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Managing pain 1. Information common to analgesics a. therapeutic class: analgesics b. establish baseline data and frequently monitor i. pain objective: pain scale subjective: characteristics, location, type of pain ii. clinical indicators of pain

reluctance to move, ambulate, eat restlessness, splinting, muscle tension higher than normal blood pressure faster than normal heart rate or respiratory rate iv. record response to therapy and analgesic at indicated time according to administration route and agent used 2. collaborate with provider for comprehensive pain management iii. provide non-pharmacological methods of pain relief such as distraction, positioning, and guided imagery with pharmacotherapy iv. eliminate factors that decrease pain tolerance: fatigue, boredom, anxiety, stress, anger, fear v. individualize pain management according to pain history context of therapy and available resources clients age, past experiences, values, expectations, physical and mental health vi. administer pharmacotherapy before severe pain develops vii. administer lowest dose of analgesic providing satisfactory pain relief according to client report viii. augment potential analgesic effect with adjunct therapy (See also: III.A.6 adjunct therapy) 3. alcohol and CNS depressants potentiate analgesic effect iii. high risk behavior

associated with increased risk of adverse effects including liver failure, respiratory depression, overdose, and death 4. opioids frequently combined with NSAIDS or acetaminophen iii. moderate to severe pain, intractable pain syndromes iv. combination allows lower dose of opioid v. benefit and adverse effects of both agents must be considered vi. keep track of total daily amount of each drug per 24-hour period when using a combination agent to prevent overdose of both drugs 5. administration methods (See also: administration routes I.D) iii. oral contraindicated with nausea and vomiting assess response to therapy 1 hour after administration slow-release preparations available: may require additional analgesic at initiation of therapy and for breakthrough pain iv. intramuscular assess response to therapy 30 minutes after administration avoid these methods with hypothermia and vasoconstriction v. subcutaneous assess response to therapy 30 minutes 1 hour after initiating therapy well-suited for clients with cancer requires ambulatory infusion pump easier to establish steady-state blood level vi. epidural and intrathecal assess response to therapy 15-45 minutes after initiating therapy itching can be severe risk of hematoma, infection, meningitis effective management of severe pain without CNS depression agents: preservative-free opioids and local anesthetics via PCA or implantable pump vii. patient-controlled analgesia (PCA) assess response to therapy 15-30 minutes after initiating therapy client controls dosing 1. client prevented from overdosing with lock-out: establishes maximum frequency of dosing 2. client and family teaching: intended for client only control used with oral, IV, subcutaneous, and epidural administration dose frequently includes a basal rate: client activates PCA for on-demand dose 1. typical basal rate of morphine sulfate: of 2-5 mg/hour 2. typical on-demand dose of morphine sulfate: 0.5-2 mg every 10 minutes 3. provides a steadier analgesic blood level


pump set-up requires specially trained personnel; controls are behind a locked panel may start equianalgesic oral opioids 30 minutes to 1 hour before discontinuing depending on the drugs involved viii. transdermal assess response to therapy 1-2 hours after initiating therapy difficult to adjust dosage agents: fentanyl and morphine increased absorption with febrile clients used in chouronic and severe pain syndromes monitor for respiratory depression and skin irritation remove old patch and cleanse area before applying new patch ix. intravenous assess response to therapy 15-30 minutes after therapy given by direct bolus short-term pain management for moderate to severe pain high risk of CNS depression especially respiratory depression x. other: sublingual, rectal 2. Therapeutic class: opioid analgesics (!high alert drugs) 1. type: opioid agonists iii. action: stimulate opioid receptors to cause analgesia; vary according to side effects, route of administration, onset, peak, and duration iv. examples

iii. iv.



uses: moderate to severe acute and chouronic pain, acute MI, intraoperative analgesia, antitussive adverse effects respiratory depression, hypertension, sedation, bradycardia, cough suppression euphoria, dizziness, hallucinations, miosis, biliary spasm nausea, pruritus, constipation, urinary retention, allergy contraindications respiratory failure, acute abdomen head injury (codeine is preferred agent) alcoholism, hypertension, hyperthermia, hepatic dysfunction nursing care (!high alert drugs) establish baseline data and monitor respiratory rate, blood pressure, bowel pattern, platelets, neuro status, allergy accurately time doses to prevent overdose; reverse effects with naloxone (Narcan) keep emergency equipment immediately available counteract adverse effects o administer antiemetic for nausea o administer antipruritic for pruritus

prevent constipation with fluid, fiber, ambulation stool softeners usually ineffective transition client from IV, IM dosing to oral dosing with equianalgesic doses (See also: Opioid analgesic equianalgesic doses table)

client teaching o ask for help when getting up o report rash, dyspnea, inadequate pain management o establish bowel habits, take with food to avoid nausea o take only as directed, do not exceed recommended dose o avoid alcohol, CNS depressants, antihistamines herbal remedies including chamomile and kava driving, making important decisions, and dangerous activity

b. type: opioid agonist-antagonists iii. action: stimulate some opioid receptors and block other opioid receptors; analgesic effect similar to morphine iv. examples nalbuphine (!high alert drug) (Nubain 10 mg IM every 3-6 hours) buprenorphine (Buprenex 0.3 mg IM, IV every 4-6 hours) v. uses: mild to moderate pain, adjunct intraoperative analgesia, labor and delivery adverse effects (See also: III.A.1.iv) reverses other opioids in system psychotic episodes, dysrhythmias, increased myocardial oxygen consumption v. contraindications physical dependence on opioids COPD, MI, CAD, HTN, hepatic dysfunction vi. nursing care (See also: III.A.1.vi opioid agonists: nursing care) screen clients for previous use of opioids d. type: opioid antagonists


action: effectively block the action of opioid receptors example: naloxone (Narcan 0.02-0.2 mg IV every 2-3 minutes; may need to repeat in 1 hour) uses: reverse adverse effects of opioids including respiratory depression and overdose, fetal respiratory depression

adverse effects 1. ventricular tachycardia and fibrillation, pulmonary edema 2. initiates acute withdrawal in clients physically dependent 3. duration of action is shorter than action of opioids 4. elimination of analgesic effect 5. cramping, nausea, vomiting, tachycardia, HTN, anxiety contraindications: opioid addiction nursing care 1. establish baseline data and monitor airway, respiratory rate, SaO2 blood pressure, heart rate and rhythm, pain intensity 2. provide information to client 3. administer with emergency equipment nearby 4. collaborate with provider for pain management

d. type: synthetic diphenylheptane derivative i. action: depresses pain impulse transmission at level of spinal cord ii. example: methadone (!high alert drug) (Methadone 20-120 mg by mouth, subcutaneously, IM daily) iii. use: opiate withdrawal, severe pain iv. adverse effects seizures, cardiac arrest, shock, respiratory depression, respiratory arrest drowsiness, dizziness, headache, nausea, vomiting, anorexia, constipation v. contraindications: opioid addiction vi. nursing care establish baseline data and monitor o pain, vital signs, RFTs, LFTs, airway, level of consciousness, pupil reaction to light o opioid intoxication: lack of analgesic effect, clinical indicators of withdrawal o client teaching report neuro changes, allergic reactions avoid CNS depressants, alcohol for 24 hours after administration change positions slowly, do not drive or engage in dangerous activity 2. Type: non-opioid analgesics d. sub-type: NSAIDs (See also: NSAIDs II.D.3) i. action: anti-inflammatory, analgesic, antipyretic, antiplatelet sub-type: cyclooxygenase-1 inhibitor (COX1 inhibitor) sub-type: cyclooxygenase-2 inhibitor (COX2 inhibitor) sub-type: aspirin e. sub-type: acetaminophen

action: blocks pain impulses that occur in response to prostaglandin synthesis, antipyretic: without antiinflammatory properties ii. example: acetaminophen (Tylenol 1 gram by mouth 3-4 times daily, not to exceed 1300 mg thouree times daily) iii. uses: mild to moderate pain or fever, in combination with opioids iv. adverse effects hepatotoxicity renal failure, myelosuppression toxicity: nausea, vomiting, abdominal pain, cyanosis, myelosuppression, delirium, seizures, coma v. contraindications intolerance to tartrazine (yellow dye #5) liver or renal failure, alcoholism vi. nursing care establish baseline data and monitor pain, temperature, LFT, creatinine, CBC, urine output, neuro status client teaching o avoid alcohol o may crush or cut tablets o do not exceed recommended dose o avoid OTC containing acetaminophen o report nausea, vomiting, abdominal pain 3. Type: anti-migraine headache agents d. sub-type: triptan i. action: cause cranial vasoconstriction and migraine headache relief by binding to serotonin (5-HT1) receptor sites ii. examples almotriptan (Axert 6.25-12.5 mg by mouth, may repeat in 2 hours) naratriptan (Amerge 1 mg or 2.5 mg by mouth, may repeat in 4 hours, do not exceed 5 mg/24 hours) sumatriptan (Imitrex 25-50 mg by mouth, may repeat in 2 hours, do not exceed 300 mg/24 hours) iii. use: treatment but not prevention of acute migraine headache iv. adverse effects hyper- and hypotension, coronary artery vasospasm, ventricular tachycardia and fibrillation dizziness, myalgia, weakness paresthesias, feeling hot, cold, or strange v. contraindications CAD, clients with vascular disease, hypertension older clients, hepatic or renal dysfunction concurrent use of ergotamine agents, MAO inhibitor vi. nursing care establish baseline data and monitor pain, associated findings, blood pressure, EKG, RFT, LFT, neuro status


screen clients for cardiovascular or neurovascular history, drugs containing ergotamine client teaching o avoid triggers: foods containing tyramine, sulfites, etc. o report chest pain, worsening symptoms, paresthesias, flushing o avoid pregnancy o do not crush tablets o remain in calm environment, away from noise, light e. sub-type: ergot derivatives i. action: constricts vascular smooth muscle in periphery, cranial vasculature, uterus ii. examples treatment: ergotamine, dihydroergotamine (Migranal 1-2 mg by mouth every 30 minutes until attack subsides, up to 6 mg) prophylaxis: methysergide (Sanserf 200 mg by mouth, IM, IV every 6-12 hours for 2-7 days) iii. uses: treatment of migraine headaches, preterm labor iv. adverse effects MI, hypo- and hypertension, tachycardia, bradycardia, edema, claudication peripheral numbness, myalgia, nausea toxicity: nausea, weakness, myalgia, intolerance to cold, paresthesias v. contraindications: vascular, hepatic, renal, peptic ulcer disease, hypertension vi. nursing care establish baseline data and monitor pain, associated findings, neuro status including blurred vision, blood pressure, heart rate, RFT, LFT treat overdose with vasodilators, heparin, and dextran client teaching o do not swallow, crush, chew SL tablets; do not drink, eat, or smoke until tablet dissolves o use of inhaler o avoid alcohol and OTC drugs f. type: anticonvulsant i. example: topiramate (Topamax) (See also: II.C.1.D.ii anticonvulsants) 4. Other pain relief agents d. type: local anesthetics i. example: lidocaine patch (Lidoderm) ii. example: lidocaine and prilocaine cream (EMLA) iii. nursing care: cream must be applied 1 hour before pain e. type: herbal remedy i. example: capsaicin apply 3-4 times daily; more effective with consistent use adverse effects: burning, extreme burning on contact with mucous membranes or eyes nursing care

o o o

wear gloves to apply, rub into skin until cream is transparent wash hands following application client teaching apply with glove, wash hands following application burning increased by heat, sweating, humidity, clothing

5. Adjunct therapy d. type: antihistamines (See also: II.K.2 antihistamines) i. examples: promethazine (Phenergan), hydrOXYzine (Vistaril) ii. use: preoperative medication, sedation, enhance analgesic effect, nausea e. type: anticonvulsants (See also: II.C.1 anticonvulsants) i. examples: gabapentin (Neurontin), carbamazepine (Tegretal) ii. use: neuropathic pain f. type: steroids (See also: II.K.1.b anti-inflammatory agents: glucocorticoids) i. example: dexamethasone (Decadron), prednisone ii. use: severe bone pain, nerve compression g. type: CNS stimulants (See also: III.D.6 stimulants) i. example: methylphenidate (Ritalin) ii. uses: counteract sedation and anorexia associated with chemotherapy h. type: antihypertensive agent and centrally-acting analgesic: alpha-adrenergic agonist (See also: II.A.4.i alpha-adrenergic agonists) i. example: clonidine (Catapres) ii. use: chronic pain syndromes 2. Managing electrolyte imbalances 1. Type: sodium d. action: the major extracellular cation: important in cell membrane function and action potential, osmotic pressure, acid-base balance, and extracellular fluid volume; controls fluid movement e. examples: 0.9% NaCl (isotonic or normal saline), 0.45% NaCl, 3% NaCl f. uses: hyponatremia, provide osmotic pressure, fluid volume expander, maintain electroneutrality g. nursing care i. establish baseline data and monitor serum sodium, hypernatremia and hyponatremia, pH, fluid status, edema, weight, neuro status ii. client teaching: read food labels for sodium content, weigh daily

2. Type: potassium a. action: the major intracellular ion; maintains intracellular fluid volume and action potential of cell membranes; maintenance of myocardial contractility b. example: potassium chloride (K-Dur) c. use: hypokalemia, concurrent diuretic therapy, ventricular dysrhythmias d. contraindications: renal failure e. nursing care i. establish baseline data and monitor serum potassium, RFT, EKG, urine output ii. use large bore needle to draw blood specimen to prevent hemolysis iii. administration never administer by IV push stop infusion with client complaints rapid infusion may cause cardiac standstill slowly infuse thourough central line or large vein


4. type: calcium

client teaching take with full glass of water do not crush or chew tablets need for follow-up care and testing avoid OTC drugs and salt substitutes action: neuromuscular function, bone strength and density, enzyme activation, blood clotting examples (See also: II.F.2.c antacids: calcium)


calcium chloride and calcium gluconate calcium citrate (Citracal) calcium carbonate (Maalox, Tums) b. uses: osteoporosis, hypocalcemia, hypersecretory (HCl) state, hyperphosphatemia, hypoparathyroidism c. nursing care establish baseline data and monitor serum calcium, magnesium, phosphorous, and albumin; bone density, orientation, headache, blood pressure, EKG provide adequate vitamin D seizure precautions for hypocalcemia administration o o IV: infuse slowly in large vein, stop infusion with client complaints of burning, prevent extravasation PO: give 1.5-2 hours after meals, avoid giving with enteric-coated tablets

prevent constipation with fluid, fiber, and exercise

client teaching o o o do not change antacids limit vitamin D intake to 400 units daily establish regular bowel habits with fluids, fiber, and exercise

1. Type: magnesium 1. action: skeletal muscle contraction, energy production, carbohydrate metabolism activation of B-complex vitamins, protein synthesis 2. example: magnesium sulfate (See also: II.F.1.d antacids: magnesium II.F.1.d) 3. uses: prevention and treatment of hypomagnesemia, pregnancy induced hypertension, malabsorption syndromes 4. nursing care (See also: II.F.1.d) vi. establish baseline data and monitor serum magnesium, potassium, and calcium; EKG, DTRs, blood pressure, respiratory rate, RFT vii. IV administration slow IV push use infusion control device for continuous infusion: stop for sudden hypotension, somnolence, or hyporeflexia

5. Type: phosphorous a. action: vitamin B-complex activation, energy production, cell division; carbohydrate, protein, and fat metabolism, acid-base balance b. uses: hyperparathyroidism, osteomalacia, cirrhosis, hypokalemia, excess IV glucose, respiratory alkalosis

C. Managing pregnancy: classification of medications by health status (pregnancy)

1. Dietary supplements a. therapeutic class: vitamins i. type: folic acid action: normal growth, prevention of macrocytic megaloblastic anemia recommended daily intake: 1-4 mg

use: prevention of neural tube defects nursing care o encourage minimum daily intake in women of childbearing age o collaborate with provider to provide 1 mg by mouth daily immediately after conception: neural tube develops very early o increase dietary intake of folic acid

type: multivitamin, prenatal formula type: vitamin K (See also: II.J.2.b hemostatic agents) action: essential ingredient in clotting cascade example: phytonadione (AquaMEPHYTON) use: prevention hemorrhagic disease of newborn 2. therapeutic class: minerals ii. type: iron (See also: II.J.1.b antianemic agents) recommended daily intake 1. 27 mg by mouth daily 2. 60-120 mg by mouth daily for iron deficiency use: reduce risk of low-birth-weight infants, increase oxygen-carrying capacity of hemoglobin and number of erythourocytes nursing care 1. establish baseline data and monitor Hct. and Hgb, serum ferritin, iron binding capacity, exercise tolerance 2. client teaching 1. stool will be very dark, sticky 2. take with food to avoid nausea 3. take with source of vitamin C such as orange juice 4. increase fiber, fluids, and ambulation to prevent constipation; avoid laxatives and stool softeners iii. type: calcium (See also: III.B.3 electrolytes: calcium) recommended daily intake 1. pregnancy and lactation 1,000 mg 2. adolescent pregnancy and lactation 1,300 mg use: fetal osteogenesis and tooth formation, blood clotting 2. Agents affecting uterine function

ii. iii.

1. therapeutic class: uterine stimulants ii. type: hormone action: act directly on uterine myofibrils to cause contractions example: oxytocin (Pitocin) use: increase strength and frequency of uterine contractions, induce labor, incomplete abortion, postpartum hemorrhage adverse effects 1. prolonged, tetanic contractions, abruptio placentae, decreased uterine blood flow, seizures 2. fetal intracranial hemorrhage, asphyxia, fetal distress contraindications: fetal distress, pregnancyinduced hypertension (PIH), cephalopelvic disproportion (CPD), hypertonic uterus, water intoxication nursing care 1. establish baseline data and monitor 1. uterine contractions: frequency, duration, and intensity and associated fetal response 2. maternal: blood pressure, heart rate, and SaO2, fluid balance, urine output, neuro status, vaginal bleeding 3. fetal: fetal heart tones (FHT) 2. administer with infusion control device 1. increase rate very slowly to desired effect: administer lowest effective dose 2. labor: 10 units per liter of IV solution 3. postpartum hemorrhage: 1040 units per liter 3. fetal distress or abnormal deceleration patterns, maternal hypotension 1. priority: stop oxytocin infusion 2. position mother on left side, lower head if possible 3. infuse isotonic fluids 4. administer supplemental oxygen 4. client teaching: report vaginal bleeding. foul-smelling lochia iii. prostaglandins action: stimulation uterine contractions and soften cervix allowing for cervical dilatation and effacement example: dinoprostone (Cervidil, Prepidil vaginal insert) use: induce labor and stimulate initial contractions, oxytocin may be started 30 minutes after insertion adverse effects

1. uterine hyperstimulation, fetal distress 2. increased risk of postpartum hemorrhage 3. fever, nausea, abdominal pain contraindications 1. fetal distress, vaginal bleeding, prolapsed umbilical cord 2. previous classical uterine incision 3. suspicion of CPD, oxytocin infusion already infusing, 6 or more previous term pregnancies nursing care 1. establish baseline data and monitor 1. maternal vital signs 2. associated fetal response 3. cervical dilatation and effacement 4. uterine contractions: frequency, duration, and intensity 2. provide information 3. remove vaginal insert with sustained uterine contractions, fetal distress, or adverse maternal effects 4. administration 1. gel-filled syringe: insert applicator in cervical os 2. suppository: place in posterior fornix of vagina , leave in place for 30 minutes 3. place rolled-up towel under client hips to prevent escape of gel 4. provide continuous maternal and fetal monitoring 5. client teaching 1. remain on bedrest 2. report vaginal bleeding, sustained contraction, dypsnea 2. therapeutic class: tocolytics ii. type: electrolytes action: depresses the CNS resulting in less Ach, inhibited neuromuscular function, smooth muscle relaxation example: magnesium sulfate IV uses: pre-term labor, anticonvulsant, PIH adverse effects 1. hypotension, respiratory failure, pulmonary edema 2. fetus: transient decrease in variability 3. flushing, nausea, constipation, blurred vision, headache 4. lethargy (may persist for 1-2 days after discontinuing therapy) 5. fewer side effects than betaadrenergic agonists nursing care 1. establish baseline data and monitor



1. contractions: intensity, duration, frequency 2. blood pressure, respiratory rate, DTRs, seizures 3. serum magnesium, level of consciousness, urine output 2. establish baseline data and monitor FHTs 3. maintain maternal Mg++ blood level at 5.5-7.5 mg/dL 4. requires loading dose Mg++ sulfate 4-6 grams IV over 15 minutes 1. maintain continuous infusion on infusion control device 2. infuse at lowest dose that achieves tocolysis: usually 14 grams/hour titrated to DTRs and serum magnesium 5. keep calcium gluconate IV at the bedside (antidote) type: beta-adrenergic agonists (See also: II.B.1.b antihypertensives: beta-adrenergic agonists) example 1. ritodrine (do not confuse with Ritalin) (Yutopar 50-100 mcg/min IV, increase 50 mcg every 10 minutes until desired outcome is achieved or maternal heart rate is 130 bpm) 2. terbutaline (Brethine 10 mcg/min increase by 5 mcg every 10 minutes until contractions stop, do not exceed 80 mcg/min) use: inhibit uterine contractions adverse effects 1. maternal myocardial ischemia, pulmonary edema, hypotension, dysrhythmias, tachycardia, palpitations 2. hyperglycemia, uterine atony contraindications fetal demise, PIH, hemorrhage, abruptio placenta, acute fetal distress nursing care 1. establish baseline data and monitor 1. uterine contractions: frequency, duration, and intensity 2. back pain, bleeding, urine output 2. establish baseline data and monitor FHTs, fetal movement 3. provide information 4. client teaching 1. report contractions occurring < every 10 minutes, lower abdominal cramps, rupture of membranes, increased pelvic pressure, decreased fetal movement 2. report chest pain, insomnia, dysuria type: calcium channel blockers (See also: II.A.4.d)

example: NIFEidipine (Procardia) use: used alone or in combination with terbutaline to relax uterine smooth muscle adverse effects 1. hypotension, bradycardia, reflex tachycardia, heart failure nursing care establish baseline data and monitor 1. uterine contractions: frequency, duration, and intensity; back pain, bleeding, urine output 2. establish baseline data and monitor FHTs, fetal movements 3. provide information 4. client teaching 1. report contractions occurring < every 10 minutes, lower abdominal cramps, rupture of membranes, increased pelvic pressure, decreased fetal movement v. type: prostaglandin synthetase inhibitors (See also: II.D.3.b) action: inhibits synthesis of prostaglandins by decreasing the related enzyme, antipyretic, anti-inflammatory example: celecoxib (Celebrex) 3. Agents used with pre-term labor 1. therapeutic class: steroids ii. type: glucocorticoid (See also: II.K.1.b antiinflammatory agents: glucocorticoids) action: acceleration of fetal lung maturity examples 1. betamethasone, IM (Celestone Soluspan) 2. dexamethosone, IV (Decadron) use: pre-term labor adverse effects 1. increased risk of infection 2. neonate: lowered cortisol levels, hypoglycemia, sepsis contraindications: labor, adequate L/S ratio, maternal hemorrhage, infection, gestational age >34 weeks nursing care 1. establish baseline data and monitor uterine contractions, L/S ratio, fetal movement, maternal fluid and electrolyte balance 2. dexamethosone: administer slow IV push 3. betamethasone: administer by deep IM injection into gluteal muscle 4. Agents used with hypertensive disorders of pregnancy 1. therapeutic class: anticonvulsants ii. type: electrolyte sub-type: magnesium sulfate (See also: III.C.2.b.i) 1. use 1. pre-eclampsia, eclampsia, pregnancy-induced hypertension (PIH)

2. continue infusion for 24 hours after birth 2. nursing care: establish baseline data and monitor breath sounds sub-type: sodium (See also: III.B.1 electrolytes: sodium) 1. use: hyponatremia associated with pre-eclampsia iii. type: hydantoin (See also: II.C.1.b anticonvulsants: hydantoins) example: phenytoin (Dilantin IV bolus 10 mg/kg body weight infused at rate not to exceed 50 mg/minute; 2 hours later: IV bolus 5 mg/kg and then maintenance doses every 12 hours based on serum drug levels; may administer simultaneously with magnesium) use: after magnesium sulfate failure in the treatment of eclampsia adverse effects 1. cerebral hemorrhage, fetal bradycardia, precipitous delivery, pulmonary edema nursing care 1. establish baseline data and monitor maternal 1. blood pressure, heart rate, EKG 2. drug level: therapeutic range: 10-20 mg/ml 3. neuro status, level of consciousness, vision loss 4. vaginal bleeding, contractions, uterine rigidity, breath sounds, RFT 2. establish baseline data and monitor FHTs, fetal movement 3. postictal: monitor for combativeness and confusion, avoid bright lights, noise, frequent disturbance 4. maintain emergency equipment immediately available including hydrALAZine, airway support, and additional antihypertensive agents 2. therapeutic class: steroids ii. type: glucocorticoids (See also: II.K.1.b antiinflammatory agents: glucocorticoids) iii. use: prepare fetus for eminent birth to increase lung maturation 3. therapeutic class: antihypertensives ii. type: alpha-adrenergic inhibitor action: stimulates central alpha2-adrenergic receptors resulting in decreased peripheral vascular resistance example: methyldopa (Aldomet 500-2000 mg by mouth daily in divided doses, IV 250500 mg every 6 hours) use: safety and efficacy well-documented for fetus and mother adverse effects 1. myocarditis, heart failure, hepatic dysfunction, myelosuppression


2. CNS depression, psychosis, orthostatic hypotension 3. nasal congestion, rash, fluid retention nursing care 1. establish baseline data and monitor blood pressure, heart rate, EKG, RFT, LFT, CBC, edema, rash, level of consciousness and mental status 2. establish baseline data and monitor FHTs and fetal movements 3. administration 1. administer orally before meals 2. shake suspension before dosing 3. dilute IV solution in sodium bicarbonate and infuse slowly 4. client teaching 1. maintain hydration 2. do not abruptly discontinue therapy 3. avoid OTC drugs and hazardous activities 4. change positions slowly, ask for help before getting up type: centrally acting vasodilator (See also: II.A.4.j antihypertensive agents: centrally acting vasodilator) example: hydralazine

5. Diabetes mellitus, gestational and idiopathic a. therapeutic class: antidiabetic agent i. type: insulin (See also: antidiabetic agents: insulin II.G.1.c) lispro, regular, and intermediate acting insulin used in multiple injections regular insulin used with continuous infusion ii. type: oral hypoglycemic agents contraindicated in pregnancy 5. Herbal agents a. general principles avoid essential oils avoid herbs and tonic herbs during first trimester avoid standardized and highly concentrated forms of herbs iv. avoid herbal stimulants and laxatives; agents used as abortifacients and to induce menstruation b. avoid: aloe, fever few, kava, licorice, St. Johns Wort and others c. use with caution: garlic, ginger, turmeric d. sources of vitamins and minerals i. raspberry leaf: vitamin C and iron ii. oat straw: calcium, magnesium, iron iii. dandelion root: vitamins A and C, beta carotene, potassium e. lack of randomized-controlled trials to test safety and efficacy in pregnancy 6. Pain management in labor and childbirth i. ii. iii.

a. information about obstetrical analgesia i. provide information to client: using anesthetics and analgesics during labor and childbirth is a balance of risk versus benefit may slow or enhance the progress of labor may lead to serious adverse effects 1. maternal: circulatory collapse 2. fetal distress or sedation ii. use alternative comfort measures alone or in combination with anesthetic and analgesic agents iii. assess mother and fetus before initiating pain management

emergency equipment for mother and neonate should be immediately available v. client teaching: remain in bed, ask for help before getting up, empty bladder c. analgesics used in labor and childbirth


type: opioid agonist-antagonist (See also: III.A.2.b opioid agonist-antagonist) example: nalbuphine(Nubain 10 mg subcutaneous injection, IM, IV every 3-6 hours, not to exceed 160 mg/day) adverse effects o sedation, respiratory depression o reverses any opioid in the system nursing care o establish baseline data and monitor pain for type, location, intensity, respiratory rate frequency, duration, and intensity of uterine contractions FHTs

type: opioid agonists (See also: III.A.2.a opioid agonist)

examples o meperidine hydrochloride (Demerol 50 mg IM every 4 hours)

morphine sulfate (Morphine sulfate 2-10 mg IM, IV every 2-4 hours) adverse effects o maternal and fetal respiratory depression, sedation o pruritus, dizziness, nausea, constipation o decreased intensity and frequency of uterine contractions nursing care o establish baseline data and monitor pain for type, location, intensity, respiratory rate uterine contractions for frequency, duration, and intensity FHTs o monitor neonate for 4-6 hours postpartum for residual respiratory depression o treatment of itching with antihistamine usually increases sedation

type: opioid antagonist (See also: III.A.2.C opioid antagonist) example: naloxone (Narcan) use: reverse maternal or neonatal respiratory depression, sedation, and hypotension caused by opioid agonists and agonist-antagonists nursing care (neonate): establish baseline data and monitor vital signs frequently for 4 hours in special care area (respiratory depression may recur after naloxone wears off) d. anesthesia using local and regional methods vi. local anesthetics (See also: II.B.4 local anesthetics) action: regional impairment of nerve impulse transmission examples o procaine hydrochloride (Novocaine) o bupivacaine hydrochloride (Marcaine) (longer acting) uses: local and regional pain management during labor and delivery, alone or in combination with opioid analgesics adverse effects o systemic toxic reaction, broad ligament hematoma, perforation of rectum o trauma to sciatic nerve contraindications: severe hypovolemia, CNS disease, bleeding disorder nursing care o maternal: establish baseline data and monitor blood pressure and heart rate


pain for type, location, intensity contractions for frequency, duration, and intensity o neonatal: establish baseline data and monitor FHTs, response to injections o provide information to client about importance of not moving during injection and related transient discomfort o remain at bedside during injections lumbar epidural and spinal blocks



other anesthesia using local anesthetics pudendal block o injection below pudendal plexus in second stage of labor o low risk of maternal hypotension or fetal depression local infiltration: injection into soft tissue of perineum, generally given for episiotomy general anesthetics: usually reserved for obstetrical emergencies when fetal demise is expected due to high risk of fetal depression (See also: general anesthetics II.C.3) adverse effects o maternal: postoperative nausea, sedation, high risk of impaired airway o fetal and neonatal: impaired oxygenation contraindications: high-risk fetus nursing care o maternal priority to protect airway until gag reflex returns and client is able to maintain airway; and maintain NPO monitor vital signs frequently prevent postpartum hemorrhage o neonatal establish baseline data and monitor vital signs, especially airway and respirations provide warmth, quickly dry infant have emergency equipment immediately available dedicate 1 neonatal nurse in delivery area

provide initial maternalnewborn bonding when mother awakens 2. adjunct therapies for obstetrical pain management ii. therapeutic classes antihistamines (See also: II.K.2 antihistamines) antiemetics (See also: II.F.1 antiemetics) barbiturates (See also: II.C.1.b.i barbiturates) iii. use in labor anxiety, apprehension antiemetic (except barbiturates) pregnancy induced hypertension iv. contraindications: active labor v. nursing care establish baseline data and monitor maternal o blood pressure and heart rate o pain for type, location, intensity o contractions for frequency, duration, and intensity establish baseline data and monitor FHTs, response to injections client teaching: ask for help before getting up, avoid driving or hazardous activities 2. Agents for Rh incompatibility 1. therapeutic class: immune globulin ii. type: Rh IgG immune globulin action o prevents formation of maternal antibodies (sensitization) against fetal cells that may enter her bloodstream during placental separation o effective with subsequent pregnancies in unsensitized woman o provides passive immunity for mother which prevents permanent active immunity (antibody formation) examples o standard dose: Rh IgG immune globulin (IM: RhoGAM, IV: WinRho SDF) o microdose: Rh IgG immune globulin IM (MICRhoGAM) use: o restricted to Rh negative mothers with Rh positive fetus to reduce risk of antenatal sensitization in mother at 28 weeks gestation with negative antibody screen within 72 hours of birth if maternal indirect Coombs' test and neonatal direct Coombs tests are negative o following amniocentesis, spontaneous or elective abortion, ectopic pregnancy, chorionic villi, percutaneous umbilical blood sampling, maternal trauma

adverse effects: lethargy, irritation at injection site, fever, myalgia contraindications: Rh+ client, allergy to blood products nursing care o establish baseline data and monitor maternal indirect Coombs test, neonatal direct Coombs test, fetal intravascular hemolysis o verify consent to treatment o microdose generally not administered after term pregnancy o do not use IM agents for IV administration, do not confuse with Gamulin Rh/MICRhoGAM o IM dose administered by IM injection into deltoid muscle or ventral gluteal site o considered a blood product follow agency policy for checking lot number of agent and cross-match verify maternal Rh blood type o client teaching for Rh- mothers: drug must be administered after subsequent pregnancies if neonates are Rh+


Classification of Medications Health Status I. Information common to psychotropic agents I. consider cultural perspective of client a. impact on behavior b. impact on psychotropic drug compliance: unique social stigma about mental illness and psychotropic agents II. establish baseline data and monitor using standardized rating scales when available a. negative and positive behavior associated with condition b. differentiation of psychiatric findings from adverse effects c. compliance with and adverse effects of therapeutic regimen d. expected therapeutic effects of psychopharmacological therapy III. client and family a. teaching take only as directed b. store away from heat, light, and moisture c. provide support, encouragement, and community resources d. provide non-pharmological strategies to avoid adverse effects e. identify barriers to compliance, develop collaborative plan to eliminate or minimize f. psychopharmacological therapy most effective when combined with psychotherapy g. expect drug titration I. need for follow-up care and testing


use of trial and error with choice of medication and dosing Therapeutic class: antidepressants I. information common to antidepressants a. actions relate primarily to norepinephourine (NE), serotonin (5HT), dopamine to I. inhibit the effects of monoamine oxidase II. block reuptake of neurotransmitters at the synaptic cleft III. regulate receptor sites and neurotransmitter breakdown b. uses I. non-organic short term and chronic depressive disorders II. panic disorder, agoraphobia, generalized anxiety disorder, post-traumatic stress disorder c. adverse effects I. increased suicidal ideation especially in children II. anticholinergic effects: dry mouth and eyes, constipation, urinary retention, sedation, insomnia III. headache, tremors, fatigue, GI upset IV. decreased libido and sexual performance, weight gain V. increased risk of adverse effects in older clients, especially sedation, dizziness, and hallucinations d. nursing care I. establish baseline data and monitor affect, weight, suicidal ideation, enjoyment, sleeping pattern, increased energy, and implementation of daily activities


client teaching o report worsening depression, suicidal ideation; seek immediate treatment for well-developed suicide plans o effective treatment usually consists of taking 2 or more agents concurrently o take as directed do not abruptly discontinue therapy do not stop taking drug when feeling better o avoid alcohol, OTC drugs, kava, and SAMe avoid driving and dangerous activities until adverse effects are well established o take drug consistently initial improvement may not be seen for 4 weeks take for 4-6 weeks before abandoning agent due to adverse effects many adverse effects will subside with consistent use

strategies for adverse effects take sedating antidepressants at bedtime use hard candy, gum, ice chips, and sips of water for dry mouth increase fluid intake, fiber in diet, and ambulation to prevent constipation

b. type: serotonin reuptake inhibitors (SSRIs) i. action: inhibits 5HT reuptake in the CNS ii. examples fluoxetine hydrochloride (Prozac 20-80 mg by mouth once or twice daily) sertraline (Zoloft 50-200 mg by mouth daily)

citalopram (Celexa 20-60 mg by mouth daily)



major depressive disorders bulimia, citalopram post-traumatic stress disorder obsessive-compulsive disorders premenstrual dysphoric disorder iv. adverse effects seizures, hemorrhage, dysrhythmias, MI, thourombophlebitis vasomotor instability, palpitation, nasal congestion, dypsnea sedation, activation, GI activation, constipation nausea, headache, sexual dysfunction tolerance paroxetine increases levels of clozapine, theophylline, warfarin fluoxetine potentiates tricyclic antidepressants and some antidysrhythmics fluoxetine and sertraline increase levels of benzodiazepines, clozapine, and warfarin v. contraindications: hepatic or renal dysfunction, mania, concurrent administration of MAOI vi. nursing care establish baseline data and monitor o CBC, platelets, LFT, urinary and bowel pattern o blood pressure, pulse; EKG for flattened T wave, heart block may crush tablets administration o may administer entire dose in AM o older client may need to take twice a day allow 5 weeks between administration of an SSRI and an MAOI to prevent serotonin syndrome client teaching o report rash, mania, seizures, and severe weight loss o increase fluid intake o use barrier contraception o take weekly doses on same day each week o change positions slowly, ask for help when getting up until adverse effects of drug are well established c. type: phenethylamine i. action: inhibit reuptake of NE and 5HT ii. example: venlafaxine (Effexor 75-225 mg by mouth daily) iii. adverse effects vaginal and uterine hemorrhage usually dose related: HTN, nervousness, anorexia iv. nursing care: taper dose over 2-weeks before discontinuing therapy d. type: tricyclic antidepressants (TCAs)

action: reduce reuptake of NE and 5HT at the synaptic clef resulting in increased stimulation of postsynaptic receptors ii. examples imipramine hydrochloride (Tofranil 75-300 mg by mouth daily in 3-4 doses) amitriptyline hydrochloride (Elavil 75-150 mg by mouth daily) iii. uses relief of depressive symptoms children: suppression of enuresis, ADHD iv. adverse effects HTN, cardiac depression, EKG changes, dysrhythmias paralytic ileus, hepatitis, hyperthermia, acute renal failure, myelosuppression weakness, fatigue, drowsiness, blurred vision, orthostatic hypotension constipation, dry mouth, urinary retention, extrapyramidal symptoms overdose: hyperthermia, seizures, delirium, coma children: higher risk of seizures, cardiotoxicity, agitation, suicide v. contraindications: recovery phase from MI, narrowangle glaucoma, seizure disorders, BPH vi. nursing care (See also: SSRI: III.D.2.b.vi nursing care) establish baseline data and monitor extrapyramidal symptoms, heart rate, EKG, blood pressure, ambulation, level of consciousness assist with ambulation avoid concurrent administration with SSRIs decreased protein-binding with phenytoin, aspirin, phenothiazines client teaching o wear sunscreen and protective clothing in the sun o change positions slowly e. type: monoamine oxidase inhibitors (MAOI) i. action: irreversibly inhibits monoamine oxidase, the enzyme responsible for terminating the actions of 5HT, norepinephourine, and dopamine; thus, increasing the concentration of neurotransmitters at the synaptic clef ii. examples phenelzine sulfate (Nardil 60-90 mg by mouth daily in divided doses) tranylcypromine (Parnate 30-60 mg by mouth daily in 2 doses) iii. uses: depressive disorders in clients who are unresponsive or intolerant of other therapies iv. adverse effects dysrhythmias, hypertensive crisis, SIADHlike syndrome, hepatic necrosis, intracranial bleeding (associated with more fatal adverse effects than any other antidepressant) dizziness, drowsiness, orthostatic hypotension, anorexia




blurred vision, dry mouth, constipation, weight gain, change in libido contraindications concurrent administration with TCA or SSRI HTN, heart failure, severe hepatic or renal dysfunction, pheochouromocytoma, severe cardiac disease, alcoholism nursing care (See also: III.D.2.b.vi SSRIs: nursing care) administer with food or milk, may crush tablet and mix in food increased risk of o serotonin syndrome when taken within 5 weeks of SSRIs o increased hypoglycemic effect when taken with antidiabetic agents client teaching o report 1. neck stiffness, chest tightness, headache 2. rash, changes in urinary patterns, color of urine 3. palpitations, dizziness, insomnia, change in strength o avoid 1. caffeine, CNS depressants, OTC cold medicine, cough syrup, drugs for weight loss or allergic rhinitis 2. foods containing tyramine 3. beware of combination foods containing tyramine

3. Therapeutic class: anxiolytic and hypnotic agents a. type: benzodiazepines



action: enhances the action of gamma-aminobutryic acid (GABA) in the synaptic clef of limbic system and reticular activating system; inhibits cell firing examples alprazolam (Xanax 0.25-0.5 mg by mouth thouree times daily up to 4 mg/day) diazepam (Valium 2-10 mg by mouth daily 2-4 times daily, IV 5-10 mg at 2 mg/min) lorazepam (Ativan 2-6 mg by mouth daily in divided doses) midazolam (Versed 0.7-0.8 mg/kg IV bolus for sedation) chlorodiazepoxide (Librium 50-100 mg by mouth, IM, IV four times daily) temazepam (Restoril 15-30 mg by mouth at bedtime) flurazepam (Dalmane 15-30 mg by mouth) use: see Therapeutic class: anxiolytic agents table (below)


adverse effects EKG changes, tachycardia, cardiac arrest, laryngospasm, bronchospasm, myelosuppression dizziness, drowsiness, confusion, blurred vision, daytime sedation dose-dependent CNS depression aggravation of sleep-related breathing disorders



amnesia, orthostatic hypotension, nausea, vomiting, hangover (confusion) older clients: accumulating drug levels with therapeutic doses, half-life may increase 4 times contraindications use with alcohol or other CNS depressant shock, coma, acute narrow-angle glaucoma psychosis, history of substance abuse, COPD nursing care establish baseline data and monitor o degree of anxiety and sedation, mental status, mood, sleep pattern, tolerance, dependency o blood pressure, heart rate, respiratory rate, breath sounds o CBC, LFT, seizure activity if administered as anticonvulsant older clients: do not abruptly stop therapy; very slowly withdraw drug administration o oral: may crush tablets, may take with food or milk o IM: give by deep injection into large muscle (discomfort) o IV: administer slowly in small amounts over 30 seconds-2 minutes, wait 15 minutes between doses keep emergency equipment immediately available during IV administration antidote: flumazenil (Romazicon 0.2 mg IV over 15-30 seconds; repeat in 45 seconds if consciousness does not occur) o administered IV push thourough IV fluid infusion o peak action within 5-10 minutes, lasts for about 1 hour o may need to administer additional doses after 1 hour

client teaching o report palpitations, worsening symptoms, trouble breathing, shortness of breath o use contraception while taking benzodiazepines o do not use for everyday stress, take only as directed o avoid driving, making important decisions, and dangerous activity o do not abruptly withdraw therapy; taper dose before discontinuing o avoid grapefruit juice, alcohol OTC drugs, herbal remedies especially kava and SAMe

antihistamines, sedating antidepressants other CNS depressants c. type: barbiturates (See also: II.C.1.b.ii anticonvulsants: barbiturates) d. other anxiolytic agents


type: combined blocker action: inhibits the action of 5HT and dopamine, increases NE levels example: busPIRone (BuSpar 20-30 mg by mouth daily in 3 doses) use: anti-anxiety with little sedative, anticonvulsant, or muscle relaxing properties adverse effects o CVA, MI, heart failure o tachycardia, palpitations, dizziness, headache, depression, stimulation, lightheadedness, paresthesias o sore thouroat, tinnitus, blurred vision, nasal congestion o nausea, dry mouth, diarrhea constipation, sweating, pain, weakness contraindications: children < 18 years-old nursing care (See also: III.D.2.b.vi SSRIs: nursing care and III.D.3.a.vi benzodiazepines: nursing care) o client teaching: therapeutic effect may take 2-3 weeks c. type: pyrazolopyrimidine hypnotics action: binds to the ?-1 receptor of GABAA to act as a sedative, hypnotic, muscle relaxatant, anticonvulsant, and anxiolytic agent examples o zaleplon (Sonata 5-20 mg by mouth at bedtime, duration of action 2 hours) o zolpidem (Ambien, Ambien CR 10 mg at bedtime, duration of action 6-8 hours) use: insomnia adverse effects o myelosuppression o drowsiness, lethargy, daytime sedation o chest pain, palpitations nursing care o establish baseline data and monitor mood, affect, sleeping patterns, drowsiness, suicidal ideation, CBC, heart rate and EKG, tolerance and dependency o screen for previous drug dependence o period to induce hypnotic action is limited o client teaching to induce sleep

1. take 30 minutes to 1 hour before desired hour of sleep 2. establish bedtime ritual: implement sleep-promoting behavior after taking hypnotic 3. avoid high-fat meals within 2 hours of bedtime do not abruptly withdraw therapy after long-term use avoid driving, dangerous activity after taking hypnotic agent avoid OTC drugs, alcohol, CNS depressants, and herbal remedies: may lead to respiratory depression 2. Therapeutic class: antipsychotic agents, information common to antipsychotic agents action

neuroleptic: suppression of psychotic behavior without depressed level of consciousness postsynaptic dopamine, serotonin, or dopamine receptor blockade of psychotic behavior in the brain to lower incidence of hallucinations, delusions, and paranoia reticular activating system depression to limit incoming stimuli

b. examples

typical antipsychotic o traditional antipsychotics: affect positive aspects of psychotic behavior o block non-selective neurotransmitter receptors with high affinity for dopamine2-receptors


atypical antipsychotic agents newer antipsychotics: lower affinity for dopamine2 receptors lower incidence of extrapyramidal symptoms but some serious adverse effects

c. uses i.

schizophrenia, paranoid psychosis, manic disorders, dementia, Alzheimers ii. delusional thinking, motor agitation, motor retardation, and confusion associated with schizophrenia, severe anxiety, severe hiccups iii. effective antiemetic iv. severe behavioral problems in children v. combativeness, agitation, uncooperativeness d. adverse effects i. hypotension, dysrhythmias, heart failure, prolonged QTc interval ii. myelosuppression, pigment deposits on retina iii. impaired thermoregulation, laryngospasm, neuroleptic malignant syndrome, tardive dyskinesia iv. orthostatic hypotension, sedation, acute dystonia, perioral tremor (rabbit syndrome) v. decreased threshold for seizures, weight gain, weakness, photosensitivity, may turn urine pink or reddish-brown, skin discoloration, bad taste

e. contraindications i. severe hypertension, CAD, prolonged QTc interval ii. hepatic and renal disease, cerebral arteriosclerosis, bleeding disorders, myelosuppression iii. Parkinsonism, severe depression, narrow angle glaucoma, during children < 12 years-old iv. alcohol or barbiturate withdrawal f. nursing care i. establish baseline data and monitor 1. mood, affect, orientation, LOC, coordination, extrapyramidal symptoms 2. dizziness, heart rate, blood pressure, EKG, LFT, RFT, CBC, urine output ii. provide client safety 1. prepare for sedation 2. assist with changing positions and ambulation 3. avoid other medication metabolized using cytochrome P450 iii. provide oral care iv. provide, support, encouragement, and community resources v. administration 1. avoid contact with skin 2. may give mixed in juice or carbonated beverage 3. give initially at very low dose at bedtime: has long half-life 4. make sure client is swallowing and not hoarding medication 5. may administer fluphenazine and haloperidol as depot injection (See also: I.D.2.b.iii intramuscular injection) 6. increased effect of both drugs with concurrent administration of CNS depressants beta-adrenergic blockers, quinidine, or procainamide vi. neuroleptic malignant syndrome 1. provide cooling and hydration 2. discontinue all psychotropic medication vii. client teaching 1. report sore throat, fever, rash, tremors, weakness, and vision changes 2. wear MedicAlert tag 3. do not abruptly withdraw therapy 4. do not crush or chew sustained release forms 5. take only as directed, continue to take when feeling good 6. increase fluids, fiber, and ambulation to prevent constipation 7. remain supine for 30 minutes after IM injection 1. ask for help before getting up, change positions slowly 8. avoid 1. driving, making important decisions, dangerous activity 2. alcohol, CNS depressants, OTC drugs, and herbal remedies, grapefruit juice

3. hot baths and showers, excessive clothing, hot sun, sunbathing, strenuous exercise 2. Therapeutic class: anti-manic agent (mood stabilizers) c. type: heavy metal i. action: alters ion transport across cell membrane in nerves and muscle cells ii. example: lithium chloride (Lithonate 300-900 mg by mouth daily, based on serum lithium levels) iii. uses: bipolar disorders, prevention of manicdepressive psychosis iv. adverse effects 1. seizures, dysrhythmias, circulatory collapse, edema, renal dysfunction, nephourotoxicity, leukocytosis 2. tremor, nausea, thirst, polyuria 3. acneiform rash, foliculitis, anticholinergic effects 4. muscle weakness, depletes glycogen stores in liver v. contraindications 1. brain trauma, obsessive-compulsive disorder, schizophourenia 2. hepatic or renal disease, severe cardiac disease, severe dehydration vi. nursing care 1. establish baseline data and monitor 1. weight, edema, sodium intake, urine output, neuro status 2. urine for albumin and glucose; serum RFT, LFT 3. lithium levels 1. therapeutic level 0.5-1.25 mEq/L 2. monitor after each dosage increase 3. monitor every 2-3 months or with behavior episode 4. lithium toxicity 1. blood level 2-3 mEq/L 2. clinical findings: vomiting, diarrhea, poor coordination, tremors, extreme thirst, tinnitus, dilute urine 3. factors that increase lithium levels: dehydration, changes in other medications, fluid and electrolyte imbalance (especially sodium), NSAIDs, tetracycline 2. significant drug-drug interactions 3. a void concurrent therapy with diuretics, NSAIDs 4. client teaching 1. may take with food, do not crush or chew capsules 2. report: tremors, impaired coordination, vomiting, diarrhea, dilute urine 3. use contraception, eat 3 regular meals daily

4. if dose is missed, take within 2 hours of next dose 5. avoid 1. dehydration, sodium-free diet 2. driving and dangerous activity 3. alcohol, OTC drugs, herbal remedies d. type: anticonvulsant (See also: II.C.1 anticonvulsants) i. action: impair normal neuronal discharge ii. examples 1. carbamazepine (Tegretol) 2. gabapentin (Neurontin) 3. lamotrigine (Lamictal) 4. topiramate (Topamax) 5. valproic acid (Depakote) iii. uses: bipolar mood disorder, schizoaffective disorder iv. adverse effects 1. seizures, myelosuppression, hepatic failure, hepatitis, pancreatitis 2. sedation, GI disturbances, dizziness v. nursing care 1. client teaching: do not abruptly discontinue therapy 3. Therapeutic class: stimulants c. information common to stimulants i. action: increase release or decrease reuptake of dopamine and NE ii. uses 1. appetite control, depression, narcolepsy 2. attention-deficit hyperactivity disorder (ADHD) in children iii. adverse effects 1. dysrhythmias, tachycardia 2. palpitations, hyperactivity, insomnia, restlessness 3. children: associated with weight loss and decreased rate of growth; approved for use in children generally > 6 years-old iv. contraindications 1. glaucoma, concurrent MAOI 2. anxiety, Tourette's syndrome, children < 6 years-old v. nursing care 1. establish baseline data and monitor 1. blood pressure, heart rate, height and weight 2. mood, affect, aggression, attention span, hyperactivity 3. sleeping pattern, appetite, tolerance; CBC, UA, blood glucose 2. client teaching 1. take at least 6-12 hours before bedtime 2. do not crush, chew, or cut time release tablets 3. report tremors, insomnia, palpitations, restlessness 4. take only as directed, do not double dose; taper dose to discontinue






5. avoid caffeine, CNS stimulants, OTC drugs, alcohol, and guarana, cola nut, and yerba mat type: piperadine derivative i. example: methylphenidate (Ritalin 5-20 mg by mouth 2-3 times daily, Concerta 18-54 mg daily) ii. use: ADHD iii. adverse effects 1. myelosuppression, exfoliative dermatitis, dysrhythmias 2. lowest side effect profile of all stimulants iv. client teaching, Concerta: shell may appear in stool, take 12 hours before bedtime type: methylphenidate derivative (amphetamine) i. example: dexmethylphenidate (Focalin 5-10 mg by mouth twice daily) ii. adverse effects: toxic psychosis, neuroleptic malignant syndrome iii. use: ADHD iv. client teaching: take every 4 hours without regard to meals type: amphetamine i. action: mimic brains most important neurotransmitters, dopamine and NE ii. example: dextroamphetamine (Dexedrine) iii. use: narcolepsy, ADHD iv. adverse effects 1. angina, hypertension, tachydysrhythmias 2. tolerance develops quickly, talkativeness, anorexia v. contraindications 1. anxiety, drug abuse, hyperthyroidism, hypertension 2. severe arteriosclerosis, cardiovascular disease, glaucoma vi. nursing care: inexpensive stimulant, manufactured illegally in U.S., prolonged duration of action type: xanthine (See also: II.B.1.b bronchodilators: xanthines) i. action: stimulates the SNS ii. example: caffeine type: oxazolidinone derivative i. action: stimulates CNS stimulation and paradoxical effect in the treatment of ADHD ii. example: pemoline (Cylert 25-112.5 mg/day) iii. use: ADHD in children >6 years-old iv. adverse effects 1. seizures, masking or aggravating Tourettes syndrome, hepatitis, hepatic failure v. contraindications: hepatic dysfunction vi. nursing care 1. administer in AM, give lowest effective dose 2. client teaching: report tremors, jaundice, bleeding, dark urine

Total Parenteral Nutrition: Nursing Care of Clients I. Nutritional support a. Nutritional deficiency 1. clinical indications for hyperalimentation: clients who a. cannot use GI tract for absorption of nutrients b. require nutritional therapy to maintain or improve nutritional status c. have risk factors for malnutrition 1. body mass index for height and age below average 2. admission to hospital, nursing home, rehabilitation facility 3. anorexia, nausea, vomiting from agent, event, or condition 4. inadequate nutritional intake, increased nutritional loss, or increased metabolic rate unsuitable for health maintenance 5. impaired ability to prepare, obtain, or eat food I. substance abuse, older clients II. low socioeconomic status, educational deficiencies III. dysphagia, infection, multiple chronic illnesses, trauma 2. clinical indicators of malnutrition a. gold standard: pre-albumin below normal (protein deficiency) b. other labs: low hemoglobin, transferrin, cholesterol, total lymphocytes c. physical findings 1. gums and teeth in poor repair 2. reddened and open areas, susceptibility to infection 3. dull, dry eyes, nails, skin, hair, inadequate muscle bulk b. Hyperalimentation 1. partial parenteral nutrition a. indications: central line contraindicated, postoperative ileus prolonged b. infusion 1. via large peripheral IV 2. solutions I. isotonic lipid emulsion: may be administered with IV solution II. hypertonic amino acid and dextrose solution 2. total parenteral nutrition (TPN) a. long-term intensive nutritional support for 1. trauma, major surgery, hypermetabolic state 2. GI impairment: inflammation, malabsorption, obstruction, side effects of chemotherapy b. hyperalimentation solution 1. contains hypertonic dextrose and amino acid solutions I. 25%-35% dextrose II. 3%-5% amino acids III. 10%-20% lipids 2. infuses via central venous catheter in subclavian or internal jugular vein


3. includes electrolytes, minerals, trace elements, and insulin added by pharmacist 4. prepared under strict aseptic technique c. benefit 1. individualized according to client need 2. provides protein-sparing action: calories 3. supplies amino acids for tissue repair and healing 4. delivers all nutrients with lower risk of fluid overload than nutritional equivalent of standard IV therapy 3. complications from central venous catheter (See also: I.D.4.a.iii central venous intravenous line) 4. selected complications from TPN solution a. infection: solution provides breeding ground for microorganisms b. fluid imbalance 1. hypertonic solution infuses directly into venous circulation 2. fluid shifts occur due to I. hyperosmolar nature of solutions II. rapid infusion without sufficient insulin, with hyponatremia or hypokalemia Nursing care a. Establish baseline data and monitor 1. vital signs, SaO2, right atrial pressure (right atrial pressure, CVP) 2. impairment of glucose metabolism a. hyperglycemia: nausea, weakness, thirst, headache, tachypnea b. hypoglycemia: diaphoresis, tachycardia, hunger, trembling, confusion 3. fluid volume status: daily weight, I & O, edema, breath sounds 4. nutritional status: skin, serum electrolytes, glucose, cholesterol, triglycerides 5. infection: temperature, WBC, insertion site 6. other: pH, neuro status, BUN, creatinine, LFTs 7. refeeding syndrome (first 24-48 hours of therapy): bradypnea, lethargy, confusion, weakness b. Prevent complications 1. rebound hypoglycemia: withdraw TPN slowly 2. microemboli: use 0.2 m-filter except with lipid emulsion 3. injury: check expiration date of solution, verify TPN order 4. hyperglycemia: verify insulin coverage, check blood glucose frequently 5. acidosis: maintain tight glycemic control, encourage coughing and deep breathing 6. infection a. avoid contamination from oily skin or tracheostomy b. insert catheter with surgical asepsis c. refrigerate until 30 minutes before using, discard after 24 hours d. sterile dressing change, use aseptic technique, change tubing daily 7. fluid shifts, hypervolemia, osmotic diuresis a. do not increase infusion rate b. maintain tight glycemic control c. verify volume infused with time strip d. start infusion slowly and titrate to client tolerance

e. administer 10% dextrose if TPN infusion is interrupted f. carefully control infusion rate, carefully program infusion device 8. air emboli a. use Luer-Lok connections b. cover site with occlusive dressing c. clamp tubing when changing solution or tubing 1. may need to position client in supine position or ask client to perform Valsalva maneuver c. Client teaching for home therapy 1. review purpose and procedure 2. verify written instructions for all procedures, troubleshooting, and complications, review procedures and equipment a. record keeping b. infusing solution c. ordering supplies d. glucose monitoring 3. verify aseptic technique 4. verify temperature in refrigerator 5. review clinical indicators of infection, hypo- and hyperglycemia, hypervolemia, air embolism Blood Product Administration


Administration of blood and blood products 1. Types a. whole blood Blood Composition

b. blood products i. red blood cells (RBCs) washed RBCs: RBCs washed with sterile saline before administration; removes some immunoglobulins and proteins packed RBCs: blood cells are separated from plasma and platelets, decreases risk of fluid overload autologous blood transfusion leukocyte-poor RBCs: removal of most leukocytes, fewer RBCs than packed RBCs ii. plasma serum albumin immune serum globulin factor concentrates: factors VIII and IX fresh frozen plasma: contains coagulation factors cryoprecipitate: clotting factors VII and VIII iii. other blood components platelets RhoGAM (See also: III.C.8 agents to prevent Rh incompatibility) granulocytes 2. Purpose and method(s) b. Restore blood volume i. provide albumin normal serum albumin plasma protein fraction ii. increase oncotic pressure serum albumin red blood cells c. Increase oxygen-carrying capacity i. increase hematocrit: red blood cells ii. increase hemoglobin: red blood cells d. Enhance immunologic defense i. provide immunological factors immune serum globulin granulocytes ii. prevent Rh-sensitization e. Enhance hemostasis i. provide clotting factors cryoprecipitate fresh frozen plasma ii. provide platelets apheresis packs random donor packs 3. Risks b. Immunologic reactions: IgG or IgM immunoglobulin binding to surface antigens of donor cells resulting in cell death i. febrile nonhemolytic reaction most common 1. usually not serious 2. usually begins within 30 minutes after beginning transfusion chills, headache, flushing, muscle pain fever: increase greater than 1 degree Centigrade or 2 degrees Fahrenheit 1. acute hemolytic reaction fever, chills, low back pain, flushing, bleeding

tachycardia, tachypnea, hypotension, oliguria higher risk of renal failure, shock, cardiac arrest, death 1. allergic transfusion reaction mild: flushing, itching, hives anaphylaxis: anxiety, hives, wheezing, chest tightness, respiratory distress, shock, cardiac arrest 1. delayed hemolytic reaction usually occurs 7-10 days after transfusion fever, chills, back pain, jaundice, anemia 1. graft-versus-host disease occurs 4-30 days after transfusion high fever, rash, stomatitis anorexia, nausea, diarrhea, liver dysfunction 1. non-cardiac pulmonary edema fever, chills, hypotension cough, orthopnea, cyanosis, shock

4. Non-immunologic b. types of reactions i. sepsis: reaction usually begins immediately ii. infection highest risk for hepatitis A and B (lower risk of C), cytomegalovirus, HIV infections iii. hypervolemia iv. disseminated intravascular coagulation (DIC) clinical indicators of non-immunologic reaction v. fever > 40 degrees Centigrade vi. dypsnea, chest tightness, tachypnea, crackles vii. hypertension, cyanosis, peripheral edema, +JVD, abnormal heart sounds, septic shock v viii. abdominal cramps, nausea, vomiting, diarrhea 5. Other risks b. hyperkalemia i. high risk due to hemolysis during collection and administration of blood products ii. especially high risk for autotransfusion hypocalcemia iii. citrate added to stored blood to prevent coagulation iv. citrate binds to calcium in client v. low risk unless client has hypocalcemia, liver dysfunction, or receiving large amounts of blood rapidly 2. Nursing care 1. Guidelines for administration b. general i. benign hives may occur ii. return transfusion record to blood bank iii. blood products more commonly used than whole blood iv. most blood products infused through IV tubing primed with normal saline v. most reactions are due to human error treat client symptomatically notify provider and blood bank occur within the first 15 minutes of a transfusion c. establish baseline data and monitor (follow agency policy for frequency and duration)

vital signs, SaO2, skin every 15 minutes and 1 hour after completion ii. breath sounds, crackles, dypsnea, +JVD iii. Hgb and Hct, urine output; serum potassium, calcium, and creatinine 2. Prevention of complications b. check before initiating transfusion i. carefully verifying documentation related to blood products follow agency policy do not remove blood product tags or identification verify data with another licensed professional from sample collection to blood administration 1. blood type, lot number, expiration date 2. identical client data on sample, prescription, and blood product ii. screen client for hypocalcemia, hyperkalemia renal failure or dialysis (risk of hyperkalemia) thyroid, parathyroid, or radical neck surgery (risk of hypocalcemia) previous transfusion reaction: immunological or non-immunological c. initiate transfusion slowly for 15-20 minutes i. remain at bedside ii. question client about unusual feelings iii. monitor vital signs every 5 minutes or follow agency policy d. infuse transfusion at prescribed rate or follow agency policy i. note volume of individual blood unit ii. infuse via infusion control device iii. follow agency policy for safe disposal of empty blood bag and tubing e. restrict use of refrigeration to that approved by blood bank i. do not store blood in the refrigerator ii. initiate transfusion within 30 minutes of removal from blood bank iii. complete transfusion in 4 hours after removal from blood bank f. collaborate with provider to i. use autologous blood or autotransfusion ii. premedicate with steroid or antihistamine iii. notify blood bank of transfusion reaction to increase scrutiny of cross-match iv. administer 10% calcium gluconate for hypocalcemia with continuous cardiac monitoring v. consider use of washed, filtered, irradiated, apheresis separated, or leukocyte-poor blood products after a transfusion reaction f. screen blood donors i. volunteer donors preferred: paid donors less likely to report past or present disease ii. screen for infectious disease: hepatitis, HIV, tuberculosis, syphilis, malaria, international


travel, residence in United Kingdom between 1980-1996 blood diseases, abnormal bleeding hypotension, anemia, jaundice, fever high risk behavior: male homosexual or bisexual malignancy, disease of heart, lungs, liver, allergies recent pregnancy, surgery, blood transfusion, vaccinations with attenuated virus

g. client teaching i. ensure informed consent of client ii. provide information about contracting infections from blood iii. provide information about administration method, monitoring, duration of transfusion, symptom recognition and reporting iv. add history of immunologic or non-immunologic transfusion reaction to client database 4. Nursing care for transfusion reaction i. immediately stop transfusion clamp IV tubing and disconnect at hub of catheter do not allow additional blood to enter clients system, do not flush tubing with saline to clear collaborate with provider for supplemental oxygen diuretics and antibiotics antihistamines, glucocorticoids monitor Hgb and Hct complete transfusion reaction form save entire administration set and blood bag, return to blood bank or follow agency policy


iii. iv. v. Dosage Calculations I.

Proportion problem I. Equation description I. each side of the equation represents the same proportion, percentage, or ratio II. example: 75% equal proportions: equal percentages: 75% = 0.75 equal ratios: 3:4 = 7.5:10 = 75:100 III. both sides of the equation represent an equal relationship but are expressed with different quantities; the two sides match Use a proportion equation to solve I. dosage calculations II. metric to metric conversion I. involves multiples of 10, 100, or 1000 II. grams mg mcg = 1 1000 1000 I. 1 gram 1000 = 1 mg II. 1 mg 1000 = 1 mcg III. 1 gram (1,000 x 1,000) = 1 mcg III. mcg mg grams = mcg x 1,000 x 1,000




1 mcg x 1,000 = 1 mg 1 mg x 1,000 = 1 gram 1 mcg x 1,000,000 = 1 gram IV. liters ml = 1 liter 1,000 I. 1 liter 1,000 = 1 ml V. ml liters = 1 ml x 1,000 = 1 liter applicable to other metric conversions


3. Dosage calculation: solve for x using a proportion problem Example: The client with heart failure receives furosemide (Lasix) 40 mg by mouth daily. The pharmacy stocks furosemide 20 mg tablets. How many tablets does the nurse administer for a 40 mg dose?

a. step one: set up proportion problem i. advantage: proportion problems are easy to set up ii. both sides of equation must match: display an
iii. equal relationship of the factors (mg and tabs) first method one side of the equation is what you have o the pharmacy stocks 20 mg tabs ? what you have: 20 mg = 1 tab the other side of the equation is what you want o the nurse wants to administer 40 mg; how many tablets does that require? o what you want: 40 mg = x tabs


second method make the equation match by placing each factor on opposite sides o one side of the equation is a factor o the other side is the second factor make the equations match o use what you have as the numerator on opposite sides o use what you want as the denominator on opposite sides

the left side of the equation displays the relationship of the factor mg according to the right side of the equation displays the relationship of


the factor tablets according to the answers for the equations in method 1 and 2 are the same step two: cross multiply and divide
o o o o o o o

1 40 = x 20 40 = 20x 20x = 40

[of furosemide (Lasix) 20 mg equals a 40 mg dose] carefully apply the desired unit of measure to the solution


Dosage calculation: solve for x using dimensional analysis (DA) a. advantage: only one equation used Example: The client receives 300 mg phenytoin (Dilantin) by mouth daily for seizures and the pharmacy sent phenytoin 125 mg/5 ml suspension. How many ml of suspension will the nurse administer? b. set-up DA equation i. left side of the equation: what you are solving for (what you want) x ml of suspension ii. right side of the equation available information related to unit of measure on the left side of equation: what you know about ml (what you know) written as a fraction

place this information on the right side of the equation so the unit of measure from the left side appears as the denominator on the right side o allows the unit of measure (ml) to be cancelled-out

in the example, the unit of measure on the left side of the equation is ml ml must then be the numerator on the right side


find the remaining information matching the unit of measure used in the numerator in the example, this information is the prescription this information is: place this information in the equation so the mg cancel-out


vii. viii. 5.

mg cancel-out

x = 12 ml/day of phenytoin elixir

Metric conversion a. metric to metric i. 0.001 kg = 1 gram = 1000 mg = 1,000,000 mcg ii. 1 mcg = 0.001 mg = 0.000001 gram iii. 1000 ml = 1 liter, 1 ml = 0.001 liter iv. 1000 mm = 100 cm = 1 meter, 1 mm = 0.1 cm = 0.001 meter b. metric to other i. 2.5 cm = 1 inch ii. 1 kg = 2.2 lbs iii. 1 gram = 15 grains iv. 30 ml = 1 ounce = 2 tablespoons c. metric to apothecary i. 1 ml = 15 minims = 15 drops (gtts) ii. 5 ml = 1 fluid dram ( ) B. Temperature conversion


centigrade =

2. Fahrenheit = Weight based dosage calculation

The child weighs 68.2 pounds. The nurse must administer amoxicillin (Amoxil) by mouth at 30 mg/kg/day in divided doses every 6 hours. How much amoxicillin does the nurse administer each day? How many milligrams of amoxicillin does the nurse administer for each dose?


Step one: convert the weight in pounds to kilograms


Step two: how much amoxicillin does the nurse administer each day? a. insert weight (kg) into dosage equation


b. the nurse administers 930 mg/day Step three: how much amoxicillin does the nurse administer for each dose? a. calculate doses/day


divide total daily dose by the number of doses i. check your answer i. total daily dose



dose = prescription

D. Intravenous calculations The nurse prepares vancomycin (Vancocin) 500 mg IV in 250 ml of normal saline to infuse over 2 hours. What is the administration rate in ml/minute?

1. Useful equations for calculating administration rate



b. administration rate expressed as

i. ii. volume for 1 minute:

2. The prescription is regular insulin (Humulin R) 100 units in 250 ml

of normal saline. The IV tubing drip rate = 20 gtts/ml. What drip rate should the nurse use to deliver 3 units/hour? a.

b. set up as proportion problem: ml/hour


cross multiply and divide

The nurse administers 7.5 ml/hr to deliver 3 units/hr. < b. determine drops/minute

i. drip rate of IV tubing = 20 gtts/ml ii. multiply (units/hr) x gtts/ml iii. iv.
ii. IV flow rate using DA The client receives epinephrine (Adrenalin) 0.25 mcg/min IV via infusion pump. The pharmacy sent epinephrine 0.1 mg in 250 ml of normal saline. What rate in ml/hr will the nurse use to program the infusion pump? a. left side of the equation: what is being solved for (what you want) i. x = ml/hr b. right side of the equation: what is available (what you have) i. ii. first section 1. since x = ml/hr, the numerator in this section must be ml

2. the information attached to ml in the example is the epinephrine solution: 1 mg in 250 ml iii. second section: the example asks for mcg, so mg must be converted to mcg

iv. third section:the example asks for

, we

have a prescription for 1. need to cancel-out mcg and relate the answer to time 2. insert prescription into equation: is what we have, what is available v. fourth section: convert minutes to hours vi. check the equation: all units of measure should cancel-out except for those that solve for x

1. in the example: x =
vii. viii. ix. x. xi. mg: cancel-out mcg: cancel-out min: cancel-out remaining units of measure: ml and hr 1.

2. 3. 2. standard equation for IV flow rate


b. place information about epinephrine above into equation


i. the solution was sent in mg, convert mg to mcg



Basic Critical Thinking Guidelines for Safe Drug Administration Before administration:

gather general baseline data o VS, lab results, allergies, co-morbidities, Ht, Wt; liver, pulmonary, renal, neuro, nutrition, hydration status identify client factors o affects on drug action from age, cultural factors, history determine purpose of therapy o indication for drug; desired therapeutic outcome reconcile medication profile o with client, family, nursing staff, provider verify prescription and client o dose, time, calculations, dosing range, dispensing method

After administration:

monitor client response o therapeutic effect, adverse effects, toxicity document findings and act o data requiring action or follow-up nursing care document nursing care o describe: care before and after, drug administration evaluate care and process o describe: med errors, problems so others, agency benefit

Client teaching

instruct client and family about drug o what to report; how to administer; food, substances, activities to avoid; need for follow-up care and testing

Basic Nursing Care to Prevent or Minimize Common Adverse Effects of Drug Therapy

Adverse effect: nursing care, monitoring, teaching

nausea, vomiting, anorexia collaborate for antiemetic, eliminate triggers, maintain NPO status monitor F/E balance, bowel sounds and pattern, food intake teaching: small, frequent meals, breathing techniques; avoid triggers constipation provide fluid, fiber, stool softener, encourage ambulation monitor bowel sounds, pattern; review diet for fluid, fiber teaching: increase fluid, fiber; ambulate; establish bowel habits diarrhea provide hygiene, skin care, close supervision to prevent injury monitor bowel pattern, F/E balance, weakness, skin, cultures teaching: increase fluid intake, wash hands, avoid irritating foods rash, allergy screen for allergies, previous reactions, provide skin care monitor airway, breathing, BP, skin, pruritus, cultures teaching: report dypsnea, pruritus, hives, worsening condition hypotension, dizziness maintain supine position, encourage fluids, review med profile monitor VS, Sa02, EKG, level of consciousness, U/O teaching: remain in bed; ask for help to stand; avoid alcohol, sedation

Basic Nursing Care to Prevent or Minimize Adverse Effects of a Drug Class or Type

Drug class or type with related adverse effects: nursing care, monitoring, and teaching o antihypertensives: orthostatic hypotension, F/E imbalance assist with activity; eliminate drug interactions, vasodilators, CNS depressants monitor BP, pulse, breath sounds, serum electrolyte levels, edema, dizziness teaching: get help to stand, report dizziness; avoid alcohol, sedatives, OTC agents, caffeine o anticholinergic agents: dry mouth, constipation, blurred vision provide sips of water, oral care; assist with activity; remove environmental hazards monitor bowel pattern, vision, oral mucous membranes teaching: frequent oral care, avoid dangerous activity, ask for help to stand o anticoagulants and antiplatelet agents: bleeding minimize invasive procedures, shaving; provide gentle oral care; assist with activity monitor bleeding, coagulation tests, CBC, bruising; remove adverse drug and food affects teaching: avoid dangerous activity, wear MedicAlert tag, avoid NSAIDs, alcohol o anticonvulsants: CNS depression, myelosuppression: infection and bleeding assist with activity; protect airway, breathing; minimize invasive procedures monitor seizure activity, CBC with diff, temperature, regional redness, swelling, or drainage teaching: wear MedicAlert tag, avoid dangerous activity, wash hands, avoid crowds, need for follow-up care and testing o antidysrhythmics: new or more dangerous dysrhythmias, changes in BP maintain F/E balance, SaO2 >95%, sinus rhythm; assist with position changes monitor PFT, EKG, BP, pulse, SaO2, serum electrolytes, LOC teaching: ask for help to stand, report irregular pulse, technique for counting pulse

antiinfective agents: renal and hepatic dysfunction obtain cultures before administration, verify administration guidelines, screen for renal and hepatic dysfunction, allergy, nephrotoxic or hepatotoxic drugs monitor RFT, LFT, jaundice, dark stool or urine, nausea and vomiting report nausea, vomiting, dark stool or urine, jaundice; need for follow-up care and testing loop, thiazide diuretics: circulatory collapse, myelosuppression, F/E imbalance, ototoxicity verify infusion guidelines, B/P, serum electrolytes, and U/O before giving monitor serum Na+ and K+, breath sounds, edema, BP, U/O teaching: report palpitations, weakness, irregular pulse, decreased U/O, temperature female hormones: thromboembolic disorders, increased risk of breast and endometrial cancer, hyperglycemia, hypercalcemia, depression, seizures monitor peripheral perfusion, edema; leg pain, tenderness; serum Ca++, glucose teaching: report lumps and abnormal bleeding, muscle twitching