Pharmacology Study Guide SPRING 2024 PDF

**Pharmacology Study Guide** - **Tadalafil** - Erectile dysfunction agents, vasodilators (phosphodiesterase type 5 inhibitors) - Treatment of erectile dysfunction, benign prostatic hyperplasia - [Contraindications:] - Hypersensitivity - Concurrent use of nitrate or riociguat -...

**Pharmacology Study Guide** - **Tadalafil** - Erectile dysfunction agents, vasodilators (phosphodiesterase type 5 inhibitors) - Treatment of erectile dysfunction, benign prostatic hyperplasia - [Contraindications:] - Hypersensitivity - Concurrent use of nitrate or riociguat - Unstable angina - Recent history of stroke within 6 months - Life threatening HF within 6months - Uncontrolled hypertension - Arrhythmias - MI within 90 days - Any other cardiovascular pathology precluding sexual activity - Know hereditary degenerative retinal disorders - Sever hepatic impairment - Congenital or acquires QT interval prolongation - Concurrent use of Class IA or III antiarrhythmics - Alpha adrenergic blockers (when used for BPH) - Women/children/newborn - [Patient Teaching:] - Take as needed for ED at least 30 min before sexual activity & not more than 1x per day - Sexual stimulation is required for erection to occur - Not indicated for use in women - Do NOT take with alpha adrenergic blockers (unless on a stable dose) or nitrates, if chest pain occurs seek immediate medical attention - Avoid excess alcohol intake (≥5 units); may ↑orthostatic hypotension, increased HR, decreased standing BP, dizziness, HA. - Notify HCP promptly if erection last longer than 4hr, if they are not satisfied with their sexual performance or develop unwanted side effects or if they experience sudden or decreased vision loss in one or both eyes or decrease/loss in hearing, ringing in the ears or dizziness - Notify HCP of all Rx/OTC meds/vitamins/herbal products-consult before taking any other meds - No protection against sexually transmitted diseases. Counsel pt that protection against STI's & HIV infection should be considered - **Oxytocin** - Hormones (oxytocics) - Induction of labor at term, facilitation of threatened abortion (IV) - Postpartum control of bleeding after expulsion of placenta (IV, IM) - [Adverse Reactions:] - Maternal adverse reactions are for IV use only: - Coma - Seizures - Hypotension - Hypochloremia - Hyponatremia - Water intoxication - ↑ uterine motility - Painful contractions - Abruptio placentae - Decreased uterine blood flow - Hypersensitivity - Fetal - Intracranial hemorrhage - Asphyxia - Hypoxia - Arrhythmias - [Nursing Implications:] - **Assessment:** - Fetal maturity, presentation, & pelvic adequacy should be assessed prior to admin for induction of labor - Assess character, frequency, & duration of uterine contractions; resting uterine tone & FHR frequently throughout admin. - If contractions occur \< 2 min apart & last 60-90 sec or longer, or if significant change in FHR develops, stop infusion & turn pt on left side to prevent fetal anoxia. Notify HCP immediately - Monitor maternal BP & pulse frequently & FHR continuously throughout admin - This drug occasionally causes water intoxication. Monitor for s/s (drowsiness, listlessness, confusion, HA, anuria) & notify HCP - **Lab Test Considerations:** monitor maternal electrolytes. Water intoxication= hypochloremia or hyponatremia - Potential Nursing Diagnoses-Deficient knowledge, related to medication regimen - **Implementation:** - Do NOT admin simultaneously by more than one route - IV administration: - Continuous Infusion: Rotate infusion containers to ensure through mixing. Store solution in refrigerator, but do NOT freeze - Infuse via infusion pump for accurate dose. Should be connection via Y-site injection to an IV of 0.9% NaCl for use during adverse reactions - [Magnesium sulfate] should be available if needed for relaxation of myometrium - **Induction of labor:** Diluent: 1mL (10 units) in 1L of compatible infusion fluid (0.9% NaCl, D5W, or LR) Concentration: 10 milliunits/mL Rate: begin infusion at 0.5-2 milliunits/min (0.05-0.2mL); increase in increments of 1-2 milliunits/min at 15-30 min intervals until contractions simulate normal labor - **Postpartum Bleeding:** Diluent: 1-4 mL (10-40 units) in 1L of compatible infusion fluid Concentration: 10-40 milliunits/mL Rate: begin infusion at a rate of 20-40 milliunits/min to control uterine atony. Adjust rate as indicted - **Incomplete or Inevitable Abortion:** Diluent: 1mL (10 units) in 500mL of 0.9% NaCl or D5W Concentration: 20 milliunits/mL Rate: 20-40 milliunits/min - **Nifedipine** - Antianginal, antihypertensives (calcium channel blocker) - Management of hypertension (extended release only), angina pectoris, vasospastic (prinzmetal's) angina - Unlabeled use: prevention of migraine, management of HF/cardiomyopathy - [Adverse Reactions:] - HA, Abnormal dreams, Anxiety, Confusion, Dizziness, Drowsiness, Jitteriness, Nervousness, Psychiatric disturbances, Weakness - Blurred vision, disturbed equilibrium, epistaxis, tinnitus - Cough, dyspnea, SOB - Arrhythmias, HF, peripheral edema, bradycardia, chest pain, hypotension, palpations, syncope, tachycardia - ↑ liver enzymes, anorexia, constipation, diarrhea, dry mouth, dysgeusia, dyspepsia, GI obstruction, N/V, ulcer - Dysuria, nocturia, polyuria, sexual dysfunction, urinary frequency - Flushing, dermatitis, erythema multiforme, ↑sweating, photosensitivity, pruritus/urticaria, rash - Gynecomastia, hyperglycemia - Anemia, thrombocytopenia - Weight gain - Joint stiffness, muscle cramps - Paresthesia, tremor - Stevens Johnston syndrome, gingival hyperplasia - [Nursing implications: ] - Monitor BP & pulse before therapy, during dose titration, & periodically during therapy. Monitor ECG periodically during prolonged therapy - Monitor I&O ratios & daily weight. Assess signs of HF (peripheral edema, rales/crackles, dyspnea, weight gain, JVD) - Pts receiving digoxin concurrently with nifedipine should have routine tests of serum digoxin levels and be monitored for s/s of dig toxicity - Assess for rash periodically during therapy. May cause stevens-Johnson syndrome. Discontinue therapy if severe or if accompanied with fever general malaise, fatigue, muscle or joint aches, blisters, oral lesions, conjunctivitis, hepatitis, and/or eosinophilia - **Angina:** assess location, duration, intensity, & precipitation factors of pts anginal pain - **Lab Test Considerations:** total serum calcium concentration is not affected by calcium channel blockers -Monitor serum potassium periodically. Hypokalemia increases risk of arrhythmias; should be corrected. -monitor renal & hepatic functions periodically during long-term therapy. Several days of therapy may cause ↑hepatic enzymes, which return to normal upon discontinuation of therapy. -Nifedipine may cause positive ANA & direct Coombs' test results - **Potential Nursing Diagnosis:** -Decreased cardiac output (indications) -Acute pain (indications) - **Implementation:** - Do not confuse with nicardipine or nimodipine - **PO:** may be admin w/o regard to meals. May be admin with meals if GI irritation becomes a problem - Do NOT open, break, crush, or chew extended-release tablets. Empty tablets that appear in stool are not significant - Avoid admin with grapefruit juice - Sublingual use is not recommended due to serious adverse drug reactions - [Patient/Fam Teaching ] - Take as directed, even if feeling well. Take missed doses ASAP unless almost time for next dose; do NOT double doses. May need to be discontinued gradually - Instruct pt how to take pulse/contact HCP if HR is \ - **Ethinyl Estradiol** - Contraceptive hormones - [Indications:] - Prevention of pregnancy - Regulation of menstrual cycle - Emergency contraception (some products) - Management of acne in women \14yr who desire contraception, have no health problems, & have failed topical treatment. - Increase folate levels in women who desire oral contraception to reduce the risk of neural tube defects in a pregnancy that occurs while takin or shortly after discontinuing the product. - [Contraindications: ] - Hypersensitivity - OB: pregnancy - History of cigarette smoking or age \>35 yrs. (↑risk of cardiovascular or thromboembolic phenomenon) - History of thromboembolic disease (DVT, PE, MI, stroke) - Protein C, protein S, or antithrombin deficiency or other thrombophilic disorders - Valvular heart disease - Major surgery with extended periods of immobility - Diabetes with vascular involvement - HA with focal neurological symptoms - Uncontrolled hypertension - History of breast, endometrial or estrogen-dependent cancer - Abnormal genital bleeding - Lover disease - Hypersensitivity to parabens (injectable only) - [Patient Teaching: ] - Oral meds take as directed same time each day. Pills should be taken in proper sequence and kept in the original container. Advise pt not to skip pills even if not having sex very often. Read pt guide before starting & with each refill - If a single dose is missed, take as soon as remembered; if not until next day, take 2 tablets & cont. on regular dosing schedule. - If 2 days in a row are missed take 2 tablets a day for the next 2 days & cont. on regular dosing schedule, using a second method of birth control for the remaining cycle. - If 3 days in a row are missed discont. Med and use another form of birth control until period begins or pregnancy is ruled out; then begin a new cycle of tablets. - For 28-day dosing schedule: if schedule is followed for the first 21 days and 1 dose is missed of the last 7 tablets it is important to take the 1^st^ tablet of next month's cycle on the regularly scheduled day. - Advise pts taking extended tablets that spotting or light bleeding may occur, especially during the first 3 months. Continue med; notify HCP if bleeding lasts \>70 k days - Advise pt of the need to use another form of contraception for the first 3 weeks when beginning to use oral contraceptives - Instruct pt to notify HCP of all Rx/OTC/vitamins/herbal products being taken & consult HCP before taking anything new - If discontinue med suddenly may cause withdrawal bleeding - If nausea becomes a problem, advise pt that eating solid food often provides relief. If nausea persist or vomiting/diarrhea occurs use a nonhormonal method of contraception & notify HCP - Report s/s of fluid retention (swelling, of ankles & feet, weight gain), thromboembolic disorders (pain, swelling, tenderness in extremities, HA, chest pain, blurred vision), mental depression, hepatic dysfunction (yellowed skin or eyes, pruritus, dark urine, light colored stools), or abnormal vaginal bleeding, women with a strong fam history of breast cancer, fibrocystic breast disease, abnormal mammograms or cervical dysplasia should be monitored for beast cancer at least yearly. - Risk of thromboembolism is highest in 1^st^ year of use & increased when a combination hormonal contraceptive is restarted after a break in use of at least 4 weeks - Stop taking if pregnancy is suspected - Caution that cigarette smoking during estrogen therapy may increase risk of serious side effects especially for women over age 35 - Use sunscreen & protective clothing to prevent increased pigmentation - Caution that hormonal contraceptives do not protect against HIV or other STI's - Notify HCP before treatment or surgery - Importance of routine follow-up physical exams including BP, breast, abdomen, & pelvic examinations; pap smears every 6-12 months - **Risperidone** - (benzoxazoles)-antipsychotics, mood stabilizer - To decrease symptoms of psychoses, bipolar mania, or autism - [Interactions: ] - **Drug-Drug:** - may ↓the antiparkinsonian effects of levodopa or other dopamine agonists - Carbamazepine, phenytoin, rifampin, phenobarbital, and other enzyme inducers ↑metabolism and may ↓effectiveness; dose adjustments may be necessary - Fluoxetine and paroxetine ↑blood levels and may ↑effects; dose adjustments may be necessary - Clozapine ↓metabolism and may ↑effects of risperidone - ↑CNS depression may occur with other CNS depressants, including alcohol, antihistamines, sedative/hypnotics, or opioid analgesics - Drug-Natural: - Kava, valerian, or chamomile can ↑CNS depression - [Assessment:] - Monitor pts mental status (orientation, mood, behavior) and mood before & periodically during therapy. Monitor closely for notable changes in behavior that could indicate the emergence/worsening of suicidal thoughts, behavior, or depression especially during early therapy. Restrict amount of drug available to pt. - Assess weight and BMI initially and throughout therapy. Monitor for symptoms of hyperglycemia polydipsia, polyuria, polyphagia, & weakness periodically - Monitor BP (sitting, standing, laying down) and pulse before & frequently during initial dose titration. May cause prolonged QT interval, tachycardia, and orthostatic hypotension. If hypotension occurs, dose may need to be ↓. - Observe pt for onset of extrapyramidal side effects (akathisia- restlessness; dystonia- muscle spasms and twisting motion; or pseudoparkinsonism- mask-like face, rigidity, tremors, drooling, shuffling gait, dysphagia) Report these symptoms; reduction of dose or discont. may be needed. Trihexyphenidyl or benztropine may be used to control symptoms - Monitor for tardive dyskinesia (involuntary rhythmic movement of mouth, face, and extremities). Report immediately-may be irreversible - Monitor for development of neuroleptic malignant syndrome (fever, resp distress, tachycardia, seizures, diaphoresis, hypertension, or hypotension, pallor, tiredness) Notify HCP immediately - Assess for fall risk. Drowsiness, orthostatic hypotension, and motor & sensory instability ↑ risk/ institute prevention if indicated. - Lab Test Considerations: - may ↑ serum prolactin levels - may cause ↑ AST & ALT - may cause anemia, thrombocytopenia, leukocytosis, & leukopenia - obtain fasting blood glucose & cholesterol levels initially/ throughout therapy - monitor CBC frequently during initial month of therapy in pts with pre-existing or hx of low WBC. May cause leukopenia, neutropenia, or agranulocytosis. Discont. If this occurs - [Patient teaching:] - Inform possibility of extrapyramidal symptoms & report immediately to HCP - Change positions slowly to minimize ortho hypotension/protect from falls - May cause drowsiness. Avoid driving/activities until known response - Notify HCP if thoughts about suicide/dying, attempts to commit suicide; new/worse anxiety, depression, feeling very agitated or restless, panic attacks, trouble sleeping, new/worse irritability; aggressive, angry/ violent, acting on dangerous impulses; extreme increase in activity/talking, or other unusual behaviors - Use sunscreen and protective clothing when exposed to sun to prevent photosensitivity reactions, extreme temps should be avoided (impairs body temp regulation) - Notify HCP of all OTC meds, vitamins, or herbals products - Avoid alcohol and other CNS depressants - Female pts notify HCP if pregnancy is planned/suspected/breastfeeding or planning to - Notify HCP of med regimen before treatment or surgery - Notify HCP promptly if sore throat, fever, unusual bleeding or bruising, rash, tremors, or symptoms of hyperglycemia occur - Importance of routine follow up exams to monitor side effects and cont. participation in psychotherapy to improve coping skills - **Terbutaline** - Bronchodilators, Adrenergic - [Indications: ] - Management of reversible airway disease due to asthma or COPD; inhalation & subcutaneous used for short-term control & oral agents as long-term - Unlabeled use: - Management of preterm labor (tocolytic) (the FDA recommends that injectable terbutaline should not be used in pregnancy for the prevention or prolonged treatment \[\> 48-72 hrs.\] of preterm labor in either the inpatient or outpatient b/c of the potential for serious maternal heart problems & death; oral terbutaline should not be used for the prevention or any treatment of preterm labor b/c of the same reason as injectable - [Adverse reactions:] - Nervousness, restlessness, tremor, HA, insomnia - Pulmonary edema - Angina, arrhythmias, hypertension, MI, tachycardia - N/V - Hyperglycemia - Hypokalemia - [Assessment:] - **Bronchodilator:** - Assess lung sounds, respiratory pattern, pulse, & BP before admin & during peak. Note amount, color, & character of sputum produced, and notify HCP of abnormal findings - Monitor pulmonary function tests before & throughout therapy to determine effectiveness of med - **Preterm Labor:** - Monitor maternal pulse & BP, frequency/duration of contractions, & FHR Notify HCP if contractions persist or increase in frequency/duration or distress of mom/baby occur - Maternal side effects include tachycardia, palpitations, tremor, anxiety, & HA - Asses maternal respiratory status for symptoms of pulmonary edema (increased rate, dyspnea, rales/crackles, frothy sputum) - Monitor mother/neonate for symptoms of hypoglycemia (anxiety, chills, cold sweats, confusion, cool, pale, difficulty in concentration, drowsiness, excessive hunger, HA, irritability, nausea, nervousness, rapid pulse, shakiness unusual tiredness or weakness) and mother for hypokalemia (weakness, fatigue, U wave on ECG, arrhythmias) - **Lab Test Considerations:** - May cause transient decrease in serum potassium, concentration with higher than recommended doses - Monitor maternal serum glucose & electrolytes (hypokalemia & hypoglycemia) monitor neonates glucose - **Toxicity & Overdose:** persistent agitation, chest pain or discomfort, ↓BP, dizziness, hyperglycemia, hypokalemia, seizures, tachyarrhythmias, persistent trembling and vomiting - Treatment=discontinuing and supportive therapy. Cardioselectivity beta blockers are used cautiously b/c they may induce bronchospasm - **Magnesium Sulfate** - Mineral & electrolyte replacements/supplements - [Indications: ] - Treatment/prevention of hypomagnesemia - Treatment of hypertension - Prevention of seizures associated with severe eclampsia, pre-eclampsia, or acute nephritis - **Unlabeled use:** - Preterm labor - Treatment of torsade de pointes - Adjunctive treatment for bronchodilation in moderate to severe acute asthma - [Nursing Assessment:] - **Hypomagnesemia/Anticonvulsant:** monitor pulse, BP, respirations & ECG frequently throughout admin or parenteral mag sulfate - Respirations should be at least 16/min before each dose - Monitor neuro status before & throughout - Institute seizure precautions - Patellar reflex (knee jerk) should be tested before each parenteral dose; if response is absent no additional doses should be admin until positive response obtained. - Monitor newborn for hypotension, hyporeflexia, & resp depression - Monitor I&O ratios. Urine output should be at least 100mL/4hr - **Lab Test Considerations:** - Monitor serum mag levels & renal function - [Implementation ] - **HIGH ALERT:** accidental overdosage of IV mag has resulted in serious pt harm & death. Have second practitioner independently double-check original order, dose calculations, & infusion pump settings. Do NOT confuse milligram(mg), gram (g), or milliequivalent (mEq) dosages - IM: admin deep IM into gluteal sites. Admin subsequent injections in alternate sides. Dilute to a concentration of 200 mg/mL prior to injection - **IV administration:** - **IV Push:** -Diluent: 50% solution must be diluted in 0.9% NaCl or D5W to a concentration of ≤20% prior to admin -Concentration: ≤20% -Rate: Not to exceed 150mg/min - **Continuous infusion:** -Diluent: D5W, 0.9% NaCl, or LR -Concentration: 0.5 mEq/mL (60mg/mL) (may use max concentration of 1.6mEq/mL) (200mg/mL) in fluid restricted pts -Rate: over 2-4hrs. Do NOT exceed a rate of 1mEq/kg/hr (125 mg/kg/hr). When rapid infusions are needed (severe asthma or torsade de pointes) may infuse over 10-20min - **Baclofen** - Antispasticity agent, skeletal muscle relaxants (centrally acting) - Admin: PO, IT - [Contraindications/Precautions:] - Contraindicated in hypersensitivity - **Use cautiously in:** - Pts whom spasticity maintains posture & balance - Pts with epilepsy (may decrease seizure threshold) - Renal impairment (decrease dose may be required) - OB, Lactation: Safety not established - Pedi: Children \ - [Adverse reactions/side effects:] - Seizures (rr), dizziness, drowsiness, fatigue, weakness, confusion, depression, HA, insomnia - Nasal congestion, tinnitus - Urinary frequency - Pruritus, rash - Hyperglycemia, weight gain - Ataxia - Hypersensitivity reactions, sweating - [Patient/Fam Teaching:] - Take as directed, take a missed dose within 1hr; do NOT double doses - Avoid abrupt withdrawal b/c it may precipitate an acute withdrawal reaction (hallucinations, ↑spasticity, seizures, mental changes, restlessness), discontinue gradually over 2 weeks or more - May cause dizziness & drowsiness/avoid driving/activities until response is known - Change positions slowly to minimize orthostatic hypotension - Avoid alcohol or other CNS depressants - Notify HCP if frequent urge to urinate/painful urination, constipation, nausea, HA, insomnia, tinnitus, depression, or confusion persists. - Report s/s of hypersensitivity (rash, itching) promptly - IT: do NOT discontinue IT therapy abruptly. May = fever, mental changes, exaggerated rebound spasticity & muscle rigidity. Do NOT miss scheduled refill app & notify HCP promptly if signs of withdrawal occur - **Diazepam** - Antianxiety agents, anticonvulsants, sedative/hypnotics, skeletal muscle relaxants (centrally acting) (benzodiazepine) - PO, IM, IV, Rectal - [Action:] - Depresses the CNS, probably by potentiating GABA, an inhibitory neurotransmitter - Produces skeletal muscle relaxation by inhibiting spinal polysynaptic afferent pathways - Has anticonvulsant properties due to enhanced presynaptic inhibition - **Therapeutic Effects:** Relief anxiety. Sedation. Amnesia. Skeletal muscle relaxation. Decreased seizure activity. - [Nursing Implications: Assessment ] - Monitor BP, pulse, & RR prior to/periodically throughout therapy & frequently during IV therapy - Assess IV site frequently during admin; may cause phlebitis & venous thrombosis - Prolonged high dose therapy may lead to psychological or physical dependence. Restrict amount of drug available to pt. Observe depressed pts closely for suicidal tendencies - Conduct regular assessment of continued need for treatment - Geri: Assess risk of falls & institute fall prevention strategies - **Anxiety:** Assess mental status (orientation, mood, behavior) & degree of anxiety - Assess level of sedation (ataxia, dizziness, slurred speech) prior to & periodically throughout therapy - **Seizures:** observe & record intensity, duration, & location of seizure activity. The initial dose offers seizure control for 15-20 min after admin. Institute seizure precautions - **Muscle spasms:** assess muscle spasm, associated pain, & limitation of movement prior to & during therapy - **Alcohol withdrawal:** Assess pt experiencing alcohol withdrawal for tremors, agitation, delirium, & hallucinations. Protect from injury - **Lab Test Considerations:** Evaluate hepatic & renal function & CBC periodically during prolonged therapy. May ↑ transaminases and alkaline phosphatase - **Toxicity & Overdose:** [Flumazenil] is an adjunct in the management of toxicity or overdose (Flumazenil may induce seizures in pts with history of seizure disorder or who are on tricyclic antidepressants) - [Patient/Fam Teaching:] - Do NOT take more than prescribed or increase dose if less effective after a few weeks w/o checking with HCP. Review package insert for Diastat rectal gel with pt/caregiver prior to admin. Abrupt withdrawal may cause insomnia, unusual irritability, or nervousness, & seizures. Sharing the med may be dangerous - May cause drowsiness, clumsiness, or unsteadiness= avoid driving/activities until response is known - Geri: Increased risk for CNS effects & potential for falls - Avoid alcohol or other CNS depressants - Notify HCP if pregnancy is planned/suspected/breast feeding - Importance of follow up exams to determine effectiveness of med - **Seizures:** carry identification describing disease process & med regimen at all times - **Lacosamide** - Anticonvulsant - PO, IV - [Indications:] - Treatment of partial-onset seizures as either monotherapy or adjunctive therapy - [Adverse Reactions:] - Suicidal thoughts, dizziness, HA, hallucinations, syncope, vertigo - Diplopia - Atrial fib/flutter, bradycardia, heart block, syncope - Drug reaction with eosinophilia & systemic symptoms (DRESS), Stevens-Johnson Syndrome, Toxic epidermal necrosis, Rash - N/V - Agranulocytosis - Ataxia - Physical dependence, psychological dependence, Multiorgan hypersensitivity reactions (drug reaction with Eosinophilia & systemic symptoms-DRESS) - [Patient/Fam Teaching:] - Take around the clock, as directed - Med should be gradually discont. over at least 1 week to prevent seizures. Advise pt to read the Med Guide before starting therapy & with each refill - May cause dizziness, ataxia & syncope. Caution pts to avoid driving/activities until response is known - Do NOT resume driving until physician gives clearance based on control of seizure disorder - If syncope occurs advise pt to lay down with legs raised until recovered & notify HCP - Inform risk of suicidal thoughts and behavior & advise that behavioral changes, emergency or worsening s/s of depression, unusual changes in mood, or emergence of suicidal thoughts behavior, or thoughts of self-harm, rash, or s/s of DRESS should be reported to HCP immediately - Notify HCP if signs of multiorgan hypersensitivity reactions (fever, rash, fatigue, jaundice, dark urine) occur - Consult HCP before taking other Rx, OTC, or herbal preparations - Avoid alcohol/CNS depressants - Rep: advise female pt to notify HCP if pregnancy is planned/suspected/breastfeeding. - Encourage pregnant pts to enroll in the pregnancy registry by calling 1-888-233-2334 call must be made by pt - **Levetiracetam** - Anticonvulsant, pyrrolidines - PO - [Indications:] - Partial onset seizures (adjunct) - Primary generalized tonic-clonic seizures (adjunct) (immediate release & injection only) - Myoclonic seizures in pts with juvenile myoclonic epilepsy (adjunct) (immediate-release and injection only) - Unlabeled use: Status epilepticus - [Pharmacokinetics:] - **Absorption:** Rapidly & completely absorbed following oral admin - **Distribution:** Unknown - **Protein Binding:** \ - [Patient/Fam Teaching:] - Pedi: explain to parents importance of using calibrated measuring device for accurate dosing - Take missed dose ASAP unless almost time for next dose - Do NOT double doses - Do NOT discont. Abruptly, may cause ↑frequency of seizures - Advise pt to read MED Guide prior and with each refill - May cause dizziness & somnolence. Caution pt to avoid driving/activities until response to med is known - Do NOT resume driving until physician gives clearance based on control of seizure disorder - Advise pt/fam to notify HCP if thoughts about suicide/dying, attempts to commit suicide, new/worse depression/anxiety, feeling very agitated or restless, panic attacks, trouble sleeping, new/worse irritability, aggressiveness, angry, violent, acting on dangerous impulses, extreme ↑ in activity and talking, or other unusual changes in behavior or mood or skin rash occurs - Notify HCP of ALL medications/contact before taking other meds - Notify HCP of med prior to treatment/surgery - Rep: Advise female pts to notify HCP if pregnancy is planned/suspected/breastfeeding - Encourage to enroll in the north American Antiepileptic Drug Pregnancy Registry by 1-888-233-2334 - Advise to carry identification describing disease process and med regimen at all times - **Phenobarbital** - Anticonvulsant, sedative/hypnotic (barbiturate) - [Time action profile]: - **PO:** Onset: 30-60min Peak: unknown Duration: \6hr - **IM/Subcutaneous:** Onset:10-30min Peak: unknown Duration: 4-6hr - **IV:** Onset: 5min Peak: 30min Duration: 4-6hr - **For sedation:** Full anticonvulsant effects occur after 2-3 weeks of chronic dosing unless a loading dose has been used - [Side Effects:] - [Hangover], delirium, depression, drowsiness, excitation, lethargy, vertigo - Resp depression - IV=laryngospasm, bronchospasm, hypotension - Constipation/diarrhea, N/V - Photosensitivity, Rashes, Urticaria - Phlebitis at IV site - Arthralgia, myalgia, neuralgia - Hypersensitivity reaction: angioedema & serum sickness, physical dependence, psychological dependence - [Patient/Fam Teaching:] - Take as directed, take missed dose ASAP if not almost time for next dose; do NOT double dose - If on prolonged do NOT discont. w/o HCP-abrupt withdrawal may cause seizures or status epilepticus - May cause daytime drowsiness/avoid driving/activities until known response - Do NOT drive till DOC clears you - Avoid alcohol/CNS depressants - Notify HCP if s/s of angioedema, fever, sore throat, mouth sores, unusual bleeding/bruising, nosebleeds, or petechiae occur - Teach sleep techniques (dark room, quiet bedtime ritual, limit daytime napping, avoid nicotine & caffeine) - Female pt using oral contraceptives use an additional nonhormonal contraceptive during therapy and until next menstrual period. Instruct pt to contact HCP IMMEDIATELY if pregnancy is planned/suspected - Pedi: Advise parent child may experience irritability, hyperactivity, and/or sleep disturbances which may diminish in a few days/few weeks or may persist until drug is stopped. An alternative med can be considered. Instruct parents to monitor for skin rash occurring 7-20 days after treatment begins & contact HCP if rash occurs. Teach fam about symptoms of toxicity (staggering, drowsiness, slurred speech) - **Desmopressin** - Hormones (Antidiuretic hormones) - Treatment of DI caused by a deficiency of vasopressin (enhanced reabsorption of water in the kidneys) - [Action:] - An analogue of naturally occurring vasopressin (antidiuretic hormone) - Primary action is enhanced reabsorption of water in the kidneys - **Therapeutic effects:** - Prevention of nocturnal enuresis. - Maintenance of appropriate body of water content in DI. - Control of bleeding in certain types of hemophilia or von Willebrand's disease. - Reduction in number of episodes of nocturia - [Adverse Reactions:] - Seizures, dizziness, drowsiness, HA, listlessness - Intranasal-epistaxis, nasal congestion, nasal discomfort, rhinitis, sneezing - Dyspnea - Hypertension, hypotension, tachycardia, (large IV doses only) - Mild abdominal cramps, nausea - Vulval pain - Flushing - Fluid retention, hyponatremia - Back pain - Phlebitis at IV site - [Assessment:] - Chronic intranasal use may cause tolerance or if admin more frequently than every 24-48 hrs. IV tachyphylaxis (short term tolerance) may develop - **Nocturnal Enuresis:** monitor frequency of enuresis throughout therapy. Use cautiously in pts at risk for water intoxication with hyponatremia - Do not use intranasal form for nocturnal enuresis - **Diabetes Insipidus:** monitor urine & plasma osmolality & urine volume frequently. Assess pt for symptoms of dehydration (excessive thirst, dry skin & mucous membranes, tachycardia, poor skin turgor) weight pt daily & assess for signs for edema - **Hemophilia:** monitor plasma factor VIII coagulant, factor VIII antigen, & ristocetin cofactor. May assess aPTT for hemophilia A & skin bleeding time for von Willebrand's disease. Assess pt for signs of bleeding - Monitor BP & pulse during IV infusion - Monitor I&O's & adjust fluid intake (especially in children & elderly) to avoid overhydration in pts receiving desmopressin for hemophilia - **Toxicity and Overdose:** S/S of water intoxication (confusion, drowsiness, HA, weight gain, difficulty urinating, seizures, & coma) - **Treatment of overdose:** decreasing dose & if symptoms are severe, admin [furosemide] - [Outcomes:] - Decreased frequency of nocturnal enuresis - Decreased in urine volume - Relief of polydipsia - Increased urine osmolality - Control of bleeding in hemophilia - **Misoprostol (Cytotec)** - Antiulcer agents, cytoprotective agents (prostaglandins) - [Action:] - Acts as a prostaglandin analogue, decreasing gastric acid secretion (antisecretory effect) & increasing the production of protective mucus (cytoprotective effect). Causes uterine contractions. - **Therapeutic Effects:** Prevention of gastric ulceration from NSAIDS. Mifepristone terminates pregnancy of less than 49 days. - [Nursing Implications: Assessment] - Assess pt routinely for epigastric or abdominal pain & for frank or occult blood in the stool, emesis, or gastric aspirate - Assess women of childbearing age for pregnancy. Misoprostol is usually begun on 2^nd^ or 3^rd^ day of menstrual period following a negative pregnancy test - Termination of pregnancy: monitor uterine cramping/bleeding during therapy - Cervical Ripening: Assess dilation of cervix periodically during therapy - [Patient Teaching:] - Take as directed/full course even if feeling better. Take missed dose ASAP unless next dose is due in 2 hr; do NOT double doses. - Sharing may be dangerous even if they have the same symptoms - Inform pt that misoprostol will cause spontaneous abortion. Women of childbearing age must be informed of this effect through verbal & written information & must use contraception throughout therapy. If pregnancy is suspected, the woman should stop taking and immediately notify HCP - Diarrhea may occur. Notify HCP if it persists longer than 1 week. - Report black tarry stool or severe abdominal pain - Avoid alcohol and foods that may cause an ↑ in GI irritation - **Cisplatin** - Antineoplastics, (Alkylating agent) - Metastatic testicular & ovarian carcinoma. Advanced bladder cancer. CANCER - Death of rapidly replicating cells, particularly malignant ones - [Adverse Reactions:] - Reversible posterior leukoencephalopathy syndrome (PRLs), seizures, malaise, weakness - [Ototoxicity, tinnitus] - Hepatotoxicity, [N/V], diarrhea - Nephrotoxicity, sterility - Alopecia - [Hypocalcemia, hypokalemia, hypomagnesemia ] - Leukopenia, thrombocytopenia, [anemia ] - Phlebitis at IV site - Hyperuricemia - Peripheral neuropathy - Anaphylactoid reactions - [Nursing Implications-Lab Test Considerations:] - Monitor CBC with differential & platelet count before & routinely throughout therapy. The nadir of leukopenia, thrombocytopenia, & anemia occurs within 18-23 days & recovery 39 days after a dose. Withhold further doses until WBC is \4,000 & platelet is \>100,000 - Monitor BUN, serum creatinine, & CCr before initiation of therapy & before each course to detect nephrotoxicity. - May cause ↑ BUN & creatinine & ↓calcium, mag, phosphate, sodium, & potassium levels that usually occur 2^nd^ week after a dose. Do NOT admin additional doses until BUN is \ - [Patient Teaching:] - Report pain at injection site immediately - Notify HCP promptly if fever, chills, cough, hoarseness, sore throat, signs of infection, lower back or side pain, painful or difficult urination, bleeding gums, bruising, petechiae, blood in stools, urine, or emesis; increased fatigue, dyspnea/orthostatic hypotension occurs. - Avoid crowds and ppl with known infections - Use soft toothbrush & electric razor & avoid falls - Don't drink alcoholic beverages or take medication containing aspirin/NSAIDS; may precipitate gastric bleeding - Report promptly any numbness/tingling in extremities or face, difficulty hearing or tinnitus, unusual swelling, or joint pain - Instruct pt not to receive and vaccinations w/o advice of HCP - Advise pt the need for contraception although the med may cause infertility - Emphasize the need for periodic lab tests to monitor for side effects - **Methylphenidate** - Central nervous system stimulant (schedule II) (oral & transdermal) - Treatment of ADHD - [Nursing Implications-Assessment: ] - Monitor BP, pulse, & RR before admin & periodically during therapy - Obtain a history (including assessment of fam hx of sudden death or ventricular arrhythmia), physical exam to assess for cardiac disease, & further evaluation (ECG & echocardiogram), if indicted, if exertional chest pain, unexplained syncope, or other cardiac symptoms occur, evaluate promptly - Monitor closely for behavioral change - Assess risk of abuse prior to prescribing, after prescribing keep accurate prescription records, educate pt/fam about risk of abuse & overdose, & evaluate need for use periodically during therapy - Screen pts with bipolar disorders for risk of manic episode (comorbid or hx of depressive symptoms/fam hx of suicide, bipolar disorder/depression) prior to staring therapy - Monitor s/s of peripheral vasculopathy (numbness & burning in fingers, digital changes) may require reduction in dose or discontinuation - **Pedi:** monitor growth, both height & weight in children on long term therapy - May produce false sense of euphoria & well-being. Provide frequent rest periods and observe pt for rebound depression after the effects of the medication have worn off. - **ADHD:** Assess children for attention span, impulse control, & interactions with others, therapy may be interrupted at intervals to determine whether symptoms are sufficient to continue therapy - **Narcolepsy:** Observe & document frequency of episodes - **Transdermal:** assess skin for signs of contact sensitization (erythema with edema, papules, or vesicles that does not improve within 48hrs or spreads beyond patch site) during therapy. May lead to systemic sensitization to other forms of methylphenidate (flare-up of previous dermatitis or prior positive patch skin test sites, generalized skin eruptions, HA, fever, malaise arthralgia, diarrhea, vomiting) if contact sensitization develops and oral med is instituted, monitor closely. - Monitor for signs of skin depigmentation. May cause persistent loss of skin pigmentation at and around the application site and at other sites distant from application site. Discontinue if depigmentation occurs - [Patient Teaching:] - Take as directed. If an oral dose is missed, take remaining doses for that day at regularly spaced intervals, do NOT double doses, take the last dose before 6pm. To minimize the risk of insomnia. Instruct the pt not to alter dose w/o consulting HCP. Abrupt stop of high doses may cause extreme fatigue and mental depression. Instruct to read Med guide prior to use and with each refill - Check weight 2-3 times weekly and report weight loss to HCP - May cause dizziness or blurred vision. Avoid driving until med response is known - Shell of Concerta tablet may appear in the stool. This is no cause for concern - Avoid caffeine - Notify HCP if nervousness, insomnia, palpitations, vomiting, skin rash or fever occurs - Notify HCP of behavioral changes - Notify HCP of ALL meds/products taken - HCP may order periodic holidays from the drug to assess progress and to decrease dependence - Important to routinely follow up to monitor progress - Transdermal: use admin chart included in package to monitor application & removal time & disposal method - Avoid exposing patch to direct external heat sources (hair dryers, heating pads, electric blankets, heated water beds, etc.) may increase rate & extent of absorption - Skin redness, itching and small bumps on the skin are common. - If swelling or blistering occurs, the patch should not be worn, and HCP notified - Caution not to apply hydrocortisone or other solutions, creams, ointments, or emollients prior to application - Advise pt referred for MRI test to discuss patch with referring HCP and MRI facility to determine if removal of patch is necessary prior to test and for directions for replacing patch - Home care issues: Pedi: advise parents to notify school nurse of med regimen - **Cyclobenzaprine** - Skeletal muscle relaxant (centrally acting) - Management of acute painful musculoskeletal condition associated with muscle spasm - Unlabeled use: management of fibromyalgia - [Side Effects:] - Dizziness, drowsiness, confusion, fatigue, HA, nervousness - Dry mouth, blurred vision - Arrhythmias - Constipation, dyspepsia, nausea, unpleasant taste - Urinary retention - [Route/Dosage:] - PO (adults): Acute painful musculoskeletal conditions - Immediate release: 10mg 3x daily (range 20-40mg/day in 2-4 divided doses; not to exceed 60mg/day) - Extended release: 15-30mg once daily - Fibromyalgia: 5-40mg at bedtime (unlabeled) - [Patient Teaching:] - Take same time each day; do NOT take more than prescribed amount. Take missed dose within 1hr of time ordered; otherwise return to normal dose schedule. Do NOT double doses - May cause drowsiness, dizziness, & blurred vision. Avoid driving until med response is known - Avoid alcohol or other CNS depressants - If constipation becomes a problem, advise pt to increase fluid intake & bulk in diet & stool softeners may alleviate this condition - Notify HCP if symptoms of urinary retention (distended abdomen, feeling of fullness, overflow incontinence, voiding small amounts) - Notify HCP immediately if s/s of serotonin syndrome occur - Good oral hygiene, frequent mouth rinses, and sugarless gum/candy may help relieve dry mouth - [Evaluation/Desired outcome:] - Relief of muscular spasm in acute skeletal muscle conditions - Maximum effects may not be evident for 1-2 weeks however has been effective for at least 12 weeks in the management of fibromyalgia - **Acyclovir** - Antiviral, (purine analogue) - Nursing Implications: - [Assessment:] - Assess lesions before & daily during therapy - Assess frequency or recurrences - Monitor for neurologic status in pts with herpes encephalitis - Lab Test Considerations: monitor BUN, serum creatinine, & CCr before & during therapy. ↑BUN & serum creatinine levels or ↓CCr may indicate renal failure - [Implementation:] - Do NOT confuse Zovirax with Doribax, Zyvox, or Zostrix - Start treatment as soon as possible after herpes simplex symptoms appear & within 24hr of a herpes zoster outbreak - PO: may be admin with food or on an empty stomach, with a full glass of water - Shake oral suspension well before admin - Buccal: apply tablet with a dry finger immediately after takin gout of blister to upper gum just above canine. Hold in place with pressure on lip for 30seconds to ensure adhesion. May be more comfortable to apply rounded side of tablet to gum surface. Apply on same side as herpes labialis symptoms within 1hr of onset of symptoms, before appearance of herpes labialis lesions. Once applied stays in positions and dissolves slowly during day; do NOT crush, chew suck, or swallow. May eat and drink while tablet is in place; avoid interfering with adhesion of tablet (chewing gum, touching, or pressing tablet after placement, wearing upper denture, brushing teeth). If teeth need to be cleaned while tablet is in place, rinse mouth gently. Drink plenty of liquids to prevent dry mouth. - [Patient Teaching:] - Additional use of OTC creams, lotions, & ointments may delay healing and may cause spreading of lesions - Not a cure. The virus lies dormant in the ganglia, and med will not prevent the spread of infection to others - Condoms should be used, and no sexual contact should be made while lesion are present - Contact HCP if symptoms are not relieved after 7 days of topical therapy or if oral med does not ↓the frequency and severity of recurrences - Immunocompromised pts may require a longer time, usually 2 weeks for crusting over of lesions - Women with genital herpes need to have yearly pap smears b/c they may be more likely to develop cervical cancer - Topical: apply ointment in sufficient quantity to cover all lesions every 3hr, 6 times/for 7 days. 0.5 in ribbon of ointment covers approximately 4 square inches. Use a finger cot or glove when applying to prevent inoculation of other areas or spread to other ppl. Keep affected areas clean and dry. Loose fitting clothes should be worn to prevent irritation - Avoid drug contact in or around eyes. Report any unexplained eye symptoms to HCP immediately; ocular herpetic infection can lead to blindness - Buccal: instruct pt on correct application and use of buccal tablet. If buccal tablet does not adhere or falls off within first 6hrs., reposition immediately with same tablet. If tablet cannot be repositioned, apply new tablet. If swallowed within the first 6hrs advise pt to drink a glass of water and apply a new tablet. Do not reapply if tablet falls out after 6hrs. - **Ketorolac (Toradol)** - NSAID, non-opioid analgesic (pyrrolidine carboxylic acid) - For short term management of pain (no more than 5 days) - [Interactions:] - **[Drug-Drug: ]** - Probenecid ↑ levels & the risk of adverse reactions; concurrent use is contraindicated. - ↑risk of bleeding when used with pentoxifylline; concurrent use is contraindicated. - Concurrent use with aspirin may ↓effectiveness - ↑adverse GI effects with aspirin, other NSAIDs, potassium supplements, corticosteroids, or alcohol - May ↓effectiveness of diuretics or antihypertensives - May ↑serum lithium levels and ↑risk of toxicity - ↑risk of toxicity from methotrexate - ↑risk of bleeding with anticoagulants, aspirin, clopidogrel, ticagrelor, prasugrel, corticosteroids, fibrinolytics, SNRIs, or SSRIs - ↑risk of adverse hematologic reactions with antineoplastics or radiation therapy - May ↑ risk of nephrotoxicity from cyclosporine - **[Drug Natural Products: ]** - ↑bleeding risk with arnica, chamomile, clove, dong quai, feverfew, garlic, ginger, ginkgo, Panax ginseng - [Assessment:] - Pts who have asthma, aspirin induced allergy and nasal polyps are at ↑risk for developing hypersensitivity reactions. Assess for rhinitis, asthma, and urticaria - Assess for rash periodically during therapy. May cause Stevens-Johnson syndrome or toxic epidermal necrolysis. Discontinue if severe or if accompanied with fever, general malaise, fatigue, muscle or joint aches, blisters, oral lesions, conjunctivitis, hepatitis and or eosinophilia - Monitor BP during initiation and periodically during therapy. May cause fluid retention and edema a leading to new onset or worsening hypertension - Pain: assess pain (note type, location, and intensity) prior to and 1-2 hrs. following admin - Lab Test Considerations: evaluate liver function especially AST & ALT if receiving prolonged therapy. May cause ↑levels - May cause prolonged bleeding time that may persist for 24-48hrs following discont of therapy - May cause ↑BUN, serum creatinine or potassium concentrations - [Implementation:] - Do not confuse Toradol (Ketorolac) with tramadol (Ultram) - Admin in higher than recommended doses does not provide increased effectiveness but may cause increased side effects. Duration of med by all routes should NOT exceed 5 days. Use lowest effective dose for shortest period of time to minimize risk of cardiovascular thrombotic events - Coadministration with opioid analgesics may have additive analgesic effects and may permit lower opioid doses - PO: Ketorolac therapy should always be given initially by the IM or IV route. Use oral therapy only as a continuation of parenteral therapy - IV PUSH: administer undiluted, Concentration: 15-30mg/mL Rate: over 15seconds - [Patient Teaching:] - How and when to ask for and take pain med - Do not take more than prescribed or longer than 5 days - May cause drowsiness or dizziness-Avoid driving/activities until med response is known - Avoid alcohol, aspirin, NSAIDs, acetaminophen, or other OTC meds w/o consulting HCP - Inform HCP of med before treatment/surgery - Consult HCP if rash, itching, visual disturbances, tinnitus, weight gain, edema, black stools, persistent HA, or flu like symptoms (chills, fever, muscle aches, pain) - Female pt notify HCP if pregnancy is planned/suspected/breastfeeding - Intranasal: instruct correct technique for admin, need to open a new bottle every 24hrs, and the 5-day limit for use - **Alendronate** - Bone resorption inhibitors (bisphosphonate) - [Indications:] - Treatment & prevention of postmenopausal osteoporosis, - Treatment of osteoporosis in men - Treatment of Paget's disease of the bone - Treatment of corticosteroid-induced osteoporosis in pts (men & women) who are receiving ≥7.5mg of prednisone/day with evidence of ↓ bone mineral density - [Administration:] - PO - [Implementation:] - PO: administer first thing in morning with 6-8oz of pain water 30 min before other medications, beverages, or food - Oral solution should be followed by at least 2oz of water - Swallow tablets whole do not crush, break, or chew - For effervescent tablets dissolve 1 tablet in half a glass (4oz) of plain room temp water (not mineral water or flavored water). Wait at least 5min after the effervescence stops, stir the solution for approximately 10 seconds and drink - [Patient Teaching:] - Instruct patient on importance of taking exactly as directed, first thing in the morning, 30 minutes before other medications, beverages, or food. Waiting longer than 30 minutes will improve absorption. Should be taken with 6-8 oz of plain water (mineral water, orange juice, coffee and other beverages decrease absorption) - If a dose is missed, skip dose and resume the next morning. Do not double doses or take them later in the day. If a weekly dose is missed, take the morning after remembered and resume the following week on the chosen day. Do not take 2 tablets on the same day. Do not discontinue without consulting the health care provider. - Remain upright for 30 minutes following dose to facilitate passage to stomach and minimize risk of esophageal irritation. Advise the patient to discontinue and notify HCP if pain or difficulty swallowing, retrosternal pain, or new/worsening heartburn. - Regular exercise and modify behaviors that increase the risk of osteoporosis (stop smoking, reduce alcohol consumption) - Eat a balanced diet and consult the provider about the need to supplement calcium and vitamin D. - Wear sunscreen and protective clothing - Inform HCP of alendronate therapy prior to dental surgery. - Report blurred vision, eye pain, or inflammation occur. - Notify HCP if pregnancy is suspected or planned. - **Insulin detemir** - Antidiabetics - Control of hyperglycemia in diabetic patients - **[Pharmacokinetics:]** - Absorption: physiochemical characteristics of long-acting insulins result in delayed and prolonged absorption - Metabolism and Excretion: metabolized by the liver, spleen, kidney, and muscle. - Onset: 3-4hr Peak: 3-14hr Duration: 6-24hr - [Nursing Implications:] - Assess for symptoms of hypoglycemia (anxiety, restlessness, tingling in hands, feet, lips, or tongue; chills; cold sweats; confusion; pale skin; difficulty in concentration; drowsiness, nightmares or trouble sleeping, excessive hunger, headache, irritability, nausea, nervousness, tachycardia, tremor, weakness, unsteady gait. And Hyperglycemia (confusion, drowsiness, flushed, dry skin, fruit-like breath odor, rapid deep breathing, polyuria, loss pf appetite, n/v, unusual thirst.) - Monitor body weight. Changes in weight may necessitate changes in insulin dose. - Assess patient for signs of allergic reaction. - Monitor blood glucose every 6 hours. More frequently during ketoacidosis and times of stress. HbA1c may be monitored every 3-6 months. - Monitor serum potassium in patients at risk for hypokalemia. - **TOXICITY AND OVERDOSE:** overdose is manifested by symptoms of hypoglycemia. Mild hypoglycemia is treated by ingestion of oral glucose. Severe hypoglycemia is a life-threatening emergency, treatment consists of IV glucose, glucagon, or epinephrine. Early signs of hypoglycemia may be less pronounced by long duration of diabetics, diabetic nerve disease, and the use of beta blockers; may result in loss of consciousness prior to patient's awareness of hypoglycemia. - [Patient/Family Teaching:] - Discuss the importance of not changing brands of insulin or syringes. - When mixing insulins, draw up insulin aspart, insulin glulisine, or insulin lispro first. Roll NPH insulin vial between palms to mix, rather than shaking. - Do not share pen with another person, even if needle is changed. - Therapy is long-term; does not cure diabetes. - Serum glucose and ketones should be closely monitored during periods of stress or illness. - Discuss the importance of compliance with nutritional guidelines and regular exercise. - Report n/v fever, unable to eat regular diet, or if blood glucose levels are not controlled. - Instruct patient on s/s of hypoglycemia and hyperglycemia and what to do if they occur. - Patients should carry a source of sugar (candy, glucose gel) and identification describing their disease and treatment regimen at all times. - Emphasize the importance of regular follow-up, especially during the first few weeks of therapy. - **Butorphanol** - Opioid analgesic - Provides partial, temporary pain relief, particularly during early, active labor - [Complications:] - Respiratory depression - Dry mouth- provide ice chips - Nausea and vomiting: administer antiemetic as prescribed - Neonatal Depression: have naloxone available at birth - Tachycardia, hypotension, decreased FHR variability - Sedation - [Contraindications:] - Contraindicated in pt who have a history of opioid dependence to prevent abstinence syndrome in the mother and newborn. - Contraindicated if delivery is within 1-4 hours of administration. - [Nursing administration:] - Prior to administering, verify that labor is well established by performing a vaginal exam showing cervical dilation of at least 4cm with the fetus engaged. - Naloxone is administered to reverse the effects of opioids for the client or for severe respiratory depression in the newborn. - Administer antiemetics as prescribed - Monitor VS and uterine contraction pattern. Provide continuous FHR monitoring - The client can be given opioid analgesics IM or IV, but the IV route is recommended during labor because of its quicker action - If the opioid is given too soon, it can delay the progression of labor. If given too late (within 1-4 hours of birth) it can depress neonatal respirations. - [Client Education: ] - This medication will cause drowsiness - Request assistance with ambulation - **[Evaluation of Effectiveness:]** - Decreased pain during labor - **Oxybutynin** - Anticholinergics - Relief of bladder spasm and associated symptoms (frequency, urgency, nocturia, and incontinence) in patients with a neurogenic or overactive bladder. - [Adverse Reactions:] - Anaphylaxis - Angioedema - **[Side effects: ]** - [Dizziness], [Drowsiness], agitation, confusion, hallucinations, headache - Blurred vision, hoarseness, - Chest pain, edema, tachycardia - [Constipation], [Dry mouth], [Nausea], abdominal pain, anorexia, diarrhea, dysphagia - Thirst, [Urinary retention], - Decreased sweating, hot flashes, - Hyperthermia - Transdermal: application site reactions, pruritus - [Patient Education:] - Take as directed. Take missed doses as soon as remembered unless almost time for next dose. - May cause drowsiness or blurred vision. Avoid driving and other activities requiring alertness until response to medication is known. - Avoid alcohol and other CNS depressants while taking this medication - To decrease dry mouth, frequently rinsing mouth, good oral hygiene, and sugarless gum or candy. Notify HCP if dryness persists \2wks. - Advise patient to stop taking medication and notify HCP immediately if signs of angioedema and/or anaphylaxis occur. - This medication decreases the body's ability to perspire. Avoid strenuous activity in a warm environment because overheating may occur. - Notify HCP if constipation or urinary retention occurs. Discuss methods of preventing constipation such as increasing dietary bulk, increasing fluid intake, and increasing mobility. - Periodic cytometry may be used to evaluate effectiveness. Ophthalmic exams should be performed periodically to detect glaucoma, especially in patients over 40 years. - Transdermal Patch: instruct patient on correct application and disposal of patch. - Open pouch by tearing along the arrows; - apply immediately. - Apply ½ patch to skin by removing ½ protective cover and applying firmly to skin. - Apply the second half by bending in half and rolling patch onto skin while removing protective liner. - Press patch firmly into place - Remove slowly; fold in half, sticky sides together, and discard - Advise patient referred for MRI to remove patch prior to test and give directions for replacing patch - Transdermal gel: - Do not apply to recently shaved skin, skin with rashes, or areas treated with lotions, oils, or powders. May be used with sunscreen. - Wash area with mild soap and water and dry completely before applying - Tear packet open just before use and squeeze entire contents into hand or directly onto application site of abdomen, arms/shoulders, or thighs. Amount og gel will be the size of a nickel. - Gently run into skin until dry - Wash hands immediately following application - Avoid application near open fire or when smoking; medication is flammable. - Do not shower, bathe, swim, exercise, or immerse the application site in water within 1 hour of application. - Cover application site with clothing if close skin to skin contact at application site is anticipated. - **Dinoprostone** - Cervical ripening agent - **[Contraindications:]** - Hypersensitivity to prostaglandins or additives in the gel or suppository. - The gel/insert should be avoided in situations in which prolonged uterine contractions should be avoided; including; previous c-section, or uterine surgery, - Cephalopelvic disproportion - traumatic delivery or difficult labor - Multiparity (6 or more pregnancies) - Hyperactive or hypertonic uterus - Fetal distress (if delivery is not imminent) - Unexplained vaginal bleeding - Placenta previa - Vasa previa - Active herpes genitalis - OB emergencies requiring surgical intervention - Situations in which vaginal delivery is contraindicated - Presence of acute pelvic inflammatory disease or ruptured membranes - Concurrent oxytocic therapy (wait for 30 minutes after removing insert before using oxytocin) - **[Implementation:]** - Abortifacient: - Warm suppository to room temperature just before use - Wear gloves when handling unwrapped suppository to prevent absorption through the skin. - Patient should remain supine for 10 minutes after insertion of suppository; then she may be ambulatory - Vaginal insert: - Place vaginal insert transversely in the posterior vaginal fornix immediately after removing from foil package. - Warming of insert and sterile conditions are not required - Use vaginal insert only with a retrieval system. - Use minimal water-soluble lubricant during insertion; avoid excess because it may hamper release of dinoprostone from insert. - Patient should remain supine for 2 hr after insertion, then she may ambulate. - Vaginal insert delivers dinoprostone 0.3mg/hr. over 12hr - Remove insert at the onset of active labor, before amniotomy, or after 12hr. - Oxytocin should not be used during or less than 30 minutes after removal of insert. - Endocervical gel: - Determine the degree of effacement before insertion of the endocervical catheter. Do not administer above the level of the internal os. Use a 20-mm endocervical catheter if no effacement is present and a 10-mm catheter if the cervix is 50% effaced - Use caution to prevent contact of dinoprostone gel with skin. Wash hands thoroughly with soap and water after administration - Bring gel to room temperature just before administration. Do not force warming with external sources (water bath, microwave) - Remove peel-off syringe and then remove the protective end cap and insert the end cap into plunger stopper assembly in barrel of syringe. - Aseptically remove catheter from package - Firmly attach catheter hub to syringe tip; click is evidence of attachment. - Fill catheter with sterile gel by pushing plunger to expel air from catheter before administration to patient - Gel is stable for 24 months if refrigerated. - Patient should be in dorsal position with cervix visualized using a speculum. - Introduce gel with catheter into cervical canal using sterile technique. - Administer gel by gentle expulsion from syringe and then remove catheter. - Do not attempt to administer small amount of gel remaining in the syringe. - Use syringe for only 1 patient. - Discard syringe, catheter, and unused packaged contents after using. - Patient should remain supine for 15-30 minutes after administration to minimize leakage from cervical canal. - Oxytocin may be administered 6-12 hours after desired response from dinoprostone gel. If no cervical/uterine response to the initial dose, repeat dose may be administered in 6 hours. - **Patient Education** - Abortifacient: - Instruct patient to notify HCP immediately if fever and chills, foul smelling vaginal discharge, lower abdominal pain, or increased bleeding occurs. - Provide emotional support throughout therapy. - Cervical Ripening - Inform patient that she may experience a warm feeling in her vaginal during administration. - Notify HCP if contractions become prolonged. - **Somatropin:** - **[Indications: ]** - Long-term treatment of growth failure in children with inadequate secretion of endogenous growth hormone (GH) - Long-term treatment of short stature from Turner syndrome - **[Contraindications & Cautions:]** - Contraindicated in patients with hypersensitivity to somatropin or its excipients. - Contraindicated in patients with closed epiphyses, active proliferative or severe nonproliferative diabetic retinopathy, or an active underlying intracranial lesion. - Contraindicated in patients with active malignancy. An increased risk of second neoplasm has been reported in childhood cancer survivors treated with somatropin. Patients with HIV and children with short stature (genetic cause) have increased baseline risk of developing malignancies. Consider the risks and benefits before initiating therapy; monitor these patients carefully. - Contraindicated in patients with Prader-Willi syndrome who are severely obese, have a history of upper airway obstruction or sleep apnea, or have severe respiratory impairment. - For patients hypersensitive to either metacresol or glycerin, don't use supplied diluent to reconstitute Humatrope. - Contraindicated in patients with acute critical illness due to complications following open heart or abdominal surgery, trauma, or acute respiratory failure. The safety of continuing somatropin treatment in patients receiving replacement doses for approved indications who concurrently develop acute critical illnesses hasn't been established. Weigh potential benefit of treatment continuation against potential risks. - Serious systemic hypersensitivity reactions, including anaphylactic reactions and angioedema, have been reported. - Use cautiously in children with hypothyroidism and in those with GH deficiency caused by intracranial lesion. - Use cautiously in patients with diabetes. - May increase risk of pancreatitis. Monitor patients for persistent abdominal pain with or without vomiting. - Patients receiving somatropin who have or are at risk for pituitary hormone deficiency may be at risk for reduced serum cortisol levels or unmasking of central (secondary) hypoadrenalism. Also, patients treated with glucocorticoid replacement for previously diagnosed hypoadrenalism may require an increase in maintenance or stress doses once somatropin therapy begins. - Dialyzable drug: Unknown. - Overdose Signs & Symptoms: Fluid retention, hypoglycemia followed by hyperglycemia, glucose intolerance, gigantism, acromegaly. - **[Patient Teaching:]** - Inform parents that children with endocrine disorders (including GH deficiency) may have an increased risk of slipped capital epiphyses. Tell parents to notify the prescriber if they notice their child limping. - Advise parents to be alert for limping or complaints of hip or knee pain in children being treated with Nutropin AQ for growth failure secondary to chronic kidney disease. - Instruct patients with diabetes to monitor glucose level closely and report changes to prescriber. - Instruct patients or parents in appropriate injection techniques and needle disposal. Tell them to rotate injection sites. - Advise patients or parents that serious systemic hypersensitivity reactions, including anaphylaxis and angioedema, can occur and to seek immediate medical attention if an allergic reaction occurs. - Stress the importance of close follow-up care and of reporting all adverse reactions.