregnancy. These drugs work by activating the alpha 2 receptors which 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 drugs can cause sodium retention and are often given with a diuretic7, 28

Common agents include:

  • Clonidine (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 drug enters the brain thrrough amino acid transporters. Metabolism occurs in the liver and is excreted in urine.28

Nursing Considerations

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

Peripherally acting

Peripherally acting antiadrenergics inhibit sympathetic vasoconstriction by inhibiting release of norepinephrine and/or depleting norepinephrine stores in adrenergic nerve endings.7,28

Common agents include:

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

Nursing Consideration

  • Assess blood pressure and pulse
  • Be aware that the elderly are more sensitive to hypotensive effects
  • Assess for dizziness, dry mouth, suddenly standing
  • Monitor liver and renal functions in laboratory tests
  • Review medication list for drug interactions. Diuretics may cause increase dizziness
  • 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.7, 28

Common agents include:

  • Diazoxide (Hyperstat IV)
  • Hydralazine (Apresoline)
  • Minoxidil (Loniten)

Nursing Considerations

Diuretics should be taken early in the day to prevent nocturia.

  • Monitor blood pressure, pulse, weight
  • Monitor patients for lupus like syndrome. (sore throat, fever, muscle ache, joint aches, rash)
  • Assess for dizziness, orthostatic hypotension, general malaise, muscle or joint pain, chest pain

Anti-inflammatories (Nonsteroidal)

These medications, also known as NSAIDs, are used to relieve 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.28 Although the exact action is not known, it is thought that NSAIDS inhibit cyclo-oxgenase 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 cyclo-oxygenase enzymes, COX -1 and COX-2. COX-1 works to protect the stomach and supports platelets. When NSAIDS are given, the COX enzymes are blocked. In long term use, stomach ulcers and bleeding can occur.28 NSAIDS are metabolized by the liver and excreted through the kidney.

Common agents include:

  • Aspirin (Acetylsalicylic acid, Ecotrin)
  • Ibuprofen (Motrin, Advil)
  • Sulindac (Clinoril)
  • Naproxen (Napron, Aleve, Ananprox, Naprosyn)
  • Oxaprozin (Daypro)

Nursing Considerations and Patient Education

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


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 sulphate and glucuronide molecules. Too much of the drug can saturate these pathways. When this happens the drug 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

Nursing Considerations and Patient Education:

  • 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 in home monitoring systems.

Antineoplastic (Chemotherapy)

There are several classes of antineoplastic drugs all of which are aimed at destroying the malignant cells by inhibiting the reproduction process. Alkylating class of drugs damage the DNA and interfere with replication.19 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 sub category 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 drugs can cause permanent heart damage in high doses.28 Therefore, there are lifetime limits placed on dosages. Hormone therapy involves sex hormones or hormone like drugs 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 drugs work by not allowing the malignant cell to use the hormones they need to propagate.7

Alkylating drugs

  • Busulfan (Myleran)
  • Carboplatin (Paraplatin)
  • Cisplatin (Platinonl-AQ)
  • Melphalan (Alkeran)
  • Streptozocin (Zanosar)


  • Capecitabine (Xeloda)
  • Floxuridine (FUDR)
  • Hyroxyurea (Hydrea)

Antitumor Antibiotics

  • Bleomycin (Blenoxane)
  • Actinomycin
  • Plicamycin (Mithracin)
  • Anthracyclines: Daunorubicin, Doxorubicin, Epirbicin, Idarubicin

Hormone balance altering

  • Anastrozole (Arimidex)
  • Nilutamide (Nilandron)
  • Megestrol acetate (Megace)
  • 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 from 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.

Nursing Considerations and Patient Education

  • Assess for signs of infection like fever, sore throa,t and malaise
  • Assess for anemia, fatigue, headache, irritability, shortness of breath
  • Evaluate for an abnormal bleeding ( patient should not use razors)
  • Educate the patient on potential hair loss, nausea and vomiting while in treatment
  • Monitor laboratory tests such as CBC including differential
  • Monitor liver function and assess for jaundice
  • Avoid OTC products containing NSAIDS and aspirin
  • Some of the drugs in the category require special handling


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

  • Chlorpromazide (Thorazine),
  • Haloperidol (Haldol),
  • Fluphenazine (Prolixin)
  • 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 drugs are25

  • Risperdone (Risperdal),
  • Brexpiprazole (Rexulti),
  • Aripiprazole (Abilify),
  • Paliperidone (Invega),
  • Ziprasidone (Geodon),
  • Olanzapine (Zyprexa).

The typical or older antipsychotics can have additional adverse side effects such 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.25

Nursing Considerations

  • Inform patients on home therapy not to alter or discontinue their medication. These medications should be tapered gradually to discontinue treatment
  • Educate patient to wear sunscreen when outside, rise slowly from a lying or sitting position, avoid hot tubs
  • Monitor blood pressure
  • Evaluate for Extrapyramidal symptoms such as akathisia, dystonia, pseudo Parkinsonism, and dyskinesia

Nursing Considerations and Patient Education

  • Change from a sitting or lying position slowly to avoid orthostatic hypotension. Avoid hot tubs and bathing in very hot water
  • Wear a sunscreen or protective clothing to prevent sunburns
  • Take extra precautions during hot weather to avoid heat stroke
  • Drowsiness or impaired mental and motor activity occurs during the first two weeks of taking the medication but tends to decrease over time
  • 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.


Antitubercular medications are used in the treatment of all forms of active TB caused by M. Tuberculosis and as a preventative for high-risk persons who may have been exposed. Treatment should begin as soon as possible and consists of combination anti-TB drugs. TB becomes easily resistant to medications. There are usually two phases of treatment- the first phase lasts for two months and the continuation phase lasting for 4 months. Each drug works slightly differently. This will help prevent cellular treatment resistance.  Isoniazid and Ethambutol work by inhibiting cell wall synthesis. Pyrazinamide has a mechanism of action that disrupts the plasma membrane and the energy metabolism. Rifampin inhibits RNA synthesis.7

Common agents include:

  • Ethambutol (EMB)
  • Isoniazid (INH)
  • Pyrazinamide (PZA)
  • Rifabutin (Mycobutin) –Used in patient with HIV. This cannot be used on patients with active TB19
  • Rifampin (Rifadin, Rimactane)

Adverse effects are dizziness, fever, GI upset, nausea, general malaise, joint pain, pruritus. More serious side effects can include thrombocytopenia, leukopenia, neutropenia, epidermal necrosis, anaphylactic reaction. Use of these medications may also increase laboratory tests such as ALT, AST, bilirubin and uric acid levels. There may also be a decrease in glucose and platelet count.19

Nursing Considerations

  • Monitor renal function
  • Assess visual acuity
  • Educate patients on side effects, including jaundice, discoloration of urine, stool, saliva, tears or sweat
  • Give medication on an empty stomach
  • Monitor for any flu-like symptoms or usual bleeding


Antivirals are used to treat and manage viral infections including influenza, HIV, herpes simplex and herpes zoster. Unlike antibiotics, antivirals are specific for 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.19 However, there are additional side effects and serious reactions with each type of antiviral classification.


  • Entry inhibitors keep the virus from attaching to the outside of the host cell preventing infection of the virus7
  • Fusion inhibitors stops the virus cell from fusing with the host cell
  • Reverse transcription inhibitors prevents single strand viruses from becoming a double strand virus. There are two types:7,10
  •     Nucleoside RT inhibitors stops virus DNA synthesis by adding a false DNA strand
  •     Non-nurcleoside RT inhibitors interfere with the ability of converting RNA to DNA
  • Integrase Inhibitors blocks the enzyme integrase that the virus uses to insert itself into a host cell
  • Protease Inhibitors interfere with the enzyme protease, which normally works on the viral proteins to help create new viral cells10
  • Multi-class Combination are 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 compromise 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 seizures 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 necrolysis 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 27

Antivirals for HerpesSide Effects
Acyclovir (Zovirax)Encephalopathic changes, tremors, confusion, hallucinations, agitation, seizures, acute renal failure, angio edema, and 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


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) -intravenousAbnormal 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 blood glucose , rash

Nursing Considerations and Patient Education

  • Monitor for side effects and complete regular assessments
  • Educate patients on side effects
  • Oral contraceptives may be rendered in effective
  • Antacids should be taken at least an hour prior to taking an antiviral medication
  • Review laboratory work


Bronchodilators are used to relax bronchiole smooth muscles to allow air to pass through easier. There are three main types of bronchodilators. They can be used together for optimal relief. These are beta-agonists, anticholinergic, and theophyllines.28, 7 Beta-agonists work on the Beta2 receptors in the lungs to dilate bronchi and bronchioles. However; they can also impact the heart, skeletal muscles and central nervous system. Beta-agonists work quickly and are given for quick relief. They are also used to prevent or reduce breathlessness associated with exercise or other specific situations.    Anticholinergic bronchodilators work to relax the muscles around the bronchi so that the muscles do not tighten and narrow. This allows for better airflow. However, anticholinergic medications can take longer to work than Beta2 agonists. There are short-acting and long-acting anticholinergics. Lastly, there are theophylline bronchodilators that affect the muscles in the breathing passages. When there is irritation, theophylline helps the passages relax, which keeps the passages open and allows for airflow. These are long-acting forms. Most bronchodilators are metabolized in the liver and excreted in the urine.7, 28

Beta 2 Agonists19

Albuterol (Proventil, Ventolin, ProAir, Accuneb)Salmeterol (serevent)
Levalbuterol ( Xoponex, Xopones)Formoterol (Foradil)
Pirbuterol (Maxair)Salmeterol and fluticasone (Advair)
Albuterol and ipratropium combination (DuoNeb solution, Combivent Respimat)Formoterol and budesonide (Symbicort)
 Formoterol and mometasone (Dulera)

Short -acting Beta 2 Agonists work within 15 to 20 minutes and last 4-6 hours

Long-acting Beta 2 Agonists are used twice a day for long-term control

Side effects include nervousness, shaky feeling, and hyperactivity; increase heart rate, trouble sleeping and upset stomach


Ipratropium bromide (Atrovent)Nebulizer or metered dose inhaler
Tiotropium bromide (Spiriva)Dry powder inhaler given once a day

Side effects of anticholergic bronchodilators are dry throat, rhinitis, palpitations, dizziness, and headache



Theophylline bronchodilators are all long-acting and are available in oral or intravenous form. Blood tests are required to test therapeutic levels. Side effects include nausea, vomiting, diarrhea, stomach ache, headache, rapid heartbeat, muscle cramps, nervousness, and hyperactivity.

Nursing Considerations and Patient Education

  • Monitor the vital signs. Improvement in the quality and rate of respiration in a short period of time is the expected clinical outcome. A sudden sharp or unexplained rise in heart rate is a useful clinical indicator of toxicity.
  • Educate patients to report insomnia or nervousness.
  • Avoid smoking or smoking area.
  • Educate patient on how to use inhalers and when to use their inhalers.

Cardiac Medications


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 antiarrhythmics. The desired end point 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.7, 28

Common adverse effects are syncope, hypotension, nausea, vomiting, diarrhea and abdominal pain. Symptoms of over dosage are hypokalemia, seizures and tachydysrhythmias.19

Class 1A

This class includes Quindine, disopyrmide 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 liver and excreted through 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.7, 29

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.7

Class 1C

Class 1C antiarrhythmias are used to treat severe, resistant ventricular arrhythmias. Medications include flecainide acetate (Tamboco), miricizine and propafenone (Rythmol). These medications slow the conduction rate but do not have much of an affect on action potential. Side effects include development of new arrhythmias, aggravation of current arrhythmia, palpitations, shortness of breath, chest pain, heart failure and cardiac arrest.7

Class II

Class II antiarrythmias 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 drugs 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 fatigue.7

Class III

Class III medications treat ventricular arrhythmias. These medication 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) and Ibutilide (Corvert). Side effects include aggravation of current arrhythmia, hypotension, bradycardia, nauseaand anorexia. Amiodarone can cause vision issue.  Ibutilide may sustain QT interval. Sotalol may cause AV block, bradycardia, bronchospasm and hypotension.7

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).7

Nursing Considerations and Patient Education

  • Monitor EEG, vital signs and apical pulse
  • Monitor drug levels when indicated
  • Monitor liver function and renal function laboratory results
  • Assess for adverse reaction
  • Educate patients on side effects
  • Monitor weight as required
  • Monitor fluid intake and output when indicated

Cardiac Glycosides

Cardiac glycosides are used 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.7, 28

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 drug.


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.7, 28

Nitrates decrease peripheral vascular resistance or afterload and decreases 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. Drugs in this class are amyl nitrate, isosorbide dinitrate, isosorbide mononitrate, and nitroglycerin. These medications are given sublingually, chewable or as an aerosol.7, 28

Beta-adrenergic medications are used for long-term prevention of angina. These include atenolol, metaoprolol, nadolol, and propranolol. These medications reduce oxygen demand as they 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.

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 of peripheral and coronary arteries. This 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, bradycardia, and AV block.19

Nursing Considerations and Patient Education

  • Assess for adverse reactions
  • Assess apical pulse and vital signs
  • Monitor serum drug levels
  • Monitor liver function and renal function laboratory tests
  • Monitor ECG as required
  • Educate patient to change positions slowly, avoid alcohol and report side effects


Corticosteroids are a class of drugs 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.28

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.7, 28

These medications include:

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

Common mineralocorticoids include:

  • Fludrocortisone (Florinef)

Nursing Considerations and Patient Education

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

Diabetic Medications (Insulin and Hypoglycemics)

Diabetic patients may be treated with injectable insulin or oral hypoglycemics, depending on the pathophysiology and severity 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 sufficient, if any insulin, so they need an exogenous source of insulin.

Insulin Activity after SQ Injection7,28
Type InsulinExample Brands/Common NameOnsetPeakDuration


15 minutes prior to meal or immediately after

Humalog15 min.0.5-1.5 hr.6 – 8 hrs.


30-60 min prior to meals

Humulin-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 70/30
30 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. Their use is rapidly decreasing and being 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.7, 28

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.

Oral hypoglycemics are used to manage mild to moderate, non-insulin dependent diabetes (NIDDM or Type II) that cannot be controlled by diet and exercise alone. The action of these medications is to lower the blood glucose by stimulating the pancreatic beta cells to synthesize and release insulin.7, 28

Common agents include:

  • 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, bloating, gas, GI disturbances and rarely anaphylaxis.19

Nursing Considerations

Educate patient on how to inject themselves and when to take medication

  • Educate patient on how to measure medication
  • Educate patient on how to obtain and read glucose levels
  • Assess patient for rash, shortness of breath, wheezing, hypotension, excess sweating
  • Monitor injection sites
  • Asses for hypoglycemia and hyperglycemia
  • Assess for diabetic nerve disease
  • Review renal and liver function laboratory reports
  • Monitor patient closely if they have a fever, are under stress, recent surgery or trauma

Narcotic Analgesics (Opioid Analgesics)

Narcotic analgesics are used to relieve pain or induce unconsciousness. These drugs 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, lightheadedness, nausea and vomiting.19

Common agents include:

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

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 are painful.

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 guides 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.7, 28

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.19

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 Zofran 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.19

Nursing Considerations and Patient Education

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

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).7,28 The hormone increases cellular metabolism which is related to growth, tissue development, brain function, and temperature regulation. Thyroid hormone replacement is usually given by oral route. Side effects are irritability, insomnia, weight loss, change in appetite, palpitations, angina, dysrhythmias, or tachycardia.19

Common agents include:

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

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 occlusion
  • 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 Calculations

Commonly used equivalents:


1 liter (L) = 1000 milliliters (ml) = 1000 cubic centimeter (cc)
1 ml = 1cc

Weight1 kilogram (kg) = 1000 grams (gm)
1 gm = 1000 milligrams (mg)
1 mg = 1000 micrograms (mcg)

To convert grams to milligrams, you would multiply the known value by the conversion factor.

For example to convert 0.015 gm. to mg. you multiply 0.015 gm. by 1000 (1 gm. =1000 mg.).

 0.015 X 1000 = 15
Therefore, 0.015 gm. = 15 mg.

Calculating Dosages:

Calculating dosages for non-parenteral medications such as pill, capsules, unscored tablets or suppositories should be rounded to the nearest whole number. To calculate the dosage for scored tablets round to the nearest half, or quarter, depending on how the tablet is scored. With problems involving oral liquid medication, it is generally accurate enough to round one decimal place. However, remember that medication for children require a greater degree of accuracy.

Suggested formula for calculation, Method I:

Prescribed dose/Available dose
x  Quantity (unit of measure) = Amount to be given.

Example: The physician orders Keflex 750 mg. On hand, you have Keflex 250 mg. per capsule. Both the medication ordered and the medication on hand is in the same unit of measure (mg).

(Prescribed dose) 750 mg./(Available dose) 250 mg.
x 1 capsule = = 3 capsules to be given
x 1 = 3

To check your answer by the alternate method of reasoning:

250 mg. x 3 = 750 mg.

Suggested formula for calculation, method II:

This method allows you to set up a ratio of what you have to what you need.

Example: Using the same example, the physician orders Keflex 750 mg. and you have Keflex 250 mg. per tablet.

Available dose : 1 :: Prescribed dose : X

250 mg. : 1 tablet :: 750 mg. : X tablets

Available dose : 1 :: Prescribed dose : X

250 mg. : 1 tablet :: 750 mg. : X tablets

250x = 750


X = 3

Calculating mcg/Kg/min.

If you know the rate:

(mcg/ml) (ml/hr)/(60 min/hr)(kg of body weight)
= mcg/kg/min

If you know the dose:

(mcg/kg/min) (60 min/hr) (kg of body weight)/mcg/ml of the solution
= ml/hr

Example: A patient is on a dopamine drip infusing at a rate of 26 ml/hr. The dopamine bag is labeled, 400 mg of dopamine in 250 ml of D5 (1600 mcg/ml). The patient weights 70 kg. To calculate the mcg/kg/min:

(1600 mcg/ml)(26 ml/hr)/(60 min/hr)(70 kg)
= mcg/kg/min
= 9.9047 = 10 mcg/kg/min

Tips for solving problems in dosage calculation:

  1. Know the units of measure that you desire in the answer. This will help you find the information you need to convert to the desired amount.
  2. Recheck your math. Use a calculator if one is available.

Calculating IV Drip Rates:

When you regulate an IV flow rate with a clamp or dial controller, the rate will usually be measured in drips/minute. IV administration sets deliver a specific number of drops per ml. The number is on the package label. Standard drip sets deliver 10-20 drops/ml. Microdrip sets deliver 60 drops/ml and blood sets usually deliver 10 drops /ml.

Suggested formula: 4

total number of ml to infuse/total number of minutes to infuse
x drip factor (gtts/ml) = flow rate (gtts/min)

Example: Administer 1000ml of D5W over 8 hours using an infusion set that delivers 10 gtts/ml.

1000ml/8 hours x 60 minutes
x 10 gtts/ml = X gtts/min
1000 ml/480 minutes
x 10 gtts/ml = X gtts/min

2.08 ml/minute x 10 gtts/ml = X gtts/min

20.8 gtts/ml = X

Round to the nearest whole for a drip rate of:

21 gtts/min (rate for a clamp or dial controller)

Dial controllers may not be accurate if the IV catheter is less than a 20 gauge.

When you use an infusion pump, the flow rate is measured in ml/hours. To find the rate in ml/hour for an infusion pump, divide the total number of ml. by the total number of hours.

1000ml/8 hr
= 125ml/hr (rate for an infusion pump)

Medication Errors

Medication errors account for over 98,000 deaths per year and are a very large part of health care costs.20 It is estimated that preventable adverse reactions account for more than 3.5 billion dollars annually for hospitals.20 The Institute of Medicine report To Error is Human: Building a Safer Health Care System revealed the seriousness of these errors and found that most were preventable.22 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 errors, 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 distractions can occur during handoff including, background noise, inconsistent information, incomplete care responsibility, conflicting communication needs and expectations, and inability to listen.22

Use of handoff tools such as SBAR (Situation, Background, Assessment, Recommendation) are a way to standardize the information that is passed between providers and facilities.22 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, and 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.22

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.20

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 specific 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. Bar coding medication for administration, computerized order entry, education, and electronic drug 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 following20:

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

High Alert Drugs

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

The Institute for Safe Medication Practices reports the drugs that are considered Look-Alike-Sound-Alike as well as high-risk drugs.  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 entire list can be found on the ISMP's website.


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.22 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.27 Bar coding 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 bar code to be effective.

Some physician 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 errors22,27 It also makes it possible to automatically check doses, drug-drug interactions, allergies and significant patient data, such as 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 and nurses who are less computer savvy may be resistant to fully implement the system. Human error is also a factor. Education and communication are again the keys to deceasing medication errors.

Select one of the following methods to complete this course.

Take TestPass an exam testing your knowledge of the course material.
Reflect on Practice ImpactDescribe how this course will impact your practice.   (No Test)


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