Name of the Drug Generic Name: epinephrine Brand Name: Injection, OTC nasal solution: Adrenalin Chloride Ophthalmic

solution: Epifrin, Glaucon Insect sting emergencies: EpiPen Auto-Injector (delivers 0.3 mg IM adult dose), EpiPen Jr. AutoInjector (delivers 0.15 mg IM for children) OTC solutions for nebulization: AsthmaNefrin, microNefrin, Nephron, S2

Dosage/Route Cardiac arrest: 1 mg IV of 1:10,000 solution q 3-5 min; double dose if administering via ET tube Anaphylaxis: 0.1- 1 mg SQ or IM of 1:1000 solution. Asthma: 0.1-0.3 mg SQ or IM of 1:10,000 solution Refractory bradycardia and hypotension: 2-10ug/min

Action/Classification Action: Stimulates beta receptors in lung. Relaxes bronchial smooth muscle. Increases vital capacity BP, HR, PR Decreases airway resistance. Classification: Beta2 Adrenergic Agonists

Indication/ Contraindications Indications: o Asthma o Bronchitis o Emphysema o All cardiac arrest, anaphylaxis o Used for symptomatic bradycardia. o Relief of bronchospasm occurring during anesthesia o Exercised-induced bronchospasm Contraindications: Contraindicate in patients with angle-closure glaucoma, shock (other than anaphylactic shock), organic brain damage, cardiac dilation, arrhythmias, coronary insufficiency, or cerebral arteriosclerosis. Also contraindicated in patient receiving general anesthesia with halogenated hydrocarbons or cyclopropane and in patients in labor (may delay second stage) Some products containing sulfites and are contraindicated in patients

Adverse Effects/ Side Effects Adverse Effects: nervousness, tremor, vertigo, pain, widened pulse pressure, hypertension nausea Side Effects: headache

Nursing Responsibilities Monitor V/S. and check for cardiac dysrhythmias Drug increases rigidity and tremor in patients with Parkinsons disease Epinephrine therapy interferes with tests for urinary catecholamine Avoid IM use of parenteral suspension into buttocks. Gas gangrene may occur Massage site after IM injection to counteract possible vasoconstriction. Observe patient closely for adverse reactions. Notify doctor if adverse reaction develop If blood pressure increases sharply, rapid-acting vasodilators such as nitrates or alpha blockers can be given to counteract

with sulfite allergies except when drug is used for serious allergic reactions or in other emergency situations. In conjunction with local anesthesia, epinephrine is contraindicated for use in finger, toes, ears, nose, and genitalia. Use cautiously with longstanding bronchial asthma and emphysema, who have developed degenerative heart disease and in those with hyperthyroidism, CV disease, hypertension, psychoneurosis, or diabetes. In pregnant woman, drug is contraindicated. In breast feeding do not use the drug or stop breast feeding.

Name of the Drug Generic Name: lidocane Brand Name: Xylocaine

Dosage/Route 1-1.5 mg/kg IVP or ETT (double dose if giving via ET tube), may repeat q 5-10 min. max 3 mg/kg; If conversion successful start an infusion of 2-4 mg/min

Action/Classification Action: Decrease cardiac excitability, cardiac contraction is delayed in the atrium and ventricle Classification: Antiarrythmic and Anesthetic

Indication/ Contraindications Indications: Decrease cardiac excitability, cardiac contraction is delayed in the atrium and ventricle Contraindications: Contraindicated in patients hypersensitive to amide-type local anesthetics and in those with Adams Stoke syndrome. Wolff-ParkinsonsWhite Syndrome, or severe degrees of SA, AV, or intraventricular block in the absence of pacemaker.

Adverse Effects/ Side Effects Adverse Effects: CNS: Confusion, tremor, lethargy, somnolence, stupor, restlessness anxiety, hallucinations, nervousness, seizure. CV: hypotension, bradychardia, new or worsened arrhythmias EENT: tinnitus, blurred or double vision. Respiratory: Respiratory depression and arrest Skin: soreness at injection site Other: anaphylaxis, Side Effects: sensation of cold, vomiting

Nursing Responsibilities Monitor EKG, BP, pulse, rhythm, continuously. Monitor serum lidocaine levels throughout theraphy; therapreutic range 1.5-5 mcg/ml Monitor intake and output Do not mix in the same syringe with amphoterin B or cefazolin Administer Lidocaine TIV. In case of circulatory depression have dopamine available

Name of the Drug Generic Name: furosemide Brand Name: Apo-Furosemide Furoside Lasix Lasix Speacial Novosemide Uritol

Dosage/Route 0.5-1 mg/kg slow IVP over 12 min, may repeat once at 2 mg/kg slow IVP over 1-2 mins.

Action/Classification Action: inhibits sodium and chloride reabsorption at the proximal and distal tubules and the ascending loop of Henlen Classification: Loop Diuretics

Indication/ Contraindications Indications: Edema associated with CHF Cirrhosis with ascites or renal dysfunction For hypertension or in combination with other antihypertensive medications. ICP, nephritic syndrome, hepatic cirrhosis Contraindications: Contraindicated to patients hypersensitive to drug or any of its components and in those with anuria. Use cautiously in patient with hepatic cirrhosis. Patients with allergies to sulfonamides may also be allergic to furosemide. In pregnant woman, use only if benefits outweighs the risk to the fetus. In breast feeding woman, do not use drug.

Adverse Effects/ Side Effects Adverse Effects: vertigo, headache, paresthesia, orthostatic hypotension, thrombophlebitis, abdominal pain, Hypokalemia, anemia, muscle spasm

Nursing Responsibilities Monitor serum glucose, and electrolyte D iet- K+ for all except aldactone I ntake and Output, daily weight U ndesirable effects; Fluid and electrolyte imbalance R eview HR, BP and electrolytes E lderly-Careful T ake with or after meals and in AM I ncrease risk of orthosthatic hypotension; move slowly C ancel alcohol

Name of the Drug Generic Name: digoxin Brand Name: Lanoxin, Digoxin, Lanoxicap

Dosage/Route Adults: For rapid digitalization, give 0.4 to 0.6 mg I.V. initially, followed by 0.1 to 0.3 mg I.V. every 4 hours, as needed and tolerated, for 24 hours. Children: digitalizing dose is based on childs age and is given in three or more divided doses over the first 24 hours. First dose is 50% of total dose; subsequent dose are given q 4 to 8 hours as needed and tolerated. Children age 10 years and older: For rapid digitalization, give 8 to 12 mcg/kg I.V. over 24 hours, divided as above, Maintenance dose is 25% to 35% of total digitalizing dose, given daily as a single dose. Children ages 5 to 10: For rapid digitalization, give 15 to 30 mcg/kg I.V. over 24 hours divided as above. Maintenance dose is 25% to 35% of total digitalizing dose, divided and given in two or three equal portions daily.

Action/Classification Action: Inhibits the sodiumpotassium ATP phase. Classification: Cardiac Glycosides

Indication/ Contraindications Indications: V-fib, V-flutter, CHF, pulmonary edema, atrial fibrillation and or flutter, and paroxysmal atrial contractions Contraindications: Contraindicated in patients hypersensitive to the drug or any of its components and in those with digitalis-induced toxicity, ventricular fibrillation, or ventricular tachycardia unless caused by heart failure. Use cautiously in patients with acute MI, in complete Av block, sinus bradycardia, PVCs,, chronic constrictive pericarditis, hyperthropic cardiomyopathy, renal insufficiency, severe pulmonary disease, or hypothyroidism.

Adverse Effects/ Side Effects Adverse Effects: CNS: hallucinations, paresthesia, stupor, vertigo. CV: Arrythmias, heart failure, hypotension. EENT: blurred vision, diplopia, light flashes, photophobia, yellow-green halos around visual images. GI: anorexia, diarrhea, nausea, vomiting. Side Effects: CNS: agitation, dizziness, fatigue, generalized weakness, headache, malaise. GI: Nausea

Nursing Responsibilities Monitor K+, Mg++, ECG, liver/renal function tests, drug level (therapeutic level 0.5-2.0 mg/ml, toxicity is >2.0 mg/ml). Before each dose assess apical pulse for full minute, record and report changes in rate or rhythm. Withhold drug and contact provider if pulse is < 60/min. or >100 (adults) or < 110/minute (children) Weigh daily Monitor I&O and signs of CHF

Children ages 2 to 5: For rapid digitalization: give 25 to 35 mcg/kg I.V. over 24 hours, divided as above. Maintenance dose is 25% to 35% of total digitalizing dose, divided and given in two or three equal portions daily. Infants ages 1 month to 2 years: For rapid digitalization. Give 30 to 50 mcg/kg I.V. over 24 hours, divided as above. Maintenance dose is 25% to 35% of the total digitalizing dose, divided and given in two or three equal portions daily. Neonates: for rapid digitalization, give 20 to 30 mcg/kg I.V. over 24 hours, divided as above. Maintenance dose is 25% to 30% of the total digitalizing dose, divided and given in two or three equal portions daily. Premature Infants: For rapid digitalization, give 15 to 25 mcg/kg I.V. over 24 hours, divided as above. Maintenance dose is 20% to 30% of the total digitalizing dose, divided and given into two or three equal portions daily.

Name of the Drug Generic Name: Sodium Bicarbonate Brand Name: Arm and Hammer Pure Baking Soda, Citrocarbonate, Soda Mint

Dosage/Route 1 mEq/kg IVP, may repeat 0.5 mEq/kg 10 min.

Action/Classification Action: Neutralizes gastric acid Decrease pepsin activity Classification: Alkalizing Agent, Buffer, Antacid, electrolyte

Indication/ Contraindications Indications: o Hyperacidity o Peptic ulcer o Hyperkalemia o Tricyclic antidepressant OD o Shock associated with severe diarrhea, dehydration, uncontrolled DM o Reflux esophagitis Contraindications: Contraindicated in patients with metabolic or respiratory alkalosis; patients who are losing chlorides from vomiting or continuous GI suction; patients taking diuretics known to produce hypochloremia alkalosis; and patients with hypocalcemia in which alkalosis may produce tetany, hypertension, seizures, or heart failure. Oral sodium bicarbonate is contraindicated in patients with acute ingestion of strong mineral acids.

Adverse Effects/ Side Effects Adverse Effects: GI: Gastric distention, belching, flatulence. Metabolic: metabolic alkalosis, hypernatremia, hypokalemia, hyperosmolarity (with overdose). Other: Pain and irritation at injection site.

Nursing Responsibilities Monitor urinary pH, calcium, electrolytes and phosphate levels. Record amount and consistency of stools. Clients on low-sodium diets should evaluate sodium contents of antacids.

Name of the Drug Generic Name: Dopamine HCl. Brand Name: Intropin; Revimine

Dosage/Route Adults: initially, 1 to 5 mcg/kg/minute by I.V. infusion. Adjust dose to desired hemodynamic or renal response, increase by 1 to 4 mcg/kg/minute at 10 to 30minute intervals.

Action/Classification Action Stimulates dopaminergic and alpha and beta receptors of the sympathetic nervous system. Action is dose-related; large doses can cause mainly alpha stimulation. Classification: Inotropic, vasopressor

Indication/ Contraindications Indications: To treat shock and correct hemodnamic imbalances, improve perfusion of vital organs, to increase cardiac output, and to correct hypotension. Contraindications: Contraindicated in patient with uncorrected tachyarrhythmias, pheocromocytoma, or ventricular fibrillation. - Use cautiously in patients with occlusive vascular disease, cold injuries, diabetic endarteritis, and arterial embolism; in pregnant woman; with a history of sulfite sensitivity; and in those taking MAO inhibitor.

Adverse Effects/ Side Effects Adverse Effects: Cv: anginal pain, arrythmias, bradycardia, conduction disturbances ectopic breasts,hypertension, hypotension, palpitations, tachycardia, vasoconstriction, widening of QRS complex. GI: vomiting. GU: azotemia Respiratory: asthma attacks, dyspnea Skin: necrosis,piloerection, tissue sloughing with extravasation. Other: anaphylaxis.

Nursing Responsibilities Blood is not a substitute for blood or fluid volume deficit. If deficit occurs, replace fluid deficit first before giving meds. During infusion, frequently monitor ECG, BP, cardiac output, CVP, pulmonary artery wedge pressure, pulse rate, urine output, and color and temperature of the limbs. If diastolic pressure rises disproportionately, decrease perfusion rate and watch out carefully for further signs of vasoconstriction unless such action is desired. Observe for adverse reaction.

Side Effects: CNS: headache GI: nausea

Check for urine output. If urine flow is decrease without hypotension, notify physician. After drug is stopped, Tamper dosage slowly to evaluate stability of blood pressure. Acidosis decrease effectiveness of dopamine.

Name of the Drug Generic Nitroglycerin Brand Nitrostat

Dosage/Route/Timing 0.3-0.4 mg SL q 5 min, max 3 doses.

Action/Classification Action: Relaxes the vascular smooth system Myocardial oxygen consumption left ventricular workload arterial BP venous return Classification Antianginal, Nitrate, Vasodilator, Coronary

Indication/ Contraindications Indication: Angina pectoris CHF associated with AMI Cardiac load reducing agent Hypertensive Crisis Contraindication: Contraindicated in patients hypersensitive to nitrates and in those with early MI. (S.L. form), severe anemia, increase ICP angle-closure glaucoma, IV nitroglycerine is contraindicated in patients with hypovolemia, hypotension, orthostatic hypotension, cardiac tamponade restrictive cardiomyopathy, constrictive pericarditis.

Adverse Effects/ Side Effects Adverse Effects CV: orthostatic hypotension, flushing, fainting. EENT: sublingual burning. Skin: Cutaneous vasodilation, contact dermatitis (patch) Side Effects CNS: headache, throbbing, dizziness, weakness. GI: nausea, vomiting. Skin: Rash

Nursing Responsibilities Record characteristics and precipitating factors of anginal pain. Monitor BP and apical pulse before administration and periodically after dose. Have client sit or lie down if taking drug for the first time. Client must have continuing EKG monitoring for IV administration Cardioverter/ defibrillator must not be discharged through paddle electrode overlying Nitro-Bid ointment or the Transderm-Nitro Patch. Assist with ambulating if dizzy. Instruct to take at first sign of anginal pain. May be repeated q 5 minutes to max. of 3 doses. If the client doesnt experience relief, advise to seek medical assistance

immediately. Name of the Drug Generic Atrophine Sulfate Brand Isopto Atropine Dosage/Route Bradycardia: 0.5 -1 mg IV (may give via ETT at double dose) q 3-5 min, max 0.04 mg/kg Cardiac arrest: 1 mg q 3-5 min, max 0.04 mg/kg Nerve gas and organophosphate symptoms, may repeat in 2 mg increments q 3 min tiltrated to relief symptoms. Action/Classification Action cholinergic receptor sites so response to acetylcholine is decreased Classification Anticholinergics Indication/ Contraindications Indication As an anti-sialagogue for preanesthetic medication to prevent or reduce secretions of the respiratory tract To restore cardiac rate and arterial pressure during anesthesia, when vagal stimulation produced by intraabdominal surgical traction causes a sudden decrease in pulse rate and cardiac action To lessen the degree of atrioventricular (A-V) heart block when increased vagal tone is a major factor in the conduction defect, as in some cases due to digitalis To overcome severe carotid sinus reflex Antidote for cardiovascular collapse from the injudicious use of a cholinergic drug. Contraindication Contraindicated in patients hypersensitive to drug and those with acute angle closure glaucoma, obstructive Adverse Effects/ Side Effects Adverse Effects CNS: restlessness, ataxia, disorientation, hallucinations, delirium, coma, insomnia, agitation, confusion. CV: tachycardia, angina, arrhythmias, flushing. EENT: photophobia, blurred vision, mydriasis. GI: dry moth, constipation, vomiting. GU: urine retention. Hematologic: leukocytosis Other: anaphylaxis Side Effects CNS: headache, excitement. CV: palpitations GI: thirst, nausea. Nursing Responsibilities Monitor VS. Re port HR M onitor for constipation, oliguria. Atr ophine could result in CNS stimulation (confusion, excitement) or drowsiness Instruct to take 30 mins before meals Eat foods high in fiber and drink plenty fluids. Avoid OTC antihistamines. Instruct client not to drive a motor vehicle or participate in activities requiring alertness. Advise to use hard candy, ice chips, etc. for dry mouth.

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uropathy, obstructive disease of GI tract, paralytic elius, toxic magacolon, intestinal atony, unstable CV status in acute hemorrhage, asthma, or myasthenia gravis. Also contraindicated in pregnant women.

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Name of the Drug Generic Morphine Sulfate Brand Immediate-release tablets: MSIR Timed-release: Kadian, M-Eslon (CAN), MS Contin, Oramorph SR Oral solution: MSIR, Rescudose, Roxanol, Roxanol T Rectal suppositories: RMS Injection: Astramorph PF, Duramorph, Epimorph (CAN) Preservative-free concentrate for microinfusion devices for intraspinal use: Infumorph

Dosage/Route ADULTS Oral One-third to one-sixth as effective as parenteral administration because of first-pass metabolism; 10 30 mg q 4 hr PO. Controlledrelease: 30 mg q 812 hr PO or as directed by physician; Kadian: 20100 mg PO daily24-hr release system; MS Contin: 200 mg PO q 12 hr. SC and IM 10 mg (520 mg)/70 kg q 4 hr or as directed by physician. IV 2.515 mg/70 kg of body weight in 45 mL water for injection administered over 4 5 min, or as directed by physician. Continuous IV infusion: 0.11 mg/mL in 5% dextrose in water by controlled infusion device. Rectal 1030 mg q 4 hr or as directed by physician. Epidural Initial injection of 5 mg in the lumbar region may provide pain relief for up to 24 hr. If adequate pain relief is not

Action/Classification Action Principal opium alkaloid; acts as agonist at specific opioid receptors in the CNS to produce analgesia, euphoria, sedation; the receptors mediating these effects are thought to be the same as those mediating the effects of endogenous opioids (enkephalins, endorphins). Classification Opioid agonist analgesic

Indication/ Contraindications Indication Relief of moderate to severe acute and chronic pain Preoperative medication to sedate and allay apprehension, facilitate induction of anesthesia, and reduce anesthetic dosage Analgesic adjunct during anesthesia Component of most preparations that are referred to as Brompton's cocktail or mixture, an oral alcoholic solution that is used for chronic severe pain, especially in terminal cancer patients Intraspinal use with microinfusion devices for the relief of intractable pain Unlabeled use: Dyspnea associated with acute left ventricular failure and pulmonary edema Contraindication Contraindicated with

Adverse Effects/ Side Effects Adverse Effect CNS: Light-headedness, dizziness, sedation, euphoria, dysphoria, delirium, insomnia, agitation, anxiety, fear, hallucinations, disorientation, drowsiness, lethargy, impaired mental and physical performance, coma, mood changes, weakness, headache, tremor, seizures, miosis, visual disturbances, suppression of cough reflex CV: Facial flushing, peripheral circulatory collapse, tachycardia, bradycardia, arrhythmia, palpitations, chest wall rigidity, hypertension, hypotension, orthostatic hypotension, syncope Dermatologic: Pruritus, urticaria, Respiratory: laryngospasm, bronchospasm, edema GI: Nausea, vomiting, anorexia, biliary tract spasm; increased colonic motility in patients with chronic ulcerative colitis

Nursing Responsibilities Assessment History: Hypersensitivity to opioids; diarrhea caused by poisoning; labor or delivery of a premature infant; biliary tract surgery or surgical anastomosis; head injury and increased intracranial pressure; acute asthma, COPD, cor pulmonale, preexisting respiratory depression; acute abdominal conditions, CV disease, supraventricular tachycardias, myxedema, seizure disorders, acute alcoholism, delirium tremens, cerebral arteriosclerosis, ulcerative colitis, fever, kyphoscoliosis, Addison's disease, prostatic hypertrophy, urethral stricture, recent GI or GU surgery, toxic psychosis, renal or hepatic dysfunction; pregnancy; lactation Physical: T; skin color, texture, lesions; orientation, reflexes, bilateral grip strength, affect; P, auscultation, BP, orthostatic BP, perfusion; R, adventitious sounds; bowel sounds, normal

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achieved within 1 hr, incremental doses of 12 mg may be given at intervals sufficient to assess effectiveness, up to 10 mg/24 hr. For continuous infusion, initial dose of 24 mg/24 hr is recommended. Further doses of 12 mg may be given if pain relief is not achieved initially. Intrathecal Dosage is usually one-tenth that of epidural dosage; a single injection of 0.21 mg may provide satisfactory pain relief for up to 24 hr. Do not inject > 2 mL of the 5 mg/10 mL ampule or > 1 mL of the 10 mg/10 mL ampule. Use only in the lumbar area. Repeated intrathecal injections are not recommended; use other routes if pain recurs. For epidural or intrathecal dosing, use preservative-free morphine preparations only. PEDIATRIC PATIENTS Do not use in premature infants. SC or IM 0.050.2 mg/kg (up to 15 mg per dose) q 4 hr or as directed by physician.

hypersensitivity to opioids; diarrhea caused by poisoning until toxins are eliminated; during labor or delivery of a premature infant (may cross immature bloodbrain barrier more readily); after biliary tract surgery or following surgical anastomosis; pregnancy; labor (respiratory depression in neonate; may prolong labor). Use cautiously with head injury and increased intracranial pressure; acute asthma, COPD, cor pulmonale, preexisting respiratory depression, hypoxia, hypercapnia (may decrease respiratory drive and increase airway resistance); lactation (wait 46 hr after administration to nurse the baby); acute abdominal conditions, CV disease, supraventricular tachycardias, myxedema, seizure disorders, acute alcoholism, delirium tremens, cerebral arteriosclerosis, ulcerative colitis, fever, kyphoscoliosis, Addison's disease, prostatic hypertrophy, urethral stricture, recent GI or GU surgery, toxic psychosis, renal or hepatic dysfunction.

GU: Ureteral spasm, spasm of vesical sphincters, urinary retention or hesitancy, oliguria, antidiuretic effect, reduced libido or potency Respiratory: Respiratory depression, apnea, circulatory depression, respiratory arrest, shock, cardiac arrest Side Effects GI: dry mouth, constipation. Skin: Tissue irritation and induration (SC injection). Other: sweating,physical tolerance and dependence, psychological dependence

output; urinary frequency, voiding pattern, normal output; ECG; EEG; thyroid, liver, kidney function tests Interventions Caution patient not to chew or crush controlled-release preparations. Dilute and administer slowly IV to minimize likelihood of adverse effects. Tell patient to lie down during IV administration. Keep opioid antagonist and facilities for assisted or controlled respiration readily available during IV administration. Use caution when injecting SC or IM into chilled areas or in patients with hypotension or in shock; impaired perfusion may delay absorption; with repeated doses, an excessive amount may be absorbed when circulation is restored. Reassure patients that they are unlikely to become addicted; most patients who receive opioids for medical reasons do not develop dependence

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GERIATRIC PATIENTS OR IMPAIRED ADULTS Use caution. Respiratory depression may occur in the elderly, the very ill, those with respiratory problems. Reduced dosage may be necessary. Epidural Use extreme caution; injection of < 5 mg in the lumbar region may provide adequate pain relief for up to 24 hr. Intrathecal Use lower dosages than recommended for adults above.

syndromes Teaching points Take this drug exactly as prescribed. Avoid alcohol, antihistamines, sedatives, tranquilizers, over-the-counter drugs. Swallow controlled-release preparation (MS Contin, Oramorph SR) whole; do not cut, crush, or chew them. Do not take leftover medication for other disorders, and do not let anyone else take your prescription. These side effects may occur: Nausea, loss of appetite (take with food, lie quietly); constipation (use laxative); dizziness, sedation, drowsiness, impaired visual acuity (avoid driving or performing tasks that require alertness and visual acuity). Report severe nausea, vomiting, constipation, shortness of breath or difficulty breathing, rash.

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