LEGAL AND ETHICAL ASPECTS OF ICU

Informed consent

• Informed consent is an agreement by a client to accept a course of treatment or a procedure after providing complete information includes the benefits and risks of treatment alternatives to the treatments and prognosis, if not treated by a health care provider. For the consent, usually the client sign a form provided by the agency, that form is the record of the informed consent.

Delegation

• "The delegation is defined as transferring to a competent individual the authority to perform a selected nursing task in a selected situation."
• "Delegation is defined as transferring responsibility for the performance of an activity or task while retaining accountability for the outcomes."
• "five right of delegation"
  • Right task – the task is delegate for a specific client such as tasks that are repetitive, require little supervision and are relatively noninvasive.
  • Right circumstances – appropriate client setting, available resources and other relevant factors are considered.
  • Right person – the right person is delegating the right task to the right person to be performed by the right person.
  • Right direction/communication – A clear, concise description of the task including its objective limits and expectation is given.
  • Right supervision – appropriate monitoring, evaluation, intervention as needed and feedback are provided.

Death and death related issue

• Advance directive
• DNR – Do-not-resuscitate order
• Euthanasia
• Certification of death
• Autopsy
• Inquest
• Organ-transplantation

Advance directive

• Advance directive is also known as advance health care directive or advance decision. Advance directive are instruction give to individuals by doctor to specify what kind of care you would like to have If you become unable to make the medical decision, such as if you are in unconscious or in coma.
• In advance directive, a form is filling by the patients that have complete instructions for the further care of patient. The living will and power of authority for health care.

(Do Not Resuscitate) DNR order

• DNR is another kind of advance directive. DNR is a request not to have CPR, if patient heart stops or if you stop breathing.
• For that as DNR form is used or to tell the doctor that you don't want to resuscitated. DNR order is written to indicate that the goal of treatment is comfortable, dignified death and that further life- sustaining measures are not indicated.

Euthanasia

• Euthanasia is also known as "mercy killing" or PAS (Physician assisted suicide). It is the act of painlessly putting the death to a person who is suffering from incurable or distressing disease (chronic or incurable disease).
• Netherland was the one of the first country to legalize the euthanasia. In India euthanasia is not legalized.

Death certification

• It is a medical certificate of the cause of death (MCCD) that is provided by the hospital, which include all the information regarding death.
• Death certificate must be made out when the person is die and this certificate is signed by the attending physician. This certificate is used as for the legal matter, such as insurance claim.

Autopsy

• The autopsy is also known as pots-mortem examination.
• Autopsy is a medical procedure performed for legal or medical purpose that consists of a thorough examination of a corpse (dead body) to determine the cause and manner of the death and to evaluate any disease or injury that may be present. It is usually performed by a specialized pathologist.
• It is the responsibility of the physician or in the some instance of the designated person in the hospital to obtain consent for an autopsy.
• Consent must be given by the decedent (before death) or by the next to kin. After autopsy, hospital cannot remain any tissue or organs without the permission of the person who consent to autopsy.

Inquest

• Inquest is the legal inquiry of the cause or the manner of the death, when the death is a result of an accident.
• The inquest is conducted under the jurisdictions of a coroner or a medical officer.
• Coroner is a public official, not necessary a physician, appointed or the elected for the inquiry of the cause of death.
• Medical examiner is a physician and usually has advanced education in pathology or forensic medicine.

Organ donation

• Under the uniform anatomical gifts Act's and the National organ transplant Act's or the human tissue Act's, person who is 18 year or older in age and heaving a sound mind may make a gifts of all or any part of their own body.
• In India, THO Act's (transplantation of human organ Act's- 1994) was passed in 1994 by parliament. The main aim is "to provide for the regulation of removal storage and transplantation of the human organs in therapeutic purpose.

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ORGANIZATION OF ICU

(According To IPHS Standards)

PHYSICAL SETUP

General

• Principle - 2 to 5 percent total medical and surgical beds in a hospital should be Critical Care beds. Minimum 4, maximum 12 bed per Critical Care unit.
• Number of beds -5% of the total hospital bed strength.
• ICUs having <6 beds are not cost effective and also do not provide enough clinical experience and exposure to skilled HR of the ICU. At the same time, ICU with bed strength of >24 are difficult to manage.

Location

• In close proximity of emergency and accident department, Operating rooms, trauma ward, diagnostic facilities, blood bank, pharmacy etc. (for Safe, easy, fast transport of a critically sick patient).
• Equipped with central suction and medical gases, uninterrupted electric supply, heating, ventilation, central air conditioning and efficient life services.
• Corridors, lifts & ramps spacious enough to provide easy movement of bed/ trolley.
• There should be single entry/exit point.
• It is required to have emergency exit points in case of emergencies and disaster.

Designing and Space

• 125 to 150 sq ft area per bed in the patient care area or the room of the patient. In addition there should be 100 to 150% extra space to accommodate nursing station, storage, patient movement area, equipment area, doctors and nurses rooms and toilet.
• One or two bigger rooms or area which may be utilized for patients to undergo bedside procedures with support Gadgets attached to them.
• 10% (one to two) rooms or beds may be designated to use exclusively as isolation rooms for cases like for burns, severely infected patients or immune compromised patients. These rooms may have 20% extra space than other rooms.

Facilities

• Nursing Station
• Clean Utility Area
• Equipment Room

Ideal critical Care unit design

HUMAN RESOURCE (Staffing Norms)

The critical care team includes a diverse group of highly trained professionals who provide care in specialized care units and work toward the best outcome possible for seriously ill patients.

All members of the team may be asked to teach patients and their families various strategies to improve health, healing, coping, and well-being specific to their area of expertise.

ICU Team

Members of the team include:

• Nurses
  • Nurse ICU Coordinator who should preferably be trained in intensive care or has five years' experience in intensive care.
  • ICU nurse-patient ratio 1:1 for ventilated cases and 1:2 for other cases.
  • 1:2 to 1:3 nurse patient ratios is acceptable for less seriously sick patients.
• Doctors
• Respiratory Therapists
• Physiotherapist
• Technicians, Computer programmer
• Biomedical Engineer
• Nutritionist
• Clinical Pharmacist
• Support staff-Cleaning staff, guards and Class IV

NURSING PROTOCOLS FOR CRITICAL CARE

(BY SIHFW RAJASTHAN)

1. No critical care patient will be left without a nurse in attendance.
2. Each nurse will be responsible for the entire care of his/her patient, and acts to coordinate care with other health team professionals.
3. Breaks will be arranged according to unit need/safe coverage by mutual agreement between each nurse and his/her coworkers. The nurse must give a full report to another staff nurse prior to leaving for a break. 
4. The staff nurse will report any changes in his/her patient's condition directly to the physician.
5. All critical care patients will have continual ECG monitoring.
6. Alarms must be left on the ECG and arterial lines at all times. Appropriate limits will be selected at the nurse's discretion according to institutional policy.
7. For a stable, non-acute patient without invasive monitoring equipment, vital signs are measured at least every hour.
8. The turning of all critically ill patients every two hours around the clock is done unless contraindicated, with skin assessment recorded as part of the every four-hour assessment.
9. All Critical Care patients will have mouth care done every four hours with inspection for oral skin sores.
10. The Critical Care nurse may restrain patients at his/her discretion. Provided documentation done according to hospital policies and procedures.
11. All dressings unless otherwise indicated will be changed daily.
12. Nursing care will be spaced out to allow periods of rest.
13. Procedures will be explained to patients; person, place and time being repeatedly stated to the patient.
14. Information and emotional support needs for the family and patient will be provided by the nurse/physician/social work/palliative care, as required.
15. The environment will be maintained in a mechanically safe condition through: dry floors, good repair of furniture, proper placement of machines and equipment, cleanliness, freedom from clutter, and good repair of equipment.
16. Isolation technique will be followed as per infection control manual.
17. Any containers of body fluids (i.e. suction canisters or chest drainage sets) must be disposed in the appropriate biohazard bag or box.
18. All medications will be reviewed by the Critical Care physicians (upon admission to Unit.) and either reordered or stopped. Nursing staff will ensure this has been done prior to carrying out any medication, treatment or investigative orders. Each treatment/medication must be listed.
19. Respiratory orders may only be carried out when written by the patient's physician. Ventilatory changes will only be done upon receipt of written order.
20. All orders written other than by the Critical Care physicians will be brought to the attention of the Critical Care physician by the nurse prior to being carried out.
21. Narcotics MAY NOT be kept at the bedside. If use is not immediate after withdrawal from the narcotic cabinet, wastage as per narcotic protocol will be carried out.
22. Visiting is negotiated between the nurse and family, with consideration given to unit activity and institutional policy.
23. The nurse/physician will notify families of significant deteriorations in the patient's condition.
24. All staff working at a bedside where an acute trauma or actively bleeding patient is being managed will wear protective goggles, masks and gloves. Protective gear is also required anytime risk of splash from body fluids exists e.g. suctioning.

EQUIPMENT'S & SUPPLIES IN ICU

Patient monitoring equipment

Patient monitoring equipment includes the following:

• Cardiac Monitors: to monitor the electrical activity of the heart. Cardiac monitors continuously measures and displays data on vital signs, such as heart rate, blood pressure, cardiac output, and blood oxygen levels.
• Pulse Oximeter: to monitor the saturation of oxygen in the blood.
• Swan-Ganz catheter or pulmonary artery catheter: is used to measure the amount of fluid filling the heart as well as to determine how the heart is functioning.
• Intracranial pressure monitor—Measures the pressure of fluid in the brain in patients with head trauma or other conditions affecting the brain (such as tumors, edema, or hemorrhaging).
• Apnea monitor—continuously monitors breathing to detect cessation in infants and adults at risk of respiratory failure.
• Arterial Line: A very thin tube (catheter) is inserted into one of the patient's arteries (usually in the arm) to allow direct measurement of the blood pressure and to measure the concentration of oxygen and carbon dioxide in the blood. The arterial line is attached to a monitor.
• Intra-aortic balloon pump (IABP): It is a mechanical device that decreases myocardial oxygen demand while at the same time increasing cardiac output. These actions combine to decrease myocardial oxygen demand and increase myocardial oxygen supply.

Life support and emergency resuscitative equipment

ICU equipment for life support and emergency resuscitation include the following:

• Ventilator (also called a respirator)—Assists with or controls pulmonary ventilation in patients who cannot breathe on their own.
• Defibrillator: A defibrillator is used to "shock" the heart from an abnormal rhythm pattern back into a normal rhythm.
• External pacemaker: It is a device used to stimulate the heartbeat electrically by means of impulses conducted through the chest wall, as used in emergency care of significant bradyarrhythmias.
• Infusion pump: An electronic device used to control the administration of intravenous fluids in very small amounts and at a carefully regulated rate over long periods. it is a device that delivers fluids intravenously or epidurally, including continuous anaesthesia, drugs, and blood infusions.
• Crash cart—Portable cart containing emergency resuscitation equipment for patients who are "coding" (that is, their vital signs are in a dangerous range), including a defibrillator, airway intubation devices, resuscitation bag/mask, and medication box.
• Suction machine

Diagnostic equipment

The use of diagnostic equipment is also required in the ICU.

• Mobile x-ray units are used for bedside radiography, particularly of the chest.
• Portable clinical laboratory devices, called point-of-care analyzers, are used for blood analysis at the bedside to provide results much faster than if samples were sent to the central laboratory.

Tubes & Catheters in the ICU

• Central venous catheter (CVC): is a soft, pliable tube that is inserted into a large vessel (vein) in the neck (internal jugular vein), in the upper chest (subclavian vein), or in the groin area (femoral vein).
• Intravenous set (IV): is a plastic catheter (tube) that is inserted into the veins (peripheral IV) or a larger size catheter inserted into the larger veins of the neck for fluids, medications, nutrition preparations, and blood products..
• Chest tubes: Chest tubes to drain fluid or air that has accumulated.
• GI Tube: used to introduce liquids, food, or medication into the stomach.
• Nasogastric Tube (NG Tube): for direct "tube feeding" to maintain the nutritional status.
• Shunt: A procedure to draw off excessive fluid in the brain.
• Urinary catheter: Urinary catheters, often referred to as Foley catheters, are inserted through the urethra into the bladder. Urinary catheters continuously drain the bladder and allow for accurate measurement of urinary output, which is extremely important in fluid management and in assessing kidney function.
• Endotracheal tubes: Endotracheal tubes are used when mechanical ventilation is necessary.
• Some common items used in Critical care unit: Bed pad, Bedpan, Gloves, Hand-washing Foam, Hospital Beds and Mattresses, Hospital Clothing, Intravenous (IV) Feeding, Intravenous (IV) Fluids, Liquid Tube Feeding, Oxygen Supply, Drug supply etc.

 

 

INTENSIVE CARE UNITS (ICU)

"A Critical Care Unit (CCU) or Intensive Care units (ICU) is defined as a specially staffed, specialty equipped, separate section of a hospital dedicated to the observation, care, and treatment of patients with life threatening illnesses, injuries, or a complication from which recovery is possible. It provides special expertise and facilities for the support of vital function and utilizes the skill of medical nursing and other staff experienced in the management of these problems."

Critical Care Unit (CCU) or Intensive Care units (ICU) are specialized units that is designed and staffed to deliver the highest level of medical and nursing comprehensive and continuous care to the critically ill patients who are deemed recoverable but who need supervision and need or likely to need specialized techniques by skilled personnel.

The Units have the following major characteristics like space, equipment and working staff and continuous service and care all around the clock 24 hours x 7 days including instantaneous monitoring of cardiovascular parameter, respiratory function, renal function and the nervous system status.

CLASSIFICATION OF CRITICAL CARE UNIT

• Level - I: Provides Monitoring, Observation and short-term ventilation. Nurse patient ratio is 1:3 and the medical staff are not present in the unit all the time.
• Level - II: Provides Observation, Monitoring and long term ventilation with resident doctors. The nurse-patient ratio is 1:2, junior medical staff is available in the unit all the time, and consultant medical staff is available if needed.
• Level - III: Provides all aspects of intensive care including invasive hemodynamic monitoring and dialysis. Nurse patient ratio is 1:1.

TYPES OF CRITICAL CARE UNIT

1. Medical intensive-care unit (MICU)
2. Surgical intensive-care unit (SICU)
3. Medical Surgical intensive-care unit (MSICU)
4. Coronary intensive care unit (CICU)
5. Cardiac Surgery intensive-care unit (CSICU)
6. Cardio-thoracic intensive-care unit (CTICU)
7. Cardiovascular intensive-care unit (CVICU)
8. Respiratory intensive-care unit (RICU)
9. Neuro-science/Neuro-intensive care unit (NSICU)
10. Neuro-trauma intensive care unit (NTICU)
11. Trauma Intensive care Unit (TICU)
12. Surgical Trauma intensive-care unit (STICU)
13. Trauma-Neuro Critical Care intensive care unit (TNCC)
14. Burn intensive-care unit (BWICU)
15. Neonatal intensive-care unit (NICU)
16. Pediatric intensive-care unit (PICU)
17. Psychiatric intensive-care unit (PSICU)
18. Overnight intensive recovery unit (OIRU)
19. Geriatric intensive-care unit (GICU)
20. Mobile Intensive Care Unit (MICU)

PURPOSE / OBJECTIVE OF ICU

• To provide around-the-clock intensive monitoring and treatment of patients who are severely ill and medically unstable—that is, they have a potentially life-threatening disease or disorder.
• To prevent deterioration of patient condition before other specific treatment are given.
• To meet any emergency at the time because of availability of all lifesaving equipment & supplies e.g.-suction machine, defibrillator, ventilator etc.
• To provide continuous observation and concentrated care for maximum survival of patient.
• To centralize and make the best use of the costly lifesaving equipment.
• To make the best use of the services of technically perfect staff handling the sophistication machine and equipment.
• To provide quality-serving care (compressive nursing care) to critically ill patient patients by the nursing personals, who are professionally, prepared to work in ICU.
• To provide on the job training to the nurse and doctors.
• To educate student with demonstrated skilled care for further research.

THE ADMISSION CRITERIA FOR ICU

The criteria for admission to an ICU are somewhat controversial—excluding patients who are either too well or too sick to benefit from intensive care—there are four recommended priorities which is used by intensivists (specialists in critical care medicine) to decide the admission. These priorities include:

• Critically ill patients in a medically unstable state who require an intensive level of care (monitoring and treatment).
• Patients requiring intensive monitoring who may also require emergency interventions.
• Patients who are medically unstable or critically ill and who do not have much chance for recovery due to the severity of their illness or traumatic injury.
• Patients who are generally not eligible for ICU admission because they are not expected to survive. Patients in this fourth category require the approval of the director of the ICU program before admission.

CATEGORIES OF DISEASES AND DISORDERS ADMITTED IN ICU

Eight categories of diseases and disorders are regarded as medical justification for admission to an ICU.

• These categories include disorders of the cardiac, nervous, pulmonary, and endocrine (hormonal) systems, together with postsurgical crises, trauma and medication monitoring for drug ingestion or overdose.
• Cardiac problems can include heart attacks (myocardial infarction), shock, cardiac arrhythmias (abnormal heart rhythm), heart failure (congestive heart failure or CHF), high blood pressure, and unstable angina (chest pain).
• Pulmonary disorders can include acute respiratory failure, pulmonary emboli (blood clots in the lungs), hemoptysis (coughing up blood), and respiratory failure.
• Endocrine emergency such as diabetic coma
• Neurological disorders may include acute stroke (blood clot in the brain), coma, bleeding in the brain (intracranial hemorrhage), such infections as meningitis, and traumatic brain injury (TBI).
• Trauma- Sever burn injury, Sever accident with multiple injure and acute poisoning
• Medication monitoring is essential, including careful attention to the possibility of seizures and other drug side effects.

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INTRODUCTION TO CRITICAL CARE

Critical care nursing is the field of nursing with a focus on the utmost care of the critically ill or unstable patients following extensive injury, surgery or life threatening diseases. The aims of Intensive and Critical Care Nursing are to promote excellence of care of critically ill patients by specialist nurses and their professional colleagues.

Critical Care

• Critical care (medicine) is the multidisciplinary healthcare specialty that cares for patients with acute, life-threatening illness or injury.
• Critical care (Intensive Care) is a healthcare specialty that cares for patients with acute, life-threatening illness or injury and involves multiple skills and specialties.

Critical Illness

• Critical illness is a condition where life cannot be sustained without invasive therapeutic interventions.

Critically Ill Patient

• Critically ill patient is defined as those patients who are at high risk for actual or potential life-threatening health problems and they are highly vulnerable, unstable and complex, thereby requiring intense and vigilant nursing care.

The Aim of the Critical Care

• The aim of the critical care is to see that one provides a care such that patient improves and survives the acute illness or tides over the acute exacerbation of the chronic illness.

CRITICAL CARE NURSING

• Critical care nursing is the field of nursing with a focus on the utmost care of the critically ill or unstable patients.
• Critical care nursing is that specialty within nursing that deals specifically with human responses to life-threatening problems.
• Critical care nursing is a branch of nursing practice that deals patients with the life-threatening problems and being supported with life saving measures.

Principles of Critical Care Nursing

• Efficacy: The extent to which care, and nursing interventions have achieved the project or desired patient outcome.

• Appropriateness: This Indicates the extent to which care, and intervention rendered are relevant to the clinical needs of the patient.

• Availability: It refers to the degree of appropriate care and intervention to meet the needs of the patient and family, i.e., the critical care units are properly staffed and equipped.
• Timeliness: The extent to which care, and intervention is provided to the patient, family. This requires your adequate knowledge and in-depth observation of the patient's progress during the different stages of the disease and the diagnoses, deviations, and readiness to act during the different stages of the disease. For example, if CPR is not performed within five minutes of the arrest, a patient with cardiac arrest can lose his life.
• Effectiveness: The degree of care and interventions are rendered in correct manner to achieve the desired or predicted patient outcome. It refers to the nurse's knowledge and skills for proper nursing diagnosis of the patient and efficient operation of machine/gadgets, administration of treatment therapies, carrying out diagnostic procedure, continuous monitoring, documentation, detection of deviations and taking necessary action.
• Safety: The extent to which the risk of interruption of the care-environment can be eliminated for patient and others including health care providers. This indicates that you should adhere to the protocol standards of critical care, which have been established and modified based on research conducted or available research into various aspects of safety such as the physical care environment, therapies, and procedure, etc.
• Efficiency: Depends on the relationship between outcomes and resources used for care, e.g., the level of competence of care providers, availability of technology needed to rescue/treat the patient, availability of needed equipment, supplies, medications, appropriate communication channels and effective communication skills. In other words, a well-established critical care system that provides collaborative, dedicated, and compassionate care.
• Respect and care: It refer to the degree to which patients and family members are involved in making decisions about care and its implementation; we must listen carefully to the customer's concerns with sensitivity and respect individual differences in their expression. Our objective as a critical care nurse is to promote quality of life rather than just survival. we can ensure this by helping the patient to gain control of his or her care through self-care decisions and gradual involvement in care activities.

CRITICAL CARE NURSE

Critical care nurse is a licensed professional nurse who is responsible for providing total nursing care of seriously acute and chronically ill patients experiencing life-threatening problems requiring complex assessment, high intensity therapies and interventions, and continuous nursing vigilance.

Ratio

• ICU nurse-patient ratio 1:1 for ventilated cases and 1:2 for other cases.
• 1:2 to 1:3 nurse patient ratios is acceptable for less seriously sick patients.

Qualifications

• Should be a registered nurse (RN)
• Should preferably have critical-care training course or orientation that includes essential information on the care of the critically ill patient.

Roles

• Care provider : help the client to obtain necessary care and supporting the basic needs and comprehensive direct care to the patient and family
• Educator: based on patient's needs and severity of the condition
• Manager: coordinates the care provided by various health care
• Advocate: protects the patient's rights

Responsibility / Functions

• Critical-care nurse will perform actions listed below:
• Assesses and implements treatment for patient responses to life-threatening health problems
• Provides direct measures to resuscitate, if necessary
• Uses independent, dependent, and interdependent interventions to restore stability, prevent complications, and achieve and maintain optimal patient responses
• Critical Care Nurse
• Provides health education to the patient and family
• Supervises patient care and ancillary personnel
• Supports patient adaptation, restores health, and preserves the patient's rights, including the right to refuse treatment

Skill

• Admission, Transfer and Discharge of patient
• Bedside Safety
• Bedside and Patient Care Planning
• Patient Care Issues –
  • Essential patient care
  • Skin Care
  • Safe Moving and handling
  • Monitoring of vital signs
• Documentation
  • Observation chart,
  • Fluid balance chart,
  • Care plan
• Respiratory Care (Airway and Breathing)
  • Airway management,
  • Manual Ventilation,
  • Care of Endotracheal/ Tracheostomy Tube
  • Respiratory Support,
  • Ventilation
  • Extubation
• Cardiovascular Care (Circulation)
  • Arterial lines
  • Central lines
  • Fluid management
  • Emergency clinical situations (shock, cardiac arrest)
• Neurological Care (Disability)
  • Level of consciousness (AVPU / GCS)
  • Sedation and analgesia
• Nutritional Care
  • Enteral nutrition
  • Glycaemia control
• Psychosocial / Spiritual Care
• Infection Control
• Laboratory Investigations

COMMONLY USED DRUGS IN ICU

ATROPINE SULFATE

Isopto Atropine

Classification

• Anticholinergics

Dosage

• Bradycardia: 0.5 mg IV every 3-5 mins, max of 0.04 mg/kg
• Cardiac Arrest: 1 mg every 3-5 mins
• Nerve and Organophosphate symptoms: may repeat in 2 mg increments q 3 mins titrated to relief symptoms

Indication

• Pre-op meds/pre-aesthetic meds
• To restore cardiac rate and arterial pressure during anaesthesia when vagal
• To lessen the degree of A-V heart block
• To overcome severe carotid sinus reflex
• Antidote for cholinergic toxicity

Side effects

• CNS: restlessness, ataxia, disorientation, hallucinations, delirium, coma, insomnia, agitation, confusion.
• CV: tachycardia, angina, arrhythmias, flushing.
• EENT: photophobia, blurred vision, mydriasis.
• GI: dry mouth, constipation, vomiting.
• GU: urine retention.
• Hematologic: leucocytosis
• Other: anaphylaxis

Adverse effects

• CNS: headache, excitement.
• CV: palpitations
• GI: thirst, nausea

Contraindications

• Hypersensitivity
• With acute angle closure glaucoma, obstructive uropathy, obstructive disease of GI tract, paralytic ileus, toxic megacolon, intestinal atony, unstable CV status in acute haemorrhage, asthma, or myasthenia gravis.
• Pregnant women.

Nursing Management

• Monitor VS.
• Report é HR
• Monitor for constipation, oliguria.
• Instruct to take 30 mins before meals
• Eat foods high in fiber and drink plenty fluids.
• Can cause photophobia
• Instruct client not to drive a motor vehicle or participate in activities requiring alertness.
• Advise to use hard candy, ice chips, etc. for dry mouth.

NITROGLYCERINE

Nitrostat

Classification

• Antianginal
• Nitrate
• Vasodilator,
• Coronary

Dosage

• 0.3-0.4 mg SL q 5 min, max 3 doses.
• Every 6 hrs except for midnight (cream)
• Wear 12 hrs a day for skin patch

Action

• Relaxes the vascular smooth system
• Reduces myocardial oxygen consumption
• Reduces left ventricular workload
• Reduces arterial BP
• Reduces venous return

Indication

• Angina pectoris
• CHF associated with AMI
• Cardiac load reducing agent
• Hypertensive Crisis

Side effects

• CNS: headache, throbbing, dizziness, weakness.
• GI: nausea, vomiting
• Skin: Rash

Adverse Reactions

• CV: orthostatic hypotension, flushing, fainting.
• EENT: sublingual burning.
• Skin: Cutaneous vasodilation, contact dermatitis (patch)

Contraindications

• Contraindicated in patients hypersensitive to nitrates
• With early MI. (S.L. form), severe anaemia, increase ICP angle-closure glaucoma, IV nitroglycerine is contraindicated in patients with hypovolemia, hypotension, orthostatic hypotension, cardiac tamponade restrictive cardiomyopathy, constrictive pericarditis.

Nursing Management

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

MORPHINE SULFATE

Immediate-release tablets:

• MSIR

Timed-release:

• Kadian, M-Eslon (CAN), MS Contin, Oramorph SR

Oral solution:

• MSIR, Rescudose, Roxanol, Roxanol T

Rectal suppositories:

• RMS

Injection:

• Astramorph PF, Duramorph, Epimorph (CAN)
• Preservative-free concentrate for microinfusion devices for intraspinal use:
• Infumorph

Classification

• Opioid Agonist Analgesic

Dosage

• Oral: 10–30 mg q 4 hr PO. Controlled-release: 30 mg q 8–12 hr PO or as directed by physician; Kadian: 20–100 mg PO daily–24-hr release system; MS Contin: 200 mg PO q 12 hr.
• SC and IM:10 mg (5–20 mg)/70 kg q 4 hr or as directed by physician.
• IV:2.5–15 mg/70 kg of body weight in 4–5 mL water for injection administered over 4–5 min, or as directed by physician. Continuous IV infusion: 0.1–1 mg/mL in 5% dextrose in water by controlled infusion device.
• Rectal:10–30 mg q 4 hr or as directed by physician.
• Action
• Acts as agonist at specific opioid receptors in the CNS to produce analgesia, euphoria, sedation

Indication

• Relief of moderate to severe acute and chronic pain
• Preoperative medication
• Analgesic adjunct during anesthesia
• Component of most preparations that are referred to as Brompton's cocktail or mixture
• Intraspinal use with microinfusion devices for the relief of intractable pain
• Unlabeled use: Dyspnea associated with acute left ventricular failure and pulmonary edema

Side Effects

• GI: dry mouth, constipation.
• Skin: Tissue irritation and induration (SC injection).
• Other: sweating,physical tolerance and dependence, psychological dependence

Adverse Effects

• CNS: Light-headedness, dizziness, sedation, euphoria, dysphoria, delirium, insomnia, agitation, anxiety, fear, hallucinations, disorientation, drowsiness, lethargy, impaired mental and physical performance, coma, mood changes, weakness, headache, tremor, seizures, miosis, visual disturbances, suppression of cough reflex
• CV: Facial flushing, peripheral circulatory collapse, tachycardia, bradycardia, arrhythmia, palpitations, chest wall rigidity, hypertension, hypotension, orthostatic hypotension, syncope
• Dermatologic: Pruritus, urticaria, Respiratory: laryngospasm, bronchospasm, edema
• GI: Nausea, vomiting, anorexia, biliary tract spasm; increased colonic motility in patients with chronic ulcerative colitis
• GU: Ureteral spasm, spasm of vesical sphincters, urinary retention or hesitancy, oliguria, antidiuretic effect, reduced libido or potency
• Respiratory: Respiratory depression, apnea, circulatory depression, respiratory arrest, shock, cardiac arrest

Contraindications

• Hypersensitivity to opioid
• Diarrhea caused by poisoning until toxins are eliminated
• During labor or delivery of a premature infant
• After biliary tract surgery or following surgical anastomosis

Nursing Management

Interventions

• Caution patient not to chew or crush controlled-release preparations.
• Dilute and administer slowly
• Tell patient to lie down during IV administration.
• Keep opioid antagonist and facilities for assisted or controlled respiration readily available during IV administration.
• Use caution when injecting SC or IM into chilled areas or in patients with hypotension or in shock
• Reassure patients that they are unlikely to become addicted

Teaching points

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

VERAPAMIL

Calan, Isoptin, Verelan, Covera HS

Classification

• Anti-anginal
• Anti-arrhythmics
• Anti-hypertensive
• Vascular headache suppressants

Dosage

• PO 80-120 mg 3x daily, increases as needed

Action

• Inhibits calcium transport into myocardial smooth muscle cells
• Decreases SA and AV conduction and prolongs AV node refractory period in conduction tissue

Indication

• Hypertension
• Angina Pectoris
• Supraventricular Arrhythmia
• Atrial flutter/fibrillation

Side Effects and Adverse Reactions

• CNS:abnormal dreams, anxiety, confusion, dizziness and headache
• EENT: blurred vision, epistaxis and tinnitus
• CV: arrhythmia, CHF, chest pain, bradycardia, hypotension and palpitations
• GU: dysuria, nocturia and polyuria
• GI: abnormal liver function, anorexia, constipation, diarrhea, nausea and vomiting

Contraindications

• Hypersensitivity
• Sick sinus syndrome
• 2nd or 3rd degree AV block
• CHF
• Cardiogenic shock
• Concurrent IV beta-blocker

Nursing ManagemeNT

• Monitor BP and pulse before therapy, during titration and therapy
• Monitor ECG, I&O, serum potassium and weight.
• Assess for CHF

DILTIAZEM

Cardizem, Dilacor, Novo-Diltiazem, Tiamate and Tiazac

Classification

• Anti-anginals
• Antiarrhythmics
• Antihypertensive
• Ca channel blocker

Dosage

• PO: 30-120 mg, 3-4x daily or 60-120 mg twice daily as SR capsules
• IV: 0.25 mg/kg

Action

• Inhibits calcium transport into myocardial smooth muscle cells
• Systemic and coronary vasodilation

Indication

• Hypertension
• Angina Pectoris
• Supraventricular Arrhythmia
• Atrial flutter/fibrillation

Side Effects and Adverse and Reactions

• CNS: abnormal dreams, anxiety, confusion, dizziness and headache
• EENT: blurred vision, epistaxis and tinnitus
• CV: arrhythmia, CHF, chest pain, bradycardia, hypotension and palpitations
• GU: dysuria, nocturia and polyuria
• GI: abnormal liver function, anorexia, constipation, diarrhoea, nausea and vomiting

Contraindications

• Hypersensitivity
• Sick sinus syndrom2nd or 3rd degree AV block
• CHF
• Cardiogenic shock
• Concurrent IV beta-blocker

Nursing Management

• Monitor BP and pulse before therapy, during titration and therapy
• Monitor I&O and weight
• Assess for CHF
• Routine serum digoxin monitoring

LIDOCAINE

Xylocaine

Classification

• CV drugs: Anti-arrhythmics
• Anesthetic

Dosage

Arrhythmia:

• IV: 0.7-1.4 mg/kg body weight. No more than 200 mg within 1 hour period
• IM: 4-5 mg/kg body weight

Action

Increases electrical stimulation of ventricle and His-purkinje system by direct action on tissues, resulting to decrease depolarization, automaticity and excitability in ventricles during diastolic phase

Indication

• Anaesthesia
• Arrhythmias
• Control of Status epilepticus refractory to other treatments

Side Effects and Adverse Reactions

GI disturbances, bradycardia, hypotension, convulsion, numbness of tongue, muscle twitching, restlessness, nervousness, dizziness, tinnitus, blurred vision, fetal intoxication, light headedness, drowsiness, apprehension, euphoria, vomiting, sensation of heat, respiratory arrest and CV collapse

Contraindications

• Hypersensitivity
• Heart block
• Hypovolemia
• Adams stroke syndromes
• Infection at site of injection

Nursing Management

• Assess pt before and after therapy
• Pts infusion must be on cardiac monitor
• Monitor ECG, if QT or QRS increases by 50% or more, withhold the drug
• Monitor BP, check for rebound HPN after 1-2 hrs
• Assess respiratory status, oxygenation and pulse deficits
• Assess renal and liver function
• Monitor CNS symptoms
• Monitor blood levels

AMIODARONE

Cordarone

Classification

• Anti-arrhythmics

Dosage

Recurrent ventricular arrhythmias:

• POà800-1600 mg/day for 1-2 wks
• PSVT, symptomatic atrial flutter: POà 600-800 mg/day for 1 month
• Arrhythmias with CHF: 200 mg/day
• Ventricular dysrrhythmias: 150 mg over the 1st 10 mins then slow 360 mg over the next 6 hrs

Action

• Blocks Na channels, prolonging myocardial cell action potential and refractory period
• Non competitive alpha and beta adrenergic blockage

Indication

• Life threatening recurrent arrhythmias
• Ventricular fibrillation
• Ventricular tachycardia

Side Effects and Adverse Reactions

Exacerbation of arrhythmias, bradycardia, SA node dysfunction, heart block, sinus arrest; flushing, fatigue, malaise, abnormal involuntary movements, ataxia, dizziness, paresthesia, decreased libido, insomnia, headache, sleep disturbances, visual impairment, blindness, corneal microdeposits, photophobia, abnormal taste, nausea, vomiting, constipation, anorexia, abdominal pain, abnormal salivation, coagulation abnormalities, non-specific hepatic disorders, pulmonary inflammation, dyspnea, toxicosis, death, edema, hypo and hyperthyroidism

Contraindications

• Severe sinus node dysfunction
• 2nd or 3rd degree AV block
• Hypersensitivity

Nursing Management

• Assess cardiovascular status before therapy
• Assess pulmonary, hepatic and thyroid function before and during therapy
• Monitor fluid and electrolytes, I&O, K, Na and Cl
• Monitor ECG, BP
• Assess vision

PROCAINAMIDE

Pronestyl, Procan-SR, Procanbid

Classification

• Antiarrhythmics

Dosage

• Arrhythmias: 50 mg/kg/day in divided doses 3-6 hourly

Action

• Blocks open Na channels and prolongs the cardiac action potential. This results in slowed conduction and ultimately the decreased rate of rise of the action potential may result on the widening of QRS on ECG

Indication

• Supraventricular and ventricular arrhythmias.
• Treatment of Wolf-Parkinson-White Syndrome

Side Effects and Adverse Reactions

• Severe hypotension, ventricular fibrillation and asystole.
• Drug induced SLE syndrome, blood disorders, fever, myocardial depression, heart failure, agrunulocytosis, psychosis, angioedema, hepatomegaly, skin irritation, hypergammaglobulinemia, GI and CNS effects

Contraindications

• Heart block
• Heart failure
• Hypotension
• Myesthenia gravis
• Digoxin toxicity
• Lactation

Nursing Management

• Assess cardiovascular status before therapy
• Assess pulmonary, hepatic and thyroid function before and during therapy
• Monitor fluid and electrolytes, I&O, K, Na and Cl
• Monitor ECG, BP
• Assess vision

EPINEPHRINE

• Injection, OTC nasal solution:
• Adrenalin Chloride
• Ophthalmic solution:
• Epifrin, Glaucon
• Insect sting emergencies:
• EpiPen Auto-Injector (delivers 0.3 mg IM adult dose), EpiPen Jr. Auto-Injector (delivers 0.15 mg IM for children)
• OTC solutions for
• Nebulization:
• AsthmaNefrin, microNefrin, Nephron, S2

Classification

• Beta2 Adrenergic Agonists

Dosage

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

Action

• Stimulates beta receptors in lung.
• Relaxes bronchial smooth muscle.
• Increases vital capacity
• Increases BP, é HR, é PR
• Decreases airway resistance.

Indication

• Asthma
• Bronchitis
• Emphysema
• All cardiac arrest, anaphylaxis
• Used for symptomatic bradycardia.
• Relief of bronchospasm occurring during anesthesia
• Exercised-induced bronchospasm

Side Effects:

• nervousness, tremor, vertigo, pain, widened pulse pressure, hypertension nausea

Adverse Effects:

• headache

Contraindications

• With angle-closure glaucoma, shock (other than anaphylactic shock), organic brain damage, cardiac dilation, arrhythmias, coronary insufficiency, or cerebral arteriosclerosis. Also contraindicated in patient receiving general anesthesia with halogenated hydrocarbons or cyclopropane and in patients in labor (may delay second stage)
• In conjunction with local anesthesia, epinephrine is contraindicated for use in finger, toes, ears, nose, and genitalia.
• In pregnant woman, drug is contraindicated.
• In breast feeding do not use the drug or stop breast feeding.

Nursing Management

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

VASOPRESSIN

Pitressin

Classification

• Pituitary Hormones
• ADH

Dosage

• Prevent and treat abdominal distention: initially 5 units IM gives subsequent injections q3-4 hours increasing to 10 units if needed.

Action

• Increase permeability of renal tubular epithelium to adenosine monophosphate and water, the epithelium promotes reabsorption of water and concentrated urine

Indication

• Diabetes Insipidus
• Abdominal Distention
• GI bleeding
• Esophageal varices

Side Effects and Adverse Reactions

• CNS: tremor, headache, vertigo
• CV: vasoconstriction, arrhythmias, cardiac arrest, myocardial ischemia, circumollar pallor, decreased CO, angina
• GI: abdominal cramps
• GU:uterine cramps
• Respi: bronchoconstriction
• Skin: diaphoresis, gangrene and urticaria

Contraindications

• With chronic nephritis and nitrogen retention
• Hypersensitivity

Nursing Management

• Give 1-2 glass of H20 to reduce adverse reactions and improve therapeutic response
• Warm vasopressin in your hands and mixed until it is distributed evenly in the solution
• Monitor urine Sp. Gravity and I&O to aid evaluation of drug effectiveness

MAGNESIUM SO₄

Classification

• Anti-convulsant
• Anti-arrhythmics

Dosage

• Arrhythmia: IV 1-6 grams over several minutes, then continuous IV infusion 3-20 mg/min for 5-48 hours.

Action

• Decreased acetylcholine released

Indication

• Mg replacement
• Arrhythmia

Side Effects and Adverse Reactions

• CNS: drowsiness, depressed reflexes, flaccid paralysis, hypothermia
• CV: hypotension, flushing, bradycardia, circulatory collapse, depressed cardiac function
• EENT: diplopia
• Respiratory: respiratory paralysis
• Metabolic: hypocalcemia
• Skin: diaphoresis

Contraindications

• Heart block and myocardial damage
• Toxemia of pregnancy

Nursing Management

• Monitor I&O. make sure urine output is 100 ml or more in 4 hrs pd before each dose
• Take appropriate seizure precautions
• Keep IV Ca gluconate at bedside

NaHCO₃

Arm and Hammer; Baking Soda

Classification

• Alkalinizers

Dosage

• Metabolic Acidosis: Usually 2-5 meq/kg IV infuse over 4-8 hr period
• Cardiac Arrest: 1 meq/kg IV of 7.5 or 8.4% sol, then 0.5 meq/kg IV q 10 mins depending on ABG

Action

• Restore buffering capacity of the body and neutralizes excessive acid

Indication

• Metabolic Acidosis
• Cardiac Arrest

Side Effects/Adverse Reactions

• CNS: tetany
• CV: edema
• GI: gastric distention, belching and flatulence
• Metabolic: hypokalemia, metabolic alkalosis, hypernatremia, hyperosmolarity with overdose
• Skin: pain @ injection site

Contraindications

• Metabolic and respiratory alkalosis
• Pt losing Cl because of vomiting or continuous GI suction or those receiving diuretics that produces hypochloremic alkalosis

Nursing Management

• Obtain blood pH, PaO2, PaCo2 and electrolyte levels
• SIVP

Na NITROPRUSSIDE

Nittropress

Classification

• Antihypertensive, Vasodilator

Dosage

• 0.25-0.3 mcg/kg/minute

Action

• Relaxes arteriolar and venous smooth muscle

Indication

• Hypertensive crisis
• To produce controlled hypotension during anaesthesia
• To reduce preload and afterload in cardiogenic shock

Side Effects/Adverse Reactions

• Headache, dizziness, increased ICP, loss of consciousness, restlessness, bradycardia, nausea, abdominal pain, methemoglodinemia, muscle twitching, pink-colored rash, irritation at infusion site

Contraindications

• Hypersensitivity
• Compensatory hypotension
• Inadequate cerebral circulation
• Acute heart failure with reduced PVR
• Congenital optic atrophy
• Tobacco-induced ambylopia

Nursing Management

• Obtain VS before giving the drug
• Place patient in supine
• Giving excessive doses of 500 mcg/kg delivered faster than 2 mcg/kg/min or using max infusion rate of 10 mcg/kg/min for more than 10 mins can cause cyanide toxicity

FUROSEMIDE

Lasix

Classification

• Loop Diuretics

Dosage

• Pulmonary edema: 40 mg IV
• Edema: 20 to 80 mg PO every day in the morning
• HPN: 40 mg PO bid. Dosage adjusted based on response

Action

• Inhibits Na and Cl reabsorption at the proximal and distal tubules and in the ascending loop of Henle

Indication

• Acute pulmonary edema
• Edema
• Hypertension

Side Effects/Adverse Reactions

• Signs of hypotension, hypokalemia and hyperglycemia

Contraindications

• Hypersensitivity
• Anuria

Nursing Management

1. Monitor wt., BP and PR
2. Monitor fluid, I&O, electrolyte, BUN and CO2 levels frequently
3. WOF signs of hypokalemia
4. Monitor uric acid levels
5. Monitor glucose levels esp in DM pts

MANNITOL

Osmitrol

Classification

• Diuretics

Dosage

• Test dose for marked oliguria or suspected inadequate renal function: 200 mg/kg or 12.5 gram as a 15% to 20% IV solution over 3-5 mins response is adequate if 30-50 ml of urine/hr is adequate, a second dose is given if still no response after 2nd dose stop the drug
• Oliguria: 50 over 90 mins to several hrs
• To induced intraocular or intracranial pressure: 1.5-2 gram/kg as a 15 % to 20% IV solution over 30-60 min
• Diuresis in drug intoxication: 12.5% to 10% solutions up to 200 g IV
• Irrigating solution during TURP: 2.5-5%

Action

• Increases osmotic pressure of glomerular filtrate, inhibiting tubular reabsorption of water and electrolytes; drug elevates plasma osmolarity, increasing water flow into extracellular fluid

Indication

• Test dose for marked oliguria or suspected inadequate renal function
• Oliguria
• To induced intraocular or intracranial pressure
• Diuresis in drug intoxication
• Irrigating solution during TURP

Side Effects/Adverse Reactions

• CN: seizures, headache and fever
• CV: edema, thrombophlebitis, hypotension and heart failure
• EENT: blurred vision and rhinitis
• GI: thirst, dry mouth, nausea, vomiting and diarrhea
• GI: urine retention
• Metabolic: dehydration
• Skin: local pain
• Others: chill

Contraindications

• Hypersensitivity
• Anuria, severe pulmonary congestion, frank pulmonary edema, active intracranial bleeding during craniotomy, severe dehydration, metabolic edema, progressive heart failure or pulmonary congestion after drug

Nursing Management

• Monitor VS,CVP,I&O, renal function fluid balance and urine K levels daily.
• Drug can be used to measure GFR
• Do not give electrolyte free solutions with blood. If blood id given simultaneously, add at least 200 meq of NaCL to each liter

NALOXONE HCL

Narcan

Classification

• Miscellaneous antagonists and antidotes

Dosage

• For suspected opioid induced respiratory depression: 0.4 to 2 mg IV, IM and SQ. repeat doses q 2-3 mins PRN
• For postoperative opiod depression: 0.01 to 0.2 mg IV q 2-3 mins, PRN. Repeat dose within 1-2 hr, if needed.
• Action
• Reverse the effects of opiods, psychotomimetic and dysphoric effects of agonist-antagonists

Indication

• For suspected opioid induced respiratory depression
• For postoperative opiod depression

Side Effects/Adverse Reactions

• CNS: seizures, tremors
• CV: ventricular fibrillation, tachycardia, HPN with higher recommended doses, hypotension
• GI: nausea and vomiting
• Respiratory: pulmonary edema
• Skin: diaphoresis

Contraindications

• Hypersensitivity
• Use cautious with cardiac irritability or opiod addiction.

Nursing Management

• Assess respiratory status frequently
• Respiratory rate increases within 1-2 mins

IPECAC SYRUP

Classification

• Antidote

Dosage

• 25-30 ml followed immediately by H2O

Action

• Irritates the stomach lining and stimulate the vomiting center

Indication

• Poisoning
• Overdose

Side Effects

• Diarrhea, drowsiness, stomach cramps, vomiting, itching, DOB, swelling of the mouth, rash and hives

Contraindications

• Hypersensitivity
• Given activated charcoal
• Unconcious
• Drowsy
• Severely drunk
• Having seizures
• With no gag reflex

Nursing Management

1. Don't administer to unconscious
2. Pt should kept active and moving ff administration
3. If vomiting does not occur after 2nd dose, gastric lavage may be considered to remove ingested substance

ACTIVATED CHARCOAL

Classification

• Antidote

Dosage

• 30-100 g with at least 8 oz of water

Action

• Inhibits GI absorption of toxic substances or irritants
• Hyperosmolarity

Indication

• Poisoning

Side Effects

• Pain, melena, diarrhea, vomiting and constipation

Contraindications

• Cyanide, mineral acids, organic solvents, intestinal obstruction, bleeding with fructose intolerance, broken GI tract, concomitant use of charcoal with sorbitol

Nursing Management

• Do not mix with chocolate and together with ipecac syrup
• Notify doctor if caused swelling or pain in the stomach

FLUMAZENIL

Romazicon

Classification

• Benzodiazepine receptor antagonists

Dosage

• 2 ml IV given over 15 seconds

Action

• Antagonizes the effects of benzodiazepines

Indication

• Benzodiazepine-induced depression of the ventilatory responses to hypercapnia and hypoxia

Side Effects

• Nausea, vomiting, palpitations, sweating, flushing, dry mouth, tremors, insomnia, dyspnea, hyperventilation, blurred vision, headache, pain at injection site

Contraindications

• Control of ICP or status epilepticus.
• Signs of serious cyclic antidepressant overdose

Nursing Management

1. Must individualize dosage. Give only smallest amount effective.
2. Give through freely running IV infusion into large vein to minimize pain at injection site
3. Note history of seizure or panic disorder
4. Assess evidence of increased ICP
5. Note evidence of sedative and benzodiazepine dependence
6. Instruct to avoid alcohol and non-prescription drugs for 1-24 hrs

DOPAMINE

Intropine

Classification

• Adrenergic drugs

Dosage

• Initially 2-5 mcg/kg/min by IV

Action

• Stimulates dopaminergic and alpha and beta receptors of the sympathetic nervous system resulting in positive inotropic effect and increased CO

Indication

• To treat shock and correct hemodynamic imbalances
• To correct hypotension
• To improve perfusion of vital organs
• To increase CO

Side Effects

• CNS: headache an anxiety
• CV: tachy, angina, palpitations and vasoconstriction
• GI: nausea and vomiting

Contraindications

• Hypersensitivity
• With uncorrect tachyarrhythmias
• Pheochromocytoma
• Ventricular Fibrillation

Nursing Management

• Most patients received less than 20 mcg/kg/min
• Drugs isn't substitute for blood or fluid volume deficit
• During infusion, monitor ECG, BP, CO, PR and color and temp of the limbs
• Do not confuse dopamine to dobutamine
• Check urine output often

DOBUTAMINE

Dobutrex

Classification

• Adrenergic drugs

Dosage

• 0.5-1 mcg/kg/min IV infusion, titrating to optimum dosage of 2-20 mcg/kg/min
• 2.5 to 10 mcg/kg/min-usual effective range to increase CO

Action

• Stimulates heart beta receptors to increase myocardial contractility and SV

Indication

• To increase CO
• Treatment of cardiac decompensation

Side Effects

• CNS: headache
• CV: HPN, tachycardia, palpitations and vasoconstriction
• GI: nausea and vomiting

Contraindications

• Hypersensitivity
• Use cautiously in pts with hx of HPN and AMI

Nursing Management

• Before starting therapy, give a plasma volume expander to correct hypovolemia and a cardiac glycoside
• Monitor ECG, BP, pulmonary artery wedge pressure and CO
• Monitor electrolyte levels
• Don't confuse dobutamine to dopamine

GLUCAGON

Classification

• Pancreatic Hormones

Dosage

• 0.5-1 mg SQ, IV, IM, repeat in 20 mins PRN

Action

• Binds with glucagon receptor

Indication

• Hypoglycemia

Side Effects

• Nausea, vomiting, hypotension, tachycardia and hypertension

Contraindications

• Hypersensitivity
• Pheochromocytoma
• Insulinoma

Nursing Management

• Monitor V/S and blood sugar level
• Response within 20 mins after injection

ALBUTEROL

Ventolin

Classification

• Bronchodilator, Adrenergic

Dosage

• 2 inhalations reputed q 4-6 hrs via neb

Action

• Activation of beta adrenergic receptors on airway smooth muscle

Indication

• Asthma
• Prevention of exercise induced spasms

Side effects

• Palpitations
• Tachycardia
• GI upset
• Nervousness

Contraindications

• Hypersensitivity

Nursing Management

• Monitor therapeutic effectiveness
• Monitor HR, BP, ABG, s/sx of bronchospasm and CNS stimulation
• Instruct on how to use inhaler properly
• Rinse mouth after use

DIPHENHYDRAMINE HCL

Benadryl

Classification

• Anti-histamine

Dosage

• 25-50 mg PO, IV or IM bid-tid

Action

• Blocks the effects Hi receptor sites

Indication

• Allergic reactions
• Motion sickness
• Cough suppression
• Sedation

Side Effects

• Xerostomia
• Urinary retention
• Sedation

Contraindications

• Acute asthmatic attack

Nursing Management

• Risk for photosensitivity
• use sunscreen