terbutaline (Rx)
ACTION: Relaxes bronchial smooth muscle by direct action on β2adrenergic receptors through the accumulation of T cAMP at β-adrenergic receptor
sites; bronchodilation, diuresis, CNS, cardiac stimulation occur; relaxes uterine
smooth muscle
USES: Bronchospasm
Unlabeled uses: Premature labor, nonresponsive status asthmaticus in children
(IV)
CONTRAINDICATIONS: Hyper- sensitivity to sympathomimetics, closed- angle
glaucoma, tachydysrhythmias
Precautions: Pregnancy, breastfeeding, geriatric patients, cardiac disorders,
hyperthyroidism, diabetes mellitus, prostatic hypertension, hypertension, seizure
disorder
Black Box Warning: Labor
DOSAGE AND ROUTES
Bronchospasm
• Adult/child $12 yr: PO 2.5-5 mg q8hr; SUBCUT 0.25 mg q15-30min, max 0.5
mg in 4 hr
• Child 6-11 yr (unlabeled): PO 0.05 mg/kg q8hr, may increase slowly
Renal dose
• Adult: PO CCr 1050 mL/min, 50% of dose; CCr <10 mL/min, avoid use
Tocolytic (preterm labor) (unlabeled)
• Adult: SUBCUT 0.25 mg q20min to 6 hr, hold if pulse >120 bpm
Available forms: Tabs 2.5, 5 mg; inj 1 mg/mL
Administer:
• With food; may be crushed
• 2 hr before bedtime to avoid sleepless- ness
IV route (unlabeled)
• Only used if subcut is ineffective
• IV after diluting each 5 mg/1 L D5W for infusion
• IV, run 5 mcg/min; may increase 5 mcg q10min, titrate to response; after 1/2-1
hr, taper dose by 5 mcg; switch to PO as soon as possible
• Store at room temperature; do not use discolored sol
SUBCUT: Onset 6-15 min, peak 1/2-1 hr, duration 11/2-4 hr, half-life 5.7 hr
INTERACTIONS
Increase: hypertensive crisis—MAOIs Increase: effects of both products— other
sympathomimetics
Decrease: action—β-blockers; do not use together
Drug/Herb
Increase: effect—green tea (large amounts), guarana
NURSING CONSIDERATIONS
Assess:
• Respiratory function: vital capacity, forced expiratory volume, ABGs, B/P,
pulse, respiratory pattern, lung sounds, sputum before and after treatment
• Tolerance in patients receiving long- term therapy; dose may have to be changed;
monitor for rebound broncho- spasm
• Paradoxical bronchospasm: dyspnea, wheezing; keep emergency equip ment
nearby
Black Box Warning: Labor: maternal heart rate, B/P, contraction, fetal heart rate;
can inhibit uterine contractions, labor; monitor for hypoglycemia; do not use
injectable product for prevention or treatment over 72 hr in preterm labor; do not
use oral product for preterm labor; avoid in breastfeeding
• Increase in fluids of >2 L/day
Evaluate:
• Therapeutic response: absence of dyspnea, wheezing
Teach patient/family:
• Not to use OTC medications because extra stimulation may occur
• About all aspects of product; to avoid smoking, smoke-filled rooms, persons with
respiratory infections
• To increase fluids by >2 L/day; to al- low 15 min between inhalation of prod- uct
and inhaled product containing steroid
• To take on time; if missed, not to make up after 1 hr; to wait until next dose
Y-site compatibilities: Insulin (regular)
SIDE EFFECTS
CNS: Tremors, anxiety, insomnia, head- ache, dizziness, stimulation
CV: Palpitations, tachycardia, hypertension, dysrhythmias, cardiac arrest, QT
prolongation
GI: Nausea, vomiting
META: Hypokalemia, hyperglycemia
RESP: Paradoxical bronchospasm, dyspnea
PHARMACOKINETICS
PO: Onset 1/2 hr, peak 1-2 hr, duration 4-8 hr, half-life 3.4 hr
indomethacin (Rx)
ACTION: Inhibits prostaglandin syn- thesis by decreasing enzyme needed for
biosynthesis; analgesic, anti-inflammatory, antipyretic
USES: RA, ankylosing spondylitis, osteoarthritis, bursitis, tendinitis, acute gouty
arthritis; closure of patent ductus arteriosus in premature infants (IV)
Unlabeled uses: Bone pain, headache, heterotopic ossification, juvenile
rheumatoid arthritis, pericarditis
CONTRAINDICATIONS: Pregnancy 3rd trimester, aortic coarctation, bleeding,
salicylate/NSAID hypersensitivity, GI bleeding
Black Box Warning: Perioperative pain in CABG
Precautions: Pregnancy 1st trimester, breastfeeding, children, bleeding disorders,
GI disorders, cardiac disorders, depression, renal/hepatic disease, asthma, diabetes,
acute bronchospasm, ulcerative colitis, seizures, Parkinson’s disease, neonates
Black Box Warning: Stroke, GI bleeding, MI, those taking NSAIDs are at greater
risk of MI and stroke, even in first few weeks of therapy.
DOSAGE AND ROUTES
Arthritis/anti-inflammatory
• Adult: PO 25-50 mg bid-tid; max 200 mg/day; EXT REL 75 mg/day, may increase to 75 mg bid
Acute gouty arthritis
• Adult: PO 50 mg tid; use only for acute attack, then reduce dose
Mild to moderate pain (Tivorbex)
• Adult: PO 20 mg tid or 40 mg bid/tid • Child >2 yr: PO 1-2 mg/kg/day in 2-4
divided doses, max 4 mg/kg/day or 150- 200 mg/day
Patent ductus arteriosus
• Neonate >7 days: IV Initially, 0.2 mg/ kg, then, if necessary, 2 more doses of
0.25 mg/kg at 12-hr intervals if urine output is >1 mL/kg/hr after prior dose or at
24-hr intervals if urine output is <1 mL/kg/hr; hold in cases of oliguria (<0.6
mL/kg/hr) or anuria
• Neonate 2-7 days: IV Initially, 0.2 mg/ kg, then, if necessary, 2 more doses of
0.2 mg/kg at 12-hr intervals if urine out- put is >1 mL/kg/hr after prior dose or at
24-hr intervals if urine output is <1 mL/ kg/hr; hold in cases of oliguria (<0.6
mL/kg/hr) or anuria
indomethacin 681
• Neonate <2 days: IV Initially, 0.2 mg/ kg, then, if necessary, 1 or 2 doses of 0.1
mg/kg at 12-hr intervals if urine output is >1 mL/kg/hr after prior dose or at 24-hr
intervals if urine output is <1 mL/kg/hr; hold in cases of oliguria (<0.6 mL/kg/ hr)
or anuria
• Neonate: PO Doses of 0.3 mg/kg q day × 2 days have been used
Available forms: Caps 25, 50 mg; ext rel caps 75 mg; caps (Tivorbex 20, 40 mg);
powder for inj 1-mg vial; supp 50 mg; oral susp 5 mg/mL
Administer:
PO route
• Do not break, crush, or chew sus relcap or reg caps I • With food to decrease GI
symptoms and prevent ulcerations
• Shake susp; do not mix with other liquids
• Store at room temperature
IV route
• After reconstituting 1 mg with 1 or 2 mL NS or sterile water for inj without
preservative; to give 1 or 0.5 mg/mL, respectively; do not dilute further
• Infuse over 20-30 min; avoid extravasation
• Do not inject/infuse via umbilical catheter to avoid dramatic shift in cerebral
blood flow
SIDE EFFECTS
CNS: Dizziness, drowsiness, fatigue, con- fusion, insomnia, anxiety, depression,
headache
CV: Peripheral edema, hypertension, CV thrombotic events, MI, stroke
EENT: Tinnitus, hearing loss, blurred vision
GI: Nausea, anorexia, vomiting, diarrhea, jaundice, cholestatic hepatitis,
constipation, flatulence, cramps, pep- tic ulcer, ulceration, perforation, GI bleeding
GU: Nephrotoxicity: dysuria, hematuria, oliguria, azotemia (IV)
HEMA: Blood dyscrasias, prolonged bleeding
INTEG: Purpura, rash, pruritus, sweating, phlebitis at IV site
PHARMACOKINETICS
PO: Onset 30 min; peak 2 hr; duration 4-6 hr; metabolized in liver, kidneys;
excreted in urine 60%, feces 33%; crosses placenta; excreted in breast milk; 99%
protein binding; half-life 1 hr 1st pass, 2.6-11.2 hr 2nd pass
INTERACTIONS
Increase: hyperkalemia—potassium- sparing diuretics
Increase: toxicity—lithium, methotrex- ate, cycloSPORINE, probenecid, cidofovir
Increase: effect of—digoxin, phenytoin, aminoglycosides
Increase: bleeding risk—anticoagulants, abciximab, clopidogrel, eptifibatide,
plicamycin, ticlopidine, tirofiban, thrombolytics, aspirin, SSRIs, SNRIs
Decrease: effect of—antihypertensives, diuretics
Drug/Herb
Increased: bleeding risk—chamomile, clove, dong quai, garlic, ginger, ginkgo
NURSING CONSIDERATIONS
Assess:
• Arthritis symptoms: ROM, pain, swell- ing before and 2 hr after treatment
Black Box Warning: Cardiac disease, CV, thrombotic events (MI, stroke) before
ad- ministration, not to be used in perioperative pain in CABG surgery
• Patent ductus arteriosus: respiratory rate, character, heart sounds
• Renal, hepatic, blood studies: BUN, creatinine, AST, ALT, Hgb before treatment,
periodically thereafter; if renal function has decreased, do not give sub- sequent
doses
• Eye/ear problems: blurred vision, tinnitus; may indicate toxicity; audiometric,
ophthalmic exam before, during, after treatment if patient receiving long-term
therapy
• Confusion, mood changes, hallucinations, especially among geriatric patients •
Asthma, nasal polyps, aspirin sensitiv- ity, may develop hypersensitivity to
indomethacin
Black Box Warning: GI bleeding/perforation: chronic use can lead to GI
bleeding, use cautiously in those with a history of active GI disease
Black Box Warning: MI, stroke: may be greater with longer-term use and in those
with CV risk factors
• Beers: avoid use in older adults; more likely to cause CNS effects
• Pregnancy/breastfeeding: do not use after 30 wk gestation; use only if benefits
outweigh fetal risk <30 wk gestation; do not breastfeed, excreted in breast milk
Evaluate:
• Therapeutic response: decreased pain, stiffness, swelling in joints; ability to move
more easily, PDA closure
Teach patient/family:
• To report blurred vision, ringing, roaring in ears; may indicate toxicity
• To avoid driving, other hazardous activities if dizziness, drowsiness occurs
• To report change in urine pattern, in- creased weight, edema, increased pain in
joints, fever, blood in urine; may indicate nephrotoxicity
• To take with food for GI upset, to use as prescribed, not to skip or double doses,
to take with 8 oz of water
• Hepatotoxicity: diarrhea, dark urine, clay-colored stools, yellowing of skin
• To report signs of GI bleeding: dark stools, hematemesis
• To report mood changes: anxiety, de- pression
• To use sunscreen, protective clothing, hat to prevent burns
• That therapeutic anti-inflammatory effects may take up to 1 month
• To avoid alcohol, NSAIDs, salicylates because bleeding may occur, discuss all
OTC, Rx, herbals, supplements with health care professional
• To report use to all health care providers
Black Box Warning: MI/stroke: to immediately report and seek medical attention
for signs/symptoms of MI/stroke; discontinue product
magnesium sulfate
ACTION: Increases osmotic pressure, draws fluid into colon, neutralizes HCl
USES: Constipation, dyspepsia; bowel preparation before surgery or exam;
anticonvulsant for preeclampsia, eclampsia (magnesium sulfate); electrolyte;
cardiac glycoside–induced arrhythmias, nutritional supplement
Unlabeled uses: Magnesium sulfate: persistent pulmonary hypertension of the
newborn (PPHN), cardiac arrest, CPR, digitoxin/digoxin toxicity, premature labor,
seizure prophylaxis, status asthmaticus, torsades de pointes, ventricular
fibrillation/tachycardia
CONTRAINDICATIONS: Hyper- sensitivity, abdominal pain, nausea/vomiting,
obstruction, acute surgical abdomen, rectal bleeding, heart block, myocardial
damage
Precautions: Pregnancy (magnesium sulfate), renal/cardiac disease
DOSAGE AND ROUTES
Laxative
• Adult: PO (milk of magnesia) 15-60 mL at bedtime
• Adult/child >12 yr: PO (magnesium sulfate) 15 g in 8 oz water; PO
(concentrated milk of magnesia) 5-30 mL; PO (magnesium citrate) 5-10 oz at
bedtime • Child 2-6 yr: PO (milk of magnesia) 5-15 mL/day
Prevention of magnesium deficiency (mg of magnesium)
• Adult/child ≥10 yr: PO (male) 350- 400 mg/day; (female) 280-300 mg/day;
(breastfeeding) 335-350 mg/day; (pregnancy) 320 mg/day
• Child 8-10 yr: PO 170 mg/day
• Child 4-7 yr: PO 120 mg/day Magnesium sulfate deficiency
(mg of magnesium)
• Adult: PO 200-400 mg in divided doses tid-qid; IM 1 g q6hr × 4 doses; IV 5 g
(severe)
• Child 6-12 yr: PO 3-6 mg/kg/day in divided doses tid-qid
Preeclampsia/eclampsia (magnesium sulfate)
• Adult: IM/IV 4-5 g IV infusion; with 5 g IM in each gluteus, then 5 g q4hr or 4
g IV INFUSION, then 1-3 g/hr CONT IN- FUSION, max 30-40 g/24 hr or 20
g/48 hr in severe renal disease
Persistent pulmonary hypertension of the newborn (PPHN) in mechanically
ventilated neonates (unlabeled)
• Premature infants >33 wk and term ne- onates: IV (magnesium sulfate) 200
mg/kg over 20-30 min, then CONT IV INFUSION 20-150 mg/kg/hr to maintain
blood magne- sium levels at 3.5-5.5 mmol/L
Status asthmaticus (unlabeled)
• Adult: IV (magnesium sulfate) 2 g
• Child: IV INFUSION (PALS) (magnesium sulfate) 25-50 mg/kg diluted in
D5W, given over 10-20 min, max 2 g/dose Premature labor (unlabeled)
• Adult: IV INFUSION (magnesium sulfate) 4-6 g given as a loading dose over
20-30 min, then 2-4 g/hr CONT INFU- SION; use infusion pump until
contractions cease; continue infusion at lowest dose over 12-24 hr; PO
(magnesium chloride/gluconate/oxide) 648-1200 mg/ day elemental magnesium in
divided doses Torsades de pointes/cardiac dysrhythmias with
hypomagnesemia (unlabeled)
• Adult: IV (magnesium sulfate) use ACLSguidelinesor1-2gin50-100mL D5W
given over 5-20 min in emergent cases or over 5-60 min
Available forms: Chloride: sus rel tabs 535 mg (64 mg Mg); enteric tabs 833 mg
(100 mg Mg); citrate: oral sol 240-, 296-, 300-mL bottles (77 mEq/100 mL);
gluconate: tabs 500 mg; liquid 54 mg/5 mL; oxide: tabs 400 mg; caps 140 mg;
hydroxide: liq 400 mg/5 mL; concentration liq 800 mg/5 mL; chew tabs 300, 600
mg;sulfate:500mg/mL; premixedinfusion 1 g/100 mL, 2 g/100 mL, 4 g/50 mL, 4
g/100 mL, 20 g/500 mL, 40 g/1000 mL Administer:
PO route
• With 8 oz water
• Refrigerate magnesium citrate before giving
• Shake susp before using as antacid at least 2 hr after meals
• Tablets should be chewed thoroughly before patient swallows; give 4 oz of water afterward
• Laxative: give on empty stomach with full glass of liquid, do not give at bedtime
IM route (magnesium sulfate)
• Give deeply in gluteal site
IV route (magnesium sulfate) •Only when calcium gluconate is available for
magnesium toxicity
SIDE EFFECTS
CNS: Muscle weakness, flushing, sweating, confusion, sedation, depressed
reflexes, flaccid paralysis, hypothermia CV: Hypotension, heart block, circulatory
collapse, vasodilation
GI: Nausea, vomiting, anorexia, cramps, diarrhea
HEMA: Prolonged bleeding time
META: Electrolyte, fluid imbalances RESP: Respiratory depression/paralysis
PHARMACOKINETICS
PO: Onset 1-2 hr
IM: Onset 1 hr, duration 4 hr
IV: Duration 1/2 hr
Excreted by kidney, effective anticonvulsant serum levels 2.5-7.5 mEq/L
INTERACTIONS
Increase: effect of neuromuscular blockers
Increase: hypotension—antihypertensives, calcium channel blockers Decrease:
absorption of tetracyclines, fluoroquinolones, nitrofurantoin Decrease: effect of
digoxin
NURSING CONSIDERATIONS
Assess:
• Laxative: cause of constipation; lack of fluids, bulk, exercise; cramping, rectal
bleeding, nausea, vomiting; product should be discontinued •Eclampsia: seizure
precautions, B/P,ECG (magnesium sulfate); magnesium toxicity: thirst, confusion,
decrease in reflexes; I&O ratio; check for decrease in urinary output •
Pregnancy/breastfeeding: use only if clearly needed (chloride), contraindicated in
labor, toxemia during 2 hr prior to delivery, appears in breast milk Evaluate:
• Therapeutic response: decreased constipation, absence of seizures (eclampsia),
normal serum calcium levels Teach patient/family:
• Not to use laxatives for long-term therapy because bowel tone will be lost
• That chilling improves taste of magnesium citrate
• To shake suspension well
• Not to give at bedtime as a laxative, may interfere with sleep; that milk of
magnesia is usually given at bedtime •To give citrus fruit after administering to
counteract unpleasant taste
• About reason for product, expected results
naloxone (Rx)
ACTION: Competes with opioids at opiate receptor sites
USES: Respiratory depression induced by opioids, opiate agonist overdose
Unlabeled uses: IBS, opiate agonist dependence, opiate agonist–induced
constipation, pruritus, urinary retention, coma, nausea, vomiting
CONTRAINDICATIONS: Hyper- sensitivity
Precautions: Pregnancy, breastfeeding, children, neonates, CV disease, opioid
dependency, seizure disorder, drug dependency, hepatic disease
DOSAGE AND ROUTES
naloxone 895
Continuous IV INFUSION route
• Dilute 2 mg/500 mL 0.9% NaCl or D5W (4 mcg/mL); titrate to response
• Do not admix with bisulfite, sulfites IM route with standard syringe
• Inject deeply into a large muscle mass; aspirate
IM route with autoinjector (Evzio)
• Remove red safety guard; Evzio must be used immediately or disposed of
properly. Give quickly into the anterolateral aspect of the thigh, through clothing if
necessary. Press firmly and hold in place 5 sec
• For neonates and infants: caregiver should pinch the middle of the outer thigh
muscle before and during drug ad- ministration. Carefully observe administration
site for evidence of residual needle parts and/or signs of infection
• Upon activation, the needle is automatically inserted, delivers the injection, and
then retracts fully
• After initial injection, seek immediate medical attention. Keep patient under
continued surveillance because the duration of action of most opioids is longer
than that of naloxone. Repeat doses q2-3min as needed
• Do NOT attempt to reuse Evzio; each device contains a single dose of naloxone
Subcut with standard syringe
• Inject undiluted solution, taking care not to inject intradermally
Subcut route with autoinjector (Evzio)
• Once the red safety guard is removed, Evzio must be used immediately or
disposed of properly. Do not attempt to replace the red safety guard once it is
removed
• Administer as quickly as possible into the anterolateral aspect of the thigh,
through clothing if necessary. Press firmly and hold in place for 5 sec
• For neonates and infants: caregiver should pinch the middle of the outer thigh
muscle before and during drug administration. Carefully observe administration
site for evidence of residual needle parts and/or signs of infection
• Upon activation, the needle is automatically inserted, delivers the injection, and
then retracts fully
Opioid-induced respiratory depression (known for suspected opiate agonist
overdose)
• Adult: IV/SUBCUT/IM 0.4-2 mg, re- peat q2-3min if needed, max 10 mg; IV
INFUSION loading dose 0.005 mg/ kg, then 0.0025 mg/kg/hr
• Child <5 yr or ≤20 kg: IV/INTRAOS- SEOUS 0.01 mg/kg slowly followed by
0.1 mg/kg if needed; IV INFUSION (PALS) 0.04-0.16 mg/kg/hr, titrate
• Adult/adolescent/child: NASAL 1 spray, may repeat q2-3min if needed
Postoperative opioid-induced respiratory depression
• Adult: IV 0.1-0.2 mg q2-3min prn
• Child: IV 0.005-0.01 mg/kg q2-3min prn
• Neonates: IM/IV/SUBCUT 0.01 mg/ kg, repeat q2-3min until adequate response
Diagnosis of opiate-agonist dependence (unlabeled)
• Adult: IM 0.16 mg; if no withdrawal symptoms after 20-30 min, give 0.24 mg
IV Nausea/vomiting from continuous morphine infusion (unlabeled)
• Adult: IV 0.2 mg
Opioid-induced pruritus (unlabeled) • Child: continuous IV infusion 2
mcg/kg/hr, may increase by 0.5 mcg/ kg/hr q4hr
Available forms: Inj 0.4, 0.4 mg/0.4 mL auto injector; nasal spray 4 mg/0.1 mL
Administer:
• Only with resuscitative equipment, O2 nearby
• Only sol prepared within 24 hr
• Store in dark area at room temperature
• Double-check dose; those taking opi- oids >1 wk are sensitive to this product •
Solution should be clear
Direct IV route
• Undiluted (suspected
dose) or diluted with sterile water for inj; give ≤0.4 mg over 15 sec; (respiratory
depression) dilute with sterile water for injection (0.1 mg/mL); <40 kg; in neonates, may give via umbilical vein
SIDE EFFECTS
CV: Rapid pulse, ventricular tachycardia, fibrillation, hypo/hypertension
GI: Nausea, vomiting
PHARMACOKINETICS
Well absorbed IM, SUBCUT; metabolized by liver, crosses placenta; excreted in
urine, breast milk; half-life 30-81 min IM/SUBCUT: Onset 2-5 min, duration 4560 min
IV: Onset 1 min, duration 45 min Nasal: Peak 20 min
INTERACTIONS
Decrease: effect of opioid analgesics
NURSING CONSIDERATIONS
Assess:
• Withdrawal: cramping, hypertension, anxiety, vomiting; signs of withdrawal in
drug-dependent individuals may occur ≤2 hr after administration; severity depends
on length of time opioids were taken, naloxone dose
• Respiratory dysfunction: respiratory depression, character, rate, rhythm; if respirations are <10/min, administer naloxone; probably due to opioid overdose;
monitor LOC, ECG, B/P
• Pain: duration, intensity, location be- fore and after administration; analgesia will
be decreased; may be used for respiratory depression
• Acute opioid reversal: patients may be- come very agitated and violent after use
• Pregnancy/breastfeeding: use only if clearly needed, cautious use in breastfeeding
Evaluate:
• Therapeutic response: reversal of respiratory depression; LOC—alert
Teach patient/family:
• When patient is lucid, about the rea- sons for, expected results of product; for
nasal administration, teach family, care- givers correct use
betamethasone (topical)
ACTION: Crosses cell membrane to attach to receptors to decrease inflammation,
itching; inhibits multiple inflammatory cytokines
USES: Inflammation/itching cortico- steroid-responsive dermatoses on the
skin/scalp
CONTRAINDICATIONS: Hyper- sensitivity, use of some preparations on face,
axilla, groin
Precautions: Pregnancy, skin infections
DOSAGE AND ROUTES
• Adult: TOP 1-2 times/day (dipropionate) or 1-3 times/day (valerate); or ap- ply
spray 0.05% bid up to 4 wk (plaque psoriasis, mild to moderate)
Available forms: dipropionate: gel, lotion, ointment, cream, spray 0.05%;
valerate: cream, lotion, ointment 0.1%, B foam 0.12%
SIDE EFFECTS
INTEG: Burning, folliculitis, pruritus, dermatitis, maceration, erythema
MISC: Hyperglycemia, glycosuria, Cushing syndrome, HPA axis suppression
PHARMACOKINETICS
Unknown
NURSING CONSIDERATIONS
Assess:
• Skin reactions: • burning, pruritus, folliculitis, dermatitis
• HPA axis suppression: usually rare with topical products
Evaluate:
• Decreased itching, inflammation on the skin, scalp
Teach patient/family:
Topical route:
• That betamethasone valerate may be used with occlusive dressings for psoriasis
or recalcitrant conditions; not to use dipropionate with occlusive dressings
Cream/ointment/lotion:
• To apply sparingly in a thin film, using gloves, and to rub gently into the
cleansed, slightly moist affected area • Not to use on broken, wet skin, area of
infection, face, or groin, axilla
Gel:
• To apply sparingly in a thin film, using gloves, and to rub gently into the
cleansed, slightly moist affected area
Scalp foam:
• To invert can and dispense a small amount of foam onto a saucer or other cool
surface; not to dispense directly onto hands; to pick up small amounts of foam with
fingers and gently massage into affected area until foam disappears; repeat until
entire affected scalp area is treated
• That treatment should be limited to 2wk
misoprostol (Rx)
USES: Prevention of NSAID-induced gastric ulcers
Unlabeled uses: Pregnancy termination, postpartum hemorrhage, cervical
ripening/labor induction (vaginal), active duodenal/gastric ulcer
CONTRAINDICATIONS: Hyper- sensitivity to this product or prostaglandins
Black Box Warning: Pregnancy, females
DOSAGE AND ROUTES
• Adult: PO 200 mcg qid with food for duration of NSAID therapy, with last dose
given at bedtime; if 200 mcg is not tolerated, 100 mcg may be given
Active duodenal/gastric ulcer (unlabeled)
• Adult: PO 100-200 mcg qid with meals at bedtime × 4-8 wk Pregnancy
termination before 63rd day (unlabeled)
• Adult: INTRAVAGINALLY 800 mcg 5-7 days after methotrexate IM
Cervical ripening induction for term pregnancy (unlabeled)
• Adult: INTRAVAGINALLY 25 mcg q3- 6hr
hydrALAZINE (Rx)
ACTION: Vasodilates arteriolar smooth muscle by direct relaxation; reduction in
blood pressure with reflex increases in heart rate, stroke volume, cardiac output
USES: Essential hypertension; hyper- tensive emergency/urgency
Unlabeled uses: HF, preeclampsia
CONTRAINDICATIONS: Hyper- sensitivity to hydralazine, mitral valvular
rheumatic heart disease, CAD Precautions: Pregnancy, breastfeeding, geriatric
patients, CVA, advanced renal disease, hepatic disease, SLE, dissecting aortic
aneurysm
DOSAGE AND ROUTES
Hypertension
• Adult: PO 10 mg qid 2-4 days, then 25 mg for rest of 1st wk, then 50 mg qid,
max 300 mg/day
• Child: PO 0.75-1 mg/kg/day in 2-4 divided doses, max 25 mg/dose, increase
over 3-4 wk to max 7.5 mg/kg/day or 200 mg, whichever is less
Hypertensive crisis
• Adult: IV BOL 10-20 mg q4-6hr, ad- minister PO as soon as possible; IM 1050 mg q4-6hr
• Child: IM/IV BOL 0.1-0.2 mg/kg/dose q4hr as needed
HF
• Adult: PO 10-25 mg tid, max 100 mg tid
Eclampsia
• Adult: IM/IV 5 mg q15-20min Available forms: Inj 20 mg/mL; tabs 10, 25, 50,
100 mg
Administer:
PO route
• Give with meals (PO) to enhance ab- sorption
IM route
• Do not admix, switch to PO as soon as possible, use only in those that cannot use
PO
• No dilution needed, inject deeply in large muscle, aspirate
Direct IV route
• IV undiluted; give through Y-tube or 3-way stopcock, give each 10 mg over ≥1
min
• To recumbent patient, keep recum- bent for 1 hr after administration
SIDE EFFECTS
CNS: Headache, dizziness, drowsiness, peripheral neuritis
CV: Palpitations, tachycardia, angina, orthostatic hypotension
GI: Nausea, vomiting, anorexia, diarrhea
INTEG: Rash, pruritus MISC: Lupuslike symptoms
PHARMACOKINETICS
Half-life 3-7 hr, metabolized by liver, 12%-14% excreted in urine, protein binding
89%; half of Mexicans, blacks, South Indians, and Caucasians are at risk for
toxicity
PO: Onset 20-30 min, peak 1-2 hr, dura- tion 2-4 hr
IM: Onset 10-30 min, peak 1 hr, duration 2-6 hr
IV: Onset 5-30 min, peak 10-80 min, duration up to 12 hr
INTERACTIONS
Increase: severe hypotension—MAOIs Increase: tachycardia, angina—
sympathomimetics (EPINEPHrine, norepinephrine)
Increase: hypotension—other antihypertensives, alcohol, thiazide diuretics
Increase: effects of β-blockers (metoprolol, propranolol)
Decrease: hydrALAZINE effects—NSAIDs, estrogens
Drug/Lab Test
Decrease: Hgb, WBC, RBC, platelets, neutrophils
Positive: ANA titer
Drug/Food
Increase: drug absorption; have patient take with food
NURSING CONSIDERATIONS
Assess:
• Cardiac status: B/P q15min × 2 hr, then q1hr × 2 hr, then q4hr after IV dose;
pulse, jugular venous distention q4hr, after IV administration
• Electrolytes, blood studies: potassium, sodium, chloride, carbon dioxide, CBC,
serum glucose, LE prep, ANA titer before, during treatment; assess for fever, joint
pain, rash, sore throat (lupuslike symptoms); notify prescriber
• Number of refills to determine compliance
• Weight daily, I&O, edema in feet, legs daily, skin turgor, dryness of mucous
membranes for hydration status
• For renal disease: dosage and administration are altered in reduced CCr, dialysis
• Crackles, dyspnea, orthopnea
• IV site for extravasation, rate
• Mental status: affect, mood, behavior, anxiety; check for personality changes •
Beers: use with caution in older adults; may exacerbate syncope in those with a
history of syncope
• Pregnancy/breastfeeding: use only if benefits outweigh fetal risk; 3rd-trimester toxicity has occurred; use caution in breastfeeding
Evaluate:
• Therapeutic response: decreased B/P Teach patient/family:
• To take with food to increase bioavailability (PO)
• To avoid OTC, herbals, supplements unless directed by prescriber
• To notify prescriber if chest pain, se- vere fatigue, fever, muscle or joint pain,
rash, sore throat; tingling, pain in hands, feet, pyridoxine can be used
• To rise slowly to prevent orthostatic hypotension
• That follow-up will be needed; to comply with other requirements, such as
exercise, weight loss, avoidance of smoking
• To notify providers of product use prior to surgery
• To avoid driving or other hazardous activities until response is known;
drowsiness, dizziness may occur
• To weigh 2× per wk and check lower extremities for swelling
• To take as prescribed, not to skip or double doses, to take at the same time of the
day, if dose is missed, take when remembered, do not discontinue abruptly
• To notify prescriber if pregnancy is suspected or planned or if breastfeeding
TREATMENT OF OVERDOSE:
Administer vasopressors, volume expanders for shock; if PO, lavage if recently
ingested, digitalization
Calcium gluconate
SIDE EFFECTS
CV: Hypotension, bradycardia, dysrhyth- mias; cardiac arrest (IV)
GI: Vomiting, nausea, constipation
GU: Hypercalciuria, renal calculi
META: Hypercalcemia
INTEG: Pain, burning at IV site, severe venous thrombosis, necrosis,
extravasation
PHARMACOKINETICS
Crosses placenta, enters breast milk, excreted via urine and feces, half-life
unknown, protein binding 40%-50% PO: Onset, peak, duration unknown,
absorption from GI tract
IV: Onset immediate, duration 1⁄22 hr
INTERACTIONS
Increase: milk-alkali syndrome—antacids Increase: dysrhythmias—digoxin
glycosides Increase: toxicity—verapamil, diltiaZEM Increase: hypercalcemia—
thiazide diuretics Decrease: absorption of fluoroquinolones, tetracyclines, iron
salts, phenytoin, thyroid hormones when calcium is taken PO Decrease: effects of
atenolol—verapamil Drug/Herb
Increase: action/side effects—lily of the valley, pheasant’s eye, shark cartilage,
squill
Drug/Food
Decrease: calcium absorption—cereal, spinach
Drug/Lab Test
Increase: calcium
NURSING CONSIDERATIONS
Assess:
• ECG for decreased QT and T wave inversion: hypercalcemia, product should be
reduced or discontinued, consider cardiac monitoring
• Calcium levels during treatment (8.5 11.5 g/dL is normal level); urine calcium if
hypercalciuria occurs
• Cardiac status: rate, rhythm, CVP (PWP, PAWP if being monitored directly)
• Hypocalcemia: muscle twitching, par- esthesia, dysrhythmias, laryngospasm
• Digoxin therapy: monitor frequently; an increase in calcium increases digoxin
toxicity risk
• Store at room temperature
Evaluate:
• Therapeutic response: decreased twitching, paresthesias, muscle spasms; absence
of tremors, seizures, dysrhythmias, dyspnea, laryngospasm; negative Chvostek’s
sign, negative Trousseau’s sign
Teach patient/family:
• To increase fluids to 2 L unless contraindicated; to add bulk to diet for
constipation; to notify prescriber of constipation
• Not to switch antacids unless directed by prescriber; not to use as antacid for >2
wk without approval by prescriber
• That therapeutic dose recommendations are figured as elemental calcium
• To avoid excessive use of alcohol, caffeine, tobacco