NurseSheet

abacavir

ah-bah-kay-veer

(Ziagen)

FIXED-COMBINATION(S)

Epzicom: abacavir/lamivudine (antiretroviral): 600 mg/300 mg. Trizivir: abacavir/lamivudine (antiretroviral)/zidovudine (antiretroviral): 300 mg/150 mg/300 mg.

G CLASSIFICATION

PHARMACOTHERAPEUTIC: Antiretroviral agent. CLINICAL: Antiviral.

ACTION

An antiretroviral that inhibits the activity of HIV-1 reverse transcriptase by competing with the natural substrate deoxyguanosine-5'-triphosphate dGTP and by its incorporation into viral DNA. Therapeutic Effect: Inhibits viral DNA growth.

PHARMACOKINETICS

Rapidly and extensively absorbed after PO administration. Protein binding: 50%. Widely distributed, including to cerebrospinal fluid (CSF) and erythrocytes. Metabolized in the liver to inactive metabolites. Primarily excreted in urine. Unknown if removed by hemodialysis. Half-life: 1.5 hr.

USES

Treatment of HIV infection, in combination with other agents.

PRECAUTIONS

CONTRAINDICATIONS: Moderate or severe hepatic impairment. CAUTIONS: Liver disease.

B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Unknown if excreted in breast milk. Do not breast-feed while taking abacavir (may increase potential for HIV transmission, adverse effects). Pregnancy Category B. Children: No safety issues noted in those 3 moU13 yr. Elderly: No information available.

INTERACTIONS

DRUG: Alcohol: May increase abacavir blood concentration and half-life. HERBAL: St. John's wort: May decrease abacavir blood concentration and effect. FOOD: None known. LAB VALUES: May increase blood glucose and serum GGT, AST, ALT, and triglyceride levels.

AVAILABILITY (Rx)

TABLETS: 300 mg. ORAL SOLUTION: 20 mg/ml.

ADMINISTRATION/HANDLING

N May give without regard to food. N Oral solution may be refrigerated. Do not freeze.

INDICATIONS/ROUTES/DOSAGE

HIV INFECTION (IN COMBINATION WITH OTHER ANTIRETROVIRALS)

PO: ADULTS: 300 mg twice a day or 600 mg once daily. CHILDREN: (3 moU16 yr) 8 mg/kg twice a day. Maximum: 300 mg twice a day.

DOSAGE IN HEPATIC IMPAIRMENT

Mild impairment: 200 mg twice a day. Moderate to severe impairment: Not recommended.

SIDE EFFECTS

ADULT: FREQUENT: Nausea (47%), nausea with vomiting (16%), diarrhea (12%), decreased appetite (11%). OCCASIONAL: Insomnia (7%). CHILDREN: FREQUENT: Nausea with vomiting (39%), fever (19%), headache, diarrhea (16%), rash (11%). OCCASIONAL: Decreased appetite (9%).

ADVERSE REACTIONS/TOXIC EFFECTS

A hypersensitivity reaction may be life-threatening. Signs and symptoms include fever, rash, fatigue, intractable nausea and vomiting, severe diarrhea, abdominal pain, cough, pharyngitis, and dyspnea. Life-threatening hypotension may occur. Lactic acidosis and severe hepatomegaly may occur.

NURSING CONSIDERATIONS

BASELINE ASSESSMENT

Question for possibility of pregnancy. Obtain baseline laboratory testing, especially liver function tests, before beginning therapy and at periodic intervals during therapy. Offer emotional support.

INTERVENTION/EVALUATION

Assess for nausea, vomiting. Determine pattern of bowel activity and stool consistency. Assess eating pattern; monitor for weight loss. Monitor lab values carefully, particularly liver function.

PATIENT/FAMILY TEACHING

N Do not take any medications, including OTC drugs, without consulting physician. N Small, frequent meals may offset anorexia, nausea. N Abacavir is not a cure for HIV infection, nor does it reduce risk of transmission to others.

abarelix A

ah-bare-eh-licks

(Plenaxis)

G CLASSIFICATION

PHARMACOTHERAPEUTIC: Gonadotropin-releasing hormone antagonist. CLINICAL: Sex hormone.

ACTION

A luteinizing hormone-releasing hormone (LHRH) antagonist that inhibits gonadotropin and androgen production by blocking gonadotropin releasing-hormone (GnRH) receptors in the pituitary. Therapeutic Effect: Suppresses luteinizing hormone, follicle stimulating hormone secretion, reducing the secretion of testosterone by the testes.

PHARMACOKINETICS

Slowly absorbed following intramuscular administration. Distributed extensively. Protein binding: 96%U99%. Half-life: 13.2 days.

USES

Treatment of men with advanced symptomatic prostate cancer in whom luteinizing hormone release hormone (LHRH) agonist therapy is not appropriate, who refuse surgical castration, and have 1 or more of the following: 1) risk of neurologic compromise due to metastases, 2) ureteral or bladder outlet obstruction, or 3) severe bone pain from bone metastases.

PRECAUTIONS

CONTRAINDICATIONS: Female patients, children, pregnancy. CAUTIONS: Patients with prolonged QT interval, patients weighing more than 225 lb (103 kg).

B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Embryolethal. Mothers should avoid breast-feeding. Pregnancy Category X. Children: Not indicated for use in pediatric patients. Elderly: No age-related precautions noted.

INTERACTIONS

DRUG: Amiodarone, procainamide, quinidine, sotalol: May increase risk of cardiotoxicity. HERBAL: None known. FOOD: None known. LAB VALUES: May increase serum transaminase, serum AST, ALT, and serum triglyceride levels. May slightly decrease blood hemoglobin concentrations. May decrease bone mineral density.

AVAILABILITY (Rx)

POWDER FOR INJECTION: 113 mg kit containing 10 ml 0.9% NaCl, 18-gauge needle, 22-gauge needle (provides 100 mg/2 ml when reconstituted).

ADMINISTRATION/HANDLING

Reconstitution N Before reconstitution, shake vial gently. Withdraw 2.2 ml 0.9% NaCl, and inject diluent quickly. N Shake immediately for approximately 15 sec. Let vial stand for 2 min. N Tap vial to reduce foaming and swirl vial occasionally. N Shake again for approximately 15 sec. N Allow vial to stand for 2 min.

Rate of administration N Following reconstitution, administer within 1 hr. N Administer at dorsogluteal or ventrogluteal region of buttock. N Following administration, monitor patient for 30 min (cumulative risk for allergic reaction increases with each injection).

Storage N Store at room temperature.

INDICATIONS/ROUTES/DOSAGE

PROSTATE CANCER

IM: ADULTS, ELDERLY: 100 mg on days 1, 15, 29 and q4wks thereafter. Treatment failure can be detected by obtaining serum testosterone concentration prior to abarelix administration, day 19 and q8wks thereafter.

SIDE EFFECTS

FREQUENT (79%U30%): Hot flashes, sleep disturbances, breast enlargement. OCCASIONAL (20%U11%): Breast pain, nipple tenderness, back pain, constipation, peripheral edema, dizziness, upper respiratory tract infection, diarrhea. RARE (10%): Fatigue, nausea, dysuria, micturition frequency, urinary retention, urinary tract infection.

ADVERSE REACTIONS/TOXIC EFFECTS

O ALERT P Immediate-onset systemic allergic reaction characterized by hypotension, urticaria, pruritus, periorbital and/or circumoral edema, shortness of breath, wheezing, and syncope may occur.

Prolongation of the QT interval may occur. Esophageal spasm, tongue swelling, wheezing, shortness of breath, and hypotension occur rarely.

NURSING CONSIDERATIONS

BASELINE ASSESSMENT

Inform patient of treatment duration and required monitoring procedures. Obtain serum transaminase levels before treatment and periodically thereafter.

INTERVENTION/EVALUATION

Monitor patient for at least 30 min each time abarelix is given. Assess for systemic allergic reaction. Measure serum testosterone concentration before administration beginning on day 29 and q8wk thereafter. Monitor periodic serum prostate-specific antigen (PSA) levels.

PATIENT/FAMILY TEACHING

N Inform physician or nurse immediately if rash, hives, itching, tingling, flushing occurs (skin reaction may occur immediately after injection or several days later).

abciximab A

ab-six-ih-mab

(c7E3 Fab, ReoPro)

G CLASSIFICATION

PHARMACOTHERAPEUTIC: Glycoprotein IIb/IIIa receptor inhibitor. CLINICAL: Antiplatelet; antithrombotic.

ACTION

A glycoprotein IIb/IIIa receptor inhibitor that rapidly inhibits platelet aggregation by preventing the binding of fibrinogen to GP IIb/IIIa receptor sites on platelets. Therapeutic Effect: Prevents closure of treated coronary arteries. Prevents acute cardiac ischemic complications.

PHARMACOKINETICS

Rapidly cleared from plasma. Initial-phase half-life is less than 10 min; second-phase half-life is 30 min. Platelet function generally returns within 48 hr.

USES

Adjunct to aspirin and heparin therapy to prevent cardiac ischemic complications in patients undergoing percutaneous coronary intervention (PCI) and those with unstable angina not responding to conventional medical therapy when PCI is planned within 24 hr.

PRECAUTIONS

CONTRAINDICATIONS: Active internal bleeding, arteriovenous malformation or aneurysm, cerebrovascular accident (CVA) with residual neurologic defect, history of CVA (within the past 2 yrs) or oral anticoagulant use within the past 7 days unless PT is less than 1.2 x control, history of vasculitis, hypersensitivity to murine proteins, intracranial neoplasm, prior IV dextran use before or during percutaneous transluminal coronary angioplasty (PTCA), recent surgery or trauma (within the past 6 wks), recent (within the past 6 wks or less) GI or GU bleeding, thrombocytopenia (less than 100,000 cells/mcl), and severe uncontrolled hypertension. CAUTIONS: Patients who weigh less than 75 kg; those older than 65 yr; those with history of GI disease; those receiving thrombolytics, heparin, aspirin, percutaneous transluminal coronary angioplasty (PTCA) less than 12 hr of onset of symptoms for acute MI, prolonged PTCA (longer than 70 min), failed PTCA.

B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Unknown if distributed in breast milk. Pregnancy Category C. Children: Safety and efficacy not established. Elderly: Increased risk of major bleeding.

INTERACTIONS

DRUG: Anticoagulants, including heparin: May increase risk of hemorrhage. Platelet aggregation inhibitors (such as aspirin, dextran, thrombolytic agents): May increase risk of bleeding. HERBAL: None known. FOOD: None known. LAB VALUES: Increases activated clotting time (ACT), aPTT, and PT. Decreases platelet count.

AVAILABILITY (Rx)

INJECTION: 2 mg/ml (5-ml vial).

ADMINISTRATION/HANDLING

L IV

Reconstitution N Use 0.2- to 0.22-micron filter; filtering may be done during preparation or at administration. N Bolus dose may be given undiluted. N Withdraw desired dose and further dilute in 250 ml of 0.9% NaCl or D5W (e.g., 10 mg in 250 ml equals concentration of 40 mcg/ml).

Rate of administration N See Indications/Routes/Dosage.

Administration precautions N Give in separate IV line; do not add any other medication to infusion. N For bolus injection and continuous infusion, use sterile, nonpyrogenic, low protein-binding 0.2- or 0.22-micron filter. N While vascular sheath is in position, maintain patient on complete bed rest with head of bed elevated at 30°. N Maintain affected limb in straight position. N After sheath removal, apply femoral pressure for 30 min, either manually or mechanically, then apply pressure dressing.

Storage N Store vials in refrigerator. Solution appears clear, colorless. Do not shake. Discard any unused portion left in vial or if preparation contains any opaque particles.

D IV INCOMPATIBILITY

Administer in separate line; no other medication should be added to infusion solution.

INDICATIONS/ROUTES/DOSAGE

PERCUTANEOUS CORONARY INTERVENTION (PCI)

IV BOLUS: ADULTS: 0.25 mg/kg 10U60 min before angioplasty or atherectomy, then 12-hr IV infusion of 0.125 mcg/kg/min. Maximum: 10 mcg/min.

PCI (UNSTABLE ANGINA)

IV BOLUS: ADULTS: 0.25 mg/kg, followed by 18- to 24-hr infusion of 10 mcg/min, ending 1 hr after procedure.

SIDE EFFECTS

FREQUENT: Nausea (16%), hypotension (12%). OCCASIONAL (9%): Vomiting. RARE (3%): Bradycardia, confusion, dizziness, pain, peripheral edema, urinary tract infection.

ADVERSE REACTIONS/TOXIC EFFECTS

Major bleeding complications may occur. If complications occur, stop the infusion immediately. Hypersensitivity reaction may occur. Atrial fibrillation or flutter, pulmonary edema, and complete AV block occur occasionally.

NURSING CONSIDERATIONS

BASELINE ASSESSMENT

Heparin should be discontinued 4 hr before arterial sheath removal. Maintain patient on bed rest for 6U8 hr following sheath removal or drug discontinuation, whichever is later. Check platelet count, PT, aPTT before infusion (assess for preexisting blood abnormalities), 2U4 hr following treatment, and at 24 hr or before discharge, whichever is first. Check insertion site, distal pulse of affected limb while femoral artery sheath is in place, and then routinely for 6 hr following femoral artery sheath removal. Minimize need for injections, blood draws, intubations, catheters.

INTERVENTION/EVALUATION

Stop abciximab and/or heparin infusion if any serious bleeding occurs that is uncontrolled by pressure. Assess skin for ecchymosis, petechiae, particularly femoral arterial access, also catheter insertion, arterial and venous puncture, cutdown, needle sites. Handle patient carefully and as infrequently as possible to prevent bleeding. Do not obtain BP in lower extremities (possible deep vein thrombi). Assess for decrease in BP, increase in pulse rate, complaint of abdominal or back pain, severe headache, evidence of GI hemorrhage. Monitor ACT, PT, aPTT, platelet counts. Question for increase in discharge during menses. Assess urine output for hematuria. Monitor for any occurring hematoma. Use care in removing any dressing, tape.

amphotericin B A

am-foe-tear-ih-sin

(Abelcet, AmBisome, Amphocin, Amphotec, Fungizone, Fungizone for Tissue Culture)

G CLASSIFICATION

CLINICAL: Antifungal, antiprotozoal.

ACTION

An antifungal and antiprotozoal that is generally fungistatic but may become fungicidal with high dosages or very susceptible microorganisms. This drug binds to sterols in the fungal cell membrane. Therapeutic Effect: Increases fungal cell-membrane permeability, allowing loss of potassium and other cellular components.

PHARMACOKINETICS

Protein binding: 90%. Widely distributed. Metabolic fate unknown. Cleared by nonrenal pathways. Minimal removal by hemodialysis. Amphotec and Abelcet are not dialyzable. Half-life: Fungizone, 24 hr (increased in neonates and children); Amphotec, 26U28 hr; Abelcet, 7.2 days; AmBisome, 100U153 hr.

USES

Abelcet: Treatment of invasive fungal infections refractory or intolerant to Fungizone. AmBisome: Empiric treatment for fungal infection in febrile neutropenic patients. Aspergillus, candida, or cryptococcus infections refractory to Fungizone or patient with renal impairment or toxicity with Fungizone. Treatment of visceral leishmaniasis. Amphotec: Treatment of invasive aspergillosis in patients with renal impairment or toxicity or prior treatment failure with Fungizone. Fungizone: Treatment of cryptococcosis, blastomycosis, systemic candidiasis, disseminated forms of moniliasis, coccidioidomycosis, and histoplasmosis, zygomycosis, sporotrichosis, aspergillosis. Topical: Treatment of cutaneous/mucocutaneous infections caused by Candida albicans (paronychia, oral thrush, perle‘che, diaper rash, intertriginous candidiasis). OFF-LABEL: Febrile neutropenia, meningoencephalitis, paracoccidioidomycosis

PRECAUTIONS

CONTRAINDICATIONS: Hypersensitivity to amphotericin B or sulfites. CAUTIONS: Renal impairment, in combination with antineoplastic therapy. Give only for progressive, potentially fatal fungal infection.

B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Crosses placenta; unknown if distributed in breast milk. Pregnancy Category B. Children: Safety and efficacy not established, but use the least amount for therapeutic regimen. Elderly: No age-related precautions noted.

INTERACTIONS

DRUG: Bone marrow depressants: May increase the risk of anemia. Digoxin: May increase the risk of digoxin toxicity from hypokalemia. Nephrotoxic medications: May increase the risk of nephrotoxicity. Steroids: May cause severe hypokalemia. HERBAL: None known. FOOD: None known. LAB VALUES: May increase BUN, serum alkaline phosphatase, serum creatinine, serum AST, and ALT levels. May decrease serum calcium, magnesium, and potassium levels.

AVAILABILITY (Rx)

CREAM (FUNGIZONE): 3% INJECTION (POWDER FOR RECONSTITUTION): 50 mg (AmBisome, Amphocin, Amphotec, Fungizone), 100 mg (Amphotec). INJECTION (SUSPENSION [ABELCET]): 5 mg/ml.

ADMINISTRATION/HANDLING

L IV

N Monitor BP, temperature, pulse, respirations; assess for adverse reactions q15min twice, then q30min for 4 hr after initial infusion. N Potential for thrombophlebitis may be less with use of pediatric scalp vein needles or (with physician order) adding dilute heparin solution. N Observe strict aseptic technique because no bacteriostatic agent or preservative is present in diluent.

Reconstitution

ABELCET

N Shake 20-ml (100-mg) vial gently until contents are dissolved. Withdraw required dose using 5-micron filter needle (supplied by manufacturer). N Inject dose into D5W; 4 ml D5W required for each 1 ml (5 mg) to final concentration of 1 mg/ml. Reduce dose by half for pediatric, fluid-restricted patients (2 mg/ml).

AMBISOME

N Reconstitute each 50-mg vial with 12 ml sterile water for injection to provide concentration of 4 mg/ml. N Shake vial vigorously for 30 sec. Withdraw required dose and empty syringe contents through a 5-micron filter into an infusion of D5W to provide final concentration of 1U2 mg/ml.

AMPHOTEC

N Add 10 ml sterile water for injection to each 50-mg vial to provide concentration of 5 mg/ml. Shake gently. N Further dilute only with D5W using specific amount recommended by manufacturer to provide concentration of 0.16U0.83 mg/ml.

FUNGIZONE

N Rapidly inject 10 ml sterile water for injection to each 50-mg vial to provide concentration of 5 mg/ml. Immediately shake vial until solution is clear. N Further dilute each 1 mg in at least 10 ml D5W to provide a concentration of 0.1 mg/ml.

Rate of administration

N Give by slow IV infusion. Infuse conventional amphotericin or Fungizone over 2U6 hr; Abelcet over 2 hr (shake contents if infusion longer than 2 hr); Amphotec over 2U4 hr; AmBisome over 1U2 hr.

Storage

ABELCET

N Refrigerate unreconstituted solution. Reconstituted solution is stable for 48 hr if refrigerated; 6 hr at room temperature.

AMBISOME

N Refrigerate unreconstituted solution. Reconstituted solution of 4 mg/ml is stable for 24 hr. Concentration of 1U2 mg/ml is stable for 6 hr.

AMPHOTEC

N Store unreconstituted solution at room temperature. Reconstituted solution stable for 24 hr.

FUNGIZONE

N Refrigerate unreconstituted solution. N Reconstituted solution is stable for 24 hr at room temperature or 7 days if refrigerated. N Diluted solution 0.1 mg/ml or less to be used promptly. Do not use if cloudy or contains a precipitate.

D IV INCOMPATIBILITIES

Abelcet, AmBisome, Amphotec: Don't mix with any other drug, diluent, or solution. Fungizone: Allopurinol (Aloprim), amifostine (Ethyol), aztreonam (Azactam), calcium gluconate, cefepime (Maxipime), cimetidine (Tagamet), ciprofloxacin (Cipro), docetaxel (Taxotere), dopamine (Intropin), doxorubicin (Adriamycin), enalapril (Vasotec), etoposide (VP-16), filgrastim (Neupogen), fluconazole (Diflucan), fludarabine (Fludara), foscarnet (Foscavir), gemcitabine (Gemzar), magnesium sulfate, meropenem (Merrem IV), ondansetron (Zofran), paclitaxel (Taxol), piperacillin and tazobactam (Zosyn), potassium chloride, propofol (Diprivan), total parenteral nutrition (TPN), vinorelbine (Navelbine).

IV COMPATIBILITIES

None known; don't mix with other medications or electrolytes.

INDICATIONS/ROUTES/DOSAGE

CRYPTOCOCCOSIS; BLASTOMYCOSIS; SYSTEMIC CANDIDIASIS; DISSEMINATED FORMS OF MONILIASIS, COCCIDIOIDOMYCOSIS, AND HISTOPLASMOSIS; ZYGOMYCOSIS; SPOROTRICHOSIS; ASPERGILLOSIS

IV INFUSION (FUNGIZONE): ADULTS, ELDERLY: Dosage based on patient tolerance and severity of infection. Initially, 1-mg test dose is given over 20U30 min. If test dose is tolerated, 5-mg dose may be given the same day. Subsequently, dosage is increased by 5 mg q12U24h until desired daily dose is reached. Alternatively, if test dose is tolerated, 0.25 mg/kg is given on same day and 0.5 mg/kg on second day; then dosage is increased until desired daily dose reached. Total daily dose: 1 mg/kg/day up to 1.5 mg/kg every other day. Maximum: 1.5 mg/kg/day. CHILDREN: Test dose of 0.1 mg/kg/dose (maximum: 1 mg) is infused over 20U60 min. If test dose is tolerated, initial dose of 0.4 mg/kg may be given on same day; dosage is then increased in 0.25-mg/kg increments as needed. Maintenance dose: 0.25U1 mg/kg/day.

INVASIVE FUNGAL INFECTIONS UNRESPONSIVE TO OR INTOLERANT OF FUNGIZONE

IV INFUSION (ABELCET): ADULTS, CHILDREN: 2.5U5 mg/kg at rate of 2.5 mg/kg/hr.

EMPIRIC TREATMENT OF FUNGAL INFECTIONS IN PATIENTS WITH FEBRILE NEUTROPENIA; ASPERGILLOSIS, CANDIDIASIS, OR CRYPTOCOCCOSIS IN PATIENTS WITH RENAL IMPAIRMENT AND THOSE WHO HAVE EXPERIENCED TOXICITY OR TREATMENT FAILURE WITH FUNGIZONE

IV INFUSION (AMBISOME): ADULTS, CHILDREN: 3U5 mg/kg over 1 hr.

INVASIVE ASPERGILLOSIS IN PATIENTS WITH RENAL IMPAIRMENT AND THOSE WHO HAVE EXPERIENCED TOXICITY OR TREATMENT FAILURE WITH FUNGIZONE

IV INFUSION (AMPHOTEC): ADULTS, CHILDREN: 3U4 mg/kg over 2U4 hr. Maximum: 7.5 mg/kg/day.

CUTANEOUS AND MUCOCUTANEOUS INFECTIONS CAUSED BY CANDIDA ALBICANS, SUCH AS PARONYCHIA, ORAL THRUSH, PERLÈCHE, DIAPER RASH, AND INTERTRIGINOUS CANDIDIASIS

TOPICAL: ADULTS, ELDERLY, CHILDREN: Apply liberally to affected area and rub in 2U4 times a day.

SIDE EFFECTS

FREQUENT (greater than 10%): Abelcet: Chills, fever, increased serum creatinine level, multiple organ failure. Ambisome: Hypokalemia, hypomagnesemia, hyperglycemia, hypocalcemia, edema, abdominal pain, back pain, chills, chest pain, hypotension, diarrhea, nausea, vomiting, headache, fever, rigors, insomnia, dyspnea, epistaxis, increased hepatic or renal function test results. Amphotec: Chills, fever, hypotension, tachycardia, increased serum creatinine level, hypokalemia, bilirubinemia. Fungizone: Fever, chills, headache, anemia, hypokalemia, hypomagnesemia, anorexia, malaise, generalized pain, nephrotoxicity. Topical: Local irritation, dry skin. RARE: Topical: Rash.

ADVERSE REACTIONS/TOXIC EFFECTS

Cardiovascular toxicity (as evidenced by hypotension, ventricular fibrillation, and anaphylaxis) occurs rarely. Altered vision and hearing, seizures, hepatic failure, coagulation defects, multiple organ failure, and sepsis may be noted.

NURSING CONSIDERATION

BASELINE ASSESSMENT

Question for history of allergies, especially to amphotericin B, sulfite. Avoid, if possible, other nephrotoxic medications. Obtain premedication orders to reduce adverse reactions during IV therapy (antipyretics, antihistamines, antiemetics, or small doses of corticosteroids given before or during amphotericin administration may control reactions).

INTERVENTION/EVALUATION

Monitor BP, temperature, pulse, respirations; assess for adverse reactions (fever, tremors, chills, anorexia, nausea, vomiting, abdominal pain) q15min twice, then q30min for 4 hr of initial infusion. If symptoms occur, slow infusion, administer medication for symptomatic relief. For severe reaction or without symptomatic relief orders, stop infusion and notify physician. Evaluate IV site for phlebitis (heat, pain, red streaking over vein). Monitor I&O, renal function tests for nephrotoxicity. Check serum potassium and magnesium levels, hematologic and hepatic function test results. Topical: Assess for itching, irritation, burning.

PATIENT/FAMILY TEACHING

N Prolonged therapy (weeks or months) is usually necessary. N Fever reaction may decrease with continued therapy. N Muscle weakness may be noted during therapy (due to hypokalemia). Topical: Application may cause staining of skin or nails; soap and water or dry cleaning will remove fabric stains. N Do not use other preparations or occlusive coverings without consulting physician. N Keep areas clean, dry; wear light clothing. N Separate personal items with direct contact to area.

acetaminophen

ah-see-tah-min-oh-fen

(Abenol J, Apo-Acetaminophen J, Atasol J, Feverall, Mapap, Tempra, Tylenol)

Do not confuse with Fiorinal, Hycodan, Indocin, Percodan, or Tuinal.

FIXED-COMBINATION(S)

Anexsia: acetaminophen/hydrocodone: 500 mg/5 mg, 650 mg/7.5 mg, 660 mg/10 mg. Balacet 325: acetaminophen/propoxyphene napsylate: 325 mg/100 mg. Capital with Codeine, Tylenol with Codeine: acetaminophen/codeine: 120 mg/12 mg per 5 ml. Darvocet-N: acetaminophen/propoxyphene: 325 mg/50 mg, 650 mg/100 mg. Fioricet: acetaminophen/caffeine/butalbital: 325 mg/40 mg/50 mg. Hycet: acetaminophen/hydrocodone: 325 mg/7.5 mg per 15 ml. Lortab: acetaminophen/hydrocodone: 500 mg/2.5 mg; 500 mg/5 mg; 500 mg/7.5 mg. Lortab Elixir: acetaminophen/hydrocodone: 167 mg/2.5 mg per 5 ml. Norco: acetaminophen/hydrocodone: 325 mg/10 mg. Percocet, Roxicet: acetaminophen/oxycodone: 325 mg/5 mg. Tylenol with Codeine: acetaminophen/codeine: 300 mg/15 mg, 300 mg/30 mg, 300 mg/60 mg. Tylox: acetaminophen/oxycodone: 500 mg/5 mg. Ultracet: acetaminophen/tramadol: 325 mg/37.5 mg. Vicodin: acetaminophen/hydrocodone: 500 mg/5 mg. Vicodin ES: acetaminophen/hydrocodone: 750 mg/7.5 mg. Vicodin HP: acetaminophen/hydrocodone: 660 mg/10 mg. Zydone: acetaminophen/hydrocodone: 400 mg/5 mg; 400 mg/7.5 mg; 400 mg/10 mg.

G CLASSIFICATION

PHARMACOTHERAPEUTIC: Central analgesic. CLINICAL: Non-narcotic analgesic, antipyretic.

ACTION

A central analgesic whose exact mechanism is unknown, but appears to inhibit prostaglandin synthesis in the CNS and, to a lesser extent, block pain impulses through peripheral action. Acetaminophen acts centrally on hypothalamic heat-regulating center, producing peripheral vasodilation (heat loss, skin erythema, sweating). Therapeutic Effect: Results in antipyresis. Produces analgesic effect.

PHARMACOKINETICS

Route Onset Peak Duration

PO 15U30 min 1 U1.5 hr 4U6 hr

Rapidly, completely absorbed from GI tract; rectal absorption variable. Protein binding: 20%U50%. Widely distributed to most body tissues. Metabolized in liver; excreted in urine. Removed by hemodialysis. Half-life: 1U4 hr (half-life is increased in those with hepatic disease, elderly, neonates; decreased in children).

USES

Relief of mild to moderate pain, fever.

PRECAUTIONS

CONTRAINDICATIONS: Active alcoholism, liver disease, or viral hepatitis, all of which increase the risk of hepatotoxicity. CAUTIONS: Sensitivity to acetaminophen, severe impaired renal function, phenylketonuria, G6PD deficiency.

B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Crosses placenta; distributed in breast milk. Routinely used in all stages of pregnancy, appears safe for short-term use. Pregnancy Category B. Children/Elderly: No age-related precautions noted.

INTERACTIONS

DRUG: Alcohol (chronic use), hepatotoxic medications (e.g., phenytoin), liver enzyme inducers (e.g., cimetidine): May increase risk of hepatotoxicity with prolonged high dose or single toxic dose. Warfarin: May increase the risk of bleeding with regular use. HERBAL: None known. FOOD: None known. LAB VALUES: May increase serum bilirubin, PT (may indicate hepatotoxicity), AST, and ALT. Therapeutic serum level: 10U30 mcg/ml; toxic serum level: greater than 200 mcg/ml.

AVAILABILITY (OTC)

CAPLETS (GENAPAP, TYLENOL): 500 mg. CAPLETS (EXTENDED-RELEASE) [MAPAP, TYLENOL ARTHRITIS PAIN]): 650 mg. CAPSULES (MAPAP): 500 mg. ELIXIR: 160 mg/5 ml. LIQUID (ORAL [TYLENOL EXTRA STRENGTH]): 500 mg/15 ml. SOLUTION (ORAL DROPS [GENAPAP INFANT]): 80 mg/0.8 ml. SUPPOSITORY (RECTAL): 80 mg (Feverall), 120 mg (Acephen, Feverall), 325 mg (Acephen, Feverall), 650 mg (Acephen, Feverall). TABLETS (GENAPAP, MAPAP, TYLENOL): 325 mg, 500 mg. TABLETS (CHEWABLE [GENAPAP, MAPAP, TYLENOL]): 80 mg.

ADMINISTRATION/HANDLING

N Give without regard to meals. N Tablets may be crushed.

RECTAL

N Moisten suppository with cold water before inserting well up into rectum.

INDICATIONS/ROUTES/DOSAGE

ANALGESIA AND ANTIPYRESIS

PO: ADULTS, ELDERLY, CHILDREN 13 YR AND OLDER: 325U650 mg q4U6h or 1 g 3U4 times/day. Maximum: 4 g/day. CHILDREN 12 YR AND YOUNGER: 10U15 mg/kg/dose q4U6h as needed. Maximum: 5 doses/24 hr. NEONATES: 10U15 mg/kg/dose q6U8h as needed.

RECTAL: ADULTS: 650 mg q4U6h. Maximum: 6 doses/24 hr. CHILDREN: 10U20 mg/kg/dose q4U6h as needed. NEONATES: 10U15 mg/kg/dose q6U8h as needed.

DOSAGE IN RENAL IMPAIRMENT

Creatinine Clearance Frequency

10U50 ml/min q6h

Less than 10 ml/min q8h

SIDE EFFECTS

RARE: Hypersensitivity reaction.

ADVERSE REACTIONS/TOXIC EFFECTS

Acetaminophen toxicity is the primary serious reaction. Early signs and symptoms of acetaminophen toxicity include anorexia, nausea, diaphoresis, and generalized weakness within the first 12U24 hr. Later signs of acetaminophen toxicity include vomiting, right upper quadrant tenderness, and elevated liver function tests within 48U72 hr after ingestion. The antidote to acetaminophen toxicity is acetylcysteine.

NURSING CONSIDERATIONS

BASELINE ASSESSMENT

If given for analgesia, assess onset, type, location, duration of pain. Effect of medication is reduced if full pain response recurs prior to next dose. Fixed-Combination: Obtain vital signs before giving medication. If respirations are 12/min or less (20/min or less in children), withhold medication, contact physician.

INTERVENTION/EVALUATION

Assess for clinical improvement and relief of pain, fever. Therapeutic serum level: 10U30 mcg/ml; toxic serum level: greater than 200 mcg/ml.

PATIENT/FAMILY TEACHING

N Consult physician for use in children younger than 2 yr; oral use longer than 5 days (children), longer than 10 days (adults), or fever longer than 3 days. N Severe/recurrent pain or high/continuous fever may indicate serious illness.

aripiprazole

air-ee-pip-rah-zole

(Abilify)

G CLASSIFICATION

PHARMACOTHERAPEUTIC: Dopamine agonist. CLINICAL: Antipsychotic agent.

ACTION

An antipsychotic agent that provides partial agonist activity at dopamine and serotonin (5-HT1A) receptors and antagonist activity at serotonin (5-HT2A) receptors. Therapeutic Effect: Diminishes schizophrenic behavior.

PHARMACOKINETICS

Well absorbed through the GI tract. Protein binding: 99% (primarily albumin). Reaches steady levels in 2 wk. Metabolized in the liver. Eliminated primarily in feces and, to a lesser extent, in urine. Not removed by hemodialysis. Half-life: 75 hr.

USES

Treatment of schizophrenia. Maintains stability in patients with schizophrenia. Treatment of bipolar disorder. OFF-LABEL: Schizoaffective disorder.

PRECAUTIONS

CONTRAINDICATIONS: None known. CAUTIONS: Concurrent use of CNS depressants (including alcohol), cardiovascular or cerebrovascular diseases (may induce hypotension), Parkinson’s disease (potential for exacerbation), history of seizures or conditions that may lower seizure threshold (Alzheimer’s disease), renal or hepatic impairment.

B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Unknown if drug crosses placenta. May be distributed in breast milk; avoid breast-feeding. Pregnancy Category C. Children: Safety and efficacy not established. Elderly: No age-related precautions noted.

INTERACTIONS

DRUG: Carbamazepine: May decrease the aripiprazole blood concentration. Fluoxetine, ketoconazole, quinidine, paroxetine: May increase the aripiprazole blood concentration. HERBAL: None known. FOOD: None known. LAB VALUES: None known.

AVAILABILITY (Rx)

TABLETS: 2 mg, 5 mg, 10 mg, 15 mg, 20 mg, 30 mg. ORAL SOLUTION: 1 mg/ml.

ADMINISTRATION/HANDLING

N Give without regard to food.

INDICATIONS/ROUTES/DOSAGE

SCHIZOPHRENIA

PO: ADULTS, ELDERLY: Initially, 10U15 mg once a day. May increase up to 30 mg/day.

BIPOLAR DISORDER

PO: ADULTS, ELDERLY: 30 mg once a day. May decrease to 15 mg/day based on patient tolerance.

SIDE EFFECTS

FREQUENT (11%U5%): Weight gain, headache, insomnia, vomiting. OCCASIONAL (4%U3%): Light-headedness, nausea, akathisia, somnolence. RARE (2% or less): Blurred vision, constipation, asthenia or loss of energy and strength, anxiety, fever, rash, cough, rhinitis, orthostatic hypotension.

ADVERSE REACTIONS/TOXIC EFFECTS

Extrapyramidal symptoms and neuroleptic malignant syndrome occur rarely. Prolonged QT interval occurs rarely.

NURSING CONSIDERATIONS

BASELINE ASSESSMENT

Assess behavior, appearance, emotional status, response to environment, speech pattern, thought content. Correct dehydration, hypovolemia.

INTERVENTION/EVALUATION

Periodically monitor weight. Monitor for extrapyramidal symptoms (abnormal movement), tardive dyskinesia (protrusion of tongue, puffing of cheeks, chewing/puckering of the mouth). Periodically monitor BP, pulse (particularly in those with preexisting cardiovascular disease). Assess for therapeutic response (greater interest in surroundings, improved self-care, increased ability to concentrate, relaxed facial expression).

PATIENT/FAMILY TEACHING

N Avoid alcohol. N Avoid tasks that require alertness, motor skills until response to drug is established.

tobramycin sulfate

tow-bra-my-sin

(AK-Tob, Apo-Tobramycin J, Nebcin, Nebcin Pediatric, PMS-Tobramycin, TOBI, Tobrex)

FIXED-COMBINATION(S)

TobraDex: tobramycin/dexamethasone (a steroid): 0.3%/0.1% per ml or per g. Zylet: tobramycin/loteprednol: 0.3%/0.5%.

G CLASSIFICATION

PHARMACOTHERAPEUTIC: Aminoglycoside. CLINICAL: Antibiotic.

ACTION

An aminoglycoside antibiotic that irreversibly binds to protein on bacterial ribosomes. Therapeutic Effect: Interferes with protein synthesis of susceptible microorganisms.

PHARMACOKINETICS

Rapid, complete absorption after IM administration. Protein binding: less than 30%. Widely distributed (doesn't cross the blood-brain barrier; low concentrations in cerebrospinal fluid (CSF). Excreted unchanged in urine. Removed by hemodialysis. Half-life: 2U4 hr (increased in impaired renal function and neonates; decreased in cystic fibrosis and febrile or burn patients).

USES

Treatment of susceptible infections due to P. aeruginosa, other gram negative organisms including skin and skin-structure, bone, joint, respiratory tract infections; postop, burn, intra-abdominal infections; complicated UTIs; septicemia; meningitis. Ophthalmic: Superficial eye infections: blepharitis, conjunctivitis, keratitis, corneal ulcers. Inhalation: Bronchopulmonary infections in patients with cystic fibrosis.

PRECAUTIONS

CONTRAINDICATIONS: Hypersensitivity to other aminoglycosides (cross-sensitivity) and their components. CAUTIONS: Renal impairment, preexisting auditory or vestibular impairment, concomitant use of neuromuscular blocking agents.

B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Drug readily crosses placenta; is distributed in breast milk. May cause fetal nephrotoxicity. Ophthalmic form should not be used in breast-feeding mothers and only when specifically indicated in pregnancy. Pregnancy Category C (B, ophthalmic form). Children: Immature renal function in neonates and premature infants may increase risk of toxicity. Elderly: Age-related renal impairment may increase risk of toxicity; dosage adjustment recommended.

INTERACTIONS

DRUG: Nephrotoxic medications, other aminoglycosides, ototoxic medications: May increase the risk of nephrotoxicity and ototoxicity. Neuromuscular blockers: May increase neuromuscular blockade. HERBAL: None known. FOOD: None known. LAB VALUES: May increase serum bilirubin, BUN, serum creatinine, serum LDH, AST, and ALT levels. May decrease serum calcium, magnesium, potassium, and sodium concentrations. Therapeutic peak serum level is 5U20 mcg/ml; therapeutic trough serum level is 0.5U2 mcg/ml. Toxic peak serum level is greater than 20 mcg/ml; toxic trough serum level is greater than 2 mcg/ml.

AVAILABILITY (Rx)

INJECTION SOLUTION: 10 mg/ml (Nebcin Pediatric), 40 mg/ml (Nebcin). INJECTION POWDER FOR RECONSTITUTION (NEBCIN): 1.2 g. OPHTHALMIC OINTMENT (TOBREX): 0.3%. OPHTHALMIC SOLUTION (AKTob, TOBREX): 0.3%. NEBULIZATION SOLUTION (TOBI): 60 mg/ml.

ADMINISTRATION/HANDLING

O ALERT P Coordinate peak and trough lab draws with administration times.

L IV

Reconstitution N Dilute with 50U200 ml D5W, 0.9% NaCl. Amount of diluent for infants, children depends on individual need.

Rate of administration N Infuse over 20U60 min.

Storage N Store vials at room temperature. N Solutions may be discolored by light or air (does not affect potency).

N To minimize discomfort, give deep IM slowly. N Less painful if injected into gluteus maximus rather than lateral aspect of thigh.

OPHTHALMIC

N Place finger on lower eyelid, pull out until a pocket is formed between eye and lower lid. N Hold dropper above pocket, place correct number of drops (¼U½ inch ointment) into pocket. Have patientt close eye gently. N Solution: Apply digital pressure to lacrimal sac for 1U2 min (minimizes drainage into nose and throat, reducing risk of systemic effects). N Ointment: Close eye for 1U2 min, rolling eyeball (increases contact area of drug to eye). N Remove excess solution or ointment around eye with tissue.

D IV INCOMPATIBILITIES

Amphotericin B complex (Abelcet, AmBisome, Amphotec), heparin, hetastarch (Hespan), indomethacin (Indocin), propofol (Diprivan), sargramostim (Leukine, Prokine).

IV COMPATIBILITIES

Amiodarone (Cordarone), calcium gluconate, diltiazem (Cardizem), furosemide (Lasix), hydromorphone (Dilaudid), insulin, magnesium sulfate, midazolam (Versed), morphine, theophylline, total parenteral nutrition (TPN).

INDICATIONS/ROUTES/DOSAGE

USUAL PARENTERAL DOSAGE

IV: ADULTS, ELDERLY: 3U6 mg/kg/day in 3 divided doses. Once daily dosing: 4U7 mg/kg every 24 hr. CHILDREN 7 DAYS AND OLDER: 6U7.5 mg/kg/day in 3U4 divided doses. CHILDREN YOUNGER THAN 7 DAYS: 2.5U4 mg/kg/day in 2 divided doses.

SUPERFICIAL EYE INFECTIONS, INCLUDING BLEPHARITIS, CONJUNCTIVITIS, KERATITIS, AND CORNEAL ULCERS

OPHTHALMIC OINTMENT: ADULTS, ELDERLY: Usual dosage, apply a thin strip to conjunctiva q8U12h (q3U4h for severe infections).

OPHTHALMIC SOLUTION: ADULTS, ELDERLY: Usual dosage, 1U2 drops in affected eye q4h (2 drops/hr for severe infections).

BRONCHOPULMONARY INFECTIONS IN PATIENTS WITH CYSTIC FIBROSIS

INHALATION SOLUTION: ADULTS: Usual dosage, 60U80 mg twice a day for 28 days, then off for 28 days. CHILDREN: 40U80 mg 2U3 times a day.

DOSAGE IN RENAL IMPAIRMENT

Dosage and frequency are modified based on the degree of renal impairment and the serum drug concentration. After a loading dose of 1U2 mg/kg, the maintenance dose and frequency are based on serum creatinine levels and creatinine clearance.

SIDE EFFECTS

OCCASIONAL: IM: Pain, induration. IV: Phlebitis, thrombophlebitis. Topical: Hypersensitivity reaction (fever, pruritus, rash, urticaria). Ophthalmic: Tearing, itching, redness, eyelid swelling. RARE: Hypotension, nausea, vomiting.

ADVERSE REACTIONS/TOXIC EFFECTS

Nephrotoxicity (as evidenced by increased BUN and serum creatinine levels and decreased creatinine clearance) may be reversible if the drug is stopped at the first sign of nephrotoxic symptoms. Irreversible ototoxicity (manifested as tinnitus, dizziness, ringing or roaring in ears, and hearing loss) and neurotoxicity (manifested as headache, dizziness, lethargy, tremor, and visual disturbances) occur occasionally. The risk of these reactions increases with higher dosages or prolonged therapy and when the solution is applied directly to the mucosa. Superinfections, particularly fungal infections, may result from bacterial imbalance with any administration route. Anaphylaxis may occur.

BASELINE ASSESSMENT

Dehydration must be treated before beginning parenteral therapy. Question for history of allergies, especially aminoglycosides and sulfite (and parabens for topical or ophthalmic routes). Establish baseline for hearing acuity.

INTERVENTION/EVALUATION

Monitor I&O (maintain hydration), urinalysis (casts, RBCs, WBCs, decrease in specific gravity). Monitor results of peak/trough blood tests. Therapeutic serum level: Peak: 5U20 mcg/ml; trough: 0.5U2 mcg/ml. Toxic serum level: Peak: over 20 mcg/ml; trough: over 2 mcg/ml. Be alert to ototoxic and neurotoxic symptoms. Evaluate IV site for phlebitis (heat, pain, red streaking over vein). Assess for rash. Be alert for superinfection, particularly genital or anal pruritus, changes of oral mucosa, diarrhea. When treating patients with neuromuscular disorders, assess respiratory response carefully. Ophthalmic: Assess for redness, swelling, itching, tearing.

PATIENT/FAMILY TEACHING

N Notify physician in event of any hearing, visual, balance, urinary problems, even after therapy is completed. N Ophthalmic: Blurred vision or tearing may occur briefly after application. N Contact physician if tearing, redness, irritation continues.

acamprosate calcium

ah-camp-pro-sate

(Campral)

G CLASSIFICATION

CLINICAL: Alcohol abuse deterrent.

ACTION

An alcohol abuse deterrent that appears to interact with glutamate and gamma-aminobutyric acid neurotransmitter systems centrally, restoring their balance. Therapeutic Effect: Reduces alcohol dependence.

PHARMACOKINETICS

Slowly absorbed from the GI tract. Steady-state plasma concentrations are reached within 5 days. Does not undergo metabolism. Excreted in urine. Half-life: 20U33 hr.

USES

Maintenance of alcohol abstinence in patients with alcohol dependence who are abstinent at treatment initiation.

PRECAUTIONS

CONTRAINDICATIONS: Severe renal impairment (creatinine clearance of 30 ml/min or less). CAUTIONS: Mental depression, renal impairment.

B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Unknown if distributed in breast milk. Pregnancy Category C. Children: Safety and efficacy not established. Elderly: Age-related decreased renal function may require dosage adjustment.

INTERACTIONS

DRUG: Antidepressants: May cause weight gain or loss. Nal-trexone: May increase acamprosate blood concentration. HERBAL: None known. FOOD: None known. LAB VALUES: None known.

AVAILABILITY (Rx)

TABLETS: 333 mg.

ADMINISTRATION/HANDLING

N Do not crush, break enteric-coated tablets. N Give without regard to meals; however, giving with food may aid in compliance of patients who regularly eat three meals daily.

INDICATIONS/ROUTES/DOSAGE

MAINTENANCE OF ALCOHOL ABSTINENCE IN ALCOHOL-DEPENDENT PATIENTS WHO ARE ABSTINENT AT INITIATION OF TREATMENT

PO: ADULTS, ELDERLY: Two tablets 3 times a day.

DOSAGE IN RENAL IMPAIRMENT

For patients with creatinine clearance of 30U49 ml/min, dosage is decreased to one tablet 3 times a day.

SIDE EFFECTS

FREQUENT (17%): Diarrhea. OCCASIONAL (6%U4%): Insomnia, asthenia, fatigue, anxiety, flatulence, nausea, depression, pruritus. RARE (3%U1%): Dizziness, anorexia, paresthesia, diaphoresis, dry mouth.

ADVERSE REACTIONS/TOXIC EFFECTS

Acute renal failure has been reported.

NURSING CONSIDERATIONS

BASELINE ASSESSMENT

Obtain BUN, serum creatinine before treatment. Assess motor responses (agitation, trembling, tension), autonomic responses (cold and clammy hands, diaphoresis).

INTERVENTION/EVALUATION

Monitor pattern of bowel activity and stool consistency. Assess sleep pattern and provide environment conducive to sleep (quiet environment, low lighting). Offer emotional support to anxious patient. Assist with ambulation if dizziness occurs.

PATIENT/FAMILY TEACHING

N Inform patient that medication does not eliminate or diminish withdrawal symptoms. N Avoid tasks that require alertness, motor skills until response to drug is established. N Advise patient that medication helps maintain abstinence only when used as a part of a treatment program that includes counseling and support.

albuterol

ale-beut-er-all

(AccuNeb, Asmavent J, Novosalmol J, Proventil, Proventil HFA, Proventil Repetabs, Ventolin, Ventolin HFA, Volmax, Vospire ER)

Do not confuse albuterol with Albutein or atenolol, or Proventil with Prinivil.

FIXED-COMBINATION(S)

Combivent: albuterol/ipratropium (a bronchodilator): 103 mcg/18 mcg per actuation. Duoneb: albuterol/ipratropium 3 mg/0.5 mg.

G CLASSIFICATION

PHARMACOTHERAPEUTIC: Sympathomimetic (adrenergic agonist). CLINICAL: Bronchodilator.

ACTION

A sympathomimetic that stimulates beta2-adrenergic receptors in the lungs, resulting in relaxation of bronchial smooth muscle. Therapeutic Effect: Relieves bronchospasm and reduces airway resistance.

PHARMACOKINETICS

Route Onset Peak Duration

PO 15U30 min 2U3 hr 4U6 hr

PO 30 min 2U4 hr 12 hr

(extended-release)

Rapidly, well absorbed from the GI tract; gradually absorbed from the bronchi after inhalation. Metabolized in the liver. Primarily excreted in urine. Half-life: 2.7U5 hr (PO); 3.8 hr (inhalation).

USES

Relief of bronchospasm due to reversible obstructive airway disease, exercise-induced bronchospasm.

PRECAUTIONS

CONTRAINDICATIONS: History of hypersensitivity to sympathomimetics. CAUTIONS: Hypertension, cardiovascular disease, hyperthyroidism, diabetes mellitus.

B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Appears to cross placenta; unknown if distributed in breast milk. May inhibit uterine contractility. Pregnancy Category C. Children: Safety and efficacy not established in children younger than 2 yr (syrup) or younger than 6 yr (tablets). Elderly: May be more sensitive to tremor or tachycardia due to age-related increased sympathetic sensitivity.

INTERACTIONS

DRUG: Beta blockers: Antagonize effects of albuterol. Digoxin: May increase the risk of arrhythmias. MAOIs, tricyclic antidepressants: May potentiate cardiovascular effects. HERBAL: None known. FOOD: None known. LAB VALUES: May increase blood glucose level. May decrease serum potassium level.

AVAILABILITY (Rx)

SYRUP: 2 mg/5 ml. TABLETS (PROVENTIL, VENTOLIN): 2 mg, 4 mg. TABLETS (EXTENDED-RELEASE): 4 mg (Proventil Repetabs, Volmax, VoSpire ER), 8 mg (Volmax, VoSpire ER). INHALATION AEROSOL (PROVENTIL, VENTOLIN): 90 mcg/spray. INHALATION SOLUTION (ACCUNEB): 0.75 mg/3 ml (0.63 mg/3 ml albuterol), 1.5 mg/3 ml (1.25 mg/3 ml albuterol). INHALATION SOLUTION: 0.083% (Proventil), 0.5% (Proventil, Ventolin).

ADMINISTRATION/HANDLING

N Do not crush/break extended-release tablets. N May give without regard to food.

INHALATION

N Shake container well before inhalation N Wait 2 min before inhaling second dose (allows for deeper bronchial penetration). N Rinse mouth with water immediately after inhalation (prevents mouth/throat dryness).

NEBULIZATION

N Dilute 0.5 ml of 0.5% solution to final volume of 3 ml with 0.9% NaCl to provide 2.5 mg N Administer over 5U15 min. N Nebulizer should be used with compressed air or O2 at rate of 6U10 L/min.

INDICATIONS/ROUTES/DOSAGE

ACUTE BRONCHOSPASM

INHALATION: ADULTS, ELDERLY, CHILDREN OLDER THAN 12 YR: 4U8 puffs q20min up to 4 hr, then q1U4h as needed. CHILDREN 12 YR AND YOUNGER: 4U8 puffs q20min for 3 doses, then q1U4h as needed.

NEBULIZATION: ADULTS, ELDERLY, CHILDREN OLDER THAN 12 YR: 2.5U5 mg q20min for 3 doses, then 2.5U10 mg q1U4h or 10U15 mg/hr continuously. CHILDREN 12 YR AND YOUNGER: 0.15 mg/kg q20min for 3 doses (minimum: 2.5 mg), then 0.15U0.3 mg/kg q1U4h as needed.

BRONCHOSPASM

PO: ADULTS, CHILDREN OLDER THAN 12 YR: 2U4 mg 3U4 times a day. Maximum: 8 mg 4 times a day. ELDERLY: 2 mg 3U4 times a day. Maximum: 8 mg 4 times a day. CHILDREN 6U12 YR: 2 mg 3U4 times a day. Maximum: 24 mg/day. CHILDREN 2U5 YR: 0.1U0.2 mg/kg/dose 3 times a day. Maximum: 12 mg/day.

PO (EXTENDED-RELEASE): ADULTS, CHILDREN OLDER THAN 12 YR: 4U8 mg q12h.

NEBULIZATION: ADULTS, ELDERLY, CHILDREN OLDER THAN 12 YR: 2.5 mg 3U4 times a day over 5U15 minutes. CHILDREN 12 YR AND YOUNGER: 0.05 mg/kg q4U6h. Minimum: 1.25 mg/dose. Maximum: 2.5 mg/dose.

CHRONIC BRONCHOSPASM

INHALATION: ADULTS, ELDERLY, CHILDREN 4 YR AND OLDER: 1U2 puffs q4U6h. Maximum: 12 puffs per day.

EXERCISE-INDUCED BRONCHOSPASM

INHALATION: ADULTS, ELDERLY, CHILDREN OLDER THAN 12 YR: 2 puffs 15U30 min before exercise. CHILDREN 12 YR AND YOUNGER: 1U2 puffs 5 min before exercise.

SIDE EFFECTS

FREQUENT: Headache (27%); nausea (15%); restlessness, nervousness, tremors (20%); dizziness (less than 7%); throat dryness and irritation, pharyngitis (less than 6%); BP changes, including hypertension (5%U3%); heartburn, transient wheezing (less than 5%). OCCASIONAL (3%U2%): Insomnia, asthenia, altered taste. Inhalation: Dry, irritated mouth or throat; cough; bronchial irritation. RARE: Somnolence, diarrhea, dry mouth, flushing, diaphoresis, anorexia.

ADVERSE REACTIONS/TOXIC EFFECTS

Excessive sympathomimetic stimulation may produce palpitations, extrasystole, tachycardia, chest pain, a slight increase in BP followed by a substantial decrease, chills, diaphoresis, and blanching of skin. Too-frequent or excessive use may lead to decreased bronchodilating effectiveness and severe, paradoxical bronchoconstriction

NURSING CONSIDERATIONS

BASELINE ASSESSMENT

Offer emotional support (high incidence of anxiety due to difficulty in breathing and sympathomimetic response to drug).

INTERVENTION/EVALUATION

Monitor rate, depth, rhythm, type of respiration; quality and rate of pulse; EKG; serum potassium, ABG determinations. Assess lung sounds for wheezing (bronchoconstriction) and rales.

PATIENT/FAMILY TEACHING

N Instruct on proper use of inhaler. N Increase fluid intake (decreases lung secretion viscosity). N Do not take more than 2 inhalations at any one time (excessive use may produce paradoxical bronchoconstriction or a decreased bronchodilating effect). N Rinsing mouth with water immediately after inhalation may prevent mouth/throat dryness. N Avoid excessive use of caffeine derivatives (chocolate, coffee, tea, cola, cocoa).

adenosine

ah-den-oh-seen

(Adenocard, Adenoscan)

G CLASSIFICATION

PHARMACOTHERAPEUTIC: Cardiac agent, diagnostic aid. CLINICAL: Antiarrhythmic.

ACTION

A cardiac agent that slows impulse formation in the SA node and conduction time through the AV node. Adenosine also acts as a diagnostic aid in myocardial perfusion imaging or stress echocardiography. Therapeutic Effect: Depresses left ventricular function and restores normal sinus rhythm.

USES

Treatment of paroxysmal supraventricular tachycardia, including those associated with accessory bypass tracts (Wolff-Parkinson-White syndrome). Adjunct in diagnosis in myocardial perfusion imaging or stress echocardiography.

PRECAUTIONS

CONTRAINDICATIONS: Atrial fibrillation or flutter, second- or third-degree AV block or sick sinus syndrome (with functioning pacemaker), ventricular tachycardia. CAUTIONS: Heart block, arrhythmias at time of conversion, asthma, hepatic/renal failure. Pregnancy Category C.

INTERACTIONS

DRUG: Carbamazepine: May increase degree of heart block caused by adenosine. Dipyridamole: May increase effect of adenosine. Methylxanthines (e.g., caffeine, theophylline): May decrease effect of adenosine. HERBAL: None known. FOOD: None known. LAB VALUES: None known.

AVAILABILITY (Rx)

INJECTION (ADENOCARD): 3 mg/ml in 2 ml, 4 ml syringes. INJECTION (ADENOSCAN): 3 mg/ml in 20 ml, 30 ml vials.

ADMINISTRATION/HANDLING

L IV

Rate of administration N Administer very rapidly (over 1U2 sec) undiluted directly into vein, or if using IV line, use closest port to insertion site. If IV line is infusing any fluid other than 0.9% NaCl, flush line first. N After rapid bolus injection, follow with rapid 0.9% NaCl flush.

Storage N Store at room temperature. Solution appears clear. N Crystallization occurs if refrigerated; if crystallization occurs, dissolve crystals by warming to room temperature. Discard unused portion.

D IV INCOMPATIBILITIES

Any drug or solution other than 0.9% NaCl or D5W.

INDICATIONS/ROUTES/DOSAGE

PAROXYSMAL SUPRAVENTRICULAR TACHYCARDIA (PSVT)

RAPID IV BOLUS: ADULTS, ELDERLY, CHILDREN WEIGHING 50 KG AND MORE: Initially, 6 mg given over 1U2 sec. If first dose does not convert within 1U2 min, give 12 mg; may repeat 12-mg dose in 1U2 min if no response has occurred. CHILDREN WEIGHING LESS THAN 50 KG: Initially 0.1 mg/kg (maximum: 6 mg). If ineffective, may give 0.2 mg/kg (maximum: 12 mg).

DIAGNOSTIC TESTING

IV INFUSION: ADULTS: 140 mcg/kg/min for 6 min.

SIDE EFFECTS

FREQUENT (18%U12%): Facial flushing, dyspnea. OCCASIONAL (7%U2%): Headache, nausea, light-headedness, chest pressure. RARE (1% or less): Numbness or tingling in arms; dizziness; diaphoresis; hypotension; palpitations; chest, jaw, or neck pain.

ADVERSE REACTIONS/TOXIC EFFECTS

May produce short-lasting heart block.

NURSING CONSIDERATION

BASELINE ASSESSMENT

Identify arrhythmia per cardiac monitor and assess apical pulse.

INTERVENTION/EVALUATION

Assess cardiac performance per continuous EKG. Monitor BP, apical pulse (rate, rhythm, quality). Auscultate patient’s breath sounds for clarity. Monitor respiratory rate. Monitor I&O; assess for fluid retention. Check electrolytes.

adenosine

ah-den-oh-seen

(Adenocard, Adenoscan)

G CLASSIFICATION

PHARMACOTHERAPEUTIC: Cardiac agent, diagnostic aid. CLINICAL: Antiarrhythmic.

ACTION

USES

PRECAUTIONS

INTERACTIONS

AVAILABILITY (Rx)

INJECTION (ADENOCARD): 3 mg/ml in 2 ml, 4 ml syringes. INJECTION (ADENOSCAN): 3 mg/ml in 20 ml, 30 ml vials.

ADMINISTRATION/HANDLING

L IV

D IV INCOMPATIBILITIES

Any drug or solution other than 0.9% NaCl or D5W.

INDICATIONS/ROUTES/DOSAGE

PAROXYSMAL SUPRAVENTRICULAR TACHYCARDIA (PSVT)

DIAGNOSTIC TESTING

IV INFUSION: ADULTS: 140 mcg/kg/min for 6 min.

SIDE EFFECTS

ADVERSE REACTIONS/TOXIC EFFECTS

May produce short-lasting heart block.

NURSING CONSIDERATION

BASELINE ASSESSMENT

Identify arrhythmia per cardiac monitor and assess apical pulse.

NURSING CONSIDERATION

adenosine

ah-den-oh-seen

(Adenocard, Adenoscan)

G CLASSIFICATION

PHARMACOTHERAPEUTIC: Cardiac agent, diagnostic aid. CLINICAL: Antiarrhythmic.

ACTION

USES

PRECAUTIONS

INTERACTIONS

AVAILABILITY (Rx)

INJECTION (ADENOCARD): 3 mg/ml in 2 ml, 4 ml syringes. INJECTION (ADENOSCAN): 3 mg/ml in 20 ml, 30 ml vials.

ADMINISTRATION/HANDLING

L IV

D IV INCOMPATIBILITIES

Any drug or solution other than 0.9% NaCl or D5W.

INDICATIONS/ROUTES/DOSAGE

PAROXYSMAL SUPRAVENTRICULAR TACHYCARDIA (PSVT)

DIAGNOSTIC TESTING

IV INFUSION: ADULTS: 140 mcg/kg/min for 6 min.

SIDE EFFECTS

ADVERSE REACTIONS/TOXIC EFFECTS

May produce short-lasting heart block.

BASELINE ASSESSMENT

Identify arrhythmia per cardiac monitor and assess apical pulse.

INTERVENTION/EVALUATION

albumin, human

al-byew-min

(Albuminar-5, Albuminar-25, Albutein, Buminate, Flexbumin, Plasbumin)

Do not confuse albumin with albuterol.

G CLASSIFICATION

PHARMACOTHERAPEUTIC: Plasma protein fraction. CLINICAL: Blood derivative.

ACTION

A plasma protein fraction that acts as a blood volume expander. Therapeutic Effect: Provides temporary increase in blood volume; reduces hemoconcentration and blood viscosity.

PHARMACOKINETICS

Route Onset Peak Duration

IV 15 min N/A N/A

(in well-

hydrated patient)

Distributed throughout extracellular fluid. Half-life: 15U20 days.

USES

Treatment of hypovolemia, hypoproteinemia. Adjunct in treatment of severe burns, neonatal hyperbilirubinemia, adult respiratory distress syndrome (ARDS), cardiopulmonary bypass, ascites, acute nephrosis or nephrotic syndrome, hemodialysis, pancreatitis, intra-abdominal infections, acute hepatic failure.

PRECAUTIONS

CONTRAINDICATIONS: Heart failure, history of allergic reaction to albumin level, hypervolemia, normal serum albumin, pulmonary edema, severe anemia. CAUTIONS: Hypertension, normal serum albumin concentration, low cardiac reserve, pulmonary disease, hepatic/renal failure.

B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Unknown if drug crosses placenta or is distributed in breast milk. Pregnancy Category C. Children/Elderly: No age-related precautions noted.

INTERACTIONS

DRUG: None known. HERBAL: None known. FOOD: None known. LAB VALUES: May increase serum alkaline phosphatase concentration.

AVAILABILITY (Rx)

INJECTION: 5% (Albuminar-5, Albutein, Buminate, Plasbumin), 25% (Albuminar-25, Flexbumin).

ADMINISTRATION/HANDLING

L IV

Reconstitution N A 5% solution may be made from 25% solution by adding 1 volume 25% to 4 volumes 0.9% NaCl or D5W (NaCl preferred). Do not use sterile water for injection (life-threatening hemolysis, acute renal failure can result).

Rate of administration N Give by IV infusion. Rate is variable, depends on use, blood volume, concentration of solute. 5%: usually given at 5U10 ml/min; 25%: usually at 2U3 ml/min. 5% administered undiluted; 25% may be administered undiluted or diluted with 0.9% NaCl or D5W. NaCl preferred. N May give without regard to patient blood group or Rh factor.

Storage N Store at room temperature. Appears as clear, brownish, odorless, moderate viscous fluid. N Do not use if solution has been frozen, appears turbid, contains sediment, or if not used within 4 hr of opening vial.

D IV INCOMPATIBILITIES

Lipids, midazolam (Versed), vancomycin (Vancocin), verapamil (Isoptin).

IV COMPATIBILITIES

Diltiazem (Cardizem), lorazepam (Ativan).

INDICATIONS/ROUTES/DOSAGE

HYPOVOLEMIA

IV: ADULTS, ELDERLY: Initially, 25 g; may repeat in 15U30 min. Maximum: 250 g within 48 hr. CHILDREN: 0.5U1 g/kg/dose (10U20 ml/kg/dose of 5% albumin) Maximum: 6 g/kg/day.

HYPOPROTEINEMIA

IV: ADULTS, ELDERLY, CHILDREN: 0.5U1 g/kg/dose (10U20 ml/kg/dose of 5% albumin). Repeat in 1U2 days.

BURNS

IV: ADULTS, ELDERLY, CHILDREN: Initially, give large volumes of crystalloid infusion to maintain plasma volume. After 24 hr, give 25 g, then adjust dosage adjusted to maintain plasma albumin concentration of 2U2.5 g/100 ml.

CARDIOPULMONARY BYPASS

IV: ADULTS, ELDERLY: 5% or 25% albumin with crystalloid to maintain plasma albumin concentration of 2.5 g/100 ml.

ACUTE NEPHROSIS, NEPHROTIC SYNDROME

IV: ADULTS, ELDERLY: 25 g of 25% injection, with diuretic once a day for 7U10 days.

HEMODIALYSIS

IV: ADULTS, ELDERLY: 100 ml (25 g) of 25% albumin.

HYPERBILIRUBINEMIA, ERYTHROBLASTOSIS FETALIS

IV: INFANTS: 1 g/kg 1U2 hr before transfusion.

SIDE EFFECTS

OCCASIONAL: Hypotension. RARE: High dose in repeated therapy: altered vital signs, chills, fever, increased salivation, nausea, vomiting, urticaria, tachycardia.

ADVERSE REACTIONS/TOXIC EFFECTS

Fluid overload may occur, marked by increased BP, and distended neck veins. Neurological changes that may occur include headache, weakness, blurred vision, behavioral changes, incoordination, and isolated muscle twitching. Pulmonary edema may also occur, evidenced by rapid breathing, rales, wheezing, and coughing.

BASELINE ASSESSMENT

Obtain BP, pulse, respirations immediately before administration. Adequate hydration required before albumin is administered.

INTERVENTION/EVALUATION

Monitor BP for hypotension/hypertension. Assess frequently for evidence of fluid overload, pulmonary edema (see Adverse Reactions/Toxic Effects). Check skin for flushing, urticaria. Monitor I&O ratio (watch for decreased output). Assess for therapeutic response (increased BP, decreased edema).

albuterol

ale-beut-er-all

(AccuNeb, Asmavent J, Novosalmol J, Proventil, Proventil HFA, Proventil Repetabs, Ventolin, Ventolin HFA, Volmax, Vospire ER)

Do not confuse albuterol with Albutein or atenolol, or Proventil with Prinivil.

FIXED-COMBINATION(S)

Combivent: albuterol/ipratropium (a bronchodilator): 103 mcg/18 mcg per actuation. Duoneb: albuterol/ipratropium 3 mg/0.5 mg.

G CLASSIFICATION

PHARMACOTHERAPEUTIC: Sympathomimetic (adrenergic agonist). CLINICAL: Bronchodilator.

ACTION

A sympathomimetic that stimulates beta2-adrenergic receptors in the lungs, resulting in relaxation of bronchial smooth muscle. Therapeutic Effect: Relieves bronchospasm and reduces airway resistance.

PHARMACOKINETICS

Route Onset Peak Duration

PO 15U30 min 2U3 hr 4U6 hr

PO 30 min 2U4 hr 12 hr

(extended-release)

Inhalation 5U15 min 0.5U2 hr 2U5 hr

Rapidly, well absorbed from the GI tract; gradually absorbed from the bronchi after inhalation. Metabolized in the liver. Primarily excreted in urine. Half-life: 2.7U5 hr (PO); 3.8 hr (inhalation).

USES

Relief of bronchospasm due to reversible obstructive airway disease, exercise-induced bronchospasm.

PRECAUTIONS

CONTRAINDICATIONS: History of hypersensitivity to sympathomimetics. CAUTIONS: Hypertension, cardiovascular disease, hyperthyroidism, diabetes mellitus.

INTERACTIONS

AVAILABILITY (Rx)

ADMINISTRATION/HANDLING

N Do not crush/break extended-release tablets. N May give without regard to food.

INHALATION

NEBULIZATION

N Dilute 0.5 ml of 0.5% solution to final volume of 3 ml with 0.9% NaCl to provide 2.5 mg N Administer over 5U15 min. N Nebulizer should be used with compressed air or O2 at rate of 6U10 L/min.

INDICATIONS/ROUTES/DOSAGE

ACUTE BRONCHOSPASM

INHALATION: ADULTS, ELDERLY, CHILDREN OLDER THAN 12 YR: 4U8 puffs q20min up to 4 hr, then q1U4h as needed. CHILDREN 12 YR AND YOUNGER: 4U8 puffs q20min for 3 doses, then q1U4h as needed.

BRONCHOSPASM

PO (EXTENDED-RELEASE): ADULTS, CHILDREN OLDER THAN 12 YR: 4U8 mg q12h.

NEBULIZATION: ADULTS, ELDERLY, CHILDREN OLDER THAN 12 YR: 2.5 mg 3U4 times a day over 5U15 minutes. CHILDREN 12 YR AND YOUNGER: 0.05 mg/kg q4U6h. Minimum: 1.25 mg/dose. Maximum: 2.5 mg/dose.

CHRONIC BRONCHOSPASM

INHALATION: ADULTS, ELDERLY, CHILDREN 4 YR AND OLDER: 1U2 puffs q4U6h. Maximum: 12 puffs per day.

EXERCISE-INDUCED BRONCHOSPASM

INHALATION: ADULTS, ELDERLY, CHILDREN OLDER THAN 12 YR: 2 puffs 15U30 min before exercise. CHILDREN 12 YR AND YOUNGER: 1U2 puffs 5 min before exercise.

SIDE EFFECTS

ADVERSE REACTIONS/TOXIC EFFECTS

NURSING CONSIDERATION

BASELINE ASSESSMENT

Offer emotional support (high incidence of anxiety due to difficulty in breathing and sympathomimetic response to drug).

INTERVENTION/EVALUATION

Monitor rate, depth, rhythm, type of respiration; quality and rate of pulse; EKG; serum potassium, ABG determinations. Assess lung sounds for wheezing (bronchoconstriction) and rales.

PATIENT/FAMILY TEACHING

alendronate sodium H

ah-len-drew-nate

(Fosamax)

Do not confuse Fosamax with Flomax.

G CLASSIFICATION

PHARMACOTHERAPEUTIC: Bisphosphonate. CLINICAL: Bone resorption inhibitor, calcium regulator.

ACTION

A bisphosphonate that inhibits normal and abnormal bone resorption, without retarding mineralization. Therapeutic Effect: Leads to significantly increased bone mineral density; reverses the progression of osteoporosis.

PHARMACOKINETICS

Poorly absorbed after oral administration. Protein binding: 78%. After oral administration, rapidly taken into bone, with uptake greatest at sites of active bone turnover. Excreted in urine. Terminal half-life: Greater than 10 yr (reflects release from skeleton as bone is resorbed).

USES

Treatment of osteoporosis in men. Treatment adjunct in glucocorticoid-induced osteoporosis, treatment and prevention of osteoporosis in postmenopausal women, treatment of Paget’s disease. OFF-LABEL: Treatment of breast cancer.

PRECAUTIONS

CONTRAINDICATIONS: GI disease, including dysphagia, frequent heartburn, gastrointestinal reflux disease, hiatal hernia, and ulcers, inability to stand or sit upright for at least 30 min; renal impairment; sensitivity to alendronate. CAUTIONS: Hypocalcemia, vitamin D deficiency.

B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Possible incomplete fetal ossification, decreased maternal weight gain, delay in delivery. Excretion in breast milk unknown. Do not give to breast-feeding women. Pregnancy Category C. Children: Safety and efficacy not established. Elderly: No age-related precautions noted.

INTERACTIONS

DRUG: Antacids, calcium supplements: May interfere with the absorption of alendronate. Aspirin, NSAIDs: May increase GI disturbances. IV ranitidine: May double the bioavailability of alendronate. HERBAL: None known. FOOD: Beverages other than plain water, dietary supplements, food: May interfere with absorption of alendronate. LAB VALUES: Reduces serum calcium and serum phosphate concentrations. Significantly decreases serum alkaline phosphatase level in patients with Paget's disease.

AVAILABILITY (Rx)

TABLETS: 5 mg, 10 mg, 35 mg, 40 mg, 70 mg. ORAL SOLUTION: 70 mg/75 ml.

ADMINISTRATION/HANDLING

N Give at least 30 min before first food, beverage, or medication of the day. N Give with 6U8 oz plain water only (mineral water, coffee, tea, juice will decrease absorption). N Instruct patient not to lie down or eat for at least 30 min after administering medication (plain water and not lying down allow medication to reach stomach quickly, minimizing esophageal irritation).

INDICATIONS/ROUTES/DOSAGE

OSTEOPOROSIS (IN MEN)

PO: ADULTS, ELDERLY: 10 mg once a day in the morning or 70 mg weekly.

GLUCOCORTICOID-INDUCED OSTEOPOROSIS

PO: ADULTS, ELDERLY: 5 mg once a day in the morning. POST-MENOPAUSAL WOMEN NOT RECEIVING ESTROGEN: 10 mg once a day in the morning.

POST-MENOPAUSAL OSTEOPOROSIS

PO (TREATMENT): ADULTS, ELDERLY: 10 mg once a day in the morning or 70 mg weekly.

PO (PREVENTION): ADULTS, ELDERLY: 5 mg once a day in the morning or 35 mg weekly.

PAGET'S DISEASE

PO: ADULTS, ELDERLY: 40 mg once a day in the morning for 6 mo.

SIDE EFFECTS

FREQUENT (8%U7%): Back pain, abdominal pain. OCCASIONAL (3%U2%): Nausea, abdominal distention, constipation, diarrhea, flatulence. RARE (less than 2%): Rash, severe bone, joint, muscle pain.

ADVERSE REACTIONS/TOXIC EFFECTS

Overdose causes hypocalcemia, hypophosphatemia, and significant GI disturbances. Esophageal irritation occurs if alendronate is not given with 6U8 oz of plain water or if the patient lies down within 30 min of drug administration.

BASELINE ASSESSMENT

Hypocalcemia, vitamin D deficiency must be corrected before therapy. Check electrolytes (especially calcium and alkaline phosphatase serum levels).

INTERVENTION/EVALUATION

Monitor electrolytes (especially calcium and alkaline phosphatase serum levels).

PATIENT/FAMILY TEACHING

N Instruct patient that expected benefits occur only when medication is taken with full glass (6U8 oz) of plain water, first thing in the morning and at least 30 min before first food, beverage, or medication of the day is taken. Any other beverage (mineral water, orange juice, coffee) significantly reduces absorption of medication. N Do not lie down for at least 30 min after taking medication (potentiates delivery to stomach, reducing risk of esophageal irritation). N Consider weight-bearing exercises, modify behavioral factors (e.g., cigarette smoking, alcohol consumption).

allopurinol

al-low-pure-ih-nal

(Aloprim, Apo-Allopurinol J, Zyloprim)

Do not confuse Zyloprim with ZORprin.

G CLASSIFICATION

PHARMACOTHERAPEUTIC: Xanthine oxidase inhibitor. CLINICAL: Antigout.

ACTION

A xanthine oxidase inhibitor that decreases uric acid production by inhibiting xanthine oxidase, an enzyme. Therapeutic Effect: Reduces uric acid concentrations in both serum and urine.

PHARMACOKINETICS

Route Onset Peak Duration

PO, IV 2U3 days 1U3 wk 1U2 wk

Well absorbed from the GI tract. Widely distributed. Metabolized in the liver to active metabolite. Excreted primarily in urine. Removed by hemodialysis. Half-life: 1U3 hr; metabolite, 12U30 hr.

USES

ORAL: Prevents attacks of gouty arthritis, nephropathy. Treatment of secondary hyperuricemia that may occur during cancer treatment. Prevents recurrent uric acid and calcium oxalate calculi. INJECTION: Management of elevated uric acid in cancer patients unable to tolerate oral therapy. OFF-LABEL: In mouthwash following fluorouracil therapy to prevent stomatitis.

PRECAUTIONS

CONTRAINDICATIONS: Asymptomatic hyperuricemia. CAUTIONS: Impaired renal, hepatic function, CHF, diabetes mellitus, hypertension.

B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Unknown if drug crosses placenta or is distributed in breast milk. Pregnancy Category C. Children/Elderly: No age-related precautions noted.

INTERACTIONS

DRUG: Amoxicillin, ampicillin: May increase incidence of rash. Angiotensin-converting enzyme (ACE) inhibitors: May cause hypersensitivity reactions. Azathioprine, mercaptopurine: May increase therapeutic effect and toxicity of azathioprine and mercaptopurine. Oral anticoagulants: May increase anticoagulant effect. Thiazide diuretics: May decrease the effect of allopurinol. HERBAL: None known. FOOD: None known. LAB VALUES: May increase BUN, serum creatinine, serum alkaline phosphatase, AST, and ALT levels.

AVAILABILITY (Rx)

TABLETS (ZYLOPRIM): 100 mg, 300 mg. POWDER FOR INJECTION (ALOPRIM): 500 mg.

ADMINISTRATION/HANDLING

L IV

Reconstitution N Reconstitute 500-mg vial with 25 ml sterile water for injection, giving a clear, almost colorless solution (concentration of 20 mg/ml). N Further dilute with 0.9% NaCl or D5W (19 ml of added diluent yields 1 mg/ml, 9 ml yields 2 mg/ml, 2.3 ml yields maximum concentration of 6 mg/ml).

Rate of administration N Infuse over 30U60 min.

Storage N Store unreconstituted vials at room temperature. N May store reconstituted solution at room temperature and give within 10 hr. Do not use if precipitate forms or solution is discolored.

N May give with or immediately after meals or milk. N Instruct patient to drink at least 10U12 eight-oz glasses of water/day. N Dosages greater than 300 mg/day to be administered in divided doses.

D IV INCOMPATIBILITIES

Amikacin (Amikin), carmustine (BiCNU), cefotaxime (Claforan), chlorpromazine (Thorazine), cimetidine (Tagamet), clindamycin (Cleocin), cytarabine (Ara-C), dacarbazine (DTIC), diphenhydramine (Benadryl), doxorubicin (Adriamycin), doxycycline (Vibramycin), droperidol (Inapsine), fludarabine (Fludara), gentamicin (Garamycin), haloperidol (Haldol), hydroxyzine (Vistaril), idarubicin (Idamycin), imipenem-cilastatin (Primaxin), meperidine (Demerol), methylprednisolone (Solu-Medrol), metoclopramide (Reglan), ondansetron (Zofran), prochlorperazine (Compazine), promethazine (Phenergan), streptozocin (Zanosar), tobramycin (Nebcin), vinorelbine (Navelbine).

IV COMPATIBILITIES

Bumetanide (Bumex), calcium gluconate, furosemide (Lasix), heparin, hydromorphone (Dilaudid), lorazepam (Ativan), morphine, potassium chloride.

INDICATIONS/ROUTES/DOSAGE

CHRONIC GOUTY ARTHRITIS

PO: ADULTS, CHILDREN OLDER THAN 10 YR: Initially, 100 mg/day; may increase by 100 mg/day at weekly intervals. Maximum: 800 mg/day. Maintenance: 100U200 mg 2U3 times a day or 300 mg/day.

TO PREVENT URIC ACID NEPHROPATHY DURING CHEMOTHERAPY

O ALERT P Maintenance dosage is based on serum uric acid levels. Discontinue following the period of tumor regression.

PO: ADULTS: Initially, 600U800 mg/day starting 2U3 days before initiation of chemotherapy or radiation therapy. CHILDREN 6U10 YR: 100 mg 3 times a day or 300 mg once a day. CHILDREN LESS THAN 6 YR: 50 mg 3 times a day.

IV: ADULTS: 200U400 mg/m2/day beginning 24U48 hr before initiation of chemotherapy. CHILDREN: 200 mg/m2/day. Maximum: 600 mg/day.

PREVENTION OF URIC ACID CALCULI

PO: ADULTS: 100U200 mg 1U4 times a day or 300 mg once a day.

RECURRENT CALCIUM OXALATE CALCULI

PO: ADULTS: 200U300 mg/day. ELDERLY: Initially, 100 mg/day, gradually increased until optimal uric acid level is reached.

DOSAGE IN RENAL IMPAIRMENT

Dosage is modified based on creatinine clearance.

Creatinine Clearance Dosage Adjustment

10U20 ml/min 200 mg/day

3U9 ml/min 100 mg/day

Less than 3 ml/min 100 mg at extended intervals

SIDE EFFECTS

OCCASIONAL: Oral: Somnolence, unusual hair loss. IV: Rash, nausea, vomiting. RARE: Diarrhea, headache.

ADVERSE REACTIONS/TOXIC EFFECTS

Pruritic maculopapular rash possibly accompanied by malaise, fever, chills, joint pain, nausea, and vomiting should be considered a toxic reaction. Severe hypersensitivity may follow appearance of rash. Bone marrow depression, hepatic toxicity, peripheral neuritis, and acute renal failure occur rarely.

NURSING CONSIDERATION

BASELINE ASSESSMENT

Instruct patient to drink 10U12 glasses (8 oz) of fluid daily while taking medication.

INTERVENTION/EVALUATION

Discontinue medication immediately if rash or other evidence of allergic reaction appears. Monitor I&O (output should be at least 2,000 ml/day). Assess CBC, uric acid and hepatic function serum levels. Assess urine for cloudiness, unusual color, odor. Assess for therapeutic response (reduced joint tenderness, swelling, redness, limited motion).

PATIENT/FAMILY TEACHING

N May take 1 wk or longer for full therapeutic effect. N Encourage drinking 10U12 glasses (8 oz) of fluid daily while taking medication. N Avoid tasks that require alertness, motor skills until response to drug is established.

allopurinol

al-low-pure-ih-nal

(Aloprim, Apo-Allopurinol J, Zyloprim)

Do not confuse Zyloprim with ZORprin.

G CLASSIFICATION

PHARMACOTHERAPEUTIC: Xanthine oxidase inhibitor. CLINICAL: Antigout.

ACTION

A xanthine oxidase inhibitor that decreases uric acid production by inhibiting xanthine oxidase, an enzyme. Therapeutic Effect: Reduces uric acid concentrations in both serum and urine.

PHARMACOKINETICS

Route Onset Peak Duration

PO, IV 2U3 days 1U3 wk-1U2 wk

Well absorbed from the GI tract. Widely distributed. Metabolized in the liver to active metabolite. Excreted primarily in urine. Removed by hemodialysis. Half-life: 1U3 hr; metabolite, 12U30 hr.

USES

PRECAUTIONS

CONTRAINDICATIONS: Asymptomatic hyperuricemia. CAUTIONS: Impaired renal, hepatic function, CHF, diabetes mellitus, hypertension.

B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Unknown if drug crosses placenta or is distributed in breast milk. Pregnancy Category C. Children/Elderly: No age-related precautions noted.

INTERACTIONS

AVAILABILITY (Rx)

TABLETS (ZYLOPRIM): 100 mg, 300 mg. POWDER FOR INJECTION (ALOPRIM): 500 mg.

ADMINISTRATION/HANDLING

L IV

Rate of administration N Infuse over 30U60 min.

Storage N Store unreconstituted vials at room temperature. N May store reconstituted solution at room temperature and give within 10 hr. Do not use if precipitate forms or solution is discolored.

N May give with or immediately after meals or milk. N Instruct patient to drink at least 10U12 eight-oz glasses of water/day. N Dosages greater than 300 mg/day to be administered in divided doses.

D IV INCOMPATIBILITIES

IV COMPATIBILITIES

Bumetanide (Bumex), calcium gluconate, furosemide (Lasix), heparin, hydromorphone (Dilaudid), lorazepam (Ativan), morphine, potassium chloride.

INDICATIONS/ROUTES/DOSAGE

CHRONIC GOUTY ARTHRITIS

PO: ADULTS, CHILDREN OLDER THAN 10 YR: Initially, 100 mg/day; may increase by 100 mg/day at weekly intervals. Maximum: 800 mg/day. Maintenance: 100U200 mg 2U3 times a day or 300 mg/day.

TO PREVENT URIC ACID NEPHROPATHY DURING CHEMOTHERAPY

O ALERT P Maintenance dosage is based on serum uric acid levels. Discontinue following the period of tumor regression.

IV: ADULTS: 200U400 mg/m2/day beginning 24U48 hr before initiation of chemotherapy. CHILDREN: 200 mg/m2/day. Maximum: 600 mg/day.

PREVENTION OF URIC ACID CALCULI

PO: ADULTS: 100U200 mg 1U4 times a day or 300 mg once a day.

RECURRENT CALCIUM OXALATE CALCULI

PO: ADULTS: 200U300 mg/day. ELDERLY: Initially, 100 mg/day, gradually increased until optimal uric acid level is reached.

DOSAGE IN RENAL IMPAIRMENT

Dosage is modified based on creatinine clearance.

Creatinine Clearance Dosage Adjustment

10U20 ml/min 200 mg/day

3U9 ml/min 100 mg/day

Less than 3 ml/min 100 mg at extended intervals

SIDE EFFECTS

OCCASIONAL: Oral: Somnolence, unusual hair loss. IV: Rash, nausea, vomiting. RARE: Diarrhea, headache.

ADVERSE REACTIONS/TOXIC EFFECTS

BASELINE ASSESSMENT

Instruct patient to drink 10U12 glasses (8 oz) of fluid daily while taking medication.

INTERVENTION/EVALUATION

PATIENT/FAMILY TEACHING

alprazolam H

ale-praz-oh-lam

(Apo-Alpraz J, Niravam, Novo-Alprazol J, Xanax, Xanax XR)

Do not confuse alprazolam with lorazepam, or Xanax with Tenex or Zantac.

G CLASSIFICATION

PHARMACOTHERAPEUTIC: Benzodiazepine (Schedule IV). CLINICAL: Antianxiety.

ACTION

A benzodiazepine that enhances the action of the inhibitory neurotransmitter gamma-aminobutyric acid in the brain. Therapeutic Effect: Produces anxiolytic effect from its CNS depressant action.

PHARMACOKINETICS

Well absorbed from GI tract. Protein binding: 80%. Metabolized in the liver. Primarily excreted in urine. Minimal removal by hemodialysis. Half-life: 11U16 hr.

USES

Management of anxiety disorders associated with depression, panic disorder. OFF-LABEL: Management of premenstrual syndrome symptoms (mood disturbances, insomnia, and cramps), irritable bowel syndrome, treatment of agoraphobia, post-traumatic stress disorder, tremors, ethanol withdrawal, anxiety in children.

PRECAUTIONS

CONTRAINDICATIONS: Acute alcohol intoxication with depressed vital signs, acute angle-closure glaucoma, concurrent use of itraconazole or ketoconazole, myasthenia gravis, severe COPD. CAUTIONS: Impaired renal/hepatic function.

B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Crosses placenta; distributed in breast milk. Chronic ingestion during pregnancy may produce withdrawal symptoms, CNS depression in neonates. Pregnancy Category D. Children: Safety and efficacy not established. Elderly: Use small initial doses with gradual increase to avoid ataxia (muscular incoordination) or excessive sedation.

INTERACTIONS

DRUG: Alcohol, other CNS depressants: Potentiate effects of alprazolam and may increase sedation. Fluvoxamine, itraconazole, ketoconazole, nefazodone: May inhibit metabolism and increase serum concentrations of alprazolam. HERBAL: Kava kava, valerian: May increase CNS depressant effect of alprazolam. St. John's wort: May reduce effectiveness of alprazolam. FOOD: Grapefruit, grapefruit juice: May inhibit alprazolam's metabolism. LAB VALUES: None known.

AVAILABILITY (Rx)

ORAL SOLUTION (ALPRAZOLAM INTENSOL): 1 mg/ml. TABLETS (XANAX): 0.25 mg, 0.5 mg, 1 mg, 2 mg. TABLETS (EXTENDED-RELEASE [XANAX XR]): 0.5 mg, 1 mg, 2 mg, 3 mg. TABLETS (ORALLY-DISINTEGRATING [NIRAVAM]): 0.25 mg, 0.5 mg, 1 mg, 2 mg.

ADMINISTRATION/HANDLING

PO, IMMEDIATE-RELEASE

N May be given without regard to meals. N Tablets may be crushed.

PO, EXTENDED-RELEASE

N Administer once daily. N Do not crush, chew, break. Swallow whole.

PO, ORALLY DISINTEGRATING

N Place tablet on tongue, allow to dissolve. N Swallow with saliva.

INDICATIONS/ROUTES/DOSAGE

ANXIETY DISORDERS

PO (IMMEDIATE-RELEASE): ADULTS: Initially, 0.25U0.5 mg 3 times a day. May titrate q3U4 days. Maximum: 4 mg/day in divided doses. ELDERLY, DEBILITATED PATIENTS, PATIENTS WITH HEPATIC DISEASE OR LOW SERUM ALBUMIN: Initially, 0.25 mg 2U3 times a day. Gradually increase to optimum therapeutic response.

PO (ORALLY-DISINTEGRATING): ADULTS: 0.25U0.5 mg 3 times a day. Maximum: 4 mg/day in divided doses.

ANXIETY WITH DEPRESSION

PO: ADULTS: 2.5U3 mg/day in divided doses.

PANIC DISORDER

PO (IMMEDIATE-RELEASE): ADULTS: Initially, 0.5 mg 3 times a day. May increase at 3- to 4-day intervals. Range: 5U6 mg/day. Maximum: 10 mg/day. ELDERLY: Initially, 0.125U0.25 mg twice a day. May increase in 0.125-mg increments until desired effect attained.

PO (EXTENDED-RELEASE):

O ALERT P To switch from immediate-release to extendedUrelease form, give total daily dose (immediateUrelease) as a single daily dose of extendedUrelease form. ADULTS: Initially, 0.5U1 mg once a day. May titrate at 3- to 4-day intervals. Range: 3U6 mg/day. Maximum: 10 mg/day. ELDERLY: Initially, 0.5 mg once daily.

PO (ORALLY-DISINTEGRATING): ADULTS: Initially, 0.5 mg 3 times a day. May increase at 3- to 4-day intervals. Range: 5U6 mg/day. Maximum: 10 mg/day.

PREMENSTRUAL SYNDROME

PO: ADULTS: 0.25 mg 3 times a day.

SIDE EFFECTS

FREQUENT: Ataxia; lightheadedness; transient, mild somnolence; slurred speech (particularly in elderly or debilitated patients). OCCASIONAL: Confusion, depression, blurred vision, constipation, diarrhea, dry mouth, headache, nausea. RARE: Behavioral problems such as anger, impaired memory, paradoxical reactions such as insomnia, nervousness, or irritability.

ADVERSE REACTIONS/TOXIC EFFECTS

Abrupt or too rapid withdrawal may result in pronounced restlessness, irritability, insomnia, hand tremors, abdominal and muscle cramps, diaphoresis, vomiting, and seizures. Overdose results in somnolence, confusion, diminished reflexes, and coma. Blood dyscrasias have been reported rarely.

BASELINE ASSESSMENT

Offer emotional support to anxious patient. Assess motor responses (agitation, trembling, tension), autonomic responses (cold/clammy hands, diaphoresis).

INTERVENTION/EVALUATION

For those on long-term therapy, perform liver/renal function tests, blood counts periodically. Assess for paradoxical reaction, particularly during early therapy. Evaluate for therapeutic response: calm facial expression, decreased restlessness, insomnia.

PATIENT/FAMILY TEACHING

N Drowsiness usually disappears during continued therapy. N If dizziness occurs, change positions slowly from recumbent to sitting position before standing. N Avoid tasks that require alertness, motor skills until response to drug is established. N Smoking reduces drug effectiveness. N Sour hard candy, gum, sips of tepid water may relieve dry mouth. N Do not abruptly withdraw medication after long-term therapy. N Avoid alcohol. N Do not take other medications without consulting physician.

alteplase, recombinant A

all-teh-place

(Activase, Cathflo Activase)

Do not confuse alteplase or Activase with Altace.

G CLASSIFICATION

PHARMACOTHERAPEUTIC: Tissue plasminogen activator (tPA). CLINICAL: Thrombolytic

ACTION

A tissue plasminogen activator that acts as a thrombolytic by binding to the fibrin in a thrombus and converting entrapped plasminogen to plasmin. This process initiates fibrinolysis. Therapeutic Effect: Degrades fibrin clots, fibrinogen, and other plasma proteins.

PHARMACOKINETICS

Rapidly metabolized in the liver. Primarily excreted in urine. Half-life: 35 min.

USES

Treatment of acute MI, acute ischemic stroke, acute massive pulmonary embolism. Treatment of occluded central venous catheters. OFF-LABEL: Acute peripheral occlusive disease, basilar artery occlusion, cerebral infarction, deep vein thrombosis, femoropopliteal artery occlusion, mesenteric or subclavian vein occlusion, pleural effusion (parapneumonic).

PRECAUTIONS

CONTRAINDICATIONS: Active internal bleeding, AV malformation or aneurysm, bleeding diathesis, intracranial neoplasm, intracranial or intraspinal surgery or trauma, recent (within past 2 mo) cerebrovascular accident, severe uncontrolled hypertension. CAUTIONS: Recent (within 10 days) major surgery or GI bleeding, OB delivery, organ biopsy, recent trauma (CPR, left heart thrombus, endocarditis, severe hepatic/renal disease, pregnancy, elderly, cerebrovascular disease, diabetic retinopathy, thrombophlebitis, occluded AV cannula at infected site).

B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Use only when benefit outweighs potential risk to fetus. Unknown if drug crosses placenta or is distributed in breast milk. Pregnancy Category C. Children: Safety and efficacy not established. Elderly: Risk of bleeding with thrombolytic therapy increased, careful patient selection, monitoring recommended.

INTERACTIONS

DRUG: Anticoagulants, including cefotetan, heparin, plicamycin, valproic acid: May increase risk of hemorrhage. Platelet aggregation inhibitors, including aspirin, NSAIDs, ticlopidine: May increase risk of bleeding. HERBAL: Arnica, astragalus, bilberry, black currant, cat's claw, chaparral, dong quai, evening primrose, fenugreek, feverfew, garlic, ginger, ginkgo biloba, kava kava, licorice, tan-shen: May increase the risk of bleeding. FOOD: None known. LAB VALUES: Decreases plasminogen and fibrinogen levels during infusion, which decreases clotting time (and confirms the presence of lysis). Decreases Hgb and Hct.

AVAILABILITY (Rx)

POWDER FOR INJECTION: 2 mg (Cathflo Activase), 50 mg (Activase), 100 mg (Activase).

ADMINISTRATION/HANDLING

L IV

Reconstitution N Reconstitute immediately before use with sterile water for injection. N Reconstitute 100-mg vial with 100 ml sterile water for injection (50-mg vial with 50 ml sterile water) without preservative to provide a concentration of 1 mg/ml. May be further diluted with equal volume D5W or 0.9% NaCl to provide a concentration of 0.5 mg/ml. N Avoid excessive agitation; gently swirl or slowly invert vial to reconstitute.

Rate of administration N Give by IV infusion via infusion pump. See individual dosages. N If minor bleeding occurs at puncture sites, apply pressure for 30 sec; if unrelieved, apply pressure dressing. N If uncontrolled hemorrhage occurs, discontinue infusion immediately (slowing rate of infusion may produce worsening hemorrhage). N Avoid undue pressure when drug is injected into catheter (can rupture catheter or expel clot into circulation).

Storage N Store vials at room temperature. N After reconstitution, solutions appear colorless to pale yellow. N Solution is stable for 8 hr after reconstitution. Discard unused portions.

D IV INCOMPATIBILITIES

Dobutamine (Dobutrex), dopamine (Intropin), heparin, nitroglycerin.

IV COMPATIBILITIES

Lidocaine, metoprolol (Lopressor), morphine, nitroglycerin, propranolol (Inderal).

INDICATIONS/ROUTES/DOSAGE

ACUTE MI

IV INFUSION: ADULTS WEIGHING GREATER THAN 67 KG: 100 mg over 90 min, starting with 15-mg bolus over 1U2 min, then 50 mg over 30 min, then 35 mg over 60 min. Or a 3-hour infusion, giving 60 mg over first hr (6U10 mg as bolus over 1U2 min), 20 mg over second hr, and 20 mg over third hr. ADULTS WEIGHING 67 KG OR LESS: 100 mg over 90 min, starting with 15-mg bolus, then 0.75 mg/kg over 30 min (Maximum: 50 mg), then 0.5 mg/kg over 60 min (Maximum: 35 mg). Or 3-hour infusion of 1.25 mg/kg giving 60% of dose over first hr (6%U10% as 1- to 2-min bolus), 20% over second hr, and 20% over third hr.

ACUTE PULMONARY EMBOLI

IV INFUSION: ADULTS: 100 mg over 2 hr. Institute or reinstitute heparin near end or immediately after infusion when aPTT or thrombin time (TT) returns to twice normal or less.

ACUTE ISCHEMIC STROKE

O ALERT P Dose should be given within the first 3 hr of the onset of symptoms.

IV INFUSION: ADULTS: 0.9 mg/kg over 60 min (load with 0.09 mg/kg [10% of 0.9 mg/kg dose] as IV bolus over 1 min).

CENTRAL VENOUS CATHETER CLEARANCE

IV: ADULTS, ELDERLY: 2 mg; may repeat after 2 hr.

SIDE EFFECTS

FREQUENT: Superficial bleeding at puncture sites, decreased BP. OCCASIONAL: Allergic reaction, such as rash or wheezing; brusing.

ADVERSE REACTIONS/TOXIC EFFECTS

Severe internal hemorrhage may occur. Lysis of coronary thrombi may produce atrial or ventricular arrhythmias or stroke.

NURSING CONSIDERATIONS

BASELINE ASSESSMENT

Obtain baseline BP, apical pulse. Record weight. Evaluate 12-lead EKG, CPK, CPK-MB, electrolytes. Assess Hct, platelet count, thrombin (TT), aPTT, PT, fibrinogen level before therapy is instituted. Type and hold blood.

INTERVENTION/EVALUATION

Perform continuous cardiac monitoring for arrhythmias. Check BP, pulse, and respirations q15 min until stable, then hourly. Check peripheral pulses, heart and lung sounds. Monitor chest pain relief and notify physician of continuation or recurrence (note location, type, intensity). Assess for bleeding: overt blood, blood in any body substance. Monitor PTT per protocol. Maintain BP; avoid any trauma that might increase risk of bleeding (e.g., injections, shaving). Assess neurologic status.