Anticoagulants Oral Parenteral Substances to Avoid with ... · Parenteral Dalteparin (Fragmin) Enoxaparin (Lovenox) Heparin sodium Substances to Avoid with Anticoagulants Allopurinol

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Anticoagulants

Anticoagulants

Oral

Warfarin sodium (Coumadin) Dabigatran etexilate mesylate (Pradaxa) Rivaroxaban (Xarelto)

Parenteral

Dalteparin (Fragmin) Enoxaparin (Lovenox) Heparin sodium S u b s t a n c e s t o A v o i d w i t h A n t i c o a g u l a n t s

Allopurinol (Zyloprim) Cimetidine (Tagamet) Corticosteroids Gingko and ginseng (herbs) Green leafy vegetables and foods high in vitamin K Nonsteroidal anti-inflammatory drugs Oral hypoglycemic agents Phenytoin (Dilantin) Salicylates Sulfonamides

1. Anticoagulants prevent the extension and formation of clots by inhibiting factors in the clotting cascade and decreasing blood coagulability.

2. Anticoagulants are administered when there is evidence or likelihood of clot formation: myocardial infarction, unstable angina, atrial fibrillation, deep vein thrombosis, pulmonary embolism, and the presence of mechanical heart valves.

3. Anticoagulants are contraindicated with active bleeding (except for disseminated intravascular coagulation), bleeding disorders or blood dyscrasias, ulcers, liver and kidney disease, and hemorrhagic brain injuries.

B. Side/adverse effects 1. Hemorrhage 2. Hematuria 3. Epistaxis 4. Ecchymosis 5. Bleeding gums 6. Thrombocytopenia 7. Hypotension

C. Heparin sodium 1. Description

a. Heparin prevents thrombin from converting fibrinogen to fibrin. b. Heparin prevents thromboembolism. c. The therapeutic dose does not dissolve clots but prevents new thrombus

formation. 2. Blood levels

a. The normal activated partial thromboplastin time (aPTT) is 20 to 36 seconds in most laboratories but may be as high as 40 seconds.

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b. To maintain a therapeutic level of anticoagulation when the client is receiving a continuous infusion of heparin, the aPTT should be 1.5 to 2.5 times the normal value.

c. Activated partial thromboplastin time therapy should be measured every 4 to 6 hours during initial continuous infusion therapy and then daily.

d. If the aPTT is too long (longer than 80 seconds), the dosage should be lowered.

e. If aPTT is too short (less than 60 seconds), the dosage should be increased. 3. Interventions

a. Monitor aPTT. b. Monitor platelet count. c. Observe for bleeding gums, bruises, nosebleeds, hematuria, hematemesis,

occult blood in the stool, and petechiae. d. When heparin is administered subcutaneously, it is injected into the abdomen

with a ⅝-inch needle (25 to 28 gauge) at a 90-degree angle; the injection site should not be aspirated or rubbed

e. Continuous infusions must be delivered through an infusion pump and the infusion pump should be pre-programmed to ensure precise rate of delivery.

f. Reinforce instructions to the client regarding measures to prevent bleeding. g. The antidote to heparin is protamine sulfate.

D. Enoxaparin (Lovenox)—low-molecular-weight heparin 1. Description: Enoxaparin has the same mechanism of action and use as heparin but is

not interchangeable. It has a longer half-life than heparin. 2. Interventions

a. Administered by subcutaneous injection only to the recumbent client in the anterolateral or posterolateral abdominal wall. Do not expel the air bubble from the prefilled syringe or aspirate during injection.

b. Monitor the same laboratory values as for heparin and observe for bleeding. c. The antidote to enoxaparin is protamine sulfate.

E. Warfarin sodium (Coumadin, Jantoven) 1. Description

a. Warfarin suppresses coagulation by acting as an antagonist of vitamin K by inhibiting four dependent clotting factors (X, IX, VII, and II).

b. Warfarin prolongs clotting time and is monitored by the prothrombin time (PT) and the international normalized ratio (INR).

c. It is used for long-term anticoagulation and is used mainly to prevent thromboembolic conditions such as thrombophlebitis, pulmonary embolism, and embolism formation caused by atrial fibrillation, thrombosis, myocardial infarction, or heart valve damage; it is also used in clients who have had a heart valve replaced with a mechanical heart valve.

2. Blood levels a. The normal PT is 9.6 to 11.8 seconds. b. Warfarin sodium prolongs the PT. The therapeutic range is 1.5 to 2 times the

control value. 3. International normalized ratio (INR)

a. The normal INR is 1.3 to 2.0. b. The INR is determined by multiplying the observed PT ratio (the ratio of the

client’s PT to a control PT) by a correction factor specific to a particular thromboplastin preparation used in the testing.

c. The treatment goal is to raise the INR to an appropriate value.

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d. An INR of 2 to 3 is appropriate for most clients, although for some clients the target INR is 3 to 4.5, such as for clients with mechanical heart valves.

e. If the INR is below the recommended range, warfarin sodium should be increased.

f. If the INR is above the recommended range, warfarin sodium should be reduced.

4. Interventions a. Monitor PT and INR. b. Observe for bleeding gums, bruises, nosebleeds, hematuria, hematemesis,

occult blood in the stool, and petechiae. c. Reinforce instructions to the client regarding measures to prevent bleeding. d. The antidote for warfarin is phytonadione (vitamin K).

F. Dabigatran etexilate (Pradaxa) 1. Description

a. Dabigatran etexilate works through direct inhibition of thrombin, preventing the conversion of fibrinogen into fibrin and activation of factor XIII.

b. Its only approved use is for clot prevention associated with nonvalvular atrial fibrillation.

c. It is administered in a fixed dose twice daily. 2. Blood levels: No blood testing is required. 3. Interventions: Observe for bleeding gums, bruises, nosebleeds, hematuria,

hematemesis, occult blood in the stool, and petechiae. G. Rivaroxaban (Xarelto)

1. Description a. Rivaroxaban works through inhibition of factor Xa. b. Approved uses include clot prevention associated with nonvalvular atrial

fibrillation and after knee and hip replacement 2. Blood levels: No blood testing is required. 3. Interventions

a. Observe for bleeding gums, bruises, nosebleeds, hematuria, hematemesis, occult blood in the stool, and petechiae.

b. No antidote is available.

Thrombolytic Medications T h r o m b o l y t i c M e d i c a t i o n s

Alteplase (Activase, tPA) Reteplase (Retavase) Tenecteplase (TNKase)

A. Description 1. Thrombolytic medications activate plasminogen. Plasminogen generates plasmin (the

enzyme that dissolves clots). 2. Thrombolytic medications are used early in the course of myocardial infarction (within

4 to 6 hours of the onset of the infarct) to restore blood flow, limit myocardial damage, preserve left ventricular function, and prevent death.

3. Thrombolytics are also used in arterial thrombosis, deep vein thrombosis, occluded shunts or catheters, and pulmonary emboli.

B. Contraindications 1. Active internal bleeding 2. History of hemorrhagic brain attack (stroke) 3. Intracranial problems, including trauma 4. Intracranial or intraspinal surgery within the previous 2 months

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5. History of thoracic, pelvic, or abdominal surgery in the previous 10 days 6. History of hepatic or renal disease 7. Uncontrolled hypertension 8. Recently required, prolonged cardiopulmonary resuscitation 9. Known allergy to the specific product or any of its preservatives

C. Side/adverse effects 1. Bleeding 2. Dysrhythmias 3. Allergic reactions

D. Interventions 1. Determine aPTT, PT, fibrinogen level, hematocrit, and platelet count. 2. Monitor the vital signs. 3. Check the pulses. 4. Monitor for bleeding. 5. Monitor all excretions for occult blood. 6. Monitor for neurological changes such as slurred speech, lethargy, confusion, and

hemiparesis. 7. Monitor for hypotension and tachycardia. 8. Injections are avoided if possible. 9. Direct pressure is applied over a puncture site for 20 to 30 minutes.

10. The client is handled as little as possible when moving. 11. Reinforce instructions to the client to use an electric razor for shaving and brush teeth

gently. 12. The medication is withheld if bleeding develops, and the health care provider (HCP) is

notified. 13. Antidote

a. Aminocaproic acid (Amicar) is the antidote b. Used only in acute, life-threatening conditions

Bleeding is the primary concern for a client taking an anticoagulant, thrombolytic, or antiplatelet

medication.

Antiplatelet Medications A n t i p l a t e l e t M e d i c a t i o n s

Oral

Aspirin (acetylsalicylic acid, ASA) Cilostazol (Pletal) Clopidogrel (Plavix) Dipyridamole (Persantine) Dipyridamole; aspirin (Aggrenox) Ticlopidine (Ticlid)

A. Description 1. Antiplatelet medications inhibit the aggregation of platelets in the clotting process,

thereby prolonging the bleeding time. 2. Antiplatelet medications may be used with anticoagulants. 3. Used in the prophylaxis of long-term complications after myocardial infarction,

coronary revascularization, stents, and brain attacks (stroke). 4. These medications are contraindicated in those with bleeding disorders and known

sensitivity. B. Side/adverse effects

1. Gastrointestinal bleeding

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2. Bruising 3. Hematuria 4. Tarry stools

C. Interventions 1. Sensitivity is determined before administration. 2. Monitor vital signs. 3. The client is instructed to take medication with food if gastrointestinal upset occurs. 4. Monitor the bleeding time. 5. Monitor for side/adverse effects related to bleeding. 6. Reinforce instructions to the client in the use of the medication. 7. Reinforce instructions to the client to monitor for side/adverse effects related to

bleeding and the measures to prevent bleeding.

Cardiac Glycosides A. Digoxin (Lanoxin) B. Description

1. Cardiac glycosides inhibit the sodium-potassium pump, thus increasing intracellular calcium, which causes the heart muscle fibers to contract more efficiently.

2. Cardiac glycosides produce a positive inotropic action, which increases the force of myocardial contractions.

3. Cardiac glycosides produce a negative chronotropic action, which slows the heart rate. 4. Cardiac glycosides produce a negative dromotropic action that slows conduction

velocity through the atrioventricular (AV) node. 5. The increase in myocardial contractility increases cardiac, peripheral, and kidney

function by increasing cardiac output, decreasing preload, improving blood flow to the periphery and kidneys, decreasing edema, and increasing fluid excretion. As a result, fluid retention in the lungs and extremities is decreased.

6. Cardiac glycosides are used for heart failure and cardiogenic shock, atrial tachycardia, atrial fibrillation, and atrial flutter; used less frequently for rate control in atrial dysrhythmias (β-blockers and calcium channel blockers are used more often)

7. These medications are contraindicated in those with ventricular dysrhythmias and second- or third-degree heart block and should be used with caution in clients with renal disease, hypothyroidism, and hypokalemia.

C. Side/adverse effects and toxic effects 1. Anorexia, nausea, vomiting, diarrhea 2. Headache 3. Visual disturbances: Diplopia, blurred vision, yellow-green halos, photophobia 4. Drowsiness 5. Bradycardia 6. Fatigue, weakness

Early signs of digoxin toxicity present as gastrointestinal manifestations (anorexia, nausea,

vomiting, diarrhea). Then heart rate abnormalities and visual disturbances appear.

D. Interventions 1. Monitor for toxicity as evidenced by anorexia, nausea, vomiting, visual disturbances,

confusion, bradycardia, heart block, premature ventricular contractions, and tachydysrhythmias.

2. Monitor serum digoxin level, electrolyte levels, and renal function test results. 3. The therapeutic digoxin range is 0.5 to 2 ng/mL. Levels greater than 2 ng/mL are toxic. 4. An increased risk of toxicity exists in clients with hypercalcemia, hypokalemia,

hypomagnesemia, or hypothyroidism.

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5. Monitor the potassium level. If hypokalemia occurs (potassium lower than 3.5 mEq/L), notify the HCP.

6. Reinforce instructions to the client to avoid over-the-counter medications. 7. Monitor the client taking a potassium-wasting diuretic or corticosteroids closely for

hypokalemia because the hypokalemia can cause digoxin toxicity. 8. Note that older clients are more sensitive to digoxin toxicity. 9. Advise the client to eat foods high in potassium, such as fresh and dried fruits, fruit

juices, vegetables, and potatoes. 10. Monitor the apical pulse for 1 full minute. 11. If the apical pulse rate is lower than 60 beats/min, the medication should be withheld

and the HCP notified. 12. Reinforce teaching the client how to measure the pulse. 13. Reinforce teaching the client to notify the HCP if the pulse rate is lower than 60 or

higher than 100 beats/min. 14. Reinforce teaching the client the signs and symptoms of toxicity. 15. Antidote: Digoxin immune Fab (Digibind) is used in extreme toxicity.

Antihypertensive Medications Thiazide diuretics T h i a z i d e a n d T h i a z i d e - L i k e D i u r e t i c s

Chlorothiazide (Diuril) Chlorthalidone (Thalitone) Hydrochlorothiazide Indapamide Methyclothiazide Metolazone (Zaroxolyn) Polythiazide (Renese)

1. Description a. Thiazide diuretics increase sodium and water excretion by inhibiting sodium

reabsorption in the distal tubule of the kidney. b. Used for hypertension and peripheral edema c. Not effective for immediate diuresis d. Used in clients with normal renal function (contraindicated in clients with

renal failure) e. Thiazide diuretics should be used with caution in the client taking lithium

because lithium toxicity can occur in the client taking digoxin, corticosteroids, or hypoglycemic medications.

2. Side/adverse effects a. Hypercalcemia, hyperglycemia, hyperuricemia b. Hypokalemia, hyponatremia c. Hypovolemia d. Hypotension e. Headaches f. Nausea, vomiting g. Constipation h. Rashes i. Photosensitivity j. Blood dyscrasias

3. Interventions a. Monitor vital signs. b. Monitor the weight.

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c. Monitor the urine output. d. Monitor electrolyte, glucose, calcium, blood urea nitrogen (BUN), creatinine,

and uric acid levels. e. Check peripheral extremities for edema. f. Reinforce instructions to the client to take the medication in the morning to

avoid nocturia and sleep interruption. g. Reinforce instructions to the client in how to record the blood pressure (BP). h. Reinforce instructions to the client to eat foods high in potassium. i. Reinforce instructions to the client in how to take potassium supplements if

prescribed. j. Reinforce instructions to the client to take medication with food to avoid

gastrointestinal upset. k. Reinforce instructions to the client to change positions slowly to prevent

orthostatic hypotension. l. Reinforce instructions to the client to use sunscreen when in direct sunlight

because of increased photosensitivity. m. Reinforce instructions to the client with diabetes mellitus to have the blood

glucose level checked periodically. Loop diuretics L o o p D i u r e t i c s

Furosemide (Lasix) Torsemide (Demadex)

1. Description a. Loop diuretics inhibit sodium and chloride reabsorption from the loop of

Henle and the distal tubule. b. Loop diuretics have little effect on the blood glucose level; however, they

cause depletion of water and electrolytes, increased uric acid levels, and the excretion of calcium.

c. Loop diuretics are more potent than thiazide diuretics, causing rapid diuresis and thus decreasing vascular fluid volume, cardiac output, and BP.

d. Loop diuretics are used for hypertension, pulmonary edema, edema associated with heart failure, hypercalcemia, and renal disease.

e. Use loop diuretics with caution in the client taking digoxin or lithium and the client on aminoglycosides, anticoagulants, corticosteroids, or amphotericin B.

2. Side/adverse effects a. Hypokalemia, hyponatremia, hypocalcemia, hypomagnesemia b. Thrombocytopenia c. Hyperuricemia d. Orthostatic hypotension e. Skin disturbances f. Ototoxicity and deafness g. Thiamine deficiency h. Dehydration

3. Interventions a. Monitor vital signs. b. Monitor the weight. c. Monitor the urine output. d. Monitor electrolyte, calcium, magnesium, BUN, creatinine, and uric acid

levels. e. Check the peripheral extremities for edema.

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f. Monitor for signs of digoxin or lithium toxicity if the client is on these medications.

g. Reinforce instructions to the client to take the medication in the morning to avoid nocturia and sleep interruption.

h. Reinforce instructions to the client in how to record the BP. i. Reinforce instructions to the client to eat foods high in potassium. j. Reinforce instructions to the client in how to take potassium supplements if

prescribed. k. Reinforce instructions to the client to take medication with food to avoid

gastrointestinal upset. l. Reinforce instructions to the client to change positions slowly to prevent

orthostatic hypotension. m. IV furosemide (Lasix) is administered slowly because hearing loss can occur if

injected rapidly.

Potassium-retaining diuretics P o t a s s i u m - R e t a i n i n g D i u r e t i c s

Amiloride hydrochloride; hydrochlorothiazide Spironolactone (Aldactone) Spironolactone; hydrochlorothiazide (Aldactazide) Triamterene (Dyrenium)

1. Description a. Potassium-retaining diuretics act on the distal tubule to promote sodium and

water excretion and potassium retention. b. Used for edema and hypertension, to increase urine output, and to treat fluid

retention and overload associated with heart failure, ascites resulting from cirrhosis or nephrotic syndrome, and diuretic-induced hypokalemia.

c. Potassium-retaining diuretics are contraindicated in severe kidney or hepatic disease and severe hyperkalemia.

d. Potassium-retaining diuretics should be used with caution in the client with diabetes mellitus, taking antihypertensives or lithium, taking angiotensin-converting enzyme inhibitors or potassium supplements because hyperkalemia can result.

The primary concern with administering potassium-retaining diuretics is hyperkalemia.

2. Side/adverse effects a. Hyperkalemia b. Nausea, vomiting, diarrhea c. Rash d. Dizziness, weakness e. Headache f. Dry mouth g. Photosensitivity h. Anemia i. Thrombocytopenia

3. Interventions a. Monitor vital signs. b. Monitor urine output. c. Monitor for signs and symptoms of hyperkalemia such as nausea, diarrhea,

abdominal cramps, tachycardia followed by bradycardia, tall peaked T wave on the electrocardiogram, and oliguria.

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d. Monitor for a potassium level greater than 5.1 mEq/L, which indicates hyperkalemia.

e. Reinforce instructions to the client to avoid foods high in potassium. f. Reinforce instructions to the client to avoid exposure to direct sunlight. g. Reinforce instructions to the client to monitor for signs of hyperkalemia. h. Reinforce instructions to the client to avoid salt substitutes because they

contain potassium. i. Reinforce instructions to the client to take with or after meals to decrease

gastrointestinal irritation.

Peripherally Acting α-Adrenergic Blockers P e r i p h e r a l l y A c t i n g α - A d r e n e r g i c B l o c k e r s

Doxazosin (Cardura) Prazosin (Minipress) Terazosin (Hytrin)

A. Description 1. These medications decrease sympathetic vasoconstriction by reducing the effects of

norepinephrine at peripheral nerve endings, resulting in vasodilation and decreased BP.

2. These medications are used to maintain renal blood flow. 3. These medications are used to treat hypertension.

B. Side/adverse effects 1. Orthostatic hypotension 2. Reflex tachycardia 3. Sodium and water retention 4. Gastrointestinal disturbances 5. Nausea 6. Drowsiness 7. Nasal congestion 8. Edema 9. Weight gain

C. Interventions 1. Monitor vital signs. 2. Monitor for fluid retention and edema. 3. Reinforce instructions to the client to change positions slowly to prevent orthostatic

hypotension. 4. Reinforce instructions to the client in how to monitor the BP. 5. Reinforce instructions to the client to monitor for edema. 6. Reinforce instructions to the client to decrease salt intake. 7. Reinforce instructions to the client to avoid over-the-counter medications.

Centrally Acting Sympatholytics (Adrenergic Blockers) C e n t r a l l y A c t i n g S y m p a t h o l y t i c s

Clonidine (Catapres) Methyldopa

A. Description 1. Centrally acting sympatholytics stimulate alpha receptors in the central nervous

system to inhibit vasoconstriction, thus reducing peripheral resistance. 2. Used to treat hypertension 3. Contraindicated in impaired liver function

B. Side/adverse effects 1. Sodium and water retention

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2. Drowsiness, dizziness 3. Dry mouth 4. Bradycardia 5. Edema 6. Impotence 7. Hypotension 8. Depression

C. Interventions 1. Monitor vital signs. 2. Reinforce instructions to the client not to discontinue medication because abrupt

withdrawal can cause severe rebound hypertension. 3. Monitor liver function tests.

Angiotensin-Converting Enzyme (ACE) Inhibitors and Angiotensin II Receptor Blockers (ARBs A n g i o t e n s i n - C o n v e r t i n g E n z y m e I n h i b i t o r s a n d A n g i o t e n s i n R e c e p t o r B l o c k e r s

Angiotensin-Converting Enzyme Inhibitors

Benazepril (Lotensin) Captopril (Capoten) Enalapril (Vasotec) Lisinopril (Prinivil, Zestril) Quinapril (Accupril) Ramipril (Altace)

Angiotensin II Receptor Blockers

Irbesartan (Avapro) Losartan (Cozaar) Valsartan (Diovan)

A. Description 1. ACE inhibitors prevent peripheral vasoconstriction by blocking conversion of

angiotensin I to angiotensin II (AII). 2. ARBs prevent peripheral vasoconstriction and secretion of aldosterone and block the

binding of AII to type 1 AII receptors. 3. These medications are used to treat hypertension and heart failure. ACE inhibitors are

also administered for their cardioprotective effect after myocardial infarction. 4. Use with potassium supplements and potassium-retaining diuretics is avoided.

B. Side/adverse effects 1. Nausea, vomiting, diarrhea 2. Persistent dry cough (ACE inhibitors only) 3. Hypotension 4. Hyperkalemia 5. Tachycardia 6. Headache 7. Dizziness, fatigue 8. Insomnia 9. Hypoglycemic reaction in the client with diabetes mellitus

10. Bruising, petechiae, bleeding 11. Diminished taste (ACE inhibitors)

A persistent dry cough is a common complaint for those taking an ACE inhibitor. The client is

instructed to contact the HCP if this side effect occurs and persists.

C. Interventions

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1. Monitor vital signs. 2. Monitor white blood cells, and protein, albumin, BUN, creatinine, and potassium

levels. 3. Monitor for hypoglycemic reactions in the client with diabetes mellitus. 4. Reinforce instructions to the client to take captopril (Capoten) 20 to 60 minutes

before a meal. 5. Monitor for bruising, petechiae, or bleeding with captopril. 6. Reinforce instructions to the client not to discontinue medications because rebound

hypertension can occur. 7. Reinforce instructions to the client not to take over-the-counter medications. 8. Reinforce instructions to the client in how to take the BP. 9. Reinforce instructions to the client that if dizziness or any other side/adverse effects

occur and persist to notify the HCP. 10. Reinforce instructions to the client that the taste of food may be diminished during

the first month of therapy. 11. Reinforce instructions to the client to report the side effect of angioedema

immediately to the HCP. Antianginal Medications

Antianginal Medications (Organic Nitrates)

Amyl nitrate inhalant Isosorbide dinitrate (Isordil, Dilitrate-SR) Isosorbide mononitrate (Imdur, Monoket) Nitroglycerin, sublingual (Nitrostat) Nitroglycerin, translingual (Nitrolingual pumpspray) Nitroglycerin, transdermal patches (Minitran, Nitro-Dur) Nitroglycerin ointment Intravenous nitroglycerin

A. Nitrates (see Priority Nursing Actions) P r i o r i t y n u r s i n g a c t i o n s !

Actions to Take If a Hospitalized Client with Cardiac Disease Complains of Chest Pain

1. The client is quickly assessed, specifically characteristics of pain, heart rate and rhythm, and blood pressure (BP).

2. A nitroglycerin tablet is administered. 3. The client should not be left alone. 4. The client is reassessed in 5 minutes. 5. Another nitroglycerin tablet is administered if pain is not relieved and the BP is stable. 6. The client is reassessed in 5 minutes. 7. A third nitroglycerin tablet is administered if pain is not relieved and the BP is stable. 8. The client is reassessed in 5 minutes. The HCP is contacted if the third nitroglycerin tablet does not

relieve the pain. 9. The event, actions taken, and the client’s response to treatment are documented.

The usual guidelines for administering nitroglycerin tablets for chest pain include administering one tablet every 5 minutes PRN for chest pain, for a total dose of three tablets. If the client does not obtain relief after taking a third dose of nitroglycerin, the HCP is notified. Before administering the first dose of nitroglycerin, the nurse quickly assesses the client, specifically the characteristics of the pain, the heart rate and rhythm, and blood pressure (BP). The nurse always stays with the client during the event to provide reassurance and relieve anxiety. Additionally, the nurse must be present if a life-threatening situation develops. The nurse assesses the client before administering each subsequent dose of nitroglycerin and pays particular attention to the BP because nitroglycerin causes hypotension. The nurse must lower the head of the bed and contact the HCP before administering another nitroglycerin if

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hypotension occurs. Agency protocols for this type of event should also be followed. The nurse documents the event, actions taken, and the client’s response to treatment.

1. Description a. Nitrates produce vasodilation. b. Nitrates decrease preload and afterload and reduce myocardial oxygen

consumption. c. Contraindicated in the client with significant hypotension, increased

intracranial pressure, severe anemia, and in those taking medication to treat erectile dysfunction (because of the risk for severe hypotension).

d. Should be used with caution with severe renal or hepatic disease e. Abrupt withdrawal of long-acting preparations is avoided to prevent the

rebound effect of severe pain from myocardial ischemia. 2. Side/adverse effects

a. Headache b. Orthostatic hypotension c. Dizziness, weakness d. Faintness e. Nausea, vomiting f. Flushing or pallor g. Confusion h. Rash i. Dry mouth j. Reflex tachycardia

3. Sublingual medications a. Monitor the vital signs. b. Offer sips of water before giving because dryness may inhibit medication

absorption. c. Reinforce instructions to the client to place under the tongue and leave until

fully dissolved. d. Reinforce instructions to the client not to swallow the medication. e. Reinforce instructions to the client to take 1 tablet for pain and to

immediately contact emergency medical services if pain is 713not relieved; in the hospitalized client, 1 tablet is administered every 5 minutes for a total of three doses and the health care provider is notified immediately if pain is not relieved following the three doses (the blood pressure is checked before each dose administration).

f. The client is informed that a stinging or burning sensation may indicate that the tablet is fresh.

g. Reinforce instructions to the client to store medication in a dark, tightly closed bottle.

h. Reinforce instructions to the client to take acetaminophen (Tylenol) for a headache.

4. Translingual medications (spray) a. The client is instructed to direct the spray against the oral mucosa. b. The client is instructed to avoid inhaling the spray.

5. Sustained-released medications: The client is instructed to swallow and not chew or crush the medication.

6. Transdermal patch a. The client is instructed to apply the patch to a hairless area, using a new patch

and different site each day. b. As prescribed, the client is instructed to remove the patch after 12 to 14

hours, allowing 10 to 12 “patch-free” hours each day to prevent tolerance.

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7. Topical ointments a. Reinforce instructions to the client to remove the ointment on the skin from

the previous dose. b. Reinforce instructions to the client to squeeze a ribbon of ointment of the

prescribed length onto the applicator paper. c. Reinforce instructions to the client to spread the ointment over a 2.5x3.5-inch

area and cover with plastic wrap, using either the chest, back, abdomen, upper arm, or anterior thigh (avoid hairy areas).

d. Reinforce instructions to the client to rotate sites and avoid touching the ointment when applying.

8. Patches and ointments a. Wear gloves when applying. b. Do not apply on the chest in the area of defibrillator-cardioverter pads/paddle

placement because skin burns can result if the paddles need to be used.

Instruct the client using nitroglycerin tablets to check the expiration date on the medication bottle

because expiration may occur within 6 months of obtaining the medication. The tablets will not

relieve the chest pain if they have expired.

β-Adrenergic Blockers

Nonselective (Block β1 and β2)

Carvedilol (Coreg) Labetalol (Trandate) Nadolol (Corgard) Nebivolol (Bystolic) Propranolol (Inderal LA) Sotalol (Betapace)

Cardioselective (Block β1)

Acebutolol (Sectral) Atenolol (Tenormin) Bisoprolol (Zebeta, Ziac) Metoprolol (Lopressor, Toprol-XL)

A. Description 1. β-Adrenergic blockers inhibit response to β-adrenergic stimulation, thus decreasing

cardiac output. 2. β-Adrenergic blockers block the release of catecholamines, epinephrine, and

norepinephrine, thus decreasing the heart rate and BP. 3. β-Adrenergic blockers decrease the workload of the heart and decrease oxygen

demands. 4. Used for angina, dysrhythmias, hypertension, migraine headaches, prevention of

myocardial infarction, and glaucoma. 5. β-Adrenergic blockers are contraindicated in the client with asthma, bradycardia,

heart failure (with exceptions), severe renal or hepatic disease, hyperthyroidism, or brain attack (stroke). Carvedilol, metoprolol, and bisoprolol have been approved for use in heart failure once the client has been stabilized with ACE inhibitor and diuretic therapy.

6. β-Adrenergic blockers should be used with caution in the client with diabetes mellitus because the medication may mask the symptoms of hypoglycemia.

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7. β-Adrenergic blockers should be used with caution in the client taking antihypertensive medications.

B. Side/adverse effects 1. Bradycardia 2. Bronchospasm 3. Hypotension 4. Weakness, fatigue 5. Nausea, vomiting 6. Dizziness 7. Hyperglycemia 8. Agranulocytosis 9. Behavioral or psychotic response

10. Depression 11. Nightmares

C. Interventions 1. Monitor the vital signs. 2. Withhold the medication if the pulse or BP is not within the prescribed parameters. 3. Monitor for signs of heart failure or worsening heart failure. 4. Check for respiratory distress and for signs of wheezing and dyspnea. 5. Reinforce instructions to the client to report dizziness, light-headedness, or nasal

congestion. 6. Reinforce instructions to the client not to stop the medication because rebound

hypertension, rebound tachycardia, or an anginal attack can occur. 7. Reinforce instructions to the client taking insulin that the β-adrenergic blocker can

mask early signs of hypoglycemia, such as tachycardia and nervousness. 8. Reinforce instructions to the client taking insulin to monitor the blood glucose level. 9. Reinforce instructions to the client in how to take pulse and BP.

10. Reinforce instructions to the client to change positions slowly to prevent orthostatic hypotension.

11. Reinforce instructions to the client to avoid over-the-counter medications, especially cold medications and nasal decongestants.

Calcium Channel Blockers C a l c i u m C h a n n e l B l o c k e r s

Amlodipine (Norvasc) Diltiazem (Cardizem, Dilacor XR, others) Felodipine (Plendil) Nicardipine (Cardene) Nifedipine (Adalat, Procardia) Nisoldipine (Sular) (Calan, Covera-HS, Verelan)

A. Description 1. Calcium channel blockers decrease cardiac contractility (negative inotropic effect by

relaxing smooth muscle) and the workload of the heart, thus decreasing the need for oxygen.

2. Calcium channel blockers promote vasodilation of the coronary and peripheral vessels. 3. Used for angina, dysrhythmias, or hypertension 4. Should be used with caution in the client with heart failure, bradycardia, or

atrioventricular block B. Side/adverse effects

1. Bradycardia 2. Hypotension 3. Reflex tachycardia as a result of hypotension

15

4. Headache 5. Dizziness, light-headedness 6. Fatigue 7. Peripheral edema 8. Constipation 9. Flushing of the skin

10. Changes in liver and kidney function C. Interventions

1. Monitor vital signs. 2. Monitor for signs of heart failure. 3. Monitor liver enzyme levels. 4. Monitor kidney function tests. 5. Reinforce instructions to the client not to discontinue the medication. 6. Reinforce instructions to the client in how to take a pulse. 7. Reinforce instructions to the client to notify the HCP if dizziness or fainting occurs. 8. Reinforce instructions to the client to not crush or chew sustained-release tablets.

Peripheral Vasodilators

P e r i p h e r a l V a s o d i l a t o r s

α-Adrenergic Blockers

Doxazosin (Cardura) Prazosin (Minipress) Terazosin (Hytrin)

Calcium Channel Blockers

Diltiazem (Cardizem, Dilacor XR, others) Nifedipine (Adalat, Procardia) Verapamil (Calan, Covera-HS, Verelan)

A. Description 1. Peripheral vasodilators decrease peripheral resistance by exerting a direct action on

the arteries or the arteries and the veins. 2. Peripheral vasodilators increase blood flow to the extremities and are used in

peripheral vascular disorders of venous and arterial vessels. 3. Peripheral vasodilators are most effective for disorders resulting from vasospasm

(Raynaud’s disease). 4. These medications may decrease some symptoms of cerebral vascular insufficiency.

B. Side/adverse effects 1. Light-headedness, dizziness 2. Orthostatic hypotension 3. Tachycardia 4. Palpitations 5. Flushing 6. Gastrointestinal distress

C. Interventions 1. Monitor the vital signs, especially the BP and heart rate. 2. Monitor for orthostatic hypotension and tachycardia. 3. Monitor for signs of inadequate blood flow to the extremities, such as pallor, feeling

cold, and pain. 4. Reinforce instructions to the client that it may take up to 3 months for a desired

therapeutic response. 5. The client is advised not to smoke because smoking increases vasospasm.

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6. Reinforce instructions to the client to avoid aspirin or aspirin-like compounds unless approved by the HCP.

7. Reinforce instructions to the client to take the medication with meals if gastrointestinal disturbances occur.

8. Reinforce instructions to the client to avoid alcohol because it may cause a hypotensive reaction.

9. The client is encouraged to change positions slowly to avoid orthostatic hypotension.

Vasodilators cause orthostatic hypotension. The client is instructed about safety measures when

taking these medications, such as the need to rise from a lying to a sitting or standing position

slowly.

Antilipemic Medications

A n t i l i p e m i c M e d i c a t i o n s

Bile Acid Sequestrants

Cholestyramine (Questran) Colestipol (Colestid)

HMG-CoA Reductase Inhibitors

Atorvastatin (Lipitor) Lovastatin (Mevacor) Pravastatin (Pravachol) Rosuvastatin (Crestor) Simvastatin (Zocor)

Other Antilipemic Medications

Ezetimibe (Zetia) Ezetimibe; simvastatin (Vytorin) Fenofibrate (Tricor) Gemfibrozil (Lopid) Nicotinic acid (Niacin) Sitagliptin; simvastatin (Juvisync)

A. Description 1. Antilipemic medications reduce serum levels of cholesterol, triglycerides, or low-

density lipoprotein. 2. When cholesterol, triglyceride, and low-density lipoprotein levels are elevated, the

client is at increased risk for coronary artery disease. 3. In many cases, diet alone will not lower blood lipid levels; therefore antilipemic

medications will be prescribed. B. Bile sequestrants

1. Description a. Bind with acids in the intestines, which prevents reabsorption of cholesterol b. Should not be used as the only therapy in clients with elevated triglyceride

levels because they may raise triglyceride levels. 2. Side/adverse effects

a. Constipation b. Gastrointestinal disturbances: Heartburn, nausea, belching, bloating

3. Interventions a. Cholestyramine (Questran) comes in a gritty powder that must be mixed

thoroughly in juice or water before administration.

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b. Monitor the client for early signs of peptic ulcer such as nausea and abdominal discomfort followed by abdominal pain and distention.

c. Reinforce instructions to the client that the medication must be taken with and followed by sufficient fluids.

C. HMG-CoA reductase inhibitors 1. Description

a. Lovastatin (Mevacor) is highly protein-bound and should not be administered with anticoagulants.

b. Lovastatin should not be administered with gemfibrozil (Lopid). c. Lovastatin is administered with caution to the client taking

immunosuppressive medications. 2. Side/adverse effects

a. Nausea b. Diarrhea or constipation c. Abdominal pain or cramps d. Flatulence e. Dizziness f. Headache g. Blurred vision h. Rash i. Pruritus j. Elevated liver enzyme levels k. Muscle cramps and fatigue

3. Interventions a. Monitor serum liver enzyme levels. b. Reinforce instructions to the client to receive an annual eye examination

because the medications can cause cataract formation. c. If lovastatin is not effective in lowering the lipid level after 3 months, it should

be discontinued.

The client who is taking an antilipemic medication is instructed to report any unexplained

muscular pain to the HCP immediately.

Other antilipemic medications 1. Description

a. Gemfibrozil should not be taken with anticoagulants because they compete for protein sites. If the client is taking an anticoagulant, the anticoagulant dose should be reduced during antilipemic therapy and the INR should be monitored closely.

b. Do not administer gemfibrozil with HMG-CoA reductase inhibitors because it increases the risk for myositis, myalgias, and rhabdomyolysis.

c. Fish oil supplements have been associated with a decreased risk for cardiovascular heart disease. Plant stanol and sterol esters and Cholestin have been associated with reducing cholesterol levels.

2. Interventions a. Monitor vital signs. b. Monitor the liver enzyme levels. c. Monitor the serum cholesterol and triglyceride levels. d. Reinforce instructions to the client to restrict intake of fats, cholesterol,

carbohydrates, and alcohol. e. Reinforce instructions to the client to follow an exercise program.

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f. Reinforce instructions to the client that it will take several weeks before the lipid level declines.

g. Reinforce instructions to the client to have an annual eye examination and report any changes in vision.

h. Reinforce instructions to the client with diabetes mellitus who is taking gemfibrozil to monitor blood glucose levels regularly.

i. Reinforce instructions to the client to increase fluid intake. j. Note that nicotinic acid has numerous side effects, including gastrointestinal

disturbances, flushing of the skin, elevated liver enzyme levels, hyperglycemia, and hyperuricemia.

k. Reinforce instructions to the client that aspirin or nonsteroidal anti-inflammatory drugs taken 30 minutes before may assist in reducing the side effect of cutaneous flushing from nicotinic acid.

l. Reinforce instructions to the client to take nicotinic acid with meals to reduce gastrointestinal discomfort.

Antiparkinsonian Medications

A. Description 1. Antiparkinsonian medications restore the balance of the neurotransmitters

acetylcholine and dopamine in the central nervous system (CNS), decreasing the signs and symptoms of Parkinson’s disease to maximize the client’s functional abilities.

2. These medications include the dopaminergics, which stimulate the dopamine receptors; the anticholinergics, which block the cholinergic receptors; and the catechol-O-methyltransferase inhibitors, which inhibit the metabolism of dopamine in the periphery.

B. Dopaminergic medications 1. Description

a. Dopaminergic medications stimulate the dopamine receptors and increase the amount of dopamine available in the CNS or enhance neurotransmission of dopamine.

b. Dopaminergic medications are contraindicated in clients with cardiac, renal, or psychiatric disorders.

Levodopa taken with a monoamine oxidase inhibitor antidepressant can cause a hypertensive

crisis.

M e d i c a t i o n s t o T r e a t P a r k i n s o n ’ s D i s e a s e

Medications Affecting the Amount of Dopamine

Amantadine Bromocriptine (Parlodel) Carbidopa; levodopa (Sinemet) Levodopa (Larodopa) Pramipexole (Mirapex) Ropinirole (Requip) Selegiline hydrochloride (Eldepryl)

Anticholinergics

Benztropine mesylate (Cogentin) Biperiden hydrochloride (Akineton)

Catechol O-Methyltransferase (COMT) Inhibitors

19

Carbidopa/levodopa/entacapone (Stalevo) Entacapone (Comtan) Tolcapone (Tasmar)

3. Side/adverse effects a. Dyskinesia b. Involuntary body movements c. Chest pain d. Nausea and vomiting e. Urinary retention f. Constipation g. Sleep disturbances, insomnia, or periods of sedation h. Orthostatic hypotension and dizziness i. Confusion j. Mood changes, especially depression k. Hallucinations l. Dry mouth

4. Interventions a. Monitor the vital signs. b. Determine the risk for injury. c. The client is instructed to take the medication with food if nausea or vomiting

occurs. d. Check for signs and symptoms of parkinsonism, such as rigidity, tremors,

akinesia and bradykinesia, a stooped forward posture, shuffling gait, and masked facies.

e. Monitor for signs of dyskinesia. f. The client is instructed to report side/adverse effects and symptoms of

dyskinesia. g. Monitor the client for improvement in signs and symptoms of parkinsonism

without the development of side/adverse effects from the medications. h. The client is instructed to change positions slowly to minimize orthostatic

hypotension. i. Reinforce instructions to the client to not discontinue the medication abruptly. j. Reinforce instructions to the client to avoid alcohol. k. The client is informed that urine or perspiration may be discolored and that

this is harmless but may stain clothing. l. The client with diabetes mellitus is advised that glucose testing should not be

done by urine testing because the results will not be reliable. m. Reinforce instructions to the client taking carbidopa-levodopa (Sinemet) to

divide the total daily prescribed protein intake among all meals of the day. High-protein diets interfere with medication availability to the CNS.

n. When administering levodopa, the client is instructed to avoid excessive vitamin B6 intake to prevent medication reactions.

C. Anticholinergic medications 1. Description

a. Anticholinergic medications block the cholinergic receptors in the CNS, thereby suppressing acetylcholine activity.

b. Anticholinergic medications reduce tremors and drooling but have a minimal effect on bradykinesia, rigidity, and balance abnormalities.

c. Anticholinergic medications are contraindicated in clients with glaucoma. d. The client with chronic obstructive lung disease can develop dry, thick mucus

secretions. 2. Medications-See List Above

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3. Side/adverse effects a. Blurred vision b. Dryness of the nose, mouth, throat, and respiratory secretions c. Increased pulse rate, palpitations, and dysrhythmias d. Constipation e. Urinary retention f. Restlessness, confusion, depression, and hallucinations g. Photophobia

4. Interventions a. Monitor the vital signs. b. Determine the risk for injury. c. Monitor the client for improvement in signs and symptoms. d. Check the client’s bowel and urinary function, and monitor for urinary

retention, constipation, and paralytic ileus. e. Monitor for involuntary movements. f. The client is encouraged to avoid alcohol, smoking, caffeine, and aspirin to

decrease gastric acidity. g. Reinforce instructions to the client to consult with the health care provider

(HCP) before taking any nonprescription medications. h. Reinforce instructions to the client to minimize dry mouth by increasing fluid

intake and using ice chips, hard candy, or gum. i. Reinforce instructions to the client to prevent constipation by increasing fluids

and fiber in the diet. j. Reinforce instructions to the client to use sunglasses in direct sunlight because

of possible photophobia. k. Reinforce instructions to the client to have routine eye examinations to assess

for intraocular pressure.

If an anticholinergic medication is discontinued abruptly, the signs and symptoms of

parkinsonism, such as rigidity, tremors, akinesia and bradykinesia, a stooped forward posture,

shuffling gait, and masked like faces may be intensified.

Anticonvulsant Medications Anticonvulsant Medications

A. Description

1. Anticonvulsant medications are used to depress abnormal neuronal discharges and prevent

the spread of seizures to adjacent neurons.

2. Anticonvulsant medications should be used with caution in clients taking anticoagulants,

aspirin, sulfonamides, cimetidine (Tagamet), and antipsychotic drugs.

3. Absorption is decreased with the use of antacids, calcium preparations, and antineoplastic

medications.

B. Interventions for clients on anticonvulsants

1. Initiate seizure precautions.

2. Monitor urinary output.

3. Monitor liver and renal function tests and medication blood serum levels

4. Monitor for signs of medication toxicity, which would include CNS depression, ataxia,

nausea, vomiting, drowsiness, dizziness, restlessness, and visual disturbances.

5. If a seizure occurs, monitor seizure activity, including location and duration.

6. Protect the client from hazards in the environment during a seizure.

C. Client education

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Cl i en t Ed u cat i on : An t i con vu l san t s ■ Take the prescribed medication in the prescribed dose and frequency.

■ Take anticonvulsants with food to decrease gastrointestinal irritation, but avoid milk and antacids, which

impair absorption.

■ If taking liquid medication, shake well before ingesting.

■ Do not discontinue the medications.

■ Avoid alcohol.

■ Avoid over-the-counter medications.

■ Wear a Medic-Alert bracelet.

■ Use caution when driving or performing activities that require alertness.

■ Maintain good oral hygiene, and use a soft toothbrush.

■ Maintain preventive dental checkups.

■ Maintain follow-up health care visits with periodic blood studies related to determining toxicity.

■ Monitor serum glucose levels (diabetes mellitus).

■ Urine may be a harmless pink-red or red-brown in color.

■ Report symptoms of sore throat, bruising, and nosebleeds, which may indicate a blood dyscrasia.

■ Inform the HCP if side/adverse effects occur, such as gingivitis, nystagmus, slurred speech, rash, or

dizziness.

D. Hydantoins: Ethotoin (Peganone), fosphenytoin (Cerebyx), phenytoin (Dilantin)

1. Hydantoins are used to treat partial and generalized tonic-clonic seizures.

2. Phenytoin (Dilantin) also is used to treat dysrhythmias.

3. Side/adverse effects

a. Gingival hyperplasia (reddened gums that bleed easily)

b. Slurred speech

c. Confusion

d. Sedation and drowsiness

e. Nausea and vomiting

f. Blurred vision and nystagmus

g. Headaches

h. Blood dyscrasias: Decreased platelet count and decreased white blood cell count

i. Elevated blood glucose level

j. Alopecia or hirsutism

k. Skin rash or pruritus

4. Interventions

a. Tube feedings may interfere with the absorption of the enteral form of phenytoin

and diminish the effectiveness of the medication; therefore, feedings should be

scheduled as far as possible from the time of phenytoin administration.

b. Monitor therapeutic serum levels to assess for toxicity.

c. Monitor for signs of toxicity.

d. Monitor for ataxia (staggering gait).

e. Reinforce instructions to the client to consult with the health care provider before

taking other medications to ensure compatibility with anticonvulsants.

Phenytoin decreases the effectiveness of some birth control pills and can have teratogenic effects if

taken during pregnancy.

E. Barbiturates: Amobarbital (Amytal), mephobarbital (Mebaral), phenobarbital (Luminal)

1. Barbiturates are used for tonic-clonic seizures and acute episodes of seizures caused by

status epilepticus.

2. Barbiturates also may be used as adjuncts to anesthesia.


22

a. Sedation, ataxia, and dizziness during initial treatment

b. Mood changes

c. Hypotension

d. Respiratory depression

e. Tolerance to the medication

F. Benzodiazepines: Clonazepam (Klonopin), clorazepate (Tranxene), diazepam (Valium), lorazepam

(Ativan), alprazolam (Xanax)

1. Benzodiazepines are used to treat absence seizures.

2. Diazepam (Valium), alprazolam (Xanax), and lorazepam (Ativan) are used to treat status

epilepticus, anxiety, and skeletal muscle spasms.

3. Clorazepate (Tranxene) is used as adjunctive therapy for partial seizures.


a. Sedation, drowsiness, dizziness, blurred vision

b. Bradycardia can occur when administered rapidly by the intravenous route.

c. Medication tolerance and drug dependency

d. Blood dyscrasias: Decreased platelet count and decreased white blood cell count

e. Hepatotoxicity

Flumazenil (Romazicon) reverses the effects of benzodiazepines. It should not be administered to

clients with increased intracranial pressure or status epilepticus who were treated with

benzodiazepines because these problems may recur with reversal.

G. Succinimides: Ethosuximide (Zarontin), methsuximide (Celontin)

1. Succinimides are used to treat absence seizures.


a. Anorexia, nausea, vomiting

b. Blood dyscrasias

H. Valproates: valproic acid (Depakene, Depacon), divalproex sodium (Depakote ER)

1. Valproates are used to treat tonic-clonic, partial and myoclonic seizures.


a. Transient nausea, vomiting, and indigestion

b. Sedation, drowsiness, and dizziness

c. Pancreatitis

d. Blood dyscrasias

e. Hepatotoxicity

I. Iminostilbenes

1. Iminostilbenes are used to treat seizure disorders that have not responded to other

anticonvulsants

2. Iminostilbenes are used to treat trigeminal neuralgia.


a. Drowsiness

b. Dizziness

c. Nausea and vomiting, dry mouth

d. Constipation or diarrhea

e. Rash

f. Visual abnormalities

g. Blood dyscrasias

h. Headache

Pituitary Medications

A. Description

1. The anterior pituitary gland secretes growth hormone (GH), thyroid-stimulating hormone

(TSH), adrenocorticotropic hormone (ACTH), prolactin, melanocyte-stimulating hormone

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(MSH), and gonadotropins (follicle-stimulating hormone [FSH] and luteinizing hormone

[LH]).

2. The posterior pituitary gland secretes antidiuretic hormone (vasopressin) and oxytocin.

B. Growth hormones and related medications (

G row t h H ormon e s an d Rel at ed Me d i cat i on s

Growth Hormones

Somatropin (Humatrope)

Mecasermin (Increlex)

Growth Hormone Receptor Antagonists

Octreotide acetate (Sandostatin)

Pegvisomant (Somavert)

1. Uses

a. Growth hormones are used to treat pediatric or adult growth hormone deficiency.

b. Growth hormone receptor antagonists are used to treat acromegaly.

c. Growth hormone releasing factor is used to evaluate anterior pituitary function.


a. May vary depending on the medication

b. Development of antibodies to growth hormone

c. Headache, muscle pain, weakness, vertigo

d. Diarrhea, nausea, abdominal discomfort

e. Mild hyperglycemia

f. Hypertension

g. Weight gain

h. Allergic reaction (rash, swelling), pain at injection site

i. Elevated aspartate aminotransferase (AST) and alanine aminotransferase (ALT)

3. Interventions

a. Check the child’s physical growth and compare growth with standards.

b. Recommend annual bone age determinations for children receiving growth

hormones.

c. Monitor vital signs, blood glucose levels, AST and ALT levels, and thyroid function

tests.

d. Reinforce teaching to the client and family about the clinical manifestations of

hyperglycemia and about other side/adverse effects of therapy and the importance

of follow-up regarding periodic blood tests.

Antidiuretic Hormones

A. Desmopressin acetate (DDVAP, Stimate, Minirin); vasopressin (Pitressin)

B. Description

1. Antidiuretic hormones enhance reabsorption of water in the kidneys, promoting an

antidiuretic effect and regulating fluid balance.

2. Antidiuretic hormones are used in diabetes insipidus.

C. Side/adverse effects

1. Flushing

2. Headache

3. Nausea and abdominal cramps

4. Water intoxication

5. Hypertension with water intoxication

6. Nasal congestion with nasal administration

D. Interventions

1. Monitor weight.

2. Monitor intake and output and urine osmolality.

3. Monitor electrolyte levels.

4. Monitor for signs of dehydration, indicating the need to increase the dosage.

24

5. Monitor for signs of water intoxication (drowsiness, listlessness, shortness of breath, and

headache), indicating need to decrease dosage.

6. Monitor blood pressure.

7. Reinforce instructions to the client in how to use the intranasal medication.

8. Reinforce instructions to the client to weigh himself or herself daily to identify weight gain.

9. Reinforce instructions to the client to report signs of water intoxication or symptoms of

headache or shortness of breath.

Thyroid Hormones

Th yroi d H or mon es Levothyroxine sodium (Synthroid, Levothroid, Levoxyl, Unithroid)

Liothyronine sodium (Cytomel, Triostat)

Liotrix (Thyrolar)

Thyroid (Armour Thyroid, Nature-Thyroid, Thyroid USP, Westhroid)

A. Description

1. Thyroid hormones control the metabolic rate of tissues and accelerate heat production and

oxygen consumption.

2. Thyroid hormones are used to replace the thyroid hormone deficit in conditions such

as hypothyroidism and myxedema coma.

3. Thyroid hormones enhance the action of oral anticoagulants, sympathomimetics, and

antidepressants and decrease the action of insulin, oral hypoglycemics, and digitalis

preparations; the action of thyroid hormones is decreased by phenytoin (Dilantin) and

carbamazepine (Tegretol).

4. Thyroid hormones should be given at least 4 hours apart from multivitamins, aluminum

hydroxide and magnesium hydroxide, simethicone, calcium carbonate, bile acid

sequestrants, iron, and sucralfate (Carafate) because these medications decrease the

absorption of thyroid replacements.

B. Side/adverse effects

1. Nausea and decreased appetite

2. Abdominal cramps and diarrhea

3. Weight loss

4. Nervousness and tremors

5. Insomnia

6. Sweating

7. Heat intolerance (mild, side effect; extreme, adverse effect)

8. Tachycardia, dysrhythmias, palpitations, chest pain

9. Hypertension

10. Headache

11. Toxicity:

Hyperthyroidism

C. Interventions

1. The client is assessed for a history of medications currently being taken.

2. Monitor vital signs.

3. Monitor weight.

4. Monitor triiodothyronine, thyroxine, and thyroid-stimulating hormone levels.

5. Reinforce instructions to the client to take the medication at the same time each day, in the

morning without food.

6. Reinforce instructions to the client in how to monitor the pulse rate.

7. Reinforce instructions to the client to avoid foods that can inhibit thyroid secretion, such as

strawberries, peaches, pears, cabbage, turnips, spinach, kale, Brussels sprouts, cauliflower,

radishes, and peas.

8. The client is advised to avoid over-the-counter medications.

9. Reinforce instructions to the client to wear a Medic-Alert bracelet.

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The client taking a thyroid hormone is instructed to report symptoms of hyperthyroidism, such as

tachycardia, chest pain, palpitations, and excessive sweating. These indicate signs of toxicity.

Corticosteroids (Glucocorticoids)

Cort i co st e roi d s : G l u coco rt i co i d s Betamethasone

Cortisone acetate

Dexamethasone

Hydrocortisone

Methylprednisolone

Prednisolone

Prednisone

Triamcinolone

A. Description

1. Glucocorticoids affect glucose, protein, and bone metabolism; alter the normal immune

response and suppress inflammation; and produce anti-inflammatory, antiallergic, and

antistress effects.

2. Glucocorticoids may be used as a replacement for adrenocortical insufficiency.


1. Hyperglycemia

2. Hypokalemia

3. Hypocalcemia, osteoporosis

4. Sodium and fluid retention

5. Weight gain

6. Mood swings

7. Moon face, buffalo hump, truncal obesity

8. Increased susceptibility to infection and masking of the signs and symptoms of infection

9. Cataracts

10. Hirsutism, acne, fragile skin, bruising

11. Growth retardation in children

12. Gastrointestinal (GI) irritation, peptic ulcer, pancreatitis

13. Seizures, psychosis

C. Contraindications and cautions

1. Contraindicated in clients with hypersensitivity, psychosis, and fungal infections

2. Should be used with caution in clients with diabetes mellitus

3. Used with extreme caution in clients with infections because they mask the signs and

symptoms of an infection

4. Increase the potency of medications taken concurrently, such as aspirin, and nonsteroidal

antiinflammatory drugs, thus increasing the risk of gastrointestinal bleeding and ulceration.

5. Use of potassium-wasting diuretics increases potassium loss, resulting in hypokalemia.

6. Dexamethasone decreases the effects of orally administered anticoagulants and antidiabetic

agents.

7. Barbiturates, phenytoin (Dilantin), and rifampin (Rifadin) decrease the effect of prednisone.

D. Interventions


2. Monitor serum electrolyte and blood glucose levels.

3. Monitor for hypokalemia and hyperglycemia.

4. Monitor intake and output, weight, and for edema.

5. Monitor for hypertension.

6. Check medical history for glaucoma, cataracts, peptic ulcer, mental health disorders, or

diabetes mellitus.

7. Monitor the older client for signs and symptoms of increased osteoporosis.

26

8. Check for changes in muscle strength.

9. Prepare a schedule for the client with information on short-term tapered doses.

10. The client is instructed that it is best to take medication in the early morning with food or

milk.

11. The client is advised to eat foods high in potassium.

12. The client is instructed to avoid individuals with respiratory infections.

13. The client is instructed to inform all HCPs of the medication regimen.

14. The client is instructed to report signs and symptoms of a medication overdose or Cushing’s

syndrome, including a moon face, puffy eyelids, edema in the feet, increased bruising,

dizziness, bleeding, and menstrual irregularities.

15. Note that the client may need additional doses during periods of stress, such as surgery.

16. The client is instructed not to stop the medication abruptly because abrupt withdrawal can

result in severe adrenal insufficiency.

17. The client is advised to consult with the HCP before receiving vaccinations.

18. The client is advised to wear a Medic-Alert bracelet.

Medications for Diabetes Mellitus

A. Insulin and oral hypoglycemic medications

1. Description

a. Insulin increases glucose transport into cells and promotes conversion of glucose to

glycogen, decreasing serum glucose levels.

b. Oral hypoglycemic agents stimulate the pancreas to produce more insulin, increase

the sensitivity of peripheral receptors to insulin, decrease hepatic glucose output,

or delay intestinal absorption of glucose, thus decreasing serum glucose levels.

2. Contraindications and concerns

a. Insulin is contraindicated in clients with hypersensitivity.

b. Oral hypoglycemic agents are contraindicated in type 1 diabetes mellitus.

c. β-Adrenergic blocking agents may mask signs and symptoms

of hypoglycemia associated with hypoglycemic medications.

d. Anticoagulants, chloramphenicol (Chloromycetin), salicylates, propranolol

(Inderal), monoamine oxidase inhibitors, pentamidine (Pentam 300, Nebupent),

and sulfonamides may cause hypoglycemia.

e. Corticosteroids, sympathomimetics, thiazide diuretics, phenytoin (Dilantin),

thyroid preparations, oral contraceptives, and estrogen compounds may cause

hyperglycemia.

f. Side/adverse effects of the sulfonylureas include gastrointestinal symptoms and

dermatological reactions; hypoglycemia can occur when an excessive dose is

administered or when meals are omitted or delayed, food intake is decreased, or

activity is increased.

Sulfonylureas can cause a disulfiram (Antabuse) type of reaction when alcohol is ingested.

Oral hypoglycemic medications

1. Prescribed for clients with type 2 diabetes mellitus

2. Sulfonylureas

S u l fon yl u reas an d N on su l fon yl u re as

Sulfonylureas

Glimepiride (Amaryl)

Glipizide (Glucotrol)

Glyburide (DiaBeta, Micronase)

Tolazamide (Tolinase)

Tolbutamide

27

Biguanide

Metformin (Glucophage)

Alpha Glucosidase Inhibitors

Acarbose (Precose)

Miglitol (Glyset)

Thiazolidinediones

Pioglitazone (Actos)

Rosiglitazone (Avandia)

Meglitinides

Repaglinide (Prandin)

Gliptins

Sitagliptin (Januvia)

Metformin and alogliptin (Kazano)

Metformin and linagliptin (Jentadueto)

Metformin and saxagliptin (Kombiglyze XR)

Metformin and sitagliptin (Janumet)

a. Sulfonylureas may be classified as first- or second-generation sulfonylureas.

b. Sulfonylureas stimulate the beta cells to produce more insulin.

3. Biguanides

a. May be used alone or in combination with a sulfonylurea

b. Suppresses hepatic production of glucose and increases insulin sensitivity

c. Side/adverse effects: Diarrhea (most common), lactic acidosis (most serious)

4. Alpha-glucosidase inhibitors

a. Delay absorption of ingested carbohydrates (sucrose and complex carbohydrates),

resulting in smaller increase in blood glucose level after meals

b. Do not increase insulin production

c. Can be given alone or in combination with sulfonylureas

d. Will not cause hypoglycemia when given alone

e. Given with first bite of meal

5. Thiazolidinediones

a. Insulin-sensitizing agents that lower blood glucose by decreasing hepatic glucose

production 585and improving target cell response to insulin

b. May cause liver toxicity

6. Meglitinides

a. Stimulate pancreatic insulin secretion

b. Quicker and shorter duration of action; therefore, less chance of hypoglycemia

because blood glucose-lowering effect wears off quickly

c. Very fast onset of action allows client to take the medication with meals and skip a

dose when a meal is skipped.

7. Interventions

a. The client’s knowledge of diabetes mellitus and the use of oral antidiabetic agents

are assessed.

b. A medication history regarding the medications that the client is taking currently is

obtained.

c. Monitor vital signs and blood glucose levels.

d. Reinforce instructions to the client to recognize the signs and symptoms of

hypoglycemia and hyperglycemia.

e. Reinforce instructions to the client to avoid over-the-counter medications unless

prescribed by the HCP.

f. Reinforce instructions to the client not to ingest alcohol with sulfonylureas.

28

g. Reinforce instructions to the client that insulin may be needed during stress,

surgery, or infection.

h. Reinforce instructions to the client in the necessity of compliance with prescribed

medication.

i. Reinforce instructions to the client in how to take each specific medication, such as

with the first bite of the meal for meglitinides and alpha-glucosidase inhibitors.

j. Reinforce instructions to the client to wear a Medic-Alert bracelet.

Metformin (Glucophage) may need to be withheld temporarily before and for 48 hours after any

radiologic study that involves the administration of intravenous contrast dye because of the risk of

contrast-induced nephropathy and lactic acidosis. The HCP needs to be consulted for specific

prescriptions.

Insulin

1. Insulin primarily acts in the liver, muscle, and adipose tissue by attaching to receptors on

cellular membranes and facilitating the passage of glucose, potassium, and magnesium.

2. Insulin is prescribed for clients with type 1 diabetes mellitus and type 2 diabetes mellitus in

clients whose blood glucose level is not controlled with oral hypoglycemic agents.

S t ori n g In su l i n ■ Avoid exposing insulin to extremes in temperature.

■ Insulin should not be frozen or kept in direct sunlight or a hot car.

■ Before injection, insulin should be at room temperature.

■ If a vial of insulin will be used up in 1 month, it may be kept at room temperature; otherwise, the vial should

be refrigerated.

Administering insulin

Insulin glargine (Lantus) and insulin detemir (Levemir) cannot be mixed with any other types of

insulin.

a. To prevent dosage errors, be certain that there is a match between the insulin

concentration noted on the vial and the calibration of units on the insulin syringe.

The usual concentration of insulin is U 100 (100 units/mL).

b. Most insulin syringes have a 27- to 29-gauge needle that is about ½ inch long.

c. Before use, swirl the insulin vial gently or rotate between palms to ensure that the

insulin and ingredients are mixed well; otherwise, an inaccurate dose will be

drawn; vigorously shaking the bottle will cause bubbles to form.

d. Premixed insulins (NPH and regular insulin; insulin aspart protamine and insulin

aspart) are available as 70/30 (most commonly used), and premixed insulin lispro

protamine and insulin lispro 75/25 and 50/50 are also available.

e. Inject air into the insulin bottle. (A vacuum makes it difficult to draw up the

insulin.)

f. When mixing insulins, draw up the shortest-acting insulin first.

29

g. Short-acting (i.e., regular, lispro, aspart, and glulisine) insulin may be mixed with

NPH.

h. Lispro insulin may be mixed with Humulin N.

i. Insulin aspart protamine (Novolog Mix 70/30) may be mixed with NPH insulin

only.

j. A mixed dose of insulin is administered within 5 to 15 minutes of preparation;

after 586this time, the short-acting insulin binds with the NPH insulin and its

action is reduced.

k. Aspiration after insertion of the needle is generally not recommended with self-

injection of insulin.

l. Insulin is administered at a 45- to 90-degree angle in clients with normal

subcutaneous mass and at a 45- to 60-degree angle in thin persons or those with a

decreased amount of subcutaneous mass.

Rapid- and short-acting insulins are the only types of insulin that can be administered intravenously.

D. Exenatide (Byetta)

1. A synthetic hormone classified as an incretin mimetic that is administered subcutaneously

30

2. Used for clients with type 2 diabetes mellitus (not recommended for clients taking insulin,

nor should clients be taken off of insulin and given exenatide)

3. Restores first-phase insulin response (first 10 minutes after food ingestion), lowers the

production of glucagon after meals, slows gastric emptying (which limits the rise in the

blood 587glucose level after a meal), reduces fasting and postprandial blood glucose levels,

and reduces caloric intake, resulting in weight loss

4. Packaged in premeasured doses (pen) that require refrigeration (cannot be frozen)

5. Administered as a subcutaneous injection in the thigh, abdomen, or upper arm within 60

minutes before morning and evening meals; not taken after meals; if a dose is missed, the

treatment regimen is resumed as prescribed with the next scheduled dose.

6. Can cause mild to moderate nausea that abates with use

E. Glucagon (also available as GlucaGen)

1. Hormone secreted by the alpha cells of the islets of Langerhans in the pancreas

2. Increases blood glucose level by stimulating glycogenolysis in the liver

3. Can be administered subcutaneously, intramuscularly, or intravenously

4. Used to treat insulin-induced hypoglycemia when the client is semiconscious or

unconscious and is unable to ingest liquids

5. The blood glucose level begins to increase within 5 to 20 minutes after administration.

6. The family is instructed in the procedure for administration.

Bronchodilators

A. Description

1. Sympathomimetic bronchodilators relax the smooth muscle of the bronchi and dilate the

airways of the respiratory tree, making air exchange and respiration easier for the client.

2. Methylxanthine bronchodilators stimulate the central nervous system and respiration, dilate

coronary and pulmonary vessels, cause diuresis, and relax smooth muscle.

3. Used to treat allergic rhinitis and sinusitis, acute bronchospasm, acute and chronic asthma,

bronchitis, chronic obstructive pulmonary disease, emphysema, and other restrictive

airway diseases.

4. Contraindicated in individuals with hypersensitivity, peptic ulcer disease, severe cardiac

disease and cardiac dysrhythmias, hyperthyroidism, or uncontrolled seizure disorders

5. Used with caution in clients with hypertension, diabetes mellitus, or narrow-angle

glaucoma

6. Theophylline increases the risk of digoxin toxicity and decreases the effects of lithium and

phenytoin (Dilantin).

7. If theophylline and a β2-adrenergic agonist are administered together, cardiac dysrhythmias

may result.

8. β-Blockers, cimetidine (Tagamet), and erythromycin increase the effects of theophylline.

9. Barbiturates and carbamazepine (Tegretol) decrease the effects of theophylline.


1. Palpitations and tachycardia

2. Dysrhythmias

3. Restlessness, nervousness, tremors

4. Anorexia, nausea, and vomiting

5. Headaches and dizziness

6. Hyperglycemia

7. Mouth dryness and throat irritation with inhalers

8. Tolerance and paradoxical bronchoconstriction with inhalers

C. Interventions

1. Monitor for restlessness and confusion.

2. Monitor vital signs and lung sounds.

3. Monitor for cardiac dysrhythmias.

31

4. Check for cough, wheezing, decreased breath sounds, and sputum production.

5. Provide adequate hydration.

6. The medication is administered at regular intervals around the clock to maintain a sustained

therapeutic level.

7. Oral medications are administered with or after meals to decrease gastrointestinal irritation.

8. Monitor for a therapeutic serum theophylline level of 10 to 20 mcg/mL.

9. Intravenously administered aminophylline or theophylline preparations should be

administered slowly and always via an infusion pump.

10. Client education

a. Not to crush enteric-coated or sustained- release tablets or capsules

b. To avoid caffeine-containing products such as coffee, tea, cola, and chocolate, as

well as over-the-counter medications

c. About the side/adverse effects of bronchodilators

d. How to monitor the pulse and to report any abnormalities to the health care

provider (HCP)

e. How to use an inhaler, spacer, or nebulizer and how to monitor the amount of

medication remaining in an inhaler canister

f. The importance of smoking cessation and information regarding support resources

g. To monitor blood glucose levels if diabetes mellitus is a coexisting condition

h. To wear a Medic-Alert bracelet, particularly if the client has asthma

Theophylline toxicity is likely to occur when the serum level is higher than 20 mcg/mL. Early signs of

toxicity include restlessness, nervousness, tremors, palpitations, and tachycardia.

Anticholinergics

A. Inhaled medications that improve lung function by blocking muscarinic receptors in the bronchi,

which results in bronchodilation

B. Effective for treating chronic obstructive pulmonary disease, allergy-induced asthma, and exercise-

induced bronchospasm

C. Side effects include dry mouth and irritation of the pharynx; sucking on sugarless candy will help to

relieve symptoms

D. Systemic anticholinergic effects rarely occur but can include increased intraocular pressure, blurred

vision, tachycardia, cardiovascular events, urinary retention, and constipation.

The client with a peanut allergy should not take ipratropium (Atrovent HFA and Combivent) because

both products contain soy lecithin, which is in the same plant family as peanuts.

IV. Glucocorticoids (Corticosteroids)

A. Glucocorticoids act as anti-inflammatory agents and reduce edema of the airways; they are used to

treat asthma and other inflammatory respiratory conditions.

V. Leukotriene Modifiers

A. Description

1. Used in the prophylaxis and treatment of chronic bronchial asthma (not used for acute

asthma episodes)

2. Inhibit bronchoconstriction caused by specific antigens and reduce airway edema and

smooth muscle constriction

3. Contraindicated in clients with hypersensitivity and in breastfeeding mothers

4. Should be used with caution in clients with impaired hepatic function

5. Coadministration of inhaled glucocorticoids increases the risk of upper respiratory infection.


1. Headache

2. Nausea and vomiting

3. Dyspepsia

4. Diarrhea

32

5. Generalized pain, myalgia

6. Fever

7. Dizziness

C. Interventions


2. Check lung sounds for adventitious breath sounds.

3. Monitor liver function laboratory values.

4. Monitor for cyanosis.

D. Client education

1. To take medication 1 hour before or 2 hours after meals

2. To increase fluid intake

3. Not discontinue the medication and to take as prescribed, even during symptom-free

periods

VI. Inhaled Nonsteroidal Antiallergy Agent

A. Description

1. Antiasthmatic, antiallergic, and mast cell stabilizers inhibit mast cell release after exposure

to antigens.

2. Used to treat allergic rhinitis, bronchial asthma, and exercise-induced bronchospasm

3. It is contraindicated in clients with known hypersensitivity.

4. Orally administered cromolyn sodium is used with caution in clients with impaired hepatic

or renal function.


1. Cough, sneezing, nasal sting, or bronchospasm after inhalation

2. Unpleasant taste in the mouth

C. Interventions


2. Monitor respirations and check lungs for adventitious sounds.

D. Client education

1. To administer oral capsules at least 30 minutes before meals

2. Not to discontinue the medication abruptly because a rebound asthmatic attack can occur;

the medication needs to be taken as prescribed.

The client taking inhaled medications is instructed to drink a few sips of water before and after

inhalation to prevent a cough and an unpleasant taste in the mouth.

Antihistamines

An t i h i st ami n es Cetirizine (Zyrtec) Chlorpheniramine (Chlor-Trimeton, Chlorphen, Aller-Chlor, others)

Desloratadine (Clarinex)

Dimenhydrinate (Dramamine)

Diphenhydramine (Benadryl)

Fexofenadine (Allegra)

Levocetirizine (Xyzal)

Loratadine (Claritin, Alavert, others)

A. Description

1. Called histamine antagonists or H1 blockers; these medications compete with histamine for

receptor sites, thus preventing a histamine response.

2. When the H1 receptor is stimulated, the extravascular smooth muscles, including those

lining the nasal cavity, are constricted.

3. Decrease nasopharyngeal, gastrointestinal, and bronchial secretions by blocking the

H1 receptor

4. Used for the common cold, rhinitis, nausea and vomiting, motion sickness, urticaria, and as

a sleep aid

33

5. Can cause central nervous system (CNS) depression if taken with alcohol, opioids,

hypnotics, or barbiturates

6. Should be used with caution in clients with chronic obstructive pulmonary disease because

of their drying effect

7. Diphenhydramine (Benadryl) has an anticholinergic effect and should be avoided in clients

with narrow-angle glaucoma.


1. Drowsiness and fatigue

2. Dizziness

3. Urinary retention

4. Blurred vision

5. Wheezing

6. Constipation

7. Dry mouth

8. Gastrointestinal irritation

9. Hypotension

10. Hearing disturbances

11. Photosensitivity

12. Nervousness and irritability

13. Confusion

14. Nightmares

C. Interventions


2. Monitor for signs of urinary dysfunction.

3. Administered with food or milk.

4. Subcutaneous injection is avoided; administered by intramuscular injection in a large

muscle if the intramuscular route is prescribed.

D. Client education

1. To avoid hazardous activities, alcohol, and other CNS depressants

2. If the medication is being taken for motion sickness, take it 30 minutes before the event and

then before meals and at bedtime during the event as prescribed.

3. To suck on hard candy or ice chips for dry mouth

Tuberculosis Medications

Fi rs t - an d S econ d - Li n e Med i cat i on s fo r Tu b e rcu l osi s

First-Line Agents

Ethambutol (Myambutol)

Isoniazid

Pyrazinamide

Rifabutin (Mycobutin)

Rifampin (Rifadin)

Rifapentine (Priftin)

Second-Line Agents

Amikacin (Amikin)

Capreomycin sulfate (Capastat Sulfate)

Ciprofloxacin (Cipro)

Cycloserine (Seromycin)

Ethionamide (Trecator)

Kanamycin (Kantrex)

Levofloxacin (Levaquin)

Moxifloxacin (Avelox)

p-Aminosalicylic acid (Paser)

34

Streptomycin

A. Description

1. Offers the most effective method for treating the disease and preventing transmission

2. Treatment of identified lesions depends on whether the individual has active disease or has

been exposed to the disease.

3. Treatment is difficult because the bacterium has a waxy substance on the capsule that makes

penetration and destruction difficult.

4. The use of a multidrug regimen destroys organisms as quickly as possible and minimizes

the emergence of drug-resistant organisms.

5. Active tuberculosis is treated with a combination of medications to which the organism is

susceptible.

6. Individuals with active tuberculosis are treated for 6 to 9 months; however, clients with

human immunodeficiency virus (HIV) infection are treated for a longer period of time.

7. After the infected individual has received medication for 2 to 3 weeks, the risk of

transmission is greatly reduced.

8. Most clients have negative sputum cultures after 3 months of compliance with medication

therapy.

9. Individuals who have been exposed to active tuberculosis are treated with preventive

isoniazid for 9 to 12 months.

B. First- or second-line medications

1. First-line medications provide the most effective antituberculosis activity.

2. Second-line medications are used in combination with first-line medications but are more

toxic.

3. Current infecting organisms are proving resistant to standard first-line medications; the

resistant organisms develop because individuals with the disease fail to complete the

course of treatment, so surviving bacteria adapt to the medication and become resistant.

4. Multidrug therapies are instituted because of the resistant organisms.

C. Multidrug-resistant strain of tuberculosis (MDR-TB)

1. Resistance occurs when a client receiving two medications (first-line and second-line

medications) discontinues one of the medications.

2. The client briefly experiences some response from the single medication, but then large

numbers of resistant organisms begin to grow.

3. The client, infectious again, transmits the drug-resistant organism to other individuals.

4. As this event is repeated, an organism develops that is resistant to many of the first-line

tuberculosis medications.

First-Line Medications for Tuberculosis

A. Isoniazid

1. Description

a. Bactericidal

b. Inhibits the synthesis of mycolic acids and acts to kill actively growing organisms in

the extracellular environment

c. Inhibits the growth of dormant organisms in the macrophages and caseating

granulomas

d. Is active only during cell division and is used in combination with other

antitubercular medications

2. Contraindications and cautions

a. Contraindicated in clients with hypersensitivity or with acute liver disease

b. Use with caution in clients with chronic liver disease, alcoholism, or renal

impairment.

c. Use with caution in clients taking nicotinic acid (niacin).

d. Use with caution in clients taking hepatotoxic medications because the risk for

hepatotoxicity increases.

e. Alcohol increases the risk of hepatotoxicity.

35

f. May increase the risk of toxicity of carbamazepine (Tegretol) and phenytoin

(Dilantin)

g. Isoniazid may decrease ketoconazole (Nizoral) concentrations.


a. Hypersensitivity reactions

b. Peripheral neuritis

c. Neurotoxicity

d. Hepatotoxicity and hepatitis; increased liver function test levels

e. Pyridoxine (vitamin B6) deficiency

f. Irritation at injection site with intramuscular administration

g. Nausea and vomiting

h. Dry mouth

i. Dizziness

j. Hyperglycemia

k. Vision changes

4. Interventions

a. Monitor for hypersensitivity.

b. Monitor for hepatic dysfunction.

c. Monitor for sensitivity to nicotinic acid.

d. Monitor liver function test results.

e. Monitor for signs of hepatitis, such as anorexia, nausea, vomiting, weakness,

fatigue, dark urine, or jaundice; if these symptoms occur, withhold the medication

and notify the registered nurse.

f. Monitor for tingling, numbness, or burning of the extremities.

g. Monitor mental status.

h. Monitor for visual changes, and notify the registered nurse if they occur.

i. Monitor for dizziness and initiate safety precautions.

j. Monitor complete blood count (CBC) and blood glucose levels.

k. Isoniazid is administered 1 hour before or 2 hours after a meal because food may

delay absorption.

l. Isoniazid is administered at least 1 hour before antacids, especially those antacids

that contain aluminum.

m. Pyridoxine is administered as prescribed to reduce the risk of neurotoxicity.

Many tuberculosis medications can cause toxic effects such as hepatotoxicity, nephrotoxicity,

neurotoxicity, optic neuritis, or ototoxicity. Teach the client about the signs of toxicity and inform the

client that the HCP needs to be notified if any signs arise.

5. Client education

a. Not to skip doses and to take the medication for the full length of the prescribed

therapy

b. Not to take any other medication without consulting the HCP

c. About the importance of follow-up HCP visits, vision testing, and laboratory tests

d. To avoid alcohol

e. To take medication on an empty stomach with 8 oz of water 1 hour before or 2

hours after meals and to avoid taking antacids with the medication

f. To avoid tyramine-containing foods because they may cause a reaction such as red

and itching skin, a pounding heartbeat, light-headedness, a hot or clammy feeling,

or a headache; if this does occur, the client should notify the HCP.

g. To recognize the signs of neurotoxicity, hepatitis, and hepatotoxicity

h. To notify the HCP if signs of neurotoxicity, hepatitis and hepatotoxicity, or visual

changes occur.

B. Rifampin (Rifadin)

1. Description

36

a. Inhibits bacterial RNA synthesis

b. Binds to DNA-dependent RNA polymerase and blocks RNA transcription

c. Used with at least one other antitubercular medication


a. Contraindicated in clients with hypersensitivity

b. Used with caution in clients with hepatic dysfunction or alcoholism

c. Use of alcohol or hepatotoxic medications may increase the risk of hepatotoxicity.

d. Decreases the effects of several medications, including oral anticoagulants, oral

hypoglycemics, chloramphenicol (Chloromycetin), digoxin (Lanoxin),

disopyramide phosphate (Norpace), mexiletine (Mexitil), quinidine

polygalacturonate, fluconazole (Diflucan), methadone hydrochloride (Dolophine),

phenytoin (Dilantin), and verapamil hydrochloride (Calan SR)


a. Hypersensitivity reaction, including fever, chills, shivering, headache, muscle and

bone pain, and dyspnea

b. Heartburn, nausea, vomiting, diarrhea

c. Red-orange–colored body secretions

d. Vision changes

e. Hepatotoxicity and hepatitis

f. Increased uric acid levels

g. Blood dyscrasias

h. Colitis

4. Interventions


b. Monitor CBC, uric acid, and liver function test results.

c. Monitor for signs of hepatitis; if they occur, the medication is withheld and the HCP

is notified.

d. Monitor stools for signs of colitis.

e. Monitor mental status.

f. Monitor for visual changes.

5. Client education

a. Not to skip doses and to take medication for the full length of the prescribed

therapy

b. Not to take any other medication without consulting the HCP

c. About the importance of follow-up HCP visits and laboratory tests

d. To avoid alcohol

e. To take medication on an empty stomach with 8 oz of water 1 hour before or 2

hours after meals and to avoid taking antacids with the medication

f. That urine, feces, sweat, and tears will be red-orange and that soft contact lenses can

become permanently discolored

g. To notify the HCP if jaundice (yellow eyes or skin) develops or if weakness, fatigue,

nausea, vomiting, sore throat, fever, or unusual bleeding occurs

C. Ethambutol (Myambutol)

1. Description

a. Bacteriostatic

b. Interferes with cell metabolism and multiplication by inhibiting one or more

metabolites in susceptible organisms

c. Inhibits bacterial RNA synthesis and is active only during cell division

d. Slow-acting and must be used with other bactericidal agents


a. Contraindicated in clients with hypersensitivity or optic neuritis and children

younger than 13 years

b. Used with caution in clients with renal dysfunction, gout, ocular defects, diabetic

retinopathy, cataracts, or ocular inflammatory conditions

37

c. Used with caution in clients taking neurotoxic medications because the risk for

neurotoxicity increases


a. Hypersensitivity reactions

b. Anorexia, nausea, vomiting

c. Dizziness

d. Malaise

e. Mental confusion

f. Joint pain

g. Dermatitis

h. Optic neuritis

i. Peripheral neuritis

j. Thrombocytopenia

k. Increased uric acid levels

l. Anaphylactoid reaction

4. Interventions

a. Monitor the client for hypersensitivity.

b. Monitor results of CBC, uric acid, and renal and liver function tests.

c. Monitor for visual changes such as altered color perception and decreased visual

acuity; if changes occur, the medication is withheld and the HCP is notified.

d. Administered once every 24 hours and administered with food to decrease

gastrointestinal upset

e. Monitor uric acid concentration and check for painful or swollen joints or signs of

gout.

f. Monitor intake and output and for adequate renal function.

g. Monitor mental status.

h. Monitor for dizziness and initiate safety precautions.

i. Monitor for peripheral neuritis (numbness, tingling or burning of the extremities);

if it occurs, the HCP is notified.

5. Client education

a. That nausea, related to the medication, can be prevented by taking the daily dose at

bedtime or by taking the prescribed antinausea medications

b. Not to skip doses and to take the medication for the full length of the prescribed

therapy

c. Not to take any other medication without consulting the HCP

d. About the importance of follow-up HCP visits, vision testing, and laboratory tests

e. To notify the HCP immediately if any visual problems occur, or a rash, swelling

and pain in the joints, numbness, tingling, or burning in the hands or feet occurs

D. Pyrazinamide

1. Description

a. The exact mechanism of action of pyrazinamide is unknown.

b. May be bacteriostatic or bactericidal, depending on its concentration at the infection

site and susceptibility of infecting organism

c. Used with at least one other antitubercular medication after failure or

ineffectiveness of the primary medication(s)


a. Contraindicated in clients with hypersensitivity

b. Used with caution in clients with diabetes mellitus, renal impairment, or gout, and

in children

c. May decrease the effects of allopurinol (Zyloprim), colchicine (Colcrys), and

probenecid

d. Cross-sensitivity is possible with isoniazid, ethionamide (Trecator), or nicotinic

acid


38

a. Increases liver function tests and uric acid levels

b. Arthralgia, myalgia

c. Photosensitivity

d. Hepatotoxicity

e. Thrombocytopenia

4. Interventions


b. Monitor CBC, liver function test results, and uric acid levels.

c. Observe for hepatotoxic effects; if they occur, the medication is withheld and the

HCP is notified.

d. Monitor for painful or swollen joints.

e. Monitor blood glucose level because diabetes mellitus may be difficult to control

while client is taking the medication.

5. Client education

a. To take the medication with food to reduce gastrointestinal distress

b. To avoid sunlight or ultraviolet light until photosensitivity is determined

c. To notify the HCP if any side/adverse effects occur

d. Not to skip doses and to take the medication for the full length of the prescribed

therapy

e. Not to take any other medication without consulting the HCP

f. About the importance of follow-up HCP visits and laboratory tests

Anticoagulants Oral Parenteral Substances to Avoid with ... · Parenteral Dalteparin (Fragmin) Enoxaparin (Lovenox) Heparin sodium Substances to Avoid with Anticoagulants Allopurinol

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