Requirements for Hospital Duty Part 1 NURSING DRUG STUDIES

Generic Name (Brand Name) Acetaminophen (N-acetyl-paminophenol) Pregnancy Category B Suppositories: Abenol (CAN), Acephen Oral: Aceta, Apacet, Atasol (CAN), Genapap, Genebs, Liquiprin, Mapap, Panadol, Tapanol, Tempra, Tylenol Drug Classification & Indication Antipyretic Analgesic (nonopioid) Indication: Analgesicantipyretic in patients with aspirin allergy, hemostatic disturbances, bleeding diatheses, upper GI disease, gouty arthritis Arthritis and rheumatic disorders involving musculoskeletal pain (but lacks clinically significant antirheumatic and antiinflammatory effects) Therapeutic actions ADULTS Antipyretic: Reduces fever by acting PO or PR directly on the By suppository, 325650 mg q 46 hypothalamic heat-regulating hr or PO, 1,000 mg tid to qid. Do center to cause not exceed 4 g/day. vasodilation and sweating, which PEDIATRIC PATIENTS helps dissipate heat. PO or PR Doses may be repeated 45 times/day; do not exceed five doses in 24 hr; give PO or by suppository Age 03 mo 411 mo 1223 mo 23 yr 45 yr 68 yr 910 yr 11 yr Dosage (mg) 40 80 120 160 240 320 400 480 Analgesic: Site and mechanism of action unclear. Dosage, Route, Frequency Adverse Reaction CNS: Headache CV: Chest pain, dyspnea, myocardial damage when doses of 58 g/day are ingested daily for several weeks or when doses of 4 g/day are ingested for 1 yr GI: Hepatic toxicity and failure, jaundice GU: Acute kidney failure, renal tubular necrosis Hematologic: Methemoglobinemia cyanosis; hemolytic anemiahematuria, anuria; neutropenia, leukopenia, pancytopenia, thrombocytopenia, hypoglycemia Hypersensitivity: Contraindication and cautions Contraindicated with allergy to acetaminophen. Use cautiously with impaired hepatic function, chronic alcoholism, pregnancy, lactation. Nursing Responsibility Assessment History: Allergy to acetaminophen , impaired hepatic function, chronic alcoholism, pregnancy, lactation Physical: Skin color, lesions; T; liver evaluation; CBC, LFTs, renal function tests

Do not exceed the recommended dosage. Consult physician if needed for children < 3 yr; if needed for longer than 10 days; if continued fever, severe or

 Common cold, flu, other viral and bacterial infections with pain and fever Unlabeled use: Prophylactic for children receiving DPT vaccination to reduce incidence of fever and pain

Rash, fever Route Onset Peak Duration Oral Varies 0.5 34 hr 2 hr

recurrent pain occurs (possible serious illness). Avoid using multiple preparations containing acetaminophen. Carefully check all OTC products. Give drug with food if GI upset occurs. Discontinue drug if hypersensitivity reactions occur. Treatment of overdose: Monitor serum levels regularly, Nacetylcysteine should be available as a specific antidote; basic life support measures may be necessary.

Generic Name (Brand Name)

Aminophylline (theophylline ethylenediamine) Xanthine Pregnancy Category C

Drug Classification & Indication Bronchodilator

Dosage, Route, Frequency

Therapeutic actions Relaxes bronchial smooth muscle, causing bronchodilation and increasing vital capacity, which has been impaired by bronchospasm and air trapping; in higher concentrations, it also inhibits the release of slow-reacting substance of anaphylaxis (SRS-A) and histamine.

Adverse Reaction

Contraindication and cautions

Nursing Responsibility

Individualize dosage: Base adjustments on clinical responses; monitor serum theophylline levels; maintain therapeutic range of 1020 mcg/mL; base dosage on lean body mass; 127 mg aminophylline Symptomatic dihydrate = 100 mg theophylline anhydrous. relief or ADULTS prevention of bronchial Oral asthma and reversible bronchospas Acute symptoms requiring rapid m associated theophyllinization in patients not receiving with chronic theophylline: An initial loading dose is bronchitis required, as indicated below: and emphysema Unlabeled uses: Patient Loading Followed Maintenance Respiratory Group by stimulant in Young 6 mg/kg 3 mg/kg 3 mg/kg q 6 Cheyneadult q 4 hr hr Stokes smokers 3 doses respiration; Adult 6 mg/kg 3 mg/kg 3 mg/kg q 8 treatment of nonsmokers q 6 hr hr apnea and who are 2 doses bradycardia otherwise in premature healthy babies

Long-term therapy: Usual range is 600

Serum theophylline levels < 20 mcg/mL: Adverse effects uncommon Serum theophylline levels > 20 25 mcg/mL: Nausea, vomiting, diarrhea, headache, insomnia, irritability (75% of patients) Serum theophylline levels > 30 35 mcg/mL: Hyperglycem ia, hypotension, cardiac arrhythmias, tachycardia (> 10 mcg/mL in premature

Contraindicated Assessment with hypersensitivit History: y to any Hypersensitivity xanthine or to to any xanthine ethylenediamin or to e, peptic ulcer, ethylenediamine, active gastritis; peptic ulcer, rectal or active gastritis, colonic cardiac irritation or arrhythmias, infection (use acute myocardial rectal injury, CHF, cor preparations). pulmonale, severe Use cautiously hypertension, with cardiac severe arrhythmias, hypoxemia, acute renal or hepatic myocardial disease, injury, CHF, hyperthyroidism, cor pulmonale, alcoholism, severe labor, lactation, hypertension, rectal or colonic severe irritation or hypoxemia, infection renal or hepatic (aminophylline disease, rectal hyperthyroidis preparations) m, alcoholism, labor, lactation, pregnancy. Physical: Bowel sounds,

1,600 mg/day PO in three to four divided doses. Rectal 500 mg q 68 hr by rectal suppository or retention enema. PEDIATRIC PATIENTS Children are very sensitive to CNS stimulant action of theophylline; use caution in younger children who cannot complain of minor side effects. < 6 mo: Not recommended.

< 6 yr: Use of timed-release products not recommended. Oral Acute therapy: For acute symptoms requiring rapid theophyllinization in patients not receiving theophylline, a loading dose is required. Dosage recommendations are as follows:

Patient Group Children 6 mo9 yr Children 916 yr

Loading 6 mg/kg

6 mg/kg

Followed by 4 mg/kg q 4 hr 3 doses 3 mg/kg q 4 hr 3 doses

Maintenance 4 mg/kg q 6 hr 3 mg/kg q 6 hr

newborns); seizures, brain damage CNS: Irritability (especially children); restlessness, dizziness, muscle twitching, seizures, severe depression, stammering speech; abnormal behavior characterized by withdrawal, mutism, and unresponsive ness alternating with hyperactive periods CV: Palpitations, sinus tachycardia, ventricular tachycardia, lifethreatening ventricular

normal output; P, auscultation, BP, perfusion, ECG; R, adventitious sounds; frequency of urination, voiding, normal output pattern, urinalysis, LFTs, renal function tests; liver palpation; thyroid function tests; skin color, texture, lesions; reflexes, bilateral grip strength, affect, EEG

Interventions Administer to pregnant patients only when clearly needed neonatal tachycardia, jitteriness, and withdrawal apnea observed when mothers received

 Long-term therapy: 12 mg/kg per 24 hr PO; slow clinical adjustment of the oral preparations is preferred; monitor clinical response and serum theophylline levels. In the absence of serum levels, adjust up to the maximum dosage shown below, providing the dosage is tolerated.

Age

Maximum Daily Dose < 9 yr 30.4 mg/kg/day 912 yr 25.3 mg/kg/day 1216 yr 22.8 mg/kg/day > 16 yr 16.5 mg/kg/day or 1,100 mg, whichever is less

GERIATRIC PATIENTS OR IMPAIRED ADULTS Use caution, especially in elderly men and in patients with cor pulmonale, CHF, liver disease (half-life of aminophylline may be markedly prolonged in CHF, liver disease). Oral Acute therapy: For acute symptoms requiring rapid theophyllinization in patients not receiving theophylline, a

arrhythmias, circulatory failure GI: Loss of appetite, hematemesis, epigastric pain, gastroesopha geal reflux during sleep, increased AST GU: Proteinuria, increased excretion of renal tubular cells and RBCs; diuresis (dehydration) , urinary retention in men with prostate enlargement Respiratory: Tachypnea, respiratory arrest Other: Fever, flushing, hyperglycemi a, SIADH, rash

xanthines up until delivery. Caution patient not to chew or crush enteric-coated timed-release forms. Give immediaterelease, liquid dosage forms with food if GI effects occur. Do not give timed-release forms with food; these should be given on an empty stomach 1 hr before or 2 hr after meals. Maintain adequate hydration. Monitor results of serum theophylline levels carefully, and arrange for reduced dosage if serum levels exceed

loading dose is necessary as follows:

therapeutic range of 1020 mcg/mL. Take serum samples to determine peak theophylline concentration drawn 1530 min after an IV loading dose. Monitor for clinical signs of adverse effects, particularly if serum theophylline levels are not available. Ensure that diazepam is readily available to treat seizures.

Patient Group Older patients and cor pulmonale CHF

Loading 6 mg/kg

Followed Maintenance by 2 mg/kg 2 mg/kg q 8 q 6 hr 2 hr doses 2 mg/kg 12 mg/kg q q 8 hr 2 12 hr doses

6 mg/kg

Route Oral IV

Onset 16 hr Immediate

Peak 46 hr 30 min

Duration 68 hr 48 hr

Metabolism: Hepatic; T1/2: 315 hr Distribution: Crosses placenta; enters breast milk Excretion: Urine

Teaching points IV facts Preparation: May be infused in 100200 mL of 5% dextrose injection or 0.9% sodium chloride injection. Infusion: Do not exceed 25 mg/min infusion rate. Substitute oral therapy or IV therapy as soon as Take this drug exactly as prescribed; if a timed-release product is prescribed, take this drug on an

possible; administer maintenance infusions in a large volume to deliver the desired amount of drug each hour. Adult: 6 mg/kg. For acute symptoms requiring rapid theophyllinization in patients receiving theophylline: a loading dose is required. Each 0.6 mg/kg IV administered as a loading dose will result in about a 1 mcg/mL increase in serum theophylline. Ideally, defer loading dose until serum theophylline determination is made; otherwise, base loading dose on clinical judgment and the knowledge that 3.2 mg/kg aminophylline will increase serum theophylline levels by about 5 mcg/mL and is unlikely to cause dangerous adverse effects if the patient is not experiencing theophylline toxicity before this dose. Aminophylline IV maintenance infusion rates (mg/kg/hr) are given below:

empty stomach, 1 hour before or 2 hours after meals. Do not to chew or crush timed-release preparations. Administer rectal solution or suppositories after emptying the rectum. It may be necessary to take this drug around-the-clock for adequate control of asthma attacks. Avoid excessive intake of coffee, tea, cocoa, cola beverages, and chocolate. Smoking cigarettes or other tobacco products impacts the drug's effectiveness. Try not to

Patient Group Young adult smokers Adult nonsmokers who are otherwise healthy

First 12 hr 1 0.7

Beyond 12 hr 0.8 0.5

Pediatric: After an IV loading dose, these maintenance rates (mg/kg/hr) are recommended:

Patient Group

First 12 hr

Beyond 12

Children 6 mo9 yr Children 916 yr

1.2 1

hr 1 0.8

smoke. Notify your health care provider if smoking habits change while taking this drug. Frequent blood tests may be necessary to monitor the effect of this drug and to ensure safe and effective dosage; keep all appointments for blood tests and other monitoring. You may experience these side effects: Nausea, loss of appetite (taking this drug with food may help if taking the immediaterelease or liquid dosage forms); difficulty sleeping, depression, emotional lability (reversible).

Geriatric: After a loading dose, these maintenance infusion rates (mg/kg/hr) are recommended:

Patient Group Other patients, cor pulmonale CHF, liver disease

First 12 hr 0.6 0.5

Beyond 12 hr 0.3 0.10.2

Compatibility: Aminophylline is compatible with most IV solutions, but do not mix in solution with other drugs, including vitamins. Y-site incompatibility: Dobutamine, hydralazine, ondansetron.

 Report nausea, vomiting, severe GI pain, restlessness, seizures, irregular heartbeat.

Generic Name (Brand Name) Betamethason e

Drug Classification & Indication Corticosteroid (long acting)

(bay ta meth' a Glucocorticoid sone) Hormone Indication: betamethasone Systemic administration Topical dermatologic ointment, cream, lotion, gel Hypercalcemi a associated with cancer Short-term management of inflammatory and allergic disorders, such as rheumatoid arthritis, collagen diseases (eg SLE), dermatologic diseases (eg pemphigus), status asthmaticus, and autoimmune disorders Hematologic disorders: Thrombocytopeni a purpura,

betamethasone dipropionate Topical dermatologic ointment, cream, lotion, aerosol: Diprolene, Diprolene AF, Diprosone, Maxivate, Taro-Sone (CAN), Teladar

Therapeutic actions ADULTS Binds to intracellular corticosteroid Systemic administration receptors, thereby initiating many Individualize dosage, based on severity and response. Give natural complex reactions that are daily dose before 9 AM to minimize adrenal suppression. responsible for its anti-inflammatory Reduce initial dose in small and increments until the lowest immunosuppressiv dose that maintains e effects. satisfactory clinical response is reached. If long-term therapy is needed, alternateday therapy with a shortacting corticosteroid should be considered. After long-term therapy, withdraw drug slowly to prevent adrenal insufficiency. Oral (betamethasone): Initial dosage, 0.6 7.2 mg/day IV (betamethasone sodium phosphate): Initial dosage, up to 9 mg/day. IM (betamethasone sodium phosphate; betamethasone sodium phosphate and

Dosage, Route, Frequency

Adverse Reaction CNS: Vertigo, headache, paresthesias, insomnia, seizures, psychosis, cataracts, increased IOP, glaucoma (in long-term therapy) CV: Hypotension, shock, hypertension, and CHF secondary to fluid retention, thromboembolis m, thrombophlebitis , fat embolism, cardiac arrhythmias Electrolyte imbalance: Na+ and fluid retention, hypokalemia, hypocalcemia Endocrine: Amenorrhea, irregular menses, growth retardation, decreased

Contraindication and cautions Systemic (oral and parenteral) administration Contraindicate d with infections, especially tuberculosis, fungal infections, amebiasis, vaccinia and varicella, and antibiotic-resistant infections, lactation. All forms Use cautiously with kidney or liver disease, hypothyroidism, ulcerative colitis with impending perforation, diverticulitis, active or latent peptic ulcer, inflammatory bowel disease, CHF, hypertension, thromboembolic disorders, osteoporosis, seizure disorders,

Nursing Responsibility Assessment History (systemic administration): Infections, fungal infections, amebiasis, vaccinia and varicella, and antibiotic-resistant infections; kidney or liver disease; hypothyroidism; ulcerative colitis with impending perforation; diverticulitis; active or latent peptic ulcer; inflammatory bowel disease; CHF; hypertension; thromboembolic disorders; osteoporosis; seizure disorders; diabetes mellitus; lactation Physical: Baseline weight, T, reflexes and grip strength, affect and

erythroblastopeni a betamethasone sodium phosphate Systemic, including IV and local injection: Betnesol (CAN), Celestone Phosphate Ulcerative colitis, acute exacerbations of MS, and palliation in some leukemias and lymphomas

acetate): Initial dosage, 0.59 mg/day. Dosage range is onethird to one-half oral dose given q 12 hr. In life-threatening situations, dose can be in multiples of the oral dose.

betamethasone sodium phosphate and acetate Systemic, IM, and local intraarticular, intralesional, intradermal injection: Celestone Soluspan

Intrabursal, intra-articular, intradermal, intralesional Trichinosis with neurologic or (betamethasone sodium phosphate and acetate) myocardial involvement 0.252 mL intra-articular, depending on joint size; 0.2 Intra-articular or softmL/cm3 intradermally, not to tissue administration exceed 1 mL/wk; 0.251 mL at 3- to 7-day intervals for Arthritis, psoriatic plaques, disorders of the foot. and so forth Topical dermatologic cream, ointment (betamethasone Dermatologic dipropionate) preparations Relief of inflammatory and pruritic manifestations of steroid-responsive dermatoses Apply sparingly to affected area bidqid. PEDIATRIC PATIENTS

Systemic administration Individualize dosage on the basis of severity and response rather than by formulae that correct adult doses for age or weight. Carefully observe

betamethasone valerate

carbohydrate tolerance, diabetes mellitus, cushingoid state (long-term effect), increased blood sugar, increased serum cholesterol, decreased T3 and T4 levels, hypothalamicpituitary-adrenal (HPA) suppression with systemic therapy longer than 5 days GI: Peptic or esophageal ulcer, pancreatitis, abdominal distention, nausea, vomiting, increased appetite, weight gain (long-term therapy) Musculoskeletal : Muscle weakness, steroid myopathy, loss of muscle mass, osteoporosis, spontaneous

diabetes mellitus.

orientation, P, BP, peripheral perfusion, prominence of superficial veins, R and adventitious sounds, serum electrolytes, blood glucose

Interventions Systemic use Give daily dose before 9 AM to mimic normal peak corticosteroid blood levels. Increase dosage when patient is subject to stress. Taper doses when discontinuing high-dose or longterm therapy. Do not give live virus vaccines with immunosuppressiv e doses of

Topical dermatologic ointment, cream, lotion: Betaderm (CAN), BetaVal, Celestoderm (CAN), Luxiq, Prevex B (CAN), Psorion Cream, Valisone

growth and development in infants and children on prolonged therapy. Route Systemi c Onset Varie s Duratio n 3 days

fractures (longterm therapy) Other: Immunosuppress ion, aggravation, or masking of infections; impaired wound healing; thin, fragile skin; petechiae, ecchymoses, purpura, striae; subcutaneous fat atrophy; hypersensitivity or anaphylactoid reactions

corticosteroids. Topical dermatologic preparations Examine area for infections, skin integrity before application. Administer cautiously to pregnant patients; topical corticosteroids have caused teratogenic effects and can be absorbed from systemic site. WARNING: Use caution when occlusive dressings or tight diapers cover affected area; these can increase systemic absorption of the drug. Avoid prolonged use near eyes, in genital and rectal areas, and in skin

Pregnancy Category C

The following effects are related to various local routes of steroid administration: Intra-articular: Osteonecrosis, tendon rupture, infection Intralesional therapy: Blindness when applied to face and head Topical dermatologic ointments, creams, sprays:

Local burning, irritation, acneiform lesions, striae, skin atrophy

creases.

Teaching points Systemic use Do not stop taking the oral drug without consulting your health care provider. Take single dose or alternateday doses before 9 AM. Avoid exposure to infections; ability to fight infections is reduced. Wear a medical alert tag so emergency care providers will know that you are on this medication. You may experience these side effects: Increase in appetite, weight

gain (counting calories may help); heartburn, indigestion (eat frequent small meals; take antacids); poor wound healing (consult with your care provider); muscle weakness, fatigue (frequent rest periods will help). Report unusual weight gain, swelling of the extremities, muscle weakness, black or tarry stools, fever, prolonged sore throat, colds or other infections, worsening of original disorder. Intrabursal, intra-articular therapy Do not overuse joint after therapy, even if pain is gone. Topical dermatologic

preparations Apply sparingly; do not cover with tight dressings. Avoid contact with the eyes. Report irritation or infection at the site of application.